;;>',_' i ■ .;:.• • '■::'>■ >V: :.'V "■'. i'11- ■■'' '•"• ■ ■* ':■■ ."'■»■' ' ■' ft; :■'" ': -■'•.'^d?r'"'. Sfosrj^ ^*^2>%-**/ TREATISE DISEASES OF FEMALES. WILLIAM P. DEWEES, M. D LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THE ROYAL MEDICAL SOCIETY OF DENMARK, &C. &C. NINTH EDITION, WITH THE AUTHOR'S LAST IMPROVE- MENTS AND CORRECTIONS. PHILADELPHIA: LEA & BLANCHARD. 1847. v •*•' » . . WP Ei/stern District of Pennsylvania to wit:— BE IT REMEMBERED, that, on the twentieth day of November, in the fifty- first year of the Independence of the United States of America, A. D. 1827, William P. Dewees, M. D., of the said district, hath deposited in this office the title of a book, the right whereof he claims as Author, in the words following, to wit:— " A Treatise on the Diseases of Females. By William P. Dewees, M. D. Pro- fessor of Midwifery in the University of Pennsylvania, &c. &c" In conformity to the Act of the Congress of the United States, entitled, "An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned—And also to the Act, entitled, "An Act supplementary to an Act, entitled, 'An Act for the Encouragement of Learning, by securing the Copies of Maps, Charts, and Books, to the Authors and Proprietors of such Copies, during the times therein mentioned,' and extending the benefits thereof to the arts of designing, engraving, and etching Historical and other Prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. GRIGGS & CO., PRINTERS. TO N. CHAPMAN, M. B. PROFESSOR OF INSTITUTES AND PRACTICE OF PHYSIC, &C. &C. THIS WORK IS INSCRIBED, WITH SENTIMENTS OF THE HIGHEST ESTEEM, FOR HIS MANY VIRTUES, AND THE SINCEREST ADMIRATION OF HIS VARIOUS TALENTS, • BY HIS OBLIGED FRIEND, THE AUTHOR. AUTHOR'S ADVERTISEMENT. The following pages are presented to the public without preface or apology. The necessity of a work on the Diseases of Females, and especially the most common of them, seems to be pretty generally acknow- ledged ; but the difficulty of executing it can only be known to him who undertakes it. This will plead with the liberal, for moderation in criticism ; though it may be no extenuation with those of a contrary feeling. From the observations of the former, we hope to profit, should any such honour the work with their notice ; and from the latter, we will not flinch, however severe the castigation, as we know it is much easier to find fault than to excel. PUBLISHERS' ADVERTISEMENT. The present edition of this valuable work contains the revisions and additions of the author, made by him a short time previous to his death. Philadelphia, July, 1847. 1* CONTENTS. CHAPTER I. Page Of the Peculiarities of the Female System, - - 13 CHAPTER II. Of the Diseases of the External and Internal Organs, - 21 Sect. I. Of the Tumours aud Excrescences of the Exter- nal Parts, - - - -22 II. Of the Diseases of the JVymphce, - - ib. III. Of the Diseases of the Clitoris, - - 24 IV. Of the Adhesion of the Labia Pudendi of Chil- dren, - - - - 25 V. Of the Abscesses of the Labia, - - 28 VI. CEdematous Swelling of the Labia, - - 29 VII. Of Bloody Infiltrations in the Labia during or after delivery, - - - - 31 VIII. Imperforation, and too great Density of the Hy- men, ' - - - - - 38 IX. Of Pruritus, or Aphthous Condition of the Vulva and Vagina. - - - - 42 CHAPTER III. Of the Diseases of the Vagina, - - - - 50 CHAPTER IV. Of Leucorrhcea, - - - - - 51 Method of Cure, ----- 68 CHAPTER V. Of the History of Mensh-uation, - - - 75 Vlll CONTENTS. CHAPTER VI. Pajrc Of Deranged Menstruation, - - - " . Sect. I. 1. Of the Tardy Appearance of the Menses, - ti- ll. 2. Of the Suppression of the Menses? - • - 106 Case I. - - - - HI Case II. - - - - 112 III. 3. Of the Immoderate Flow of the Menses, - 119 IV. 4. Of Dysmenorrhcea, or Painful Menstruation, 121 V. 5. Of the Decline of the Menses, - - 134 CHAPTER VII. Of Menorrhagia, - - - - - 146 CHAPTER VIII. Of the Signs which usually accompany Pregnancy, - 157 Sect. I. 1. Suppression of the Menses, - 158 II. 2. Nausea and Vomiting, - 163 III. 3. Enlargement of the Mammce, - 164 IV. 4. AreolcB, - ib. V. 5. Formation of the Milk, - 165 VI. 6. Enlargement of the Abdomen, - 166 VII. 7. Increased size of the Uterus, - 167 VIII. 8. Pouting out of the Navel, - - 168 IX. 9. Spitting of Frothy Saliva, - ib. X. 10. Salivation, - 169 XI. 11. Of Quickening, - - 170 CHAPTER IX. Of the General Condition of the System, and the Effects of certain Remedies during Pregnancy, - - 176 Bleeding, - ~ - - - 182 Purging, - - - - 184 Emetics, - - - - - 185 Blisters, - - - - - 186 CHAPTER X. On some of the Diseases of Pregnancy, - - - 187 Sect. I. Of the Febrile Condition of the System during Pregnancy, - - - - ib. CONTENTS. IX Sect. II. Of Vomiting, .... 191 III. Of Heartburn, - - - - 195 IV. Of Salivation, - 196 V. Of Pain in the Right Side, - - 198 VI. Of Inquietude and Want of Sleep, - - 200 VII. Of Costiveness, - - - - 201 CHAPTER XL Of Hemorrhoids, or Piles, .... 204 CHAPTER XII. Of Palpitation of the Heart, - - - 212 CHAPTER XIII. Of the Displacement of the Uterus, - - 214 Sect. I. Prolapsus of the Uterus, ... ib. II. Of the Chronic Inversion of the Uterus, - 227 CHAPTER XIV. Of the Diseases of the Uterus, Ovaria and Tubes, - 232 Sect. I. Of the Disorders and Diseases of the Uterus, - ib. II. Of the Diseases of the Ovaries, - - 233 III. Of the Diseases of the Tubes, - - 234 CHAPTER XV. Of the Particular Diseases of the Uterus, - - 236 Sect. I. Of the Carcinoma Uten, - 238 II. Of the Treatment of Carcinoma Uteri, - 240 1. Abstracting Blood, - - - 241 2. Purging, - 243 3. Abstemious Diet, - 245 4. Cleanliness, - 246 5. Rest, - - - 248 III. Of the Polypus of the Uterus, - - 256 Case 1......262 Case II. .... ib. Case III. 263 Case IV. -, - - 264 Case V. .... 265 Case VI. - - - 266 X contents. Page Sect. IV. Mode of applying the Ligature for Polypi, - ~Jj' V. Of the Cauliflower Excrescence, - - ~'* VI. Of the Symptoms, - - . - - ^T4 VII. Of the Prognostics, - - - ™- VIII. Of the Treatment of Cauliflower Excrescence, £to IX. Of Hydatids of the Uterus, - - 27 J X. Of the Irritable Uterus, - - -28b CHAPTER XVI. Of Uterine Hemorrhage, - 307 Sect. I. 1. Of the Connexion of the Ovum with the Uterus, - - - - ib. II. 2. Of the Causes which may tend to destroy this Connexion, - 308 III. 3. Of the Mode of Action of certain of the remote Causes, - - - - ib. IV. 4. Of the Periods of Pregnancy at which Hemor- rhage may take place, - 312 First Period, - - - - 314 Second Period, - 322 V. Delivery considered as a Mode of arresting He- morrhage, - 324 CHAPTER XVII. Hysteritis, or Inflammation of the Uterus, - - 329 Sect. I. Species First. 1. Causes, - - 330 2. Symptoms, - - - - 331 3. Constitutional Symptoms, - - 332 II. Species Second. On the mixed Inflammation of the Uterus, or Accidental Puerperal Fever, 336 Treatment, ----- 338 a. Bleeding, - - - - ib. b. Purging, ... - 340 c. Fomentations, - ib. d. Blisters, - - - - 341 e. Sudorifics, ... - ib. f. Opium, - 342 g. Emetics, - ib. CHAPTER XVIII. Of Puerperal Fever, - - • . . . 343 History, ------ 346 Predisposing Causes, - 348 CONTENTS. XI Page Prophylactics, - - - - - 351 Seat of the Disease, and its proximate Causes, - 353 Period of Attack, and Symptoms, - - 369 Diagnosis, ----- 375 Prognosis, - 377 Pontagious Nature of Puerperal Fever, - - 380 Treatment, - - - - - 381 1. Bleeding, Stage First, - - - 391 Purging, ----- 405 Emetics, - - - - . - ib. Blisters, ----- 408 Fomentations, - 409 Spirit of Turpentine, ... ib. Mercurial Frictions, ... 410 2. Of the Gangrenous Stage, - 412 3. Of the Stage of Effusion, - 417 General Directions and Rules, - 418 CHAPTER XIX. Phlegmasia Dolens, or Milk Leg, 420 Symptoms and General Character of Phlebitis, - 434 Case I. - 435 Case II. - 437 Caselll. --- - *'&. Case IV. - - - - 438 Method of Cure, - 442 Blood-letting and Leeching, 443 Purging, fyc. - - - - £5. Topical Applications, - £6. Opium, . . . . 444 External Applications, - - - 445 Blisters, - ib. Bandaging, - 446 CHAPTER XX. Of Milk Abscess, - 447 Of the Treatment, - 451 1. ZocaZ Applications, - 452 2. Regimen, - - - - 455 3. Purging, - - - - £6. 4. Puncturing, ib. Xll CONTENTS. Page 5. Caustic, - ., 6. Seton, ----- *o- 7. After-Treatment, - - - 40' CHAPTER XXI. Of Hysteria,......458 Sect. I. Of the predisposing Causes, - - - 4b4 II. Of the exciting Causes, - - - 466 1, 2. Wind and Tough Phlegm, - - 467 3. Worms, - - - - 471 4. Aliments, improper in Quantity or Quality, - - - - 472 5. Scirrhous or other Obstructions in the Stomach, or Intestines, fyc. - 473 6. Violent Affections of the Mind, - 474 III. Of the Phenomena of Hysteria, - - 475 IV. Diagnosis, ----- 478 V. Treatment, - - - - 479 Case I......483 Case II......484 1. Of the Paroxysm, - 485 2. To prevent the Recurrence of Paroxysms, - 495 Explanation of the Plates, - 507 Index, ------- 519 ON THE DISEASES OE FEMALES. CHAPTER I. OF THE PECULIARITIES OF THE FEMALE SYSTEM. However powerful the influence of education and modes of life may be upon the human frame, they are not capable of effecting so great a change upon the female constitution, as to deprive it of its distinctive peculiarities. Yet we are aware that much is done by these great agents; and that when they have been employed under equal circumstances, for an equal period, an approxima- tion of physical and moral similarity has been observed ; though they have never been able to alter the general character of the female so much, as to leave the slightest doubt to which of the sexes the individual belongs, even independently of sexual pecu- liarity. The intentions of nature in the formation of man, are not, nor cannot be fulfilled, by one sex alone ; both must concur in this great object; and it would be idle to decide, by any process of reasoning, to which is assigned the most important role in this great work. Participation is essential to the end in view; and to each is allotted respective duties; duties which cannot be ex- changed or even varied ; for they are immutable. To preserve, therefore, the moral and physical distinctions in his favourite creatures, and to prevent either neglect or confusion in the per- formance of the duties assigned to them, the Deity has imposed such distinctness of organization upon the sexes, as defies aliena- tion, or exchange in the exercise of the functions resulting from it.* * Alphore le Roi is of opinion, that most of the causes which degenerate the human family, originate with the female; he says, " With a view more effectually 14 PECULIARITIES OF THE FEMALE SYSTEM. In this place, however, we have only to detail, and that very briefly, the peculiarities which distinguish the female from the male ; peculiarities, which impose upon her functions and diseases altogether her own. For both her particular organization and her temperament are made subservient to the important part she is destined to perform ; upon her devolves conception, gestation, delivery, suckling, and all the contingencies connected with these processes. To what evils, then, do not these processes subject the female! yet, before she experiences them, she is liable to all such, as may arise from sexual functions and organization: and before she can perform one of the ultimate intentions of her creation, she is ob- noxious from mere structure to painful, and sometimes to fatal diseases. For to her the period of puberty is oftentimes replete with evils; she is constantly liable to irregularities in her menstrua, and menaced severely by their consequences. She may be visited by them precociously, and be debilitated by their quantity, or frequency; or they may be withheld so long, as to involve her health in ruin. Or she may be defective or exuberant in struc- ture ; and be obliged to submit, if not to dangerous, yet perhaps to indelicate operations, to compensate for the one or for the removal of the other. Besides these, she is liable to all the dis- eases of the male, that do not depend upon sexual distinction; and thus is multiplied upon her, almost all the evils that can be- fal two sexes. The anatomical and physiological peculiarities of the female are both numerous and curious; we shall only, however, succinctly enumerate a few. One of the most striking differences between the male and fe- male, is the inferiority of her stature. Her whole osseous fabric is more delicate and less extended. The bones of her cranium are thinner, smaller, and more pliant; and the space destined to be filled with the brain, is smaller. The chest is more elevated, in consequence of the ribs forming nearly right angles with the spine; and these bones themselves, are broader and flatter, than in the male. This disposition of the ribs renders the thorax shorter, though its upper part is larger; but the sternum and cartilages have less length, and are flatter; the clavicles are longer and less crooked. The pelvis of the female differs in a number of points from that of the male; it is to follow the labyrinth of the human economy, it appears necessary to atudy that of the female; in this we may perceive more certainly and frequently than in that of the man, the cause and progress of diseases. Moreover, the degeneration of the species always begins in nature with the female; to study the diseases of them is to arrive at the source of all that belong to the human speci.8." Hi»toirc Na- torelle de la Groesesse et rAccouchement, p. viii. PECULIARITIES OF THE FEMALE SYSTEM. 15 calculated to subserve one of the most important as well as inte- resting functions of the body; namely, the passage of the child during labour: hence, we find all its diameters larger than those of the male; together with a much greater expansion of the bones which constitute the arch of the pubes, &c. The general character of the bones, as well as their connex- ions with each other, differ from those of the male; their angles are less silent; and consequently their articulations are better concealed. The muscular system also differs; its mobility is much greater; the whole of the fibres of the female seem to possess a greater tenuity and sensibility; hence, the proneness of the female to spas- modic, and convulsive diseases; hence, the greater susceptibility of impressions from physical and moral causes: hence, the greater quickness of contraction of the muscles ; and hence, less perma- nency of impressions. The nervous system has also its peculiar properties; the nerves themselves are smaller, and of more delicate structure. They are endowed with greater sensibility, and of course are liable to more frequent and stronger impressions from external agents, or moral influences; and thus the nervous, with the muscular sys- tem, contribute to render the female liable to spasmodic diseases, and obnoxious to inordinate stimulation. But these peculiarities are considered by some, rather an ad- vantage, than an evil. Thus> Vigarous declares, " Cette sensi- bilite excessive, loin d'etre un mal, devient un avantage dans leur condition ; car plus les sensations sont grandes, moins' elles sont durable, parce que la mollesse et la flaccidite des solids leur faisant opposer moins de resistance, leur rear.tinn est moins forte et cesse bientot." " HI n'en est pas de merae dans l'homme ; la rigidite et la force de ses solides exigent plus d'energie et un plus grand degre d'entensite dans la cause qui agit sur lui; mais aussi 1'effect est plus durable, par la grand resistance que sont en etat d'opposer ses organs, resistance qui le fait souvent succomber. Je compa- rerois volentiers, dans ce cas, la femme a ce frele roseau, qui, in- capable de resistance, flechit humbleraent la tete sous l'effort de la tempete, et la releve doucement quand le calme est revenue ; et l'homme a ce chene altier, qui se trouve abultu, par la seule raison qu'il est fort et capable de resister."* In the sanguiferous system, we may perhaps recognise the united peculiarities of the muscular and nervous systems; for in that system, we constantly find the circulation carried on with more rapidity, but with less force; the arteries are smaller, more irritable, and more easily urged into action, and less easily ap- * Maladies des Femmes. Vol. i. p. 40. 16 PECULIARITIES OF THE FEMALE SYSTEM. (>eased, after having been inordinately excited. The veins offer ess resistance to any given distending force; hence, they are more strongly marked upon the surface of the body; more de- cidedly full, or permanently distended ; and more disposed to be- come varicose. The arteries have smaller calibers ; are quicker in their action ; and but rarely ossify. The cellular system is more abundant; more flexible; and more easily distended. It is better supplied wkh rooistupe ; and from the compressibility of its texture, permits the blood vessels to divaricate, and pass unrestrainedly in all directions through it. From its abundance, and especially about the articulations of the great joints, and large foldings of the body, a roundness and beauty is given to parts, which in the male are angular, and per- haps even sometimes unsightly. The cutaneous system differs much from that of the male ; for it of itself, almost becomes an object of beauty. Its texture is infinitely finer, more highly polished', and' more decidedly trans- parent. It permits the veins to ramify gracefully through its structure ; to be distinctly seen, and thus forming a fine contrast with the white ground on which they repose. It shows, from its fineness, to the greatest possible advantage, the arterial termina- tions which so beautifully assemble upon the cheeks. Its sensi- bility is much greater ; and its sympathies, if not more extensive, are certainly more vivid, than in the male. It is also much more distensible ; especially that portion of it which covers the abdo- men ; and makes, by this means, an important provision for the period of gestation. The capillary system, also appears to be more developed in the female than in the male system. Thus the great aptitude of the system nf the former, to diseasps attended with paleness of the skin, oedema, dropsy, and hemorrhages, and thus involving affections of both the serous and the mucous surfaces. The lymphatic system of the female does not differ widely as regards conformation, from that system in the male: it absorbs and transmits perhaps with more rapidity, its appropriate fluids ; yet, there is no other known peculiarity in it, except the lympha- tic vessels are more numerous ; and when they have a certain pre- dominance, they constitute a temperament; and then, unfortu- nately for the possessor, it but too certainly and too frequently, becomes the seat of terrible, and oftentimes incurable disease. The peculiarities which we have thus briefly pointed out, ne- cessarily render the female constitution one of a marked, and distinct character. The assemblage of the differences which-con- stitute it, renders it, in general terms, one in-which the solids are less dense and resisting: for these are found'to be more relaxed and flabby than in the male, owing, probably, to the predominance of the cellular and nervous systems. The lymphatic system is PECULIARITIES OF THE FEMALE SYSTEM. 17 more extensive than the sanguineous ; which it is supposed, gives to the female a greater quantity of fluids than to the male. To the operation of several of the peculiarities above enume- rated, is attributed the sup-posed predominant temperament of the female constitution ; namely, the sanguineous temperament, so much insisted on by Rouse], and agreed to by Vigarous. In attributing the sanguineous temperament, as the predomi- nant one of the female, we only mean to express it as occurring as a general rule ; for we are aware, that there are many excep- tions to be found; for, among them, as with the male, every tem- perament may be seen. It has, however, been given so general- ly ; that some object must attach to its frequency ; and perhaps the opinion of Vigarous, is as plausible as- any. He says, " des- tinees, comme elles le sont (females) a passer de revolutions en revolutions, a eprouver des transitions brusques dans leur maiere d'etre, la nature a du former les femmes d'une trempe molle, pour les mettre en etat de resister aux orages auxquels elle sont exposees," p. 39, vol. i. Besides the systems just enumerated as belonging to the human system, many are disposed1 to give to the female another, namely, the uterine system; and which they endow with an extent of in- fluence that belongs to no other. It has been handed down to us from time immemorial, that the uterus exerts a paramount power over every other system; and governs them with a sway no less whimsical than potent. That it creates, exalts, or modifies disease, in every portion of the body ; hence, the aphorism of Hippocrates, " morbbrum omnium qui muliebres vocantur uteri in causa sint." That.it not only forms, or governs the moral character of the female, but regulates the physical movements of her body :henoe, the declaration of Van Helmont: " propter solum uterum, est mulier id quod est." By many, the uterus has been deelared to possess a separate and peculiar life ; that it has its own mode of existence; and is totally independent of the laws$ which govern the other portions of the system. Aretseus compared' it to " an animal confined within another animal; that it travelled without restraint from any portion of the body to another; that it would take possession of any sense; or occupy any viscera, whether situated at the right or the left side of the body; but that its movements were rather towards the inferior portions of it. It was like a wander- ing being; that it relished agreeable odours, and would move itself towards the place from which they appeared to emanate; but would remove itself in sadness, from places which had disa- greeable smells," &c* Sydenham, Cullen, Good, and very many others, have given * ChamboDi- 2* 18 PECULIARITIES OF THE FEMALE SYSTEM. to this organ, power to produce, or modify disease. To venture an opinion, that would very much differ, from the sentiments of the great men just named, would have the appearance of fastidi- ousness at least, if not of rashness. But, as we have never wit- nessed any decided instance of this exclusive influence of the uterus in the production or modification of disease, we feel our- selves justified in entering our protest against its possessing such unlimited sway. In doing this, however, let us make ourselves as clearly understood'as the nature of the thing wiH permit. First.—We have ever found the unoccupied uterus to be one of great passiveness when in a state of perfect health; and that so hong as it preserved this condition, it manifested no ageney in the production of disease, or in modifying it, when present. Thus, fever, inflammation, either local or general, or spasm, has never appeared-to us to derive advantage, or suffer inconvenience, from the influence of this organ. Second.—That when in a state of disease, we have found several parts of the body sympathize with the uterus: as the stomach, the head, the breast, &c; but precisely the same thing may be said of other parts of the body ; yet, for neither of these is such influence claimed", as is bestowed upon the uterus. Thus, the brain, the stomach, the kidneys, the liver, &c. when in a diseased state, will' have particular parts, deranged, by a sym- pathetic influence ; yet it has never been asserted", that either of these parts had' at any other time, or uncrer any other circum- stance but disease, an agency in producing or modifying the af- fections of other portions of the body. Third.—While the uterus is performing one of its functional duties, namely, forming the menstrual fluid ; when it is known to be in a state of excitement, and, decidedly engorged with blood; a time when it would most likely exert an influence, if it really possessed any; we never find this organ exerting a power over other parts, so long as the functional process is carried on healthi- ly ; and'during this period, we have hitherto not been able to de- tect the slightest influence over any disease, that may have been present in the system; nor has it ever made us vary a prescrip- tion, or modify a treatment. Fourth.—That when the menstruous function is performed with pain and difficulty, other portions of the system are found to suffer from sympathy; but in no greater degree, than these very parts have been known to suffer, when some other organ was the seat of irritation. In dysmenorrhcea, we have known the back and stomach suffer severely, the first from pretty intense pain, and the second by severe vomiting ; but we have seen the same- consequences attend an irritated kidney, or an inflamed neck of the bladder. Fifth,—That when this organ.is, labouring under severe dis- PECULIARITIES OF THE FEMALE SYSTEM. 19 ease ; as inflammation, scirrhus, or cancer; where all its ordinary functions are either deranged, perverted, or suspended, and this foj a long period together, we do not find, that it involves the system in any severer penalties than any other equally important viscus would, under similar circumstances. Sixth.—That when its functional processes are irregularly and imperfectly performed ; or .are altogether suspended ; if the gene- ral health suffer from this cause, it is not because the uterus has any superior power to effect this, but because a link is broken (and we are willing to admit it to be an important link,) whereby the chain of healthy functions is maintained. A similar condi- tion of any of the other viscera would be followed by the same consequences. Seventh.—That when the uterus is impregnated, various other portions of the system are deranged, in consequence of their strong sympathy with this organ ; but even here, the complaints are not sui generis ; for every one ofthem can be, and have been very often similated from other causes.* The whole phenomena of impregnation are so well understood as not to require reciting; but has not almost every body witnessed the whole train of these morbid sympathies to arise from very different causes? We would then ask, what evidence is there, that the uterus possesses such unlimited sway over the healthy or diseased movements of almost every other portion of the body? Does not this error proceed from the influence of authority, and a su- pineness and indifference to rational inquiry or correct observa- tion ? Should the names of Hippocrates, Galen, Aretseus, Van Helmont, and a hundred others of greater or less authority, be permitted so to satisfy the judgment, or so paralyze exertion, as to prevent all investigation? The discoveries of Gall and Spurzheim on the influence of the cerebral system upon other portions of the body, render it much more probable, that the various morbid phenomena attributed to the influence of the uterus, depend upon certain excitements in the cerebellum ; and that the several facts recorded as belonging to the genital system of the female, are themselves but evidences of the influence of cerebral irritation. In the male, at least, this point is pretty well settled—as it has been found by Larrey and others, that certain wounds or injuries of the cerebellum, entail impotence. It is, therefore, much more rational to look for sorne * In this assertion, we do not mean to inc'mde-that-beautiful and magic-like play of sympathies, whirh is established for the future welfare of the expected being; namely, the swelling of the mamma?, and the secretion of milk. These parts have a mutual, and an associated sympathy, which they with great fidelity maintain as long as they are capable of performing their appropriate functions. The nature and extent of these intercommunions are too well known to need a particular mention. 20 PECULIARITIES OF THE FEMALE SYSTEM. disturbance of the brain or nervous system, as long since sug- gested by Willis, for the origin of hysteria, &c, than to any di- rect influence of the uterine system. . Do not let it be understood, from what we have just said, that we undervalue the importance of the uterus as an organ ; for as an organ we are free to admit, that it has high destinies to fulfil ; we only wish to insist, that it has no exclusive, or concurrent power, to produce, modify, exalt, or diminish, any disease or af- fection of the body, beyond several other viscera ; and, perhaps, less than some. The stomach, decidedly, and, perhaps, the liver, have a more marked influence, either in a state of health, or of disease, over the animal economy, than the uterus. Nor are we to be supposed" to countenance the opinions ad- vanced by Mr. Fogo,* some few years since, in a paper entitled, " On the degree of importance which should be attached to the functions of the uterus, in regard to health." He declares it as his opinion, that the uterus is of so little consequence to the ani- mal economy, that it might be spared from the body, without the system suffering by its removal. He calls it " a simple, passive, accommodating organ ; and, on this account, can have but little influence or control upon the functions of the body. If the value of an organ be tested by such estimates, to what a low value would the brain or the stomach be reduced? The stomach may, especially, be called " a simple, passive, accommodating organ ;" possessing, perhaps, in a greater degree, these qualities, than even the uterus itself. In the first place, its structure is less complicated than the uterus; it is equally pas- sive, when permitted to be so; and it is doubtless, as " accom- modating ;" as the efforts of the gourmand have frequently proved. Yet Mr. Fogo, himself, would not hesitate to admit, that this " simple, passive, accommodating organ," cannot well be spared, because it possesses these qualities. In a word, we are of opinion, that the uterus ranks in the first order of the viscera; that its health is every way important to the general health of the system ; but that it does not exert any particular power over other portions of the body, more than any other important viscus would, under the same circumstances; namely, of disease. That its influence is greatest, while per- forming, or giving evidence of its best state of health; namely, during gestation. * See an answer to Mr. Fngo's paper, in " Essays connected with Midwifery," by William P. Dewees, M. D., &c. DISEASES OF THE EXTERNAL AND INTERNAL ORGANS. 21 CHAPTER II. OF THE DISEASES OF THE EXTERNAL AND INTERNAL ORGANS. The structure of the external organs is such as to render them liable to a variety of complaints that always excite alarm, how- ever free they may be from danger. Indeed, any disease of these parts creates a great deal of apprehension, especially in the married, or the pregnant woman. Women, especially the mar- ried, are often kept in a state of great anxiety, when labouring under any affection of these parts, until they can be assured it is not one of a particular Icind, and that it will not be attended with danger. On this account, it is of consequence to the young practitioner, that he be acquainted with their general diseases, both in the uni-mpregnated, and in the impregnated state of the uterus. It may be observed, as a general rule, with respect to the eco- nomy of these parts, that, from their great vascularity and sensi- bility, inflammation runs on very rapidly to suppuration, and is accompanied with much paiq. Indeed,, we have seen severe in- flammation of the labia terminate very rapidly in gangrene, though much exertion had been made to prevent it. It may, also, be observed, that suppuration of the labia is attended with more than a usual degree of fetor; owing, most pr°wtJ,-, «~ their very cellular strurhu-fl: tti- *«»- :- A""d to 'l,e m°re easily when much accumulated, than when in more spare pro- portions. wc »~«;r c\^ odd, that parts thus organized, granu- late more slowly after suppuration, than many other portions of the body, from the same cause. From the looseness of the texture of some of these parts, espe- cially the nymphae and labia, they become sometimes very much enlarged, from very slight irritation ; and when there has been a neglect of proper cleanliness, the natural secretions become acrid from stagnation* and. produce itching, which, though slight at first very much increases by the indulgence of scratching; and if this be persisted in the parts become inflamed, and sometimes swell inordinately, but does no mischief ordinarily, if not too long persevered in. This happens especially with those who have a dread of water after the catemenial discharge; and who neglect to wash themselves after these purgations. On this account, it is important that the parts should be daily washed with warm water particularly during the flow, and immediately after the menses have ceased ; or if the woman be subject to fluor albus. 22 DISEASES OF THE NYMPH*. The prejudices of some women on the subject of washing, should be removed, by the practitioner making it a point to recommend its frequent use, when consulted on these diseases. Sect. I.—Of Tumours and Excrescences of the External Parts. Some parts of the external organs are more liable to tumours and excrescences than others; thus, the labia and nymphae are more frequently the seats of these affections than other portions of the vestibulum. The nymphae appear more obnoxious to in- durations and excrescences, than even the labia; and they are especially so, when they are sufficiently long to protrude beyond the labia. Sect. II.—Diseases of the Nymphce. When these bodies become much enlarged, they present a very dark colour* are dense, and sometimes studded with a num- ber of little tumours resembling Warts.f From their position, they are constantly liable to irritation; and in cold weather, to excoriation. Sometimes violent inflammation seizes upon these parts in consequence of the reaction, which follows a great re- ductiqn of temperature. In such cases rest should be enjoined; a free purging insti- tuted ; and if the arterial system become involved, blood should wc laKcu rroia the arm ; or from near the part, by leeching. A SOlt bread &r*a---ul .,---1,;„„ 0y,„„M y,a applipH to tho port, and renewed as frequently as occasion may require; that is in warm weather, every three or four hours ; in ood „x wij wcatner, more seldom. These parts from the intensity of the inflammation, (especially if they have been much irritated by scratching,) sometimes run on to suppuration. When this takes place, they must be treated as any other suppurating surface; taking care that the labia are not permitted to coalesce during the healing. We once saw an instance of the nymphae suppurating, and by this means getting rid of a number of warty excrescences, with which they had been studded. Should these excrescences attend, or follow a venereal affec- tion, it might be well, in some instances where the disease is obstinate, to try the effect of mercury ; but this remedy holds out but little prospect of success, unless there be present an unsub- • Mr. Burn* says white; hut this we have never seen. t Duges says he has seen them from the size of a pea, to that of a turkey's egg. We have never seen any so large as the latter. DISEASES OF THE NYMPHJE. 23 dued venereal taint. When they are in the form of warts, and these very numerous, as is the case very often, nothing will suc- ceed so well as keeping the parts very dry, and exposed as much as possible to the air. The following case will illustrate this practice sufficiently. Mrs.-----, had been severely injured by her husband giving her the venereal disease in its most aggravated form ; namely, chancres and buboes. About six months after she appeared to have recovered from these affections, she found a vast number of little tumours spread over the labia, the nymphae, and other por- tions of the vulva, which increased rapidly in number as well as augmented in size ; from the whole surface of which there issued a disagreeable smelling matter which excited itching; and when the parts were rubbed, blood would follow. Ihe gentleman who had attended this patient for the venereal complaint, was called on again on account of the warts; he pre- scribed mercury to salivation ; this was complied with; but the little warty tumours increased to such an extent, that a severe bleeding would follow every attempt at conjugal enjoyment. We were now consulted. The whole vulva was found to be completely occupied by these warty productions; and were almost without number, and of great variety of sizes. As we had treat- ed these productions in the male with success by exposing them to the air and keeping them perfectly dry, it was agreed, that our patient should follow this plan. The patient was ordered to bed, and the labia were kept sepa- rate, by means of adhesive plaster: this being done, the whole vestibulum, and crop of warts, were exposed. A quantity of prepared chalk was dusted upon the surface, and no other appli- cation was permitted if we except the occasional washings with warm water, to remove the incrusted chalk ; that is, morning .and evening. This plan, though a little difficult of accomplish- ment,* succeeded in about a fortnight to remove every excre- scence, so as not to leave a vestige behind. It was truly remarkable to see with what rapidity these para- site productions lost their lives, by depriving them of moisture. They would drop off in large portions at every bathing of the parts, until all perished in turn. Besides the excrescences just noticed, these parts are subject to prodigious enlargements; and sometimes require the knife for their removal. There is a preparation of this kind in the Museum of the Medical College of Pennsylvania, of an enormous size, and well worth the trouble of an examination. The extirpation of these tumours is considered by all surgeons, we believe to be perfectly safe. The operation never seems to expose any large vessels. And Dr. Denman informs us, he has seen the enlarged nymphae and excrescences removed by the knife, 24 DISEASES OF THE CLITORIS. without the necessity of tying a single blood-vessel. Introd. Francis's ed. p. 100. In certain parts of the world, the nymphae are peculiarly lia- ble to enlargement ; in some instances they have measured seve- ral inches, as among the Bosjesman women, if the accounts of travellers are to be depended upon. On the shores of the Persian gulf, the Christian women of Abyssinia, and in parts of Egypt, the girls have these parts removed as a ceremony ; it is intended to resemble circumcision. Sect. III.—Diseases of the Clitoiis. The clitoris has occasionally been the seat of scirrhus, and of cancer, but when either of ttosse seize the part, the cure is hope- less, unless the whole of the disease can be removed by an ope- ration. In the Medical and Physical Journal, vol. v., p. 1., Mr. Simmons relates a case of enlarged clitoris, which he removed by excision, which measured in length nine inches; while the cir- cumference of the stem measured five.* It is the augmentation of this part, and especially when it as- sumes an equivocal form, that has given rise to the absurd opinion of hermaphrodites. It occurs most frequently in hot climates. We have seen a number of instances in new-born children, where this part, as well as the nympbee, have stood entirely with- out the labia. Whether these parts increased in the same pro- portion as the body enlarged, we have never had an opportunity to ascertain. The existence of the hermaphrodite has gained the assent of the greater part of mankind; so much so, that it would be diffi- cult to disabuse them : we shall, therefore, not attempt it. To the, physician, frequent appeals are made for his opinion on this sub- ject ; and he too often yields to the popular belief; but he should be informed, that, so far, no well-attested instance of this com- pound of sexes, has ever been produced in the human subject. A resemblance in conformation does not prove identity of func- tion; and, consequently, the general similarity of appearance, be- tween the clitoris of the female and the penis of the male, how- ever striking, does not prove them to be intended for the same * " A clitoris was amputated some time ago in Mercer's Hospital, in this city, (Dublin) which, in volume, was about equal to the head of a child of two years old." Churchill's Diseases of Females, p. 25, Am. Ed. Diseases of this part, from the gratification experienced by rubbing or scratch. ing, have led, according to Mr. Churchill, to the establishment of Nympho-Mania' p. 17. The frequent mention of this complaint his induced me to the belief, that it is no uncommon occurrence in both Great Britain and France, but which is surely not the case in this country. ADHESION OF THE LABIA PUDENDI. 25 purposes. And it may be observed, that this similarity is more in the external form, than in the internal structure. Nor do the instances in other mammalise, purporting to be of the same kind, afford fhe slightest support to this opinion. For, perhaps, every instance hitherto examined, has proved to arise from a defect in the arrangement or organization of the sexual organs. Besides, in the higher classes of animals, it does not comport with the general analogy of nature, that one should pos- sess the generative powers of both sexes. Dr. Francis informs us, that " the latest decisions in juridical medicine, reject the possibility of both sexes in the same indivi- dual of the human species."* Sect. IV.— Of Adhesion of the Labia Pudendi of Children. The labia pudendi of young children are very often found ad- herent. This may be congenite ; but we believe it to be very rarely so. We have seldom seen this condition of the parts, in children under six months old ; and still more rarely, after the age of a year. From these facts, it would seem to be almost always adventitious, and owing principally to a want of cleanli- ness. Had the child been born with the labia in this condition, it is more than probable it would have been discovered early, as nurses, generally speaking, are at least curious, if not always careful. When we consider the delicacy, and vascularity of the mem- brane lining the internal face of the labia ; the ease with which inflammation is provoked in parts so organized ; when we recol- lect how quickly the secretions of the parts become acrid, where proper attention to cleanliness is not bestowed upon them; and how readily a slight inflammation may be increased by the flow of urine ; we shall cease to wonder at the frequency of this com- plaint, and, perhaps, be even surprised, that it does not occur oftener. We have reason to believe, that, in many instances, this com- plaint had existed some time before it was discovered: this may especially be the case with fat or lusty children, and where the most scrupulous attention is not constantly paid to the condition of these parts. Therefore, it must be looked upon in general, as arising from a reprehensible neglect; for it is the bounden duty of every mother, however averse she may be from the performance of it, to carefully inspect these parts from time to time ; particu- larly until the child is fifteen or eighteen months old, in order 3 » Denman, p. 106. 26 ADHESION OF THE LABIA PUDENDI. that the inconvenience under consideration may not take place; or if it have, that it may be detected early. . Parents should direct, and the performance should be insisted on, that these parts be regularly cleansed every time the child is washed by carefully separating the labia, and applying water liberally to them ; thev should then be tenderly dried with a sort linen cloth, and dusted with hair powder, or powdered starch, in which there is no blue. If this were regularly done in early in- fancy, the parts would become so hardened, as to diminish the risk, very much, of its taking place after less attention is paid to them. We have dwelt upon this subject, because we know its im- portance ; and because it has not sufficiently attracted attention. Sometimes unfortunately for the female, it has not been disco- vered during infancy; and it is especially unfortunate, when it remains concealed until womanhood ; when perhaps, the first intimation she may receive of her situation, is at a time, when of all others, she would wish to have been ignorant of it. The alternative, now, subjects her to an operation, which should have been performed in early life. This complaint sometimes becomes relieved, spontaneously. This occurs, probably, more frequently than we are aware of; as the causes which may produce it, are so constantly operating, as to lead us. to suppose this accident to exist in cases where it has not been detected. We have had two instances of this spon- taneous change to happen, under our own observation. In one of these, there was so much inflammation and tender- ness in the parts, that we did not think it advisable to operate, until the existing state of things were changed. We directed soft bread and milk poultices, and a cathartic. On our next exami- nation, we found that a complete separation had taken place, by the adhering parts having suppurated. Two raw surfaces were now exposed, which required much attention to prevent reunion in healing. The other case was something similar: suppuration had com- menced, and the connecting medium was nearly destroyed, when it was first observed. It was poulticed as in the other case; and when about to heal, care was taken to prevent a second coalescence. This condition of the labia is easily detected by their refusing to be separated when the attempt is made for this purpose. For when the labia are separated by force as much as their condition will permit, a continuous line of union will be observed through •their whole track; that is, from the meatus urinarius posteriorly, and to the fourchette below; of course, the os externum is en- tirely concealed. The child passes its water with some little ADHESION OF THE LABIA PUDENDI. 27 difficulty; and when the complaint has been suffered to run on, or not discovered until womanhood, the menstruous fluid is eva- cuated through the same external aperture, by which the urine is discharged.* There is but one remedy, that we know of, for this complaint —and that is, dividing the parts. This is very easily performed, by passing a probe-pointed bistoury into the orifice immediately before the meatus urinarius, and cutting downward to the infe- rior junction of the labia. A small dossil of lint, moistened with sweet oil, may be insinuated between the separated portions. The wound heals without the smallest difficulty j in two or three days. Dr. Denman, however, gives another opinion upon this sub- ject: he says, " In such cases, we have been directed to sepa- rate them (the labia) with a knife ; and how far such an opera- tion may be necessary in the adult, if the parts should cohere, either in consequence of some new affection, or if a cohesion, originating in infancy, should continue to adult age, must depend upon the judgment of the surgeon. But, in infants, such an operation is neither requisite nor proper; because, a separation may always be made, by a firm and somewhat distracting pres- sure upon each labium at the same time, which scarcely makes the child complain; though the small vessels, which had inoscu- lated from one labium to the other, may be perceived to be dragged out during the continuance of the pressure. When a separation of the cohering labia has been made in the manner before mentioned, a folded piece of linen, moistened in a very weak solution of the zincum vitriolaturn, or some lightly astrin- gent liquor, should be applied every night when the child is put to rest, to prevent the reunion, to which there is a great disposi- tion." Introduction to Midwifery, Francis's Edition, p. 101. We cannot, from our own experience, give an opinion upon the success of Dr. Denman's mode of operating in adhesions of the labia. But his reputation as a man of skill and judgment, would justify any one in making the attempt he proposes ; though we should, ourselves, not be induced to imitate it. The little pain, and the entire success which has followed, the use of the knife in the numerous cases we have employed it, give our mind a strong bias in its favour. A preference for the mode recommended by Dr. D., can only arise from an ill-founded dread of the knife ; it would, unquestionably, have required vio- lent exertions to have torn some of the adhesions we have seen; * That is, there is no other outlet for the discharges from the uterus but that which the urine has preserved for itself; and by this ofien passing.it prevents the entire adhesion of the labia. But this does not constitute the "imperforate hymen." 28 ABSCl SSES OF THE LABIA. and much pain and inflammation, we think, would have followed such efforts. Sect. V.—Abscesses of the Labia. A variety of causes may excite inflammation in the labia ; and, when once produced, it is always interrupted with difficulty; (he vascular and cellular construction of these parts, contribute much to hasten the suppurative stage. We do not remember a single instance in which a phlegmonous inflammation terminated by resolution, though in several instances, the chances were as fair for trial, (from the early application of the patient for relief,) as these cases generally are. Indeed, our failures to procure resolution have been so uniform, that of late years we do not attempt it; on the contrary, the immediate application of the ung. hydrarg. fort, sine tereb., of a warm bread and milk poul- tice, is always advised. The progress of this inflammation to suppuration, is usually so rapid, that but little time is permitted to make an attempt to pro- cure resolution. The suppurative stage we have known to take place in a few hours; and it seldom continues beyond three or four days.* This complaint is usually announced by a sense of heat, or rather (ff burning, in one of the labia, and if it be touched, even slightly, pain is felt. Pain is also experienced, upon any motion which employs the lower extremities, and especially upon sitting down, or crossing the legs. The internal face of the labium is found distended, very red, and protruding beyond the external covering of this part. It is from the great tenuity of this internal membrane, and, on this account, bearing distention so ill, that we may look for the little success that has followed either genera! and local bleeding, purging, low diet, or sedative applications, to prevent suppuration. We have seen these-abscesses in children, in several instances, follow bruises of these parts; they seem to be more painful in young subjects than in older ; they are almost always accom- panied in children, as in older people, by fever; and require a strict antiphlogistic treatment. We have .thought the application of the ung. hydrarg. fort, sine tereb, to be more useful than poul- tices, especially in young subjects ; as it is always difficult to confine a poultice to the parts with sufficient exactness. One of the most painful and largest abscesses of this kind we remember to have seen, arose from a young lady sitting down suddenly * " This disease may be distinguished from Hernia by greater firmness »f the ■welling, and iUnmre circumscribed character. It is increased by couy bougies gradually enlarged." Dr. Denman informs us, thann a case of this kind, the efforts of the husband to overcome the resistance of the parts, so irritated them as to produce a purulent dischwge from them, which was * Morgagni mentions a case in which ihe vag,„a Was only one.third of the common length; this was termmatea by a firm flesh, substance-this woman was barren "Columbus dissected a woman who always complained of great pain in coitii. The vagina was very short, and had no uterus at its termination " Burns, p. 87. t Since writing the above, a woman of thirty-five years of aKe presented her self for advice. She informed me she never had menstruated nor had sugar of lead, should not exceed a t-cruple to eight ounces of water. f Mr. Jewel sp^aUs or metastases to the join's in (his complaint from having this discharge too suddenly topped. This we have never witnessed. LEUCORRHCEA. 73 for the neglect of cleanliness—this must, therefore, be insisted on; the bowels must be purged ; and as the system is more frequently, and extensively implicated in this, than in the former stages, we are oftener obliged to bleed, and to enforce a strict observance of a vegetable and milk diet We may, as in the second stage, where the subject will permit, commence with the injections of a weak solution of the acetate of lead ; then perseveringly em- ploy the cantharides—in using it in this stage, I depart from the method just recommended, if the disease be of long standing, by more gradually increasing the dose, or making the intervals of increase two or three days longer. My reasons for this is, that the system may not too suddenly be affected by it; for I have observed, that when strangury is hastily induced, the effects are neither so satisfactory, nor so permanent, as when more slowly brought on—I may, however, remark in general, that the more susceptible the system is of the influence of this medicine in moderate doses, the more easily the cure is accomplished. In this stage, as on the other occasions, I do not use the astrin- gent injections until the sign for their employment shows itself; that is, an increase and thinning of the discharge.* Even the first injections of this kind should be rather more feeble than those formerly directed; but the strength must be increased as the parts become more accustomed to them. I go on again and again, to renew the strangury, should the first not be sufficient. Nor am I discouraged, if the "complaint does not yield to several; for I am very rarely disappointed in the opera- tion of this medicine, when sufficiently persevered in. I confess, however, that I have occasionally found the cantha- rides unsuccessful; but cannot this most truly be said of every known remedy ? I have now and then succeeded with the balsam copaiva, after the other has been fully tried without advantage ; and I have also effected cures in some obstinate cases, by the use of alum and nitre—five grains of alum, and ten of nitre, given three times a day, have proved very successful after other reme- dies have failed.f In a late work, (1830,) on the subject of Leucorrhcea, by Mr. Jewell, the solution of the nitrate of silver, applied to the neck of the uterus and vagina, by means of a piece of sponge, canula, or syringe, is highly spoken of. He commences with a solution of two or three grains to the ounce of water, and gradually in- * Dr. Hunt, as quoted by Dr. Churchill says, he has cured Leucorrhaea by giving two grains of Capsicum morning, noon, and evening. t We are aware that this is an unchemical mixture; but at the same time we must observe that theve unchemical compounds have furnished us with some of our best remedies ; witness the acetate of Zinc when prepared by mixing a solu- tion of acet. Plumb, and sulpli. of Zinc. This is truly an unchemical mixture,— but every body that has tried it as a collyrium, in certain stages of ophthalmia, are satisfied with it. 7 74 LEUCORRHCEA. creases it to four or five grains, as the parts become accustomed to its action. It is to be used three times a day, unless it produce too much pain—in which case it is to be reduced in strength, or wait until the irritation cease. In the use of this remedy, care must be taken to guard against its stain, which is indellible. This will be best obviated by the patient guarding herself as if she were labouring under a cata- menial period; or by wearing, during its use, black muslin or calico shifts. The sponge appears to be the least exceptionable mode of using this solution ; this is done by saturating a piece of this substance of sufficient size to be retained after being well im- bued, with the solution—this is to be renewed three times a day. Or the curved pipe syringe may be employed three or four times a day, unless it irritates too. much—a sensation of warmth after its use is rather to be coveted. He appears to have ill-founded prejudices against the employ- ment of cantharides. He also recommends the tincture of iodine in small doses; but he has not produced any indisputable evi- dence that it has been useful. He appears to have adopted all the principles and opinions contained in this chapter, and though he makes respectful mention of the author, he gives him no credit for his opinions upon this disease, though all his distinctions, and plans of cure, are identical with those contained in this chapter. Mr. Graham recommends the sulphate of zinc in this disease —three grains of the sulphate made up with common turpentine, three times a day, the dose to be increased if necessary. Edinb. Med. and Surg. Journ. vol. 26. The discharge which attends the prolapsus uteri is owing al- together, or at least in great part, to the mechanical irritation the surface of the vagina suffers, from this displaced organ, and does not come under our present consideration. The leucorrhcea of habit, is sometimes more obstinate than any other form of this complaint; especially if it be of very long standing, and in persons beyond the middle period of life, and who are inattentive to cleanliness. It will, however, yield, for the most part, to the remedies already mentioned, if sufficiently persevered in ; though it may require the exciting of strangury rather oftener. I have, in a few instances of this kind, used an injection made of two grains of corrosive sublimate to an ounce of water, with great advantage. It. should be used but once a day, for the first two or three days; then twice a day for an equal period ; and then three times a day, until heat or other signs of irritation be perceived, unless it "has been previously excited. This irritation must be kept up for a week or ten days; it mav then be followed by the saturine injections.* * The secale cornutum is recommended with great confidence in leucorrhcea and also in gonorrhoea, both by Dr. Negri and Dr. Ryan. About five grains three HISTORY OF MENSTRUATION. 75 There is a discharge of purulent matter, that has been consi- dered as a species of leucorrhcea. It generally begins with pain about the region of one of the ovaria, and will continue for two, three, or four days ; the abscess then discharges (for such it is,) and gives immediate relief; the patient will continue easy until there is a fresh accumulation of pus; this takes place pretty re- gularly, every three or four weeks, then goes through the same process of ulceration and discharge. I have never found this complaint obedient to medicine; I have used an injection of the nitrate of silver, three grains to the ounce of water, which would moderate this discharge, but never to subdue it; it sometimes cures itself. Dr. Churchill mentions a disease very similar to this, which he and some others call, " abscess of the uterus, ova- ry," &c, &c, and for which he says, (after the acute symptoms have passed away.) he applies a blister to the sacrum, once or twice, if necessary. This produces an immediate diminution of the discharge and a mitigation of suffering; but he says nothing of a cure. Leucorrhcea proceeding from hemorrhoids, I believe will ad- mit of no relief, until the latter complaint be removed. The same may be said of the leucorrhcea arising from ascarides; this con- dition of the vagina, however, is chiefly confined to children. CHAPTER V.—Sect. I. OE THE HISTORY OF MENSTRUATION. The diseases connected with menstruation are so important, that I have thought it best to premise them with a general history of this process, lhat the deviations from health should be seen in stronger contrast, as well as better understood. The menstrual discharge may, with much propriety, be con- sidered as peculiar to the human female; if there be exceptions to this rule, they are few, and but ill ascertained.* We are told that the female of a certain species of monkey is liable to it; but, perhaps, in no other way than the bitch, the cow, the mare, the female elephant, &c, are. said to be; for these, in the time of heat, have sometimes a sanguineous discharge from the vagina. But this must not be considered as a.genuine .menstrual evacua- times a day, is the average dose in these cases; they recommend its suspension, if it excite much pain. Of its utility, in such capes we can say nothing from our own experience. See London Med. Journ. for 1834. * " De tousles eircs vivans, la femme seule eprouve reriodiquement une eva- cuation sanguine naturelle, et indepcndante d'aucune alteration pathologique."— Frank. 76 HISTORY OF MENSTRUATION. tion, as it proceeds merely from the rupture or abrasion of some small vessel, during the excessive engorgement that is wont to take place in the vaginae of these animals at such times. Besides, no moral end could be answered in the brute, as in the human female, by such a discharge. Indeed some would deny the menstrual discharge to be an ori- ginal function, even in the human female, as Roussel, and after him Emmet; that this evacuation is the result of the social condi- tion of man, and not the consequence of organization. Roussel has endeavoured to prove this, by declaring that man, in a state of society, feeds more than is absolutely necessary for his exi- gencies ; and that he becomes plethoric in consequence ; and that this condition must be relieved by some artificial drain in the male, by hemorrhage from some part or other of the body ; and, in the female, by the menstrual discharge. He declares, " Que le flux menstruel, bien loin d'etre une in- stitution naturelle, est au contraire un besoin factice contracte dans Vetat social."* But it may be asked, what is to be under- stood by " l'etat social?" If it be declared, it does not express the condition of man in a state of refinement, it must be admitted to mean, man united by some social compact: yet, so far, wherever he has been found, we have unquestionable proof that women menstruate; notwithstanding Roussel declares, that the uterus of the Brazilian woman does not perform this function. But, were this true with these particular women, (a circum- stance much to be doubted,) it would be but an exception, and should not be taken, or rather mistaken, for the rule. Among all the aboriginal females of this country hitherto examined, no such exception prevails: yet, were this a design of nature, it might most reasonably be looked for, among these varied, widely spread, and simple people. Why this opinion of Roussel should have found abettors, it is difficult to say; since it has neither facts nor reasoning to sustain it. The hypothesis is founded upon circumstances totally inade- quate to the effect—namely, " Les hommes resembles ont toujours cherche a resserrer les liens de la cordialite dans les festins. La joie est plus vive, et les epanchmens plus tendres dans ces momeps ou la machine se remonte par une nouvelle nourriture: on est alors'plus content des autres, parcequ'on est plus content de soi meme ; l'absence de soucis laisse al-ors a la nasure la liberte de jouir de tous ses droits, et meme d*en abuser; car il arrive souvent que, ne demelant plus la sensation des mets cPavec Pirn- pression de la gaite; elle prerid le change, et se surcharge d^limens qu'elle croit encore necessaries, longtemps apres que le besoin est satisfait."f The consequence of these indulgences, he supposes to be a * Systeme Physique et Morale de la Femme, p. 113. t Ibid., p. 113. HISTORY OF MENSTRUATION. 77 plethora; and this plethora finds an abatement in the female by the menstrual discharge: and in the male, by hemorrhages from various parts of the body, according to the period of life; or if the hemorrhages do not take place, the consequences of the excess of blood show themselves in a variety of other forms; as affections of the chest, rheumatism, hypochondriasm, stone, gout, asthma, &c, &c. It will be perceived that this doctrine is but a modification of the one long before promulgated by Galen—the only difference is that Galen thought women were ever subject to the men- strual discharge; and that a plethoric- condition of the system was essential to its production: while Roussel supposes^ this plethora to be of artificial origin; and that the menstrual dis- charge is the fortuitous consequence, and intended to relieve the system from danger. A few observations will be sufficient to destroy this curious and ill-established speculation. 1st. From no record of the his- tory of the human race does it appear other than, that the fe- male was always obnoxious to this discharge—thus, by Moses, it is distinctly stated to have obtained among the women of his time, and we have every reason to believe, as an arrangement of nature; so also among all the tribes of the most savage people. In this country, most abundant proof is given, in the journeys of Major Long, that the menstrual evacuation is a constant attend- ant on the females, and where they existed in the greatest pos- sible simplicity. 2d. The cause assigned by Roussel, namely " plethora," exists where this discharge has been interrupted ; and to recall the means often requires the abstraction of blood and other debilitating remedies. 3d. This function is oftentimes per- formed with the utmost regularity, and in the accustomed quan- tity, where the most decided debility prevails. 4th. That this * discharge is certainly prevented, however long and regularly it may have been, established, by the removal of, or. from the dis- eased condition of the ovaries. 5th. That an abstraction "of blood just before the period, or. at any other time, does not pre- vent it. Besides, very- many, indeed all the mammiferous' animals, have at certain, periods a discharge from the vagina, which is either essential to fecundation, or gives evidence of the capacity, for, or of the desire of, the animal at that moment to be impreg- nated ; and this discharge is sometimes coloured, accidentally as observed above,, but not necessarily;; and that this evacua- tion, is, in some manner, connected' with impregnation, is evi- dent, since, it never appears in. its healthy condition, but at the periods when the animal is capable of fecundation.* It is * Frank appears to be of a different opinion upon this point; he says that."na- 7* 78 HISTORY OF MENSTRUATION. equally certain that the human female is also capable of being impregnated after each healthy menstrual period. But this must be taken' with some modification. It is every way certain there are womea that are sterile with, every mark of complete de- velopment of the organs, as far as function is concerned, and as far as can be detected by the eye or. the knife of the anatomist. Yet some imperfections must exist for fecundation or the forma- tion of healthy ova is the natural arrangement, but the product of the ovaria is not always in a condition to profit by the appli- cation of the male semen, the woman remains barren for life. But when these failures take place, can we be certain that the male is no^ in fault? we know this to be so in some instances. We have more than one instance where the woman remained bar- nen with one husband; to become widows, and pnove prolific after a second marriage. Nor is this discharge in the brute, a mere increase of quantity of the ordinary secretion of the parts—it differs essentially from it, at least in its sensible qualities; as is made evident to the dis- criminating olfactories of the male.* Thus it would appear, that nature intended some end should be answered by this peculiar condition of even the brute; is it not, then, equally certain, a si- milar end is, answered in tbe humaa female, by the menstrual evacuation ?■ Again, this discharge commences only when the female is in a condition to meet and overcome the ordinary contingencies of impregnation and delivery.f Now, were this merely a fortui- tous discharge, why should it occur only at the period at which the female can propagate her species, and always at a certain period of female life ? For I must protest against the opinion ©f Roussel and some others,, who. suppose impregnation may take hire has subjected the females of all well-organized animals to this menstrual tribute, but that she does not always require it with the same rigour; that is, un- der the penalty of sterility." Now,we think Dr. F. has assumed rather too much in his hypothesis; first, because there are sterile animals, and we believe they are only so in the absence of this sign of coalescence; for it is constantly the practice of breeders of animals, to wait for all evidence of heat before they are subjected to the male; secondly,, because it is notorious that animals do not conceive if put to the male or entirely refuse him, if this modification of the menses be not pre- sent; thirdly, he is certainly of opinion, from hip own words, that it is for the m««t part an essential to generation ; and; therefore, must^ as a general rule have been intended for this purpose; and.consequently,,if impregnation do take'place and this discharge be absent.it is only an. exception to the rule with such ani- mal, and in this respect, xs like the human female ; for he declares that this has taken- place in females so circumstanced; and, therefore, is as much a law with tha one as with the other. * " In some animals,,the reproductive liquid communicates to all the other li- quids a strong odour, which.causes both this.species and the sex to be easily d.s- tiaguished." Walker on Intermarriages, p. 40. + Mr-Bourne» a r«BPectable and intelligent South Sea missionary when asked kX Mr. Eoberton, "Have ycu observed-that e«rly marriages (giving The ages at HISTORY OF MENSTRUATION. 79 place before the menstrual action has been awakened, or after it has become dormant.* That impregnation has taken place before there was a coloured discharge from the vagina, and even after it has ceased, I am every way willing to admit; but neither of these circumstances prove the absence of the menstrual action ; or that action which only exists during the integrity of the ovaria ; but which ceases, or never takes, place, when,these bodies are imperfect; and which action is essential, either directly, or indirectly, to impregnation. Rousself declares menstruation to be " less a cause than a sign of fecundity." In this I agree: for the menstrual action cannot be a cause of fecundity, since this capacity is known to depend upon the ovaria. Yet it is every way. essential to propagation, that the internal secreting surface of the uterus be in a healthy condition, and this manifested' by a healthful catamenial dis- charge ; or, in other words, only when the quantity and quality of the menses are free from objection,, and the ovaries, at the same time, in perfect health. Sect. II.—Causes which may diminish capacity, fyc. It may, therefore, be considered as highly probable, that the absence of the capacity to be impregnated, will sometimes de- pend upon the imperfect condition of either the uterus itself, or of the ovaries. If the former, it may consist in some derange- ment of the secreting surface of this organ ; for though there may be a regular discharge of a coloured fluid, and this so nearly re- sembling the perfect secretion as to deceive the senses, it may yet want an essential condition, or quality, and thus entail barren- ness—hence, all women are not fruitful who may have a regular catamenial discharge; though, as far as can be determined by appearances, this discharge is every way healthy, and, at the same time, the ovaries free from fault. Nor is it, perhaps, difficult to explain, or rather to imagine, how this may happen. I adopt the opinion that the menstrual which they occur) are generally soon productive?" answered, that in very early marriages several years elapsed. In this Mr. Ellis, the celebrated missionary, concurred.—Mr. Roberlan. on Menstruation, Ediuburg Medical and Chirurgical Journal for October, 1832. This would seem to prove the position laid down in the text. For it was long since observed by Mr. John Hunter, that'when a woman begins to breed at an early period, as at fifteen, and has her children fast, she seldom breeds longer than thirty or thirty-five ; hence we may* suppose either that the parts are then worn out, or that the breeding constitution is over. If a woman begins older, as at twenty or twenty-five, she may continue to breed to the age of forty or more." —Phil. Trans, vol. Ixxvii. p. 233. • * Does it not seem extraordinary that the plethora of Roussel should not exist until a certain period of life, (puberty;) and this period, uniformly modified by climate, &c, or that it should not-take place after another certain period of life, (after the cessation of the menses,) to maintain this discharge! t Page 117. 80 HISTORY OF MENSTRUATION. discharge is a genuine secretion, and that the interna face o linino- of this or|an is the portion which furnishes it: now, will be evident, that whenever this part is in any way deranged the qua ity o ts product must also be impaired ; but the injury does S Jnsist so much in the imperfect elaboration of the menstrual fluid, as in the inability of this surface to furnish a ^all^\d^ cidua after impregnation has taken place ; for there can be little doubt but that the same apparatus furnishes both one and the other. This condition of the uterus, I have reason to think, is not of unfrequent occurrence: an ovum may be fecundated, and duly conveyed to the cavity of the uterus ; but it perishes there, from the want of a healthy decidua: it is,, therefore, cast off un- perceived at the next menstrual purgation-; and thus the woman is relatively barren. ,'•■,• r a „ „*DP,1C What strengthens this-opinion is, that this lesion of the uterus is frequently repaired, by either proper remedies, or by the powers of the system alone ; and the woman afterwards becomes fruitful. I am fully persuaded I have witnessed a number of such cases If it depend upon an imperfection of the ovaria, it may not, perhaps, admit of relief. The diseases of the ovaria may consist 1st, in their imperfect development; 2dly, in derangement ol structure ; 3dly, in a want of healthy organization ot the ova themselves. Now, either of these conditions of the ovaria may be so complete as to altogether destroy their influence upon the secreting surface of the uterus; the catamenial discharge may, therefore, continue, with all due regularity, and yet the woman may be barren ; and, hence, this discharge cannot be considered, rigidly, as a constant sign of fertility. Yet it may be safely admitted, as a general rule, that women who menstruate regularly and'without pain, or the expulsion of coagula, or false membrane, are fecund; and that the reverse of these conditions is almost sure to be attended with sterility. It may also be observed, that we cannot attach much consequence to the quantity evacuated; for the woman who may evacuate double the quantity of another, is not for this reason more cer- tainly prolific. I have known a number of instances of repeated impregnations, where, as far as could be ascertained, not more than two ounces were habitually evacuated ; and this not occupy- ing more than a day and a half, or two.days, for its elimination ; while on the contrary, I have known women who were barren, discharge three or four times this quantity ; and the fluid bear all the sensible marks- of a healthy secretion. From this it would appear, that mere regularity in returns ; the elimination of a pro- per quantity of fluid, and this fluid apparently of a healthy cha- racter do not always declare the woman to be fecund. Yet, when'the woman has never menstruated, or when this discharge has altogether ceased, agreeably to the ordinary arrangement of HISTORY OF MENSTRUATION. 81 nature or from disease, she either never becomes impregnated, or ceases to become so, if she ever have been. It is true we are told, as observed before, by highly respecta- ble authority, that impregnation has taken place before the erup- tion of the menses,* as well as after their final cessation. The explanation of this seeming exception is not difficult, for the rea- son already assigned; namely, that because a coloured fluid was not observed, it was taken for granted that the uterus had never assumed the menstrual action, or had not resumed it after it had ceased as a law of the system. Sect. III.—Early Appearance of the Menses. Now, it is admitted by practical writers,f as a fact of no very rare occurrence, that the menstruous evacuation is sometimes serous, and this for several periods, before the menstrual blood, properly so called, shows itself, to more decidedly mark the esta- blishment of the process. This is especially the case with those, who have this discharge to commence early. And it may be well to caution the young practitioner against a common and natural error,—when this anticipating discharge takes place, not to mistake it for leucorrhcea,. and attempt its sup- pression. We shall have occasion, in another place, to point out the influence of leucorrhcea upon the menstruous discharge. See Sec. on the Tardy Appearance of the Menses. I was consulted some months since, in the case of a young lady between twelve and thirteen years of age, who was labour- ing under a diseased spine, but who was also afflicted with head- ach, palpitations of the heart, and great sickness of stomach. She had also at somewhat regular periods a pain in the small of the back, with a bearing down sensation, a desire to pass water, an inclination to go to stool, &c. From these circumstances her mother concluded, and in this I concurred, that an effort was making for the production of the menses, though the common external signs of puberty were almost entirely wanting. I, how- ever, requested the mother to be careful in examining the linen worn by her daughter at these periods, and ascertain whether there was not a discharge from the vagina resembling leucor- rhcea. This was done: she reported there were considerable marks upon her linen ; and this was observed for at least four * Rondelet mentions a woman who was delivered twelve times ; and Joubert another, who bore eighteen children, neither of whom had ever menstruated.— Gardien Traite d'accouchemens, Vol. I. p. 220. t Gardien says, "Si quelquefois le sang sort brusquement sous couleur rouge, le plu< constammant les regies commencement par un flux sereux et finissent de meme."—Traite" complet. d'accouchemens, Vol. I. p. 238. 82 HISTORY OF MENSTRUATION. periods: after this the menses, with their usual appearances, were established, and continued with tolerable regularity up to the present time. This is the third instance I have witnessed of rather precocious menstruation in girls with diseased spines; whether there be a connexion between this affection, and the functions of the uterus, must be left to future observations to de- termine. Thus we see, it is easy to err on this point with young girls, and to suppose they may have conceived before the catamenial period had commenced; nor is the error less liable to be made in those rare instances of impregnation, after the final cessation is supposed to have taken place ; for in several well-attested in- stances of pregnancy at advanced periods of life, it was found, upon close examination, an effort had been made by the system to restore the catamenial flux by a periodical serous discharge. In one case, which fell in part under my own notice, this effort was certainly made; but perhaps without the knowledge of the person concerned ; yet it was sufficiently evident to the indivi- dual who washed her clothes, and who furnished me with the account; for it is presumable, with such evidence of returning youthfulness, she would scarcely have risked the consequences which followed her amour. I was requested, in the month of March, 1795, to visit a young child, ill with the natural small-pox. At almost every visit I paid the child, I observed an aged woman much afflicted at its danger- ous condition. Having an opportunity during the absence of this person to inquire who she was, I was informed, to my great surprise, that she was the mother of the child. I thought my informant was attempting to impose upon me, and told her so; but she seriously declared I might rely upon the fact. I was now informed that the mother of the child had never been married, and that she was in her sixty-first year when the child was born. The case interested me m.uch, and my inquiries became more particular; and from much conversation I learnt, that the old woman had ceased to menstruate at forty-five, but that, about two years before the period of my attendance on the child, she (the nurse of the child, and the washerwoman of the mother,) had observed monthly evidence of a return of the catamenia; it was not much coloured, yet sufficiently so to excite attention. Now, this case would certainly pass for an instance of impregna- tion after the menses had ceased ; and it must be admitted to be one, every way calculated to mislead. I have therefore con- cluded, that the cases upon record, purporting to be of this kind, may have been similar to the one now related.* * A case is related in the Edinb. Ann. Registar, Vol. IX. p. 608 of a Mrs. Ashby, or Firnby, near Spilsby, who was delivered of twins in her fifty-fourth HISTORY OF MENSTRUATION. 83 So far, facts seem to oppose the idea, that impregnation can take place before the menstrual action has been established, and after it has finally ceased: let us now see if reasoning will not corroborate them. It will not be disputed, that a part cannot perform its peculiar or appropriate action, until such part is completely developed, or its organization perfected ; consequently, the uterus will not be subject to the menstrual action, until the surface which furnishes this fluid is perfect in its arrangement; and not then, unless it receive the peculiar stimulus given by, or it sympathize with, the perfect ovarium, or ovaria. Now, by all we learn from either experiment or accident, it is certain, that the menstrual action is for ever prevented, by the extirpation or destruction of the ovaria; consequently, this action is dependent for its existence upon a state of perfectness of one or both of these bodies. It is equally certain, that if the ovaria be incomplete, they can- not furnish perfect ova, or ova capable of fecundation : nor can they give or excite that action which furnishes the menstruous fluid. If, on the other hand, the ovaria be properly developed, and the menstrual action does not take place, it is but reasonable to suppose, that some imperfection must exist in the uterus itself; and if this be admitted, it would seem to follow, that a perfect action cannot be expected from an imperfect organ ; and it will be farther granted, that no process in the human system requires greater perfection of organs, than those subservient to genera- tion. Therefore, as regards the main point, it is unimportant whe- ther the imperfection be seated in the ovaria, or in the secreting surface of the uterus; for, if it exist in either, coition cannot be entirely successful. If an ovarium furnish a perfect ovum, it may be fecundated, though the menstrual action had never taken place ; but this is but one step in the march of generation ; for if the ovum be not properly cherished after it shall have been de- posited in the uterus, it will soon perish and be cast off'. For, that it may be sustained and properly developed, it is essential, that the uterus produce the decidua; and that it cannot furnish this sine qua non, is highly probable, as the organization which is to yield it, is the same as that which performs the menstrual secretion; and that this part is imperfect is put beyond doubt, since it has formed this fluid. That impregnation may be successful, a healthy condition of the internal surface of the uterus is required, and a sound condi- tion of at least one of the ovaria. For if these organs be imper- fect, either fecundation cannot result, or it will take place una- ycar; and Haller gives instances still more extraordinary—viz. one at fifty-eight, one at sixty-three, and another at seventy. 84 HISTORY OF MENSTRUATION. vailingly. Thus, if the ovaria, from disease or imperfection, cannot furnish an ovum that cannot profit by the application of the male semen, fecundation will not i.ssue: if, on the other hand, the internal face of the uterus be diseased, and incapable of furnishing the decidua, the ovum must perish, though fecun- dated. It is, therefore, but reasonable to conclude, that if the uterus be not sufficiently developed to secrete the menstruous fluid, it must be imperfect; and if imperfect, it cannot perform what is essential for the preservation of the ovum after it has been placed in its cavity. Fecundation, after the cessation of the menses, must be equal- ly doubtful; since it is probable it would require a renewal of the menstruous action, that fecundation should be successful. At present we are not sufficiently acquainted with the conditions es- sential to this cessation; or, in other words, what changes take place in either the ovaria, or in the secreting surface of the uterus itself, when this period arrives. We only know it does take place; but how, we are altogether ignorant. The moral cause of the cessation is better comprehended than the physical. It would seem but fair to conclude, that if the early part of female life require a certain condition of the uterus and ovaria, to render coition successful, it would be no less necessary at the more advanced stage: I have attempted to prove this necessity ; and the same arguments will also serve for the latter period. For, it is evident, that the ovaria and uterus must have suffered a change, or the woman would have continued to menstruate : now, it is of little moment whether the change occur in the uterus or in the ovaria; since a certain alteration in either will incapacitate the woman, both for menstruation, and conception. It is, however, probable, that the ovaria suffer deterioration earlier than the uterus; as many women continue to menstruate regularly for a considerable time, before the final cessation, with- out conceiving. The ovaria may cease to produce ova to be fecundated; and the absence of this power may eventually cause the final departure of the menses; since they would be no longer necessary, or useful. It is, also, probable, from impregnation now and then taking place long after the disappearance of the menses, that an ova- rium may regain its productive powers, and furnish a new and healthy ovum; and when it does regain this capacity, the in- ternal face of the uterus may reassume its menstrual action, and impregnation may, under such circumstances, be the consequence. But that it may be eventually successful, precisely the same con- dition of the uterus must exist, namely, the formation of the decidua, as when this process was successful in the earlier periods of life ; for if this be wanting, the same consequences must ne- cessarily follow, as would then result. HISTORY OF MENSTRUATION. 85 It seems that the production of efficient ova is governed by some general law in each individual female: in the brute it is regulated with great exactness, as they have regular periods of salacity; and this salacity may depend upon the presence of a perfected ovum or ova. In the human female these periods are not so exactly limited, as individuals differ very much in their capacity to be impregnated; and each has a marked period, caeteris paribus. Thus, some women are impregnated every twelve or thirteen months; others are eighteen months or two years; while others enjoy much longer intervals. I know a lady who conceived but once every seven years, and she bore four children at these intervals. I have known several to have a lapse of three years between each pregnancy, &c. It would seem from these facts, that it requires a lapse of a certain period to perfect an ovum ; and that this process is much more rapid in some instances than in others. But when the ovaria lose the power of furnishing ova, as at the cessation of the menses, impregnation ceases of course. The ovaria sometimes, however, regain the power, after it has been long lost, of furnishing healthy ova, or they become much more tardy in producing them, as a wo- man will have much longer intervals; or this maybe accelerated, if she have been tardy; therefore, some women have their chil- dren at uncertain intervals; one lady with whom I was ac- quainted, had not a child until she had been married 19 years; her husband was a hale hearty looking man as one in a thousand. She never became impregnated again! And I have known more than one instance, where the lady had seven children in six years, &c. Impregnation after the final cessation of the menses, is of ex- tremely rare occurrence, and should be ranked among those ex- traordinary instances, in which the system makes an attempt to renew certain lost functions, or to repair lost parts. Thus, the eye-sight has been restored, after having remained imperfect many years; the hearing in like manner, has returned after long deafness; the teeth have been renewed after they have been many years lost, &c. Is it not then more than probable, that when such cases occur, all the functions ordinarily esteemed essential to this process in the early part of life, should obtain when it takes place after the menses have ceased ? Now a healthy menstrual action is a sine qua non to impregnation, in the earlier parts of life ; it would seem, therefore, to be indispen- sable to this end, at the latter period: and where impregnation has obtained, we cannot well question, but it has been preceded by this action. 8 86 HISTORY OF MENSTRUATION. Sect. IV.— The time at which they appear. The period at which the menses make their appearance, is variable ; it is much influenced by constitution, climate, and mode of life. As a general rule, it takes place at puberty, or at that period at whichlhe female is capable of propagating her species ; and this period varies, as climate may differ.* They constantly, however, keep pace with the development of the body ; where this is rapid, they will appear proportionably earlier; where this process is slower, they will appear later : but whenever the menses appear as regular evacuations, they mark the period of puberty; thus, in hot countries, women commence to menstruate at eight or nine years of age, and are not unfrequently mothers at ten. In the more northern regions, as in Lapland, &c, this evacua- tion is generally delayed until the female has attained her eigh- teenth or nineteenth year: in the temperate latitudes the average period will be found from the fourteenth to the sixteenth year. A difference will, nevertheless, be found in the women who may reside in cities, and in those who dwell in the country of each respective portion of the globe. It may also be observed, that in cold countries, women continue to menstruate for a longer period than in warm ; for as a general rule, it will be found, they are obnoxious to this discharge, double the period that elapses before it commences. Thus, women who have not this discharge until eighteen, will be found to have it until beyond fifty ; those who commence at fourteen or fifteen, will leave off at about forty-five ; those who begin so early as eight or nine, will have it cease at twenty-five or six: " citius pubescunt, citius se- nescunt." This fact appears to be disputed by Frank ;f he " says that the early appearance of the menses does not hasten the period of cessation ; for in the Milanese, where he practised ten years, this discharge takes place one or two years earlier than in Germany; yet it is no uncommon thing to see women perfectly regular at the forty-eighth or fiftieth year." This may be ; and most pro- bably is the case—but this account tells but the half that is ne- cessary to the establishment of the law he lays down ; for he has not declared that the females he found regular at forty-eight or fifty, had in every instance begun a year or two sooner than the * We have heard of a lady within a few days, who is now fifty years of age, who did not commence to menstruate until she was forty-five years; then she menstruated regularly until the present lime (Dec. 1840.) We know well a lady aged twenty-three years, who menstruates but once in a year. t Traite de Medecine Pratique, torn. 3, p. 397. HISTORY OF MENSTRUATION. 87 women of Germany, and which would be essential to the fact he thus attempts to prove.* There are, however, a number of curious objections to the general rules we have attempted to lay down : these consist in the precocious appearance,! an unusual protraction of the menses. Haller, Van Sweiten, &c, give instances of each kind. I have seen several cases where this discharge was regularly continued until the fifty-fourth or fifty-fifth year.J Sect. V.—Symptoms which announce their approach. This evacuation rarely fails to be announced by a variety of symptoms, of greater or less severity, or danger; among girls who have been delicately and luxuriously brought up, and who have their nervous system rendered morbidly sensible or vibra- tile, a great variety of nervous symptoms, as they are called, pre- cede the eruption of the menses; such as ringing of the ears; a sense of suffocation ; palpitation of the heart; starting from slight and sudden noises ; precarious and whimsical appetite ; loathings and cravings; convulsive twitchings ; convulsions; chorea sancti viti, &c; all of which are sometimes instantly relieved by a trifling discharge from the vagina; and this not necessarily coloured. The last mentioned circumstance, must have been observed by every attentive practitioner, who may have had charge of * We could record a number of instances where the menses were continued much beyond their ordinary period, and where after ceasing some time, were resumed with their accustomed regularity; but we shall limit onr observations t.i one case, and that because it is recent nnd well authenticated. This case is recorded in the Ann. Univ. de Med. A female aged ninety-four continued to men- struate from the fifty-third to the ninety-fourth year. Her relatives were remark- able for their longevity ; she is at present in perfect health.—American Journ. of the'Medical Sciences for Feb. 1831. t There have been instances of the catamenia commencing soon after birth, An instance of this kind is given by Mr. Whitmnre, in Med. Chirur, Trans. Lon- don, vol. 4th. This paiient had this evacaution regularly from birth, at stated in. tervals of three weeks. In her fourth year she died after a very short illness. On dissection, an unusual development of the uterus, &,c., was discovered. The other daughters of this family had nothing peculiar. t The following table, exhibits the nges of three hundred and twentv-six fe- males, nt which they bcrran to menstruate. It is furnished by Mr. Roberton, in the North of England Medical and Surgical Journal. In their 11th year, 6. In their 16th year, ~>i. 12th " 12. l'th " 50. ]3th " 31. 18th " 19. 14th " 60. 19th " 18. loth " 72. 20lh " 4. To this list may be added the case related by Madame Boivin, in her account of a new cause of abortion. The subject of this caso commenced to menstruate ut seven years of ngc, and did so regularly after her tenth year. 88 HISTORY OF MENSTRUATION. females ; and it is one worthy of note, as it goes to confirm what has been advanced above of the identity of the action which pro- duces these fluids though so different in their appearance. The vascular system is sometimes also much disturbed: we often witness determinations of blood to various parts of the body ; as to the head; the lungs; the mammae; the stomach and bowels, &c; for the relief of which, we are obliged to abstract blood, or employ other remedies, if a kindly discharge from the uterus do not quickly tranquillize the disturbed and embarrassed circula- tion. Sometimes the inconveniences are confined to the genital sys- tem—in such cases, a sense of weight; bearing down ; ardor urinae ; pain in the region of the uterus, &c, are experienced; all of which, for the most part, announce the approaching dis- charge. It is at this period, also, that nature perfects her work, both as regards development and proportion; it is the period of the most perfect beauty, of which the female is susceptible; it is the one at which the moral changes are not less remarkable than the physical; it is a moment, of all others, the most replete with con- sequences to the inexperienced and confiding female. At this period a great variety of interesting and curious phe- nomena present themselves: the voice is found to change ; the neck and throat to increase in size, and to become more symme- trical; the mammas to swell; the nipple to protrude ; the chest to expand: the eyes to acquire intelligence, and an increase of brilliancy; in a word, a new being, almost, is created. The quantity of fluid expended at a menstruous period differs in different individuals; with girls who precociously menstruate, the quantity is in general smaller, and the returns less regular. Climate exerts an influence upon the quantity discharged, as well as upon the periods at which this evacuation shall commence. Thus, in the equatorial and more northern regions, it is less than in the more temperate climates.* Sect. VI.—Quantity discharged. A variety of causes, independent of climate,f are said to have the power of increasing the menstrual discharge ; as all circum- * Gardien. p. 227. + Of this several instances have occurred, to prove that uterine development may be independent of the general influence of climate; for a case is mentioned that in Kentucky a girl of eleven was safely delivered of a living child, the p irent bore all the usual marks of complete development. And another instance has been commonicated to me by Mr. William M. Egbert, in which a girl in New Jersey became a mother at twelve; and is now the mother of several other children. HISTORY OF MENSTRUATION. 89 stances suited to increase the activity of the system ; and thus tend to its more hasty development. Such are the passions of the mind frequently indulged in, as anger and joy ; a diet rendered too stimulating by either spices or spirits of any kind. All such as would have a tendency to produce a plethora of the uterus, and thus increasing its sensibility ; as the frequent use of foot- baths, foot-stoves, &c, all such as excite a pruriency of the ima- gination ; and lastly, those which augment the quantity of blood, as too full a diet, especially chocolate as a constant article of food ;* too long indulgence in feather beds, and the want of suffi- cient exercise. It would be difficult to ascertain the exact quantity of fluid evacuated at each period, as it cannot be well subjected to mea- surement ; hence the discrepancies upon this subject. Hippocrates set it down at twenty ounces: there can be no doubt but this is very much overrated ; at an average, from four to six ounces may be considered as the proper mean. It usually employs from three to six days for its evacuation, and, for the most part, is extremely regular in its returns. I know a number of females who can tell not only the day on which it will return, but even indicate the hour at which it will show itself.f With other females, however, it is less regular; but it rarely exceeds the twenty-eighth day with such as are in good health, if we except, when it approaches the period for its final cessation. When the time approaches at which this evacuation is about to cease, agreeably to the arrangement of nature, this flux becomes more desultory, as regards the periods of return, and the quantity eliminated. The discharge may return every two or three weeks, or it may procrastinate, until the fifth or sixth week, or sometimes even longer ; and instead of the four or five ounces which were wont to be effused, twenty, or even more, may be. evacuated. But it must be remarked, that when the quantity becomes so ex- cessive, it is not a genuine menstruous product that is poured out —for this process is now accompanied by a true hemorrhage ; as is evinced by the expulsion of coagula. Sect. VII.—From whence the menses are derived. From the last expression it may be collected, that I consider the menstruous fluid not as a pure or unmodified blood: I shall * Almost all of the French writers mention the influence of this article upon the genital system. t A lady l.itelv informed me, she could, with the utmost exactitude, tell the day and hour at which this discharge wonld take pi.ice. This was made known to her by the appearance of certain feeling*, which constantly took place one week, to the hour, before the eruption of her menses, 8* 90 HISTORY OF MENSTRUATION. therefore state the reasons for this belief. " 1st. Its colour is be- tween the arterial and venal blood, being less brilliant than the former, and more florid than the latter. 2d. It never separates into parts; blood drawn or evacuated from any other part of a healthy body, does separate in a short time into its component parts. 3d. It never coagulates, though kept for years: while other blood, when free from disease, quickly does when exposed to the influence of the air. 4th. Its odour is remarkably distinct from that of the circulating mass ; and it is less disposed to putrefaction. It has been supposed, because the menstruous fluid does not cdagulate, that it contains no fibrine ; but it is more probable that this substance has been deprived of the power of coagulation by being subjected to the influence of the vessels of the secerning portion of the uterus. This opinion is strengthened by recurring to the fact, that the coagulating lymph always accompanies the red globules, wherever the latter may be found. The menstruous blood may therefore be considered as a sub- stance differing from the blood of the circulating mass in at least two remarkable properties ; namely, in not coagulating ; and, se- condly, in not separating into parts. It is true, there are many of high authority, who declare a contrary belief. Hippocrates de- clares it to be pure blood ; similar to that of a victim, if the vic- tim be in heal h ; and this opinion has been handed down to the present day, without being challenged by inquiry, or subjected to dispute.* If mere blood Were evacuated from the uterus at the menstrual periods, it would be, strictly speaking, a hemorrhage ; but that this is not the case, the whole phenomena of this process seem to declare. I have stated, above, some reasons for my disbelief on this point; and shall now add, that had this operation con- sisted in the mere evacuation of unchanged blood, it would be attended by precisely the same inconveniences as almost always attend hemdrrhage from this part; namely, pain of an alternate kind, arising from the contractions of the uterus to expel coagula which always form, and which require for their expulsion the ef- forts of the uterus. It may also be added, that in cases of imperforate hymen, the accumulated menstruous blood constantly remains fluid, though a little thickened ; and when relieved by an operation from its confinement, it is found to flow with considerable freedom from * We believe we are safe, when we say, that a large majority of those who have written on the subject of menstruation, consider the mensirual fluid as a pure hemorrhagic blood ; some few seem to agree to a modification of this opinion; but this does not amount, either to a concession or dei.ial of its being a secretion ; of this number, are Bichat and Broussais. HISTORY OF MENSTRUATION. 91 the orifice made for this purpose. No coagula present them- selves, as would be the case, were the fluid unchanged blood. That the menstruous blood may contain all the constituent parts of common blood, I do not mean at present to dispute, since I am not prepared to say in how many, or how few details it may differ, upon a strict analysis: it is sufficient for my present purpose to state, that it must experience some change during its elimination, as it is uniformly deprived of the property of coa- gulation when in a healthy state. This last circumstance, from its uniformity, must have a mean- ing ; I have just stated what I believe to be the probable inten- tion of this change, namely, the comfort of the woman ; but it may have a higher object: it may be essential to the propagation of our species. Certain it is, the sensible properties of this eva- cuation differ in certain individuals ; and it is found, that when this discharge is very profuse or very sparing ; when many coa- gula are thrown off"; when it is thin and pink-coloured; when very black, and resembling, in some measure, coffee-grounds; or when it is discharged with pain, and accompanied by a whitish membrane, the women, so circumstanced, are constantly barren, so far as my observations have extended. As I do not believe this discharge to be a mere exudation from the internal surface of the uterus, and constituting a genuine hemorrhage, it is proper to declare, what I believe its real na- ture is. I look upon this discharge to be a genuine secretion, from the mucous membrane with which the cavity of the uterus is lined ; since it would be difficult to explain by any other pro- cess than some peculiar mode of arterial action, the change which evidently is wrought upon the coagulating lymph ; and we know that this constituent of the blood is, in many instances, under the immediate influence of this set of vessels, as is proved in cases of scurvy; death from a blow on the stomach ; a certain stage of yellow fever ; small-pox, &c. In these cases, the blood loses the power of coagulation by some peculiar arterial action ; and this sometimes, in a very short time. The same effect is produced by the uterine arteries during the menstrual process ; and this process may, with much propriety, be termed a secretory process. The menstrual fluid has been considered as a secretory product for very many years, and this opinion is now adopted by many of the physiologists of the present day: thus, Haller, Bordeu, San- ders, John Hunter, &c, called menstruation, without hesitation, a secretion. It is perhaps, at the present day, impossible to say who first broached this doctrine. The credit has been given to each of the gentlemen just named, but not with justice, as I shall show immediately. In Rammazini's "Essai sur les Maladies des Artisans," p. 214, 92 HISTORY OF MENSTRUATION. we find the following passages: " II y a tout lieu de croire que le sano- des regies a quelque qualite maligne et cachee; et on lui a donne a juste titre le nom de secretion et excretion." In this passage the word secretion appears to be familiarly employed, and was the one most probably used in common parlance among tbe medical men of the day. Fourcroy, the translator of this work from the Latin, in a note to a part of the paragraph from which the above extract is taken, says, " Rien cependant n'etoit plus naturel, sans avoir re- cours aux phenomenes chymiques, que de concevoir le flux des regies, comme une secretion, qui a son organe, ses periods reglee, sa marche et son department, ainsi que toutes les autres secre- tions," p. 216. From these extracts it is evident that neither of the gentlemen above mentioned is justly entitled to the honour of the sugges- tion, for the first edition of Rammazini's work was published in 1700. Indeed, it would seem, from the manner in which it is mentioned in this work, that the doctrine was not new at that time: at least there is no claim laid to originality by Ramma- zini. Sect. 8.— The Uterus, is it lined by a Mucous Membrane ? I consider the uterus to be liried with a membrane of the mu- cous class, as taught by Bichat and others, notwithstanding its existence has been lately called into question. In examining the latest authority on this subject within my reach, I find it doubt- fully mentioned by Meckel, in his Manuel d'Anatomie, as trans- lated by Jourdan and Breschet, vol. iii. p. 611. He says— " La face interne de la matiice est tapisse par une membrane muqueuse rougeatre, presque lisse, garnie seulment de villosites tres fines, qui se continue superieurement, et de chaque cote, avec celles des trompes, inferieurement avec celle du vagin. Dans 1'etat frais, cette membrane adhere d'une maniere si intime a la substance fibreuse sous-jacente, qu'on ne peut l'en isoler, quoique sa structure annonce assez qu'elle appertient a la classe des membranes rauqueuses ; mais, avec du soin et de precautions, on parvient a en detacher quelques lambeaux, apres avoir soumis, la matrice a la maceration." " Son union intime avec le reste de la substance de la matrice a fait revoquer son existence en doute par plusieurs anatomistes."* * "C'est l'opinion de Chaussier et de Ribes. Me. Boivin dit aussi n'avoir ja- mais apcrgu cettee membrane muqueuse, et pense que la face interne de la ma- trice n'est formee que par l'extrcmite des vaisseaux exhalans qui s'y ouvrent. TJne pireille explication est tres vague, sin on meme tout a fail inintelligible. L'Aiiilogie, quand il n'y aurait pis d'dutre motif que celui-la, no pcrmettrait pas de douter que la face interne dela m ttiicc ne soil tupissi-e pir une m mbrane."__ Notes des Traductcurs. HISTORY OF MENSTRUATION. 93 It is truly a matter of surprise, that it should be questioned for an instant, that the uterus is lined with a membrane, and this of the mucous kind; for neither the authority of Morgagni, Boer- haave, nor Haller, all of whom Chaussier has called to his aid to support the opinion, can possibly alter the structure of this part; for a membrane is obvious to the eye; and when macerated, is tangible to the fingers; and the nature of its discharges proves it to be a mucous membrane. It has been thought by some to be of the deciduous kind, and regularly cast off after each delivery, or even after abortions. There is much reason, from the ap- pearance of this part after delivery, to countenance this opinion —it, however, wants confirmation. But if this suggestion were admitted in its fullest extent, it would not militate against the pre- sumption that it is a mucous membrane. For this membrane must be considered as possessing a considerable variety of function under particular circumstances: for mucous membranes are made to throw out, not only mucus, but pus, and even modifications of these substances. It is, in truth, most intimately connected with the substance of the uterus, and cannot, perhaps, ever be separated from it in the recent and sound state. But this only proves the closeness of its connexion, and not its non-existence. Indeed, this strict union strikes me as highly useful in the economy of gestation: for were it loosely and uncertainly attached to the substance of the uterus, much inconvenience would necessarily result from the great dis- tention this organ undergoes during pregnancy. Upon opening an unimpregnated uterus, and viewing the cavity it presents, we are immediately struck with the smoothness and polish of its surface: now, it may be proper to ask, what is this whitish and shining surface which presents itself! Can it be the extremities of the exhalants of Me. Boivin! or the proper substance of the uterus, as insisted on by Chaussier? Will an arrangement like that of Me. Boivin, or Messrs. Chaussier and Ribes, secrete a mucous fluid; yield a fluor albus ; or render a pus ? Or, in other words, will any other surface, save a mucous surface, display the phenomena of a confessed mucous membrane. The existence of this membrane is denied, because it cannot be separated from the substance of the uterus. And when it is urged that this can be effected by maceration, or incipient putrefaction, they declare the separated portion to be no membrane, but some accidental concretion. It is said by Chaussier and Ribes, that the membrane which lines the vagina, terminates at the orifice of the uterus. The quality of the menstrual blood has been a matter of much dispute with many of the writers upon this subject. It is by some considered perfectly innoxious, and by others as extremely dele- terious. The ancients attributed to it the most baleful effects upon both living and inanimate matter. Thus, Pliny declares the 94 HISTORY OF MENSTRUATION. approach of a menstruating woman will turn new wine sour, ren- der fruit trees steril, or even destroy them ; burn up the seeds and fruit of a garden, if she should sit near them, &c. &c.; while J?al- lopius, Rodrigue a Castro, Baillou,* &c, assure us, in its natural state, that it is perfectly free from all bad qualities. La Motte, though apparently willing to remove the imputation urged against the menstrual blood by Pliny and others, cannot altogether divest himself of the prejudices of the times and of education. He seems disposed, however, to compromise between the force of opposing facts, (which he confesses daily to have observed,) and the in- fluence of names and of instruction, by relating, with great naivete, the following story. After having timidly attempted the refutation of Pliny and others, " that the menstrual blood is most injurious," he says, " But I see sufficient to make me apprehend the presence of wo- man in this situation, especially if she have red hair. I had a servant of this kind. One day I gave a breakfast to a number of my friends; white wine is the kind which is usually preferred upon these occasions; especially iT you intend to eat oysters; and mine was excellent; and was drawn by this servant. My friends expatiated upon the goodness of my wine. The next day I break- fasted in like manner with one of the friends who had been with me ; but he had no wine but red ; I immediately sent for some of my white wine ; but it was found so spoiled as to serve for nothing but vinegar. The same servant aided in salting some pork, which was afterwards found to be spoiled ; though the part which was salted by another person, in another cellar, was perfectly good." He adds, however, with his usual candour, " but I cannot say whether this may not have been the fault of the salt."f It must be admitted that this secretion is acrid, occasionally, and will leave traces of its acrimony upon the parts over which it flows; but when this happens, it must be recollected that this discharge is in a deranged state, and no longer a pure menstru- ous evacuation. This occurs more frequently towards the de- cline, than in the early part of life; and especially if there be a tendency to cancer. It must, however, be recollected, that even in such instances, the general system is not contaminated in the commencement of this condition of the uterus; the acrimony of the discharge results from an altered action of the vessels concerned in the process of elimination, and its exposure to the air; and it is not until portions of this discharge are absorbed, or until the system at large sympathizes with the diseased parts, that any evi- dence of the uterine affection is betrayed by the skin or other por- tions of the body becoming decomposed. The idea of the impurity of the menstruous blood took its rise » Ramazini, p. 214. -f Traite des Accouchemens, p. 57. HISTORY OF MENSTRUATION. 95 from the supposition that this discharge was intended to relieve the woman from certain noxious humours generated in her body from her sedentary habits, as well as other causes. Hence, so much dread was entertained, when this evacuation was inter- rupted from any other cause than pregnancy. But no alarm was excited when this flux was arrested by gestation; as it was then employed, they said, for the purposes of the foetus, and they appear willing to think the embryo cannot be injured by it. This opinion they thought was supported by the appearance of certain eruptions upon various parts of the body when this dis- charge was suppressed, and which yielded only to such reme- dies as restored this evacuation. But this fact, at the present day, would be explained upon very different views of the animal economy; and will no longer serve to support the notion of the deleterious effects of suppressed menses. Indeed, we may with much plausibility suppose that the dogma of the impurity of the menstruous blood, originated in a medico-political necessity, in the warm climate which first gave rise to the suggestion. Moses was fully aware of the consequences of the want of cleanliness among his people ; and no stranger to the inconveniences which arise from a neglect of it: he therefore looked upon women, during the period of their catamenial flow, as impure, and that they would remain so, until they were well absterged; hence his pointed directions and observances at this period. To ensure success to this scheme of cleanliness, the aid of medical specu- lation was required, and, most probably, it was not reluctantly obtained. The ancients, in a word, were scrupulously exact upon this point; for they considered the health of the woman materially connected with the menstrual discharge, and looked upon repose of body and tranquillity of mind as essential to the best performance of this secretion—they therefore forbade their females to appear in public, during its flow, lest agitation, or over-exertion, should derange this natural and important func- tion ; and to ensure compliance, urged the morbid nature of the "menstruous fluid. Indeed, they went so far, as to even forbid the employment of the bandage, now, in almost universal use with females who are menstruating, because they declared, it prevented the immediate flow of the menses, and thus permitted this fluid to accumulate, and stagnate in the vagina. It was also supposed that hemorrhages from other parts of the body must be a necessary consequence of the uterus failing to secrete the menstruous blood ; and we find, in books on medicine, very many instances, purporting to be illustrative of this hypo- thesis. I am not prepared to say that such a thing never has existed ;* but I can with the most entire confidence declare I * Gardien relates a curious case, upon the authority of M. Brule, which he considers us a proof of the diversion of the menstrual action, but which I cannot 96 HISTORY OF MENSTRUATION. never witnessed such examples; and when they occur, tbey must be considered, if entitled to any weight, but as exceptions to the rule. Have not instances occured of foetuses being found in the ovaria of virgins ? At the present day, I believe, no one will imagine, that he ob- serves a woman's health to be worse, as a regular occurrence as she approaches the period for her catamenial flow ; nor think that he sees an improvement, after this period has passed over; yet it would seem essential to the support of this conjecture, that both one and the other should happen. Nor is there much reliance to be placed upon the existence of the " menstrual fever" of the older writers, though supported by the later authority of Bordeu. That fever may occasionally be perceived at such periods, I have no reason to deny; but that it is an attendant upon this discharge as one of its phenomena, I have much reason to doubt. When this opinion arose, it was the order of the day to be minute; and an accidental circumstance was recorded, for an essential cha- racter. What shall we say of women who have never menstru- ated ? Do they enjoy equal health with those who do ? Are they capable of fecundation? As regards our own experience, we would answer each of these questions in the negative—but Frank regard but as a periodical hemorrhage; and altogether analogous to the bleeding hemorrhoids, which, in females, frequently observe as much regularity when the menses are regular ns when they may be absent. " First deviation.—The menses were suppressed in a young girl, whose life had been a series of illnessess up to that moment. She became regular after this ; for six months the discharge was evacuated from little wounds in the legs, occa- sioned by the breaking of some small vesicles. " Second deviation.—There appeared on the left arm some vesicles or pimples, (boutons ) which yielded bl'>od at t"e menstrual period during a year. Whitanilgy is there between the structure of these "vesicles or pimples" (bou'ons) and that of the uterus whi h yi Ids the menstrual fluid ? none whatever ; the blood in such instances, uuif>rmly, 1 believe, coagulates. These changes, if they take place, must be regarded in some as compensating discharges, rattier than as vicarious. " Third deviation—This was succeeded by a whiilow on the left thumb, and a chap up >n thefir-t phalanx ; and ai the end of two months the menstrual blood flowed periodically from this pari for six months. " Fourth deviation.—The girl was now attacked by an erysipelas in the face and the left eye. which term nated by two openings, one at the angle with the nose, and the other in the middle of the upper eyelid: these two openings yielded an evacuation periodically for two years; it then ceased from these part- to be voided by the left thumb. " Fifth deviation.—An erysipelas now showed itself upon the abdomen attend- ed by great itching; the navel was very painful, and fir five months the blood flowed regularly from tlii- part at each menstrual period. " Sixth deviation—A slight accident happened to the left internal malleolus of the ankle, and the blood flowed regularly from this part for four months. "Seventh deviation.—An acute pain was felt in the left ear; a discharge took place from this part for two mon lis. " When the blood did not flow from any determinate spot, it would vent it- self by a hemorrhage from the nose, or from the storm ch by vomitings preceded by headach and giddiness."—Traite" Complet. d1Accouchemens, Sec. Vol. I. p. 239. DERANGED MENSTRUATION. 97 entertains a different opinion upon each of these points. He says, " We rarely meet with women who have never menstruated; however, there have been such instances, and such women have enjoyed the most perfect health; a strong constitution; they were even fruitful." Med. Pract. Tom. 3, p. 382. To these observations, we must say, that they must have greater confirmation, before they can be relied upon as facts— for the reverse has been the constant result in the few cases which have fallen under our own notice. Nor is it very difficult to understand, that this must be the case ; since it clearly proves, that when this evacuation does not take place, it must be owing to some decided imperfection in some one part, at least, of the genital system; and that for the purposes of propagation, we are of opinion the most healthy condition of these organs is required. And we think that Frank himself yields the point completely, by his attempt to explain it. For he adds, immediately after what is above quoted, " If we meet with a great number of women thus situated, and who do not conceive, we must not accuse a defect of menstruation for it, but a vicious conformation of the genital parts." lb. CHAPTER VI. DERANGED MENSTRUATION. After giving the history of menstruation, it would seem pro- per we should furnish an account of the various derangements to which this function is liable, and the mode of treating them. The derangements to which this discharge is liable, are as follow:— 1st. Its too tardy appearance. 2d. Its interruption after having been established, commonly called the suppression of the menses. 3d. Its excess of quantity. 4th. Menorrhagia. 5th. Dysmenorrhcea, or painful menstruation. 6th. Its irregularity towards the decline of life. Sect. I.—1. Of the tardy Appearance of the Menses. In our history of menstruation we have shown, that this pro- cess is more regulated by the condition of the system than by 9 98 TARDY APPEARANCE OF THE MENSES. the age of the female : and that though the climate and manners of each portion of the globe exert an influence upon the human constitution, yet that this influence is constantly observed to ma- nifest itself in the more early, or tardy development of the geni- tal organs. This being the case, the period of puberty, or that period at which the human female is capable of propagating her species, and of which condition the menstrual discharge is the * sign, will arrive at different periods of female life ; but never, un- til the organs destined to furnish this evacuation, are sufficiently developed, to meet, and overcome, all the ordinary contingencies of impregnation and of labour. " The retardation of puberty, retards also, the development of the mental faculties; but preserves energy and freshness to the sentiments, and developes vigorous bodies; and that if in woman this state is prolonged after the ordinary periods, she appears to approximate to man, both in some of his tastes, and in some of his characteristics." (Walker on Intermarriages.) It will therefore follow, as a general rule, that climate will de- termine, in the female constitution, a period for the development of these organs; and consequently, for the appearance of the menses, in each particular portion of the globe. This being the case, a general period is established, at which this evacuation may be looked for; and this is so nearly constant, (caeteris pari- bus,) that any deviation in this respect is looked upon as a state of derangement, if not of disease; hence, the surprise that is al- ways expressed, when this evacuation anticipates the common period ; and the solicitude when it does not take place at the or- dinary time. In consequence of this general law,— a law established b'y cli- mate and manners,—many vulgar errors have arisen, which have too successfully exerted an influence upon the conduct of those who may have charge of females at this critical and interesting period of life. The average period for the first appearance of the menses, may be between the fourteenth and fifteenth year in this country. When they fail at this time, much anxiety is evinced on the part of the friends of the girl so circumstanced ; and every indisposition with which she may be attacked, is sure to be attributed to this cause. In the hope of provoking the menses, now due, as they suppose from the age of the girl, she is almost always condemned to medical discipline, and but too frequently injured by submit ting to its rules. Nothing, perhaps, would be more difficult to overcome than the prejudice of the necessity of this discharge, at a certain period of female life; and this period determined by the number of years which have passed. Women, upon this subject, are but too often incorrigibly wrong-headed ; and we are sometimes obliged to yield, for the patient's sake, an appearance TARDY APPEARANCE OF THE MENSES. 99 of acquiescence. In many instances, did we attempt to convince them of their error, it would not only be labour lost, but what is worse, would too often deliver the patient over to the discipline of some rapacious quack, or some ignorant practitioner of medi- cine. The lapse of a certain number of years is not all that is re- quired that the menses may make their appearance: the uterus, and ovaria, must be developed, and be in good health, if I may so express myself, before this discharge will show itself; and this condition of the genital system is always indicated by corres- ponding changes in certain other portions of the system—there must, and will be, evidences of womanhood, before this event can happen ;* and when these are absent, the girl should never be tortured by the class of remedies called eramenagogues. There seems to be four conditions of the female system, in which the menses are tardy in their appearance : a, Where there is little or no development of the genital' organs ; b, where this is taking place very slowly; c, where the development is inter- rupted by a chronic affection of some other part; d, where the most perfect development has taken place, yet they do not ap- pear. The management of each of these conditions is different— I shall, therefore, treat of them in order. Condition a, or where there is little or no development of the genital organs. This ^condition of the system is easily detected by the absence of all the signs which should characterize puber- ty—the breasts do not swell; nor are there capilli always on the pubes. In a girl thus circumstancptl, who otherwise is in good health, it would be worse than idle, it would be cruel and disho- nest, merely because she had attained her fourteenth or fifteenth year to subject her to medical rule, or to goad her system by stimulating emmenagogues. In such a case, if the mother or friends are rational, and to be trusted, we may honestly give our opinion of the entire insufficiency of medicine to produce the de- sired end. We should explain, so far as we can, the nature of the function of menstruation, and of the prerequisites to this dis- charge; an attempt to produce on their minds, the important conviction, that time, under proper circumstances, is all that is required, to effect the anxiously hoped for change. I have encountered many such cases—with some I have suc- ceeded in bringing the friends to my opinion ; in others I have not been so fortunate;—the latter may be divided into two classes— the one, though not convinced by our reasoning, dare not openly * I have lately seen three instances which contradict this rule—in neither of which was there the slightest development of the mammce ; but in each of these cases there was a diseased spine. Whether this condition of the spine has any influence upon the appearance of the menstrual evacuation, remains to be proved. Sec page 81. 100 TARDY APPEARANCE OF THE MENSES. bid defiance to it; because they fear responsibility; and thus will yield a reluctant acquiescence. The second, confident in their own judgment, will sometimes act upon it, to the imminent risk, if not to the destruction of the poor girl-,* who may be the object of their solicitude. With the latter when importunate we should use a tempo- rizing plan ; and by the administration of some entirely inert me- dicine, and gain time, and save the patient from permanent ill health, or an untimely grave. I but too often call to mind, with bitter recollection, the fate of a most amiable, and interesting young creature, for whom I was requested to prescribe for the expected menses, but who had not one mark which would justify an interference; and, especially, as she was in perfectly -good health—she was fifteen, it is true ; and this was all that could be urged by the mother in favour of an attempt to " bring down her courses." I relied too much upon the good sense of her anxious parent; and freely explained myself to her—she left me appa- rently satisfied with my reasoning; and I heard nothing of the poor child for six months; at the end of this time I was suddenly summoned to attend her, as she was said to be alarmingly ill. When I saw her, she was throwing up blood in considerable quantities from the lungs; she died a few days after, from the excess of this discharge. The distracted mother told me, that though she appeared satisfied with what I had said w7hen she left me, she was convinced I was wrong; and that her daughter's health required the immediate establishment of the menstrual evacuation. With this view, she determined upon the trial of a medicine of much celebrity in similar cases, vended by a quack. She procured it and gave it according to directions: in a few days her daughter became feverish, lost her appetite, and fre- quently puked; her strength failed, and after a short time she was confined to her bed—she called upon the " Doctor," and made known to him the condition of her daughter; he encouraged her to persevere : and told her that the fever, &c, was an effort nature was making for the end proposed—she persevered, fatally persevered; for in a few days more she lost her lovely and only daughter. I examined the medicine which had been exhibited ; it proved to be the oil of savin. Condition b, or where the development is taking place slowly. This condition is known by the partial alteration the mammae have undergone ; by some expansion of body; and the protrusion of capilli on the pubes. The general health sometimes suffers slightly; especially if the girl has passed the fifteenth year, and she grows rapidly—she is assailed by a train of nervous symp- toms, as they are called ; such as palpitation of the heart, rincr- * Bread pills are an excellent succedaneum, they interfere with nothing. TARDY APPEARANCE OF THE MENSES. 101 ing in the ears, headach ; a temporary diminution of strength upon any sudden exertion, loss of appetite, or a whimsical state of it, &c. This condition is not unfrequently accompanied by fluor albus; and when it is, more particularly deserves notice. This case merits attention, when the health appears to suffer; but must not be meddled with when it does not. Our exertions in favour of such patients, should tend to the in- vigoration of the system in general, and the development of the uterine system in particular. The first should be attempted, 1st, by the establishment of a regular course of exercise:—such as riding on horseback, when practicable; walking in proper wea- ther; skipping the rope within doors, when the weather will not permit exercise abroad ; dancing moderately, and with strict regard not to become over-heated, and cooling too suddenly ; 2dly, by proper attention to dress; wearing flannel next to the skin in cold weather, and properly protecting the feet and legs against cold ; carefully avoiding damp and wet places, and par- tial streams of cold air, especially when warm ; 3dly, by a diet of easily digested substances, both of the animal and vegetable kind ; avoiding all stimulating drinks, such as wine, spirits or beer, &c, under the specious pretext of their being strengthen- ing. The second must be accomplished by such medicines as have a direct or indirect action upon the uterus itself; of the direct, the tincture of cantharides appears to be the most efficient, and should be preferred to all others when leucorrhcea attends ; thirty- drops should be given three times a day, until this discharge cease. We may gradually increase the dose, should the com- plaint be obstinate ; for it is of primary importance that it be removed; for we need scarcely look for the catamenia, while this remains in any force—leucorrhcea is a kind of local deple- tion, and prevents that congestion of the uterus so favourable to development, and the production of the catamenial discharge. The parts should be regularly bathed every day with warm wa- ter ; especially during the continuance of the fluor albus. Of the indirect kind, aloes seems to be the more certain—the influence of this drug upon the uterus has been very long ac- knowledged, and was much extolled for this purpose by Mor- gagni and his contemporaries—it should be given in very small doses, and perseveringly continued; this medicine is, perhaps, preferable to the tinct. canth. where leucorrhcea does not attend; the following is the formula I generally employ :— pr. Gum. aloe. sue. 3ss. Pulv. Rhcet. opt. 3j. 01. Caryoph. gut. iv. Sapo Venet gr. viij. Syr. Rhxi. q. s.—M. f. pfl. Ir. 9* 102 TARDY APPEARANCE OF THE MENSES. One of these to be given every night, night and morning, or every other night, as they may affect the bowels—the object is to keep the bowels free, but not purged. This prescription is a remarkable instance of the power of combination; for the very small dose just recommended, will sometimes act with great force upon the bowels—so much so, sometimes, as to oblige us to reduce the above quantity one half. The same regard must be paid at the same time, to air, exercise, and diet, as just re- commended. Condition c, or where this development is prevented by a chro- nic affection of some other part. The condition is readily de- tected by the presence of any such disease, as may be capable of interrupting this discharge, after it has been thoroughly well established; such as phthisis pulmonalis; chronic inflammation of the liver, or spleen ; dropsy, &c. Under the existence of either of these diseases, the menses will almost always be sus- pended; because it will certainly interrupt the development of the organs essential to the formation of this discharge, however favourable this expansion may have commenced. This case constantly exposes the physician to the importuni- ties of the friends of the patient,- for something "to bring down the menses ;" it is in this case of all others/that they are per- suaded, nothing more is wanted, to re-establish health—the phy- sician must here conceal his real sentiments; for, however con- vinced he may be of the inefncacy of remedies for this purpose, he must not say so, if he regard the welfare of his patient. For no reasoning will convince them, that the disappearance of the catamenia depends upon the diseased condition of some other part of the body; and consequently, that until this be removed, their reappearance is not to be expected. Indeed, the attempt would be mischievous ; for the patient would most probably be taken from his, and consigned perhaps to worse hands. He should, however, declare to the friends of the patient, that this circumstance, (the absence of the menses,) has been duly weighed, and will influence his prescriptions. Iu such cases, no prescription can be availing, but that calcu- lated to remove the original disease, and of the diseases which may interrupt the menstrual action, it is not our immediate pro- vince to speak as they are not peculiar to females. It is true, however, that the long-continued suppression of the menses may seriously involve other viscera than the uterus ; and their cure, when thus implicated, may depend upon the restora- tion of this discharge; but when this is the case, it constitutes the chronic idiopathic suppression of the catamenia. A want of attention to these different states of dysmenorrhcea, that is, whe- ther they be idiopathic or symptomatic, has led to an empirical mode of treatment. TARDY APPEARANCE OF THE MENSES. 103 Condition d, or when the most perfect development has taken place, but the menses do not make their appearance. This con- dition is easily known, by the girl having all the outward signs of womanhood ; the menses is all that is wanting to complete her title to it, and fit her for the duties she is destined to fulfil. This case is sometimes attended with fluor albus; when it is, it must be treated as recommended above. At other times, there is a manifestation of an attempt by the uterus to produce the dis- charge; this is known by a pain in the back, hips, and loins, with a sensation of fulness in the pelvis, attended sometimes with a forcing or bearing down. These symptoms sometimes recur periodically ; and may even be attended by a serous discharge from the vagina, resembling whites. The tinct. canthar., as re- commended above, will rarely fail to produce the discharge, if given steadily for two or three weeks ; or the madder may be given especially if the period for the return of the pains just spoken of, be near at hand. Indeed, this seems to be the only period at which this substance is more decidedly useful than any other of the emmenagogue medicines : it acts at times so prompt- ly, as almost to call in doubt its agency ; but repeated success, under such circumstances, has convinced me of its efficacy.* From its possessing no general stimulating property, it becomes very valuable in cases of great irritability of the system, or where there may be slight febrile paroxysms ; for it seems to be a law of the animal economy, to institute fever,- whenever strength is considerably impaired ; hence, we almost always see it after wasting discharges of every kind. I have found that a strong decoction of this wood is of equal efficacy with the substance, and is much more easily taken. A pint of boiling water is directed to be poured upon an ounce of finely powdered madder and a scruple of bruised cloves; and then to be gently simmered for fifteen minutes; when cool, strain off" and give a wine-glassful every three hours. I have lately had a case of this kind, where the madder succeeded most promptly. This case rarely gives much trouble, unless the interruption has been occasioned by imprudent exposure to wet or cold: in this instance, it must be treated as an obstruction. A remarkable case of the non-appearance of the menses, was lately under the care of my friend Dr. Physick and myself. A lady of thirty years of age, had the usual concomitants of pu- berty at the ordinary age; these signs, however, were not fol- lowed by the catamenial flow, though periodical pain in the hips, loins, abdomen, particularly in the region of the uterus, numb- * Dr. Schonlein, late Professor at Wurzburg, asserts that ten grains of aloes, dissolved in a small quantity of warm water, and thrown into the rectum, at the period when catamenia should appear, is more effectual than any other emmena- goguc. Amu. Jour, of Med. Sciences, for Feb. 1836. "•, „ ' , r.t 104 TARDY APPEARANCE OF THE MENSES. ness of the thighs, &c, seemed to promise it would be so. In this situation this young lady has remained from the time of pu- berty to her present age. Previously to my seeing her she had tried, without the least benefit, all the known emmenagogues; as her sufferings were severe, and so long-continued, several medi- cal gentlemen were consulted previously, and so effectually were all the established remedies tried, that I was left almost without resource. On examining her per vaginam, nothing faulty could be discovered about the uterus. The only thing that suggested itself, as a possible remedy, was to pass a flexible catheter into the cavity of the uterus, under a hope, that something in the neck of this organ might obstruct the flow of perhaps accumulated menses. This suggestion was ac- cordingly acted upon ; and the extremity of a catheter was passed an inch and a half through the neck of the uterus. The with- drawing of the instrument was not followed by a discharge of any kind; and, consequently, our hopes were immediately de- stroyed, and our patient nowise relieved. She has never been troubled with leucorrhcea, or any other discharge from the vagi- na*. This case we looked upon as not less ambiguous, than hope- less. The sufferings of this patient were great; the abdomen, during the periods of pain, was very tender to the touch, and a little distended ; a considerable hardness was felt immediately over the region of the pubes ; but no circumscribed tumour, like the distended uterus, coul'd be discovered. This case is remarkable for several of its circumstances: 1st, there is every outward ma- nifestation of the development of its genital system; 2dly, at every return of the period at which this discharge should take place, there is pain and other symptoms which commonly announce this discharge to be at hand, when not regularly established ; 3dly, as far as an examination per vaginam could ascertain, there was no defect in the uterus itself. In this case, the most proba- ble conjecture I can make is, that there is an anatomical defect in the secreting surface of the uterus itself; and that the pains which are endured at each returning four weeks, may be owing to the plethoric, or engorged state of this organ, and which is not relieved, as in common, by the secretion of the menstrual fluid. In a very recent work on the practice of physic, by Dr. Mack- intosh, Vol. II. p. 346, we find two or three cases strongly resem- bling the one just related, and which were relieved by means similar to that recommended, or rather employed in that case and may be regarded as instances of amenorrhoea arisino- from an imperfect or imperforate state of the os uteri. It may'not be amiss to direct the attention of the reader to a remarkable circum- stance connected with the history of these cases; namely,, that here was no collection of menstruous blood in the uterus and Tardy appearance of the menses. 105 that the menstrual secretion did not appear to take place until after the perforation of the os tineas. Is this a uniform occurrence in similar ctses ? Does menstrual secretion require, as a sine qua non, an outlet for its production ? We think not, as has been as- serted—for large accumulations have taken place (as in imperfo- rate hymen) and we do not see what connexion a want of outlet can have in the menstrual secretions. " A young woman aged twenty-two, came from the country to consult Dr. J. A. Robertson, who sent her to me in the begin- ing of the winter, 1826. I collected the following particulars from herself and a female friend who accompanied her; that the menstrual discharge had not yet appeared ; that she had always been healthy till she reached the age of sixteen, from which pe- riod her health began to suffer, and since which she has regularly complained every month of pains in the back and loins, together with a sense of weight and bearing-down in the passages. For some time her sufferings were slight, and she was still able to per- form her duties as a servant, but for the last two years she has become comparatively weakly and emaciated, and has not known what it is to enjoy a day's ease ; and she stated, that she would readily submit to any thing which might cure her. The girl ap- peared to be above the middle stature, the mammse were unde- veloped, she was of an awkward shape, and indeed her appear- ance, colour of skin, and sound of voice, were rather masculine. Her abdomen was not tumid, but I was told it was occasionally swollen, particularly after meals. She seemed to be of a nervous temperament, and was exceedingly shy and timid. Upon exami- nation, my fingers passed readily into the vagina, and the uterus was felt much lower than usual, but I could discover no orifice. Dr. Robertson had previously detected the same fact, but had not then communicated the circumstance to me, thinking he might be mistaken. I repeated the examination many times, and after feel- ing the spot where the orifice ought to have been, which was dis- tinguished by a small dimple, I attempted to introduce one of the smallest silver probes I could get made, but was unsuccessful in every attempt. It then occurred to me, that the malformation might be owing to an extension of the mucous membrane over the orifice, in which condition we sometimes see the urethra of a new- born male child. I determined upon giving her the chance of a cure, particularly as the means to be used would not certainly produce severe pain. Accordingly, the sharp and triangular extremity of a silver probe was introduced, directed by the finger, carried to the part above described, and a perforation made by em- ploying a rotatory motion: the instrument was then withdrawn, and the round point introduced, which then readily passed up to the fundus of the uterus. For several days she complained of slight pain, attended with some discharge of mucus, a little tinged 106 SUPPRESSION OF THE MENSES. here and there with bloody specks, and I did not think proper to interfere farther until the irritation had subsided. In about eight days I began to attempt a farther dilatation, which was persevered in daily, the size of the instrument being increased, till, by the twelfth or thirteenth day, I was able to introduce No. 6, male bougie, to the fundus of the uterus. On the following day there was the appearance of so much irritation, both local and constitutional, that I made no farther attempt. In two days afterwards she menstruated, and has been regular ever since, and suffers neither pain nor inconvenience. Her health and strength soon recruited, and in a short time her appearance be- came quite feminine. I saw her accidentally a few weeks before this article was written, and she is still in the enjoyment of good health.* " In the case of amenorrhoea from imperfectly formed os uteri, the patient had at various times been afflicted with violent ner- vous symptoms; pain in the abdomen, sometimes of a distressing nature, and obstinate affections of the stomach and bowels; toge- ther with occasional retention of urine, and anomalous hysterical complaints. At every menstrual period she passed a little mucus, which was now and then slightly tinged, but had never the na- tural appearance, and it was always attended with great pain. After attaining the age of twenty-three, when her health was greatly impaired, and after she had tried all known remedies in vain, she most reluctantly, and after great delay, submitted to ex- amination, and the os uteri was found so small as to be scarcely perceptible. She menstruated satisfactorily after several bougies had been passed through the os uteri, but I never succeeded in penetrating completely into the cavity of the uterus, either from an obstruction in the cervix, or, from what appears to me to be more probable, a curvature of the canal. Nevertheless, after di- lating the passage as far as could be reached, (up to No. 7, bou- gie,) she menstruated naturally, freely and without pain, and her health became wonderfully improved. It is but fair to mention, however, that this case was also complicated with extensive constriction of the rectum, which, I fear, is not yet completely removed." Sect. II.—2. Of the Suppression of the Menses. By a suppression of the menses, we are to understand, the want of return of this discharge, at the accustomed period, after * What became of the menstrual fluid that had been previously secreted ? could it have been absorbed? we think not. Or did the uterus fail to secrete it in con- sequence of the obstruction of the neck ; for it must be recollected, the symptoms of secretion had continued for more than two years. SUPPRESSION OF THE MENSES. 107 it had been well established, when not interrupted by pregnancy, suckling, or disease. For, however well established the menstrual discharge may be, it is liable to be interrupted from a variety of causes, inde- pendently of pregnancy and suckling. The little regard which the generality of females pay to this period, exposes them too frequently to a derangement of the menses; nay, some I have known so reckless of consequences, as designedly to interrupt them, by putting their feet in cold water when engaged for a party of pleasure. Frank mentions the case of a young lady who put her feet se- veral times in cold water during the flow of her menses, because she expected her lover, which quickly arrested them ; an inflam- mation of the womb followed, and she was brought, dying, into the hospital at Vienna. He also states, on the authority of a cele- brated surgeon of Helmstadt, that a young lady was attacked with amaurosis of one eye, in consequence of the sudden suppres- sion of the menses from putting her feet in cold water—and when this discharge was recalled, she fortunately recovered the sight of her eye. And of one of his relations, of fine health and rare beauty, who, after having danced all night, with her menses on her, left the ball-room in full perspiration; she would not wait for her carriage, but proceeded home, which was not far off. She was attacked with metritis, and died on the fourth day. It is not, perhaps, unworthy of observation, that amaurosis has followed in a number of cases, the sudden stoppage of the menstrual discharge. In addition to the case just related by Frank, we may add the one by Mr. Brown, in Vol. XXVI. of the Edinb. Med. and Surg. Journ. p. 279. In this case the patient was about forty years of age—she had become very much heated by a long walk in hot weather—at the end of her walk she was seized with her cata- menia, but which was entirely suppressed by a drink of cold milk; this was followed by headach, oppression, hemiplegia, and amaurosis of the left eye. Mr. B's attention was directed to the restoration of the menses, in which he succeeded in about six months ; at which time her sight was restored. Perhaps the suppression of any sanguineous discharge might have the same consequences—that the eyes are particularly liable to affections from such like causes, is rendered at least probable, by the case of spectral illusion from suppressed hemorrhois, related in Hufe- land's Journal, for September, 1824. " A gentleman of Carlsruhe, in Silesia, sixty years of age, and of upright character, liberal, unprejudiced, constantly engaged with his profession, and inclined to nothing so little as to communings with the kingdom of spirits, had long enjoyed good health, except that he had occasionally colic on exposing himself to cold, was liable from time to time to a hemorrhoidal flux, and had a cata- 108 SUPPRESSION OF THE MENSES. ract in one eye, and dimness and weakness of sight in the other. A short time before he was seized with the affection about to be related, he received a visit from his niece, who was far advanced in pregnancy accompanied by her husband. Soon afterwards the family received an alarm from a house taking fire near their dwelling. On the evening of that day, his wife remarked that he was restless, and put questions in a singular way. About six, when the candles were lighted, he insisted with his wife, that his niece had entered the room, taken his hand, and retired on his rising to meet her; that her husband escorted her; and that three other persons whom he did not know were also in the room. On going up stairs to supper, the spectral company went along with him, and after supper they returned with him to the lower room, and two of them went to bed with him. At length, tired of the illusion, he drew the coverlet over his eyes, and leaving the spec- tres to their fate, fell asleep. Next morning his spiritual friends did not make their appearance; but a new illusion of sight took their place. He thought the walls of his apartment were all checkered like a chess-board, and so vivid was the deception, that it obliterated a number of engravings which hung on the walls. This lasted two days, and after it disappeared, his vision returned to its natural state. For some time after, he complained of weakness, giddiness, and anxiety in the chest. His appetite, however, was good; he slept well; and the pulse was natural. He had not had any hemorrhoidal discharge for some time before. Gentle laxatives; bathing the feet; and afterwards the tincture of cinchona, restored him soon to his usual state of health. His mind, excepting so far as. regarded the spectral illusions, ap- pears to have been quite entire." Cold, in some form or other, may be considered as the most frequent remote cause of this suppression ; and it may be applied either in the interval, just as they are making their appearance, or after they have flowed some time. When cold is applied to the interval, with sufficient force to prevent the recurrence of this discharge, the first notice the wo- man has of its influence is, the want of return of the menses at the period next expected. For the most part, at first, neither pain, nor other inconvenience is felt; but if they have failed for several periods, the approach of ill health is then perceived, and she becomes an object of medical care. She now becomes pale, emaciated, and is much enfeebled—a train of nervous symptoms may be superadded ; as palpitation of the heart, difficulty of breath- ing, a sense of suffocation, especially after any thing has hurried the circulation—to these fluor albus may be added, which soon aggravates the previous unpleasant symptoms. If cold be applied when the menses are about to appear, or after they have flowed some time, the symptoms may be very SUPPRESSION OF THE MENSES. 109 much varied: in such cases, the patient is attacked with violent pain in the head, back, or bowels; and this with such severity, sometimes, as to create great anxiety for her safety. I have known temporary derangement, violent hysteria, and severe co- lics, result from this cause. For the relief of these, we are obliged to have recourse to blood-letting, purging, warm bath, camphor, opium> asafoetida, &c; and, for the time being, are ne- cessitated to treat the complaints as if they were independent of such a cause. For we can very rarely re-establish the discharge, after it has been thus interrupted; nor should it always be at- tempted ; for sometimes much injury is done by neglecting the consequences of this stoppage, by directing the force of our en- deavours to a recall of the discharge. I admit, that after bleed- ing and purging have been performed, advantage is sometimes derived from either the general or partial warm bath, or hot fomentations to the abdomen., especially if pain be experienced in the region of the uterus. Should pain be severe, I have found nothing answer so well as an injection composed of a gill of thin starch, a tea-spoonful of laudanum, and thirty grains of finely powdered camphor. If it be complicated with hysteria, the addi- tion of three tea-spoonsful of the tincture of asafoetida, instead of camphor, may be useful; this may be repeated pro re nata. If colic supervene upon the interruption of the menses, (after bleed- ing, should the pulse have indicated it,) I have found the most cer- tain relief given, by half-ounce doses of the elix. proprietat. every three hours, in warm sweetened milk, until the bowels are open. Having pointed out, in a cursory manner, the plan of treat- ment for the consequences of a sudden interruption of the menses, I shall now proceed to the consideration of such measures as will tend to invite their return. In doing this, I must be considered as speaking of the idiopathic suppression only, and of the mode of treatment proper for it. I must here premise, that I do not look upon every deviation in regularity, as a legitimate reason for medical interference; for many instances, with young girls, and especially those who began precociously to menstruate, there will be a want of precision in return, that must not be mistaken for disease ; for, did we subject the woman to medical treatment for every aberration of this kind, we should be condemning her to most improper discipline. So, also, it many times happens with hale, robust young women, that a temporary suspension of the menses takes place from cold or passions or emotions of the mind,* but which after a certain time will return without medi* * A lady informed me, that while menstruatm?, she fell down stairs; and from thatt moment, the discharge was suspended; nor did it reappear until the next period. And a case is related in the Lincet, where a suppression took place, from a violent fit of passion. Lancet. Vol. I. Case ix-. p. 497. See also Case, p. 136. 10 110 SUPPRESSION OF THE MENSES. cal application, or even the slightest premonition. My rule on this point constantly is, never to interfere, unless there be some evidence that the health is suffering by the absence of this dis- charge. For it very often happens, if we draw blood, (especially perhaps from the foot,) to the amount of eight or ten ounces, or as near as it can be ascertained, that the menses should flow if they were not obstructed, we very often succeed in immediately removing the obstruction. The general health rarely, if ever, suffers, before three or four successive periods have passed, unless this obstruction be accom- panied by a bad state of fluor albus. If this attend, the health may be earlier affected ; and then require to be immediately no- ticed. The remedies for this condition of the system will'vary according to the state of the system; and I cannot too earnestly recommend attention to this important practical point, as success in the treatment of these complaints, almost exclusively depends upon the discrimination. Perhaps there is not in the whole range of medical practice, such a departure from principles as in the treatment of certain female complaints—they seem to be pre- scribed for with determined empiricism; as if the laws which govern disease in general were not applicable to them. The want of success, in many of the complaints of females, is owing almost altogether to the determination to discover specifics for them ; for the existing condition of the system is never taken into calculation, when a prescription is made; hence, the almost uni- form failure of certain remedies in the hands of some practi- tioners, which are almost as uniformly successful in the hands of others. A practitioner acquires, by long habit, and correct ob- servation, a control over certain diseases, that will not yield even to the same remedies, when indiscriminately used by others— this tact in the use of certain medicines, is but the result of ac- curate observations on the various conditions of the circulating system; and when this study is neglected, it is a moot point whe- ther the remedy succeed or not. In prescribing, then, for the disease, or rather derangement, under consideration, it were almost hopeless to employ remedies without the strictest attention to the existing state of the circu- lating system ; the remedy which will relieve in one case, may not only be unavailing, but perhaps injurious in another; it there- fore behooves every one to become familiar with the various states of the pulse, before he prescribes his remedies, if he ex- pect to succeed by their employment. The fear of debility has occasioned the death of thousands; and perhaps to the end of time it will have its victims—every in- terruption of a natural action, which may involve the system at large, with nine-tenths of the writers upon diseases, originates in debility; hence the whole class of diseases we are considering, is SUPPRESSION OF THE MENSES. Ill supposed to either originate in, or be perpetuated by weakness: thus, fluor albus, and the deranged condition of the menses, are considered as diseases of weakness ; than which, as a general rule, nothing can be farther from the truth. The most opposite reme- dies will, in their turn, remove the same diseases ; and the person who cannot understand the reason of this simple fact, will never be able to combat them with success. Having stated some general notions on the management of the complaints under consideration, I shall now proceed to detail the practice essential in each particular state of the system. When the suppression is of recent date, that is, not more than of three or four months' standing, I almost always find that the pulse, so far from betraying marks of debility, manifests a tendency to an excess of action : when this is the case, we should commence the treatment with such remedies and regimen as will reduce the pulse to a proper standard, before we proceed to the exhibition of such medicines as shall have a direct tendency to produce the men- struous discharge ; which is to be done, by blood-letting, by purging, and by a strict vegetable diet. This plan is so effective, in some cases, as to require nothing more for the re-establishment of health ; and in others so indispensable, that success can only result from its employment as a preparative step. I will illustrate both of these states by appropriate cases. Case First. Miss-----, after having stood a long time on a damp brick- paved cellar on a hot day, and at the warm employment of " pre- serving," found herself chilly, and her menses arrested ; her mo- ther had her daughter's feet put in. warm water, and gave her some hot pennyroyal tea ; this removed the chilliness, but did not restore the discharge ; she was occasionally taking remedies with- out effect, until some time after the third month ; at this time she became more indisposed, and I was requested to visit her—I found her labouring under severe headach, which was much in- creased by sitting up, or motion ; her pulse full, and a little quick- ened: her tongue slightly furred, her appetite impaired, and her bowels costive. I directed her to lose twelve ounces of blood ; to be freely purged by senna; and to confine herself to rennet- whey, barley water, or thin tapioca, for nourishment. Her symptoms were much less severe next day, but not en- tirely removed—I ordered another dose of senna tea, and the same diet to be continued: on my next visit she appeared per- fectly relieved ; but I insisted on her using a spare diet for some time longer, and to take an aloetic pill every night: this plan was pursued for several days, at the end of which time her menses made their appearance. 112 SUPPRESSION OF THE MENSES. Case Second. Miss----ry after a stoppage of her menses for four months, de- sired my advice ; her health of late began to suffer considerably— she was pale and emaciated ; had some fluor albus ; headach ; loss of appetite ; and was readily agitated by slight causes ; much pal- pitation of the heart; especially on going up stairs. Her pulse was tense and hurried, skin hot, and tongue considerably furred: especially in the morning. I ordered her to lose ten ounces of blood ; to be purged by senna, and to be confined to a vegetable diet. She was relieved by these remedies ; but as the force of her pulse was not entirely subdued, I thought it best to keep the bowels loose, and confine her still to a vegetable diet. This plan was strictly persisted in for about ten days, which reduced her pulse sufficiently to bear the tincture of cantharides, in doses of five and thirty drops, three times a day: in a few days the fluor albus stopped ; and in a few more, the menses made their appear- ance. Upon these two cases, I shall merely remark, that had I given any emmenagogue medicine in the commencement, I should not have had the pleasure of seeing my patient so quickly re- stored—or, in other words, had these cases been treated as cases of debility, I am certain the complaint would have been aggra- vated ; yet in thfl last, there were strong marks of debility, agree- ably to the common notions upon this subject. The madder may be given more safely than any other remedy with which I am acquainted, without such particular attention be- ing paid to the pulse, as it excites no increase of action in it. I am in the habit of using this drug without previous preparation, when applied to near the period at which the menses should ap- pear ; and sometimes succeed most promptly with it—indeed; this is the only time at which it seems to be successful; for if it fail then, it is rarely more fortunate afterwards.* When the madder fails, I commence, in recent cases, with the tincture of cantharides, after having duly prepared the system for its reception. I rarely increase the quantity more than ten or fifteen drops beyond the original dose, as the moderate doses of thirty-five or forty have always been found sufficient with me, when the medicine would succeed at all. Should the cantharides fail, the volatile tincture of guaiacum is then ordered: which when exibited in proper cases, has never yet failed in my hands. I give it for this purpose, with a confidence I attach to no other medicine. This confidence is the result of very many years' ex- perience of its efficacy. I have often succeeded with it whare almost all the other emmenagogues have failed; nay, I- have » See p. 103. SUPPRESSION OF THE MENSES. 113 done more; I have found it to answer completely, after it was said to have had a fair trial—but this fair trial was very far from being so.* As it is much more stimulating than the madder, or cantharides, I am more attentive to have the system properly prepared. I, therefore, generally reduce the pulse lower, than for the medicines just named : this is easily effected by the loss of a little more blood than in the other cases; purging more freely; and insisting on a low diet for a few days. When speaking of the tact that is acquired in the administra- tion of certain medicines in certain diseases, I had particular re- ference to the employment of the tincture of guaiacum as an em- menagogue. I have, for more than forty years, almost daily used this medicine in suppressed catamenia; and more especially, in those of long standing, without its having failed in any case proper for its usef—more cannot be said of any remedy. I say this in the most perfect good faith, as I have learned that some of my brother practitioners have not been equally success- ful with it—but I think I can readily account for their failure : 1st, From their not placing the system in a proper situation for its use; and, 2dly, by not properly persevering, in the remedy. Neglecting these important points, it can readily be imagined, that it may not succeed ; for I deem an attention to them essential to its success; more especially in those cases, where many months of interruption have existed. I think one of its superiorities con- sists in its certainty in cases of very long standing; and I could readily furnish, from my note book, a number of instances, wdiere it succeeds to restore the menses after an interruption of from nine months to nearly three years. The mode of using it is, a tea-spoonful every morning, noon, and evening, in a wine-glassful of sweetened milk; or, where not forbidden by some peculiarity of circumstance, as much white wine, as Sherry, Teneriffe, or Madeira. The dose must be gra- dually increased, in these cases where a perseverance beyond four or five weeks becomes necessary. Should this medicine disturb the bowels too much, a few drops of laudanum must be * Mr. Jewel has used this tincture in the Middlesex Infirmary, and remarks, "In the administration of this medicine, it is but justice to state, that I have ex- perienced that, which in common we experience from all—occasional disappoint. ment; at the same time 1 conceive there is no medicine whose'effects are more certain, provided the catamenial suppression does not exist as a consequence of any organic disease."—L«nd. Med. and Phys. Journ. And Dr. Macleod, the editor of this Journal, in a note to Dr. Jewel's Report, says that he has been in the habit of employing the medicine, "and, in general, with very satisfactory re- sults. t By a proper case I mean, where the suppression is idiopathic, and not one, in which the uterus has its functions interrupted by disease, or pregnancy—for, in the latter, I have in two or three'instances been imposed upon, notwithstanding all my caution: and where I dared not suppose this condition to exist. But by these few cases, I learned, so far as they would go, that it would not produce abortion. 10* 114 SUPPRESSION OF THE MENSES. added to each dose ; but if, on the contrary, they should not be sufficiently opened, the addition of a little of the resin of jalap, or of powdered rhubarb, will be an improvement. As the tincture I employ is different from the* tincture of the shops, I think it right to subjoin my formula. B Pulv. G. Guaiac. opt. %iv. Carbon, sod. vel potas. 3iss. Pulv. Piment. - - - gi. Alcohol, dilut. - - - fti. digt.—for a few days. The volatile spirit of ammonia is to be added, pro re nata, in the proportion of a drachm or two, to every four ounces of tinc- ture ; or less, or more, agreeably to the state of the system. M. Guibert highly recommends the use of Venice turpentine, in the amenorrhoea of feeble, nervous women of lymphatic tempe- rament. He directs the following form for its exhibition:— R Terebinth, veneta. 3"ij. Sapo. venet. - - - giij. Pulv. Rad. Glycyrrh. q. s. f. mass. div. in pill. lxxv.—Two to be taken every four hours. He says that he is rarely obliged to continue this medicine be- yond twelve days, even in inveterate cases.* Dr. Lavagna has published a number of cases treated with in- jections of ammonia in solution, They are highly interesting, as they discover a new resource in this sometimes highly obstinate derangement of the menstrual action. He observes, " If we consider the different medicinal substances which compose the list of supposed emmenagogues, and the consequences which generally follow retarded or suppressed men- struation ; if we examine the mode in which these substances act on the human body, it will be readily perceived that the animating influence of love, and the physical effects of a rational indulgence of the desires by which the species is reproduced, correspond with the practical views by which we are guided in the treat- ment of amenorrhoea." And he adds, " There is hardly a phy- sician, however limited his practice, to whose lot it has not fallen to observe young females, who, at the age of puberty, were dull, languid, pale, and labouring under scanty menstruation, suddenly restored to bloom, animation, and vigour, and to the salutary sanguineous evacuation, by an opportunity being afforded them of participating in conjugal duties. Whenever I reflected on this * The spirits of turpentine has been found successful, according to Dr. Elliotson, In this stoppage. He used an ounce of the spirits of turpentine in a pint of flax' seed tea, or barley water, as .an enemata, and this was repeated twice, when the menses appeared. SUPPRESSION. OF THE MENSES. 115 fact, and considered the numerous cases by which it was estab- lished, I never doubted that any stimulating medicine which might have the effect of determining an increased sanguineous afflux to the matrix would succeed in exciting suppressed menstrual eva- cuations. Under this impression, I determined to make a trial of liquid ammonia, in cases of amenorrhoea. This highly stimu- lating volatile medicine, added to warm milk, or any other fluid, if injected in suitable quantity into the cavity of the matrix, or along the canal of the vagina, is calculated to produce a sensation of orgasm, similar to that which is known to be most favourable to the cure of suppressed menses." Lancet, Vol. I. p. 497. We have thought proper to introduce to the reader, the rea- soning of Dr. Lavagna; and though we do not altogether agree to his theory for " restoring the suppressed menses," we never- theless think, that the cases by which he illustrates his practice are no less important than convincing. We are of opinion, that his plan should be tried in cases where the ordinary means have failed: these, however, we are disposed to believe would be few, if the plans we have suggested were correctly put in practice^ and duly persevered in. It is true, that the remedies we have proposed, require oftentimes a long perseverance, and the stomach loathes them, from their quantity and constant use. Yet with these certain disadvantages, we are of opinion, that the unmar- ried women in this country, would very reluctantly submit to the alternative, however imperious the necessity. The mode of using it is, to throw up the vagina, by means of a female syringe, ten or twelve drops of the aqua ammonia purse in an ounce of milk or water, four or five times a day. It should be of such strength, as to excite an unpleasant irritation in the part, after each trial of it. If this prove rather excessive, the ammo- nia should be more diluted, or used in a smaller quantity. It would appear from the history of Dr. L's. cases, that some un- pleasant feelings are essential to the success of the remedy. If there be no mistake in the details of the cases, the action of the ammonia was very prompt, even where the suppression had assumed a chronic form.* Most of the cases required a perseve- rance of but a very few days in the injection. And, as a last resource for the girl under such circumstances marriage, from the time of Hippocrates downwards, has been re- commended, though of late, with less confidence than formerly. As a mechanical irritant it may be occasionally useful, though * Dr. Hosack (New York Med. and Phys. Jour.) declares, he treated a case successfully, of ten years' standing, by means of this remedy, after many others had been unavailingly employed. He directed a drachm of the ammonia, and a pint of rain water, to be thrown up the vagina, three times a day. The cure was effected in five weeks. I am sorry I cannot confirm the favourable accounts of Drs. Lavagna and Hosack—in my hands it has utterly failed. 116 SUPPRESSION OF THE MENSES. our own experience goes but a little way to confirm its utility. For we are of opinion, that authors have been led into error upon this point, by not discriminating between the sanguineous dis- charge, after a first coitus, and which is consequent either to the rupture of the hymen, or from the severe distention of the parts, and a genuine menstrual discharge—for the first almost invaria- bly takes place with virgins, though they may be perfectly regu- lar, and may have menstruated but a few days previously. There is another remedy proposed by Dr. C. Patterson, name- ly, stimulating the external surfaces of the mammae; which we give for what it is worth, until experience decides upon its powers. Catharine Power, aged 19 years, applied to me on the 14th Sept. 1832. She complained of headach, languor, loss of appe- tite, and inability to attend to her usual business, that of a servant. She stated, that, about the middle of April, the menstrual dis- charge being then present, she incautiously exposed herself to cold in washing clothes at a river. The catamenia then suddenly ceased, had not since returned, and from that period she had been constantly subject to ill health. She had consulted different medi- cal gentlemen, and taken a great variety of medicines, with little advantage. I directed that the clavicular half of the right mamma should be covered with a sinapism. It was allowed to remain on for thirty minutes ; and on visiting her in six or seven hours after its removal, I found the whole right breast considerably swollen, hot, and painful. The next morning the enlargement of the mamma was very much increased, the tumefaction having extended to the clavicle and axilla of the irritated side. There was no hard cir- cumscribed or prominent tumour, but a painful diffuse elastic dis- tention of the mammary gland-and surrounding cellular substance. On the evening of the day next succeeding the application of the sinapism, the poor girl, with much joy, reported that the cata- menia had appeared. The flux having continued for three or four days in moderate quantity, she then found herself greatly relieved of the headach and other most distressing symptoms ; and in a week her health was so far restored that she ceased to require any farther attendance. In this case cold evaporating lotions and gentle saline aperi- ents were employed to moderate the local phlogistic engorgement. She has continued to menstruate at her regular periods. From the facility with which the menstrual flux was induced in the preceding case, it would seem that the beneficial effects, in amenorrhoea, lately observed to arise from the long continued daily application of one or two leeches to the breasts, was entire- ly owing to the great irritation which the leech-bites had even- tually produced in these organs. The abstraction of blood by SUPPRESSION OF THE MENSES. 117 leeches from the mammae, has not, according to the reports of the cases in which they were employed, the least perceptible influ- ence over the uterine functions, until pain, heat and excessive tumefaction of the breast had been first developed.* Phlogistic engorgement of the mammae being, then, the essen- tial movement, which in this instance, determined the flow of the catamenial. discharge, it must be obvious, that for the production of the necessary irritation to effect that engorgement, the simple application of a sinapism would have been, in every respect, in- finitely preferable to the tedious and troublesome process of the daily repetition of leeching. But it must hot be supposed that mammary irritation is applicable to every form of amenorrhoea. I know that it will not be successful in every case, for I have found it to fail. Analogous to suppression, may be considered the very sparing quantity of the menstrual discharge—this may happen, 1st, to young women in the prime of life; and 2dly, to women pretty far advanced towards that period, at which the menses are about to cease. With the first, when the usual quantity fails to be dis- charged, it always excites alarm, and recourse is almost instantly had to the nostrums of old women, or perhaps regular application is made to the physician—I have seen many of these cases; and they may be classed under two heads:—1st, Where this takes place from some accidental irregularity in the secreting powers of the uterus; and, 2dly, Where there is too early a tendency to cessation. The first may be again divided into two states: 1st, When, after it has continued some time, the health seems to be impaired pretty much after the same manner, as if a decided sup- pression were present; for it has very much the s?me accom- panying symptoms ; and, when this happens, the complaint, for the most part, seems to be relieved" by the same remedies; especially, by the tincture of cantharides.f In the second state, it seemed * These cases appear to be strengthened by a case recorded by Mr. Jones, and published in the Lancet for May, 1835. The subject of this case was a woman, aged twenty-one, who had been labouring under suppression of the menses for more than eighteen months, with much consequent derangement of her general health. She had been under a variety of treatment, without benefit; and Mr. Jones dosed her for several weeks with aloetic purgatives, mineral tonics, and vegetable bitters, cantharides, secale cornutum, &c. &c, without producing the slightest appearance of the diminution of her disease. He then recommended a sinapism consisting of equal parts of mustard and linseed meal, and water q. s., to be applied over the whole of the right mamma, and there to remain as long as it could be borne. The sinapism was continued for about an hour, and a half, and on ttie evening of the same day the breast was very painful and much swollen; which symptoms increased so much on the third day, as to cause much sympto- matic ftver. On the fifth day the catamenia appeared in considerable quantity, and continued for nearly four days. The patient, after this, menstruated regularly, and is now in perfect health.—Amer. Jour, of Med. Scien. for Aug. 1835. t Dr. Lavagna uses the ammoniacal injections in these cases, with apparent success. 118 SUPPRESSION OF THE MENSES. to be in a number of the instances which fell under my notice, an habitual condition of the uterus; and, though the quantity dis- charged was sometimes extremely small, yet all the natural or pro- lific powers of the genital system appeared to be preserved: for I have known pregnancy to follow in several cases. I have pre- scribed all the usual remedies for each of these cases, without ef- fecting any change in the quantity discharged; yet, after marriage, some of these women became mothers. I have, therefore, of late years, not interfered with them, where there was no evidence of ill health. However, it must be confessed, though ill health may not attend, some who are thus circumstanced are not fruitful; but in these, so far as I have seen, it has been the anticipation of a final cessation. I have met with three instances, where this evacuation had ceased altogether before the twenty-fifth year; and two before the thirteenth year: the health of these women appeared to be as perfect, as if they had had this discharge in its most regular manner. When scanty menstruation takes place in women in the de- cline of life, it is not generally so regular in its periods as in young women ; yet, as we have never witnessed any unpleasant consequences to arise, we never thought it proper to interfere; especially in women after their five and thirtieth year. This condition of the menses is more apt to take place in unmarried women, and in widows, than in married women. In some instances of young married women, I have had strong reasons to believe it was owing to a deranged condition of the ovaria ; for they were not only barren, but had never disco- vered any desire for sexual intercourse ; or, at least, were per- fectly indifferent to it. It would seem to follow, from these observations, that the cases of deficient menstruation, in which the health appears to suffer in a greater or less degree,'are those of the most easy management; but in the treatment of them, the same regard must be paid to the condition of the vascular system, as if an absolute obstruction existed. I shall relate a case, by way of illustrating the mate- rial points in question. Mrs.----, aged twenty, during a period of her catamenial flow, suddenly heard of the death of her ab- sent husband—the menses were immediately suspended, and con- tinued so for five months ; during which time she suffered much from a train of most untoward nervous symptoms: at the end of five months there was a slight show, which was repeated at the end of another month, and so on, for two or three periods: but her health did not improve, as was fondly hoped, by this slight discharge, and I was now consulted. I found her, as stated above, with a variety of nervous symptoms; which were easily exacerbated by the slightest mental distress; toge- ther with considerable leucorrhcea—much headach ; hot skin IMMODERATE FLOW OF THE MENSES. 119 towards evening: costive bowels—she lost ten ounces of blood ; was purged by aloes and rhubarb; kept upon a milk and vegeta- ble diet; took the tincture of cantharides; and the next month she had an ample discharge. Sect. III.—3. Of the Immoderate Flow of the Menses. This complaint is much more rare than we should be led to believe, did we regard popular opinion; or even some of the writers of practical system of either medicine or widwifery. I have seen, jcomparatively, very few cases of superabundant men- ses—for in my consideration of this subject, I shall confine my- self to what should be strictly calied an inordinate menstrual secretion. This complaint has been very often confounded with uterine hemorrhage ;* because the latter almost always com- mences with a genuine menstrual evacuation, which continues for two or three days, and is then followed by a discharge of pure common blood; all of which, by careless observers, has been classed under an " immoderate flow of the menses." ' Should this confusion be admitted into the description of this complaint, we need not be surprised at the avowed frequency of immoderate menses. There is an almost endless variety of uterine constitution, if I may so term it; consequently, there will be a corresponding va- riety in the performance of its duties; hence, one woman will dis- charge twice or three times as much of the menstruous fluid.as another, without suffering from this apparent excess. For, as re- spects this discharge, excess must be regarded as a relative term ; and it should only be considered excessive, when it has an inju- rious effect upon the general health ; if it produce no debility, or other disagreeable symptoms, we have no right to call this dis- charge immoderate, or excessive ; for it is only so, as compared with those who may evacuate less, but yet be in no better health. I must therefore repeat that this discharge, in excess, is of very rare occurrence; and that, so long as it does not impair the con- stitution, it should never be meddled with; especially if it be not inimical to impregnation. I am well acquainted with a lady, who has more than once assured me, that from her earliest recollections of this discharge after it had commenced, (which was at her twelfth year,) she never enjoyed a longer exemption from it than ten days, unless * Mr. Burns says, "some women menstruate more copiously «r more frequent. ly, than by the general laws of the system they ought to do. The discharge is menstruous, and does not coagulate, which distinguishes this state from uterine hemorrhage." Voi. I. p. 155, James's Ed. 120 IMMODERATE flow of the menses. she was pregnant, or suckling; yet, during the whole of that time she had never suffered the slightest indisposition, that could be attributed to that cause: she was, therefore, two-thirds of her time, with the exceptions just mentioned, giving issue to this dis- charge. She also declared her belief, that, from what she could learn from others, she evacuated daily, as much as women in general; consequently, she must have parted with at least three or four times as much as is commonly lost during a common period. Should this complaint prove excessive, jr in our acceptation of the term, namely, where health suffers from this cause, it should be treated, perhaps, as a hemorrhage, properly so called—I say perhaps; because, I have seen but one case, where, from the quantity of the discharge, debility, and other evils were induced; and this case was treated as a common hemorrhage. Miss----, aged seventeen, was seized with a severe tertian, which, before it could be arrested, required much depletion, and left her for some time in a state of great weakness. After it was thought she was recovered, her menstrual discharges became very abundant, and recurred, as they were always wont to do, every three weeks. The quantity discharged was very great, as far as could be determined by the pulse at the time, and its appear- ance upon the cloths. She was very feeble, and was confined to her bed from weakness, before I visited her. I saw her when her menstrual period was upon her; she was greatly reduced in strength, and was much emaciated. Her pulse was frequent and weak; her feet and hands cold ; she was extremely pale ; distressed by palpitation of the heart; ringing in the ears; and great sickness of stomach. She was immediately ordered to have bottles of warm water placed at her feet; to take thirty drops of laudanum, with as much of Hoffman's anodyne liquor; two grains of the sugar of lead, with a third of a grain of opium, every hour, until the dis- charge should be moderated. The character of the discharge I was particular to ascertain; and from the most cautious exami- nation, I had no hesitation to believe, (contrary to my first im- pression,) that it was a genuine menstrual flux, of unusual severity. By the plan just mentioned, the discharge was much moderated in the course of a few hours; but early the next morning, I was sent for in great haste, as the flow had very much increased. I now ordered twenty grains of the sugar of lead, a tea-spoonful of laudanum, and a gill of lukewarm water, as an injection—this quickly arrested the discharge;, which did not return from that time; if we except a very moderate stillicidium of three or four days' continuance. In the interval, a nourishing diet was directed —quiet, and a mattress to sleep upon; also twenty drops of the elixir of vitriol, in strong, sweetened rose-leaf tea, four times a PAINFUL MENSTRUATION. 121 day, and the bowels kept open by small but repeated doses of the sulphate of magnesia. On the arrival of the next period, she was again attacked with a flow as abundant as on the former occa- sion ; the same remedies were again successfully employed. During the succeeding interval, two grains of the sacch. sat. every morning, noon, and evening, were ordered in lieu of the vitriol; she was directed to drink freely of cold chamomile and orange- peel tea; a plaster of Burgundy pitch to be applied to the back ; and the legs and feet to be kept very warmly clothed. The next discharge was considerably more moderate, but still too abundant; the sugar of lead pills were now given every two hours until the flow should cease. The interval was conducted as before ; and, after this time, there was no farther necessity of medicine. Exercise, and sea-bathing, very soon confirmed her health ; nor did she afterwards suffer any return. The plan just detailed proved successful in the instance men- tioned ; but whether it would be so in other cases, my limited experience in "excessive menstruation," will not permit me to declare—though I am disposed to think it might; and, under similar circumstances, I should certainly adopt it. Sect. IV.—4. Dysmenorrhcea, or Painful Menstruation. This disease is very common in our climate ; and is one from which not only-great suffering is experienced, but also very fre- quently one of great obstinacy. The woman is obnoxious to it during every part of the menstruating period of life. It would, perhaps, be very difficult to assign all its remote causes : the most common are the application of cold during the flow of the menses; taking cold after abortion ; and, in several instances, I have known it to follow the consummation of mar- riage. This latter cause is, perhaps, the most difficult of expla- nation ; for it would seem to have no such agency, reasoning a prion. In a number of other instances, the causes appeared to be so hidden, as not to be cognizable. The married and the single woman are alike subject to it. The suffering, at the menstrual periods, is sometimes severe beyond description: it resembles, in intensity the pains of labour, or of abortion, properly so called ; for, to either, the case may be said to have a strong analogy. It usually commences by a slight menstruous discharge, which is pretty suddenly arrested: pain now almost instantly ensues; this is described by women to be of a forcing bearing down kind ; returning at longer or shorter intervals, until a membranous substance, or small coagula, are 11 122 PAINFUL MENSTRUATION. discharged.* If it be a membranous substance, it will be found of unequal size, sometimes small, at other times large, and some- times it resembles the cavity from which it has been expelled ; at other times it will be broken into many fragments. After the expulsion of this substance, the woman enjoys ease, unless there be a fresh production ; in which case it requires, for its expulsion, fresh contractile exertions of the uterus. The quantity discharged is very various ; sometimes it is small, and at other times very abundant. I have seen a portion not much larger than my nail; and, again, I have witnessed as much as would fill a large tumbler. The periods employed for the ex- pulsion of this substance also vary ; sometimes requiring but a few hours, at other times several days. The degree of suffering is not always in proportion to the quantity of the substance ex- pelled ; indeed the pain would rather appear to be less, when much is discharged; which perhaps, is not of difficult explana- tion. There appear to be two distinct states of this affection : one, where the mammae sympathize with the uterus, by becoming tumid and oftentimes extremely painful; the other is, where there is no such affection. These two conditions are not equally ma- nageable : the one accompanied with painful breasts, so far as my observations have gone, is the more so of the two. Dr. Eberle, in the paper just alluded to, confirms the correct- ness of these observations, and offers the following exposition of this sympathy. He observes that I have offered no explanation; but he thinks it admits of one, and saySj " I have obseived, for instance, that in nearly every case, where the breasts become tumid and painful, the concreted pseudo-membranous substance, (if any is cast^ff,) is thick, and of much consistence; and in those where the mammae do not sympathize, it is usually thrown off in the form of a thin membrane. In the former case, the uterus is much more distendefd, approaching the condition of early pregnancy ; and we may presume that this state would be most * It is to be lamented that gentlemen who quote the opinions of others, should not give such opinions fairly. Dr. Eberle, in " offering some remarks upon the pathology and treatment of dysmenorrhcea," (Western Journal,) states that " some writers, and among these, Dr. Dewees, seem to think that this complaint depends invariably on the formation of a pseudo-membranous substance over the internal surface of the uterus, by which the orifices of the menstrual exhalents are ob- structed." Now it is only necessary to compare the text with this quotation, to absolve the author, at least, from such % sweeping assertion, and to prove how carelessly Dr. E. must have read,—for I neither say that the formation of a mem- branous substance is essential to dysmenorrhcea, or intimate that " the orifices of the menstrual exhalents are obstructed." I mention that either a membranous substance or coagula are formed, and I believe that this obtains in all cases of un- complicated or idiopathic dysmenorrhoea—when pain attends the menstrual pro. cess, without either of these products, it will be found that the patient is labouring under the " irritable uterus," and not dysmenorrhcea. PAINFUL MENSTRUATION. 123 apt to awaken the uterine sympathies, and thus to excite the mammary glands." To this explanation we would urge the following objections— first, that we have never observed the connexion between the condition of the mammae, and thickness or thinness of the "pseudo- membranous substance;" for we have known this sympathy to take place where the quantity discharged was very small, and we have known it absent where this product was abundant, and where even small cogula were discharged. Secondly, because Dr. E., himself, admits the same thing, virtually: for he says, that " in nearly every case where the breasts become tumid, the concreted pseudo-membranous substance, (if any is cast off,") &c. Now, is it not evident, that the doubt conveyed by the words " if any is cast off," implies that he has seen instances of mammary sympathy, without this substance, (either thick or thin,) being cast off? And if this be so, what becomes of his explana- tion, since it altogether depends upon the thickness and consist- ency of the false membrane ? Thirdly, because we do not con- sider the substitution of one inexplicable phenomenon for ano- ther equally inexplicable, as an explanation—for suppose this membrane should irritate the uterus so as to cheat it into the be- lief, that it was " approaching the condition of early pregnancy," has he informed us, or does any body know how this change is effected in the mamma?, by every conception ?" We ara all aware of the fact, but we can offer no " explanation" of it. Fourthly, assuming Dr. E's. " explanation" to be correct, does it inform us why such cases are the most easily relieved ? Besides the alternate or labour-like pains, just mentioned, there is almost always a permanent one in the back, hips, and loins, which continues until the alternate pains have ceased; indeed, this aching pain sometimes precedes the other, and announces the discharge to be at hand. In another place, I have declared, that the menstruous fluid is the product of a secretory process ;* I have there given my rea- sons for this opinion ; I now assume it as a principle ; and upon this principle, attempt to account for the formation of the mem- branous production, so often yielded in dysmenorrhcea*. But, be- fore I attempt an explanation of the formation of this membrane, I must again direct attention to a very remarkable circumstance in the character of the menstrual blood, namely, its not possess- ing the property of coagulation. From this, it appears that the blood, or a part of it, has suffered some change by the action of the uterine vessels; and that this change has been imposed upon the coagulating lymph, by the process of secretion. I have as- signed reasons for this change, when speaking of menstruation.! * See p. 90. et seq. t See p. 89. 124 PAINFUL MENSTRUATION. Now, it is not difficult to suppose that the uterus, like every other organ, may have its functions or actions changed, or altered: in consequence of which, the texture of the coagulating lymph, instead of being so subdued as to prevent coagulation, as it is wont to be when the uterine secretory action is perfect, remains nearly the same as when it entered this viscus ; except that it may be attenuated, as in some inflammatory diseases: and it will, from this imperfect elaboration, be thrown into the cavity of the uterus, without being dispossessed of the power of separation, and of coagulation. It is poured into the uterus in a very gradual manner ; and from this circumstance, may tarry there sufficiently long to separate into its constituent parts: for it now resembles common blood ; the coloured part, or red globules, from their greater weight, will leave the imperfectly subdued coagulating lymph, and fall to the bottom of the uterus, and, sooner or later, be discharged ; while the coagulating lymph, either in part or altogether, will be left to spread itself over the internal face of the uterus, and there quickly assume, as is usual with it when in contact with living parts, the appearance of a membrane.* This membrane will be, to all in- tents and purposes, an extraneous substance to the uterus ; and will sooner or later urge it to repeated contractions, to throw it off; which contractions will be painful, like those of labour : hence, the pain in this kind of menstruation. ■ Dr. Eberle considers this explanation as contrary to sound pa- thological principles, and to the import of the essential phenomena of dysmenorrhcea, and proves this by ringing the changes upon the word " Impaired." Now, this word, as connected with the other portions of the text, does not mean " weakened" but merely altered, or changed; and if this explanation of its meaning be accepted, Dr. E's objection to the pathology offered, is not per- haps so irreconcilable as he appears to think. Besides, we must again accuse the Doctor of reading carelessly, or else of wresting the meaning of our words. He adds, that " Analogy also affords us good grounds for this opinion ;" (namely, that in dysmenor- rhcea, the uterine system approaches to a state of inflammation.) "Lymph is never thrown out so as to form membranous concre- tions, except from inflamed or highly irritated surfaces." To the objections of Dr. E., we would observe, first, that we have never pretended to point out the pathological condition of the internal surface or other portions of the uterus, in dysmenorrhcea * Morgagni explains the production of the membranes formed in the case he relates, differently, but perhaps not more satisfactorily. He says, " It was easy to conceive, that the viscid particles of the serum of the blood, issuing from the uterine orifices of the vessels, which had formerly been discharged in the form of a fluor albus, were now become more viscid, and adhered to all the internal parie- tes of the uterus, and by this means were concreted into a polypous membrane. Epist. xlviii. art. 12. PAINFUL MENSTRUATION. 125 —all we have advanced is, that some change was effected in the secretory surface, and that, instead of the fluid discharged during the-menstrual period, presenting the appearances it is wont to do in the healthy condition of this surface, it permits a separation of its constituent parts, thus proving some change or imperfection in the action which produced it. Now, whether this be owing to inflammation, or high irritation, we have neither declared nor de- nied. Secondly, we have in no part of this chapter, declared, intimated, nor do we believe, that " lymph." alone is poured out, as from inflamed surfaces, in dysmenorrhoea: on the contrary, we have expressly stated, that the lymph and colouring matter of the blood were both present in the healthy menstruousfluid—but that in healthy menstruation, the lymph was altered by the process of elimination, as it no longer coagulated; but not so in dysmenor- rhoea. Thirdly, that Dr. E. is at variance with himself; for, he first attempts to show, that the phenomena of dysmenorrhcea, de- clare, that " the whole uterine system is morbidly increased, and that it approaches to the state of inflammation." To prove this, he says, there is a " sense of fulness and pain in the pelvis, loins, and thighs—the accelerated, and often tense pulse—the hot and feverish skin, decidedly indicate a congested and irritated state of the pelvic organs." We shall not remark at present upon the fidelity of this history of symptoms, as the assumption of their truth will best at this moment serve our purpose—which is, to show what we have just asserted, that Dr. E. is at variance with himself. Now, we will ask any candid person, at all conversant with pa- thology, whether the Doctor has not made out clearly, that in dys- menorrhcea, there is both an inflamed and highly irritated surface, in the uterine cavity. Yet he wants to prove, that there is no lymph poured out; because, "lymph is never poured out so as to form membranous concretions, except from inflamed or highly irritated surfaces!" The treatment of this complaint consists in the temporary, and the permanent; the first consists in the administration of remedies to relieve pain at the commencement of, and during the attack ; and the most efficient, and uniformly certain for this purpose, that I have yet discovered, is camphor in sufficient doses; the follow- ing is the formula I generallly use:— R. Gum. Camphor. 9i. Sp. vin. rect. . q. sf. pulv.-—Adde Pulv. G. Arab. 3'u Sacch. alb. q. s. Aq. Cinnara. simp. 31. M. One-half of this draught is to be given the instant pain is ex- perienced; and if it be not relieved in an hour or-two, the other 11* 126 PAINFUL MENSTRUATION. halfistobe given—this quantity, however, is not always suffi- cient to subdue pain; in this case let the mixture be repeated— or the same quantity of camphor may be finely powdered, and given in ten grain doses every hour, mixed in a little sirup of any kind, until relief be procured. Sometimes the stomach" is much deranged in this complaint, and will suffer nothing to remain upon it; when this happens, I order twenty or thirty grains of camphor to be rubbed down with a few drops of the spirit of wine to a very fine powder; one drachm of laudanum ; and three ounces of thin starch or flax-seed tea, as an injection per anum. The quantity of this medicine may be varied according to the exigency, and may be repeated agreeably to the necessity of the case. Should this be too suddenly discharged, or fail in giving relief, it may be repeated. Opium in various shapes, has also been administered; either alone, or in combination with camphor, or ipecacuanha. The ergot has also been recommended. I have tried it; and, with one exception, it has failed. It must, however, be declared, that my experience in the use of this substance has not been exten- ^ sive ; and even in the few trials I made, perhaps I may not have given it a fair chance. These doubts have lately arisen, from two or throe of my friends telling me it had been entirely suc- cessful with them ; and, also, from a case of success occurring within a short time in my own practice. As the case was un- usual, by combining with it a rare occurrence, namely, menor- rhagia, I will relate it. In October, 1S25, Mrs. —— applied to be relieved of painful menstruation, together with an immoderate discharge of blood. The pain appeared to be produced by the discharge of coagula ; at least there was no appearance of membrane in the fluid she passed. She also had leucorrhoea to a considerable extent. I ordered her the ergot in the following form :— R. Pulv. secale cornut. gss. Ext. gentian. ^i. M. f. pil. xv. One every morning, noon, and evening. She began the use of pills.about a week after a period, and continued them until the next made its appearance. At this time she found herself much relieved, both as regarded pain, and the quantity discharged. The next period was still better ; and since, she has had no farther trouble. Warm bath, pediluvium, and bleeding, have also been prescribed ; but nothing has suc- ceeded with me so well as camphor.* * In severe cases, or those which resist the camphor or laudanum, might not the hydrocyanic acid be useful ? I am sorry to say, that I cannot answer this query in the affirmative at present. PAINFUL MENSTRUATION. 127 The radical treatment consists in the exhibition of remedies in the interval, with a view to prevent the recurrence of paffl—the one which has proved most successful, is the volatile tincture of guaiacum, given as directed in suppressed menses. The same regard to the state of the system as is there recommended, is also here insisted on. Perseverance, for two or three months, is oftentimes necessary. I think I have observed that this medi- cine is more decidedly useful, where the first menstrual period, after its use is more than usually severe. This has been pretty uniformly found a favourable sign. Though the tincture of guaiacum has been generally success- ful, it has not been uniformly so.* In two instances where it failed, the ext. cicutae succeeded: and in one other-where it had not been successful, the tincture of cantharides gave perfect re- lief. I have never met with a case of fruitfulness where there was a discharge of membrane, though Morgagni relates one in which it was otherwise.! As this is a rare and curious case, I shall take the liberty of introducing it. " A noble lady, of tall stature and good health, had suffered several miscarriages in the early part of her pregnancies; but between these miscarriages, she would carry her children to the full time. She sometimes had twins, and very difficult labours. She was also troubled slightly with leucorrhcea. Of this she had become well about her thirty-fourth I have used this substance but a few times, and then without the slightest advan- tage. The acetate of ammonia has been vaunted in this complaint; but it has entirely failed in the two or three trials I have made of it, though given in much larger doses than has been recommended. I have lately seen the muriate of ammonia much lauded in the paroxysms of this complaint; but have not yet made trial of it. The doses are from eight to ten grains, and taken pro re nata. * This remedy in the hands of others, 1 learn has not been equally successful. I can only account for this in one of two ways: first, they have not, perhaps, prepared it as directed ; secondly, and the most-probable, they have not persevered sufficiently long in its use; for it is still successful in most cases, in my hands. tit may be well to correet an error of quotation in this place, that has crept into a recent work. It makes me say, that no woman can conceive who is la- bouring under dysmenorrhcea; now, this is no where advanced by me. Yet I do not hesitate to say, that so far as my experience goes, I have never met with an instance of fruitfulness, where this membranous product was expelled.: I there- fore fully agree with Dr. Denman upon this point. Dr. Mackintosh seems to have, fallen into a similar error, when he thinks Dr. D. wrong upon this point; for Dr. D's declaration is precisely what we have stated above, namely, that a woman does not conceive when this membrane is produced—but does not say, that no woman conceives who is labouring under dysmenorrhcea; for to dysme- norrhcea, this membranous production is not a sine qua non; and where this mem- brane is not formed, impregnation may occasionally take place. Dr. Ryan renders this more probable than ever: he relates two cases, wherein he says the dysmenorrhcea was aggravated by marriage. These were instances of pregnancy occurring during its existence. But he observes, that neither dis- charged this membrane. So that the broad assertion remains uncontroverted,— that pregnancy docs not take place, where this membrane is discharged. 128 PAINFUL MENSTRUATION. year; but was afflicted, at each return of her menses, with pains resembling labour. About the second or third day she would discharge a membranous body of a triangular form, and which appeared to have filled up the whole of the cavity of the uterus. " The exclusion of this substance was followed by a great io- chial discharge ; it did not always come away whole; but when this happened, the lochia also followed. As the patient had abstained for some time from intercourse with her husband, and had suffered much, she began to think it would be more ad- vantageous to her, if she could be free from the pains for nine months at least, and determined to lie alone no longer; where- fore, in the month of March, 1824, she became pregnant, but only carried the foetus until June. "But in July, and the two following months, her menstrua flowed properly and without uneasiness. In October, she had no return of her menses; and the pains returned in November, with the discharge of a membranous body.' She continued to suffer from time to time after this, until the cessation of the menses put an end to it." Epist. xlviii. art. 12. It is evident that impregnation, took place in the instance above named; yet the patient miscarried at the third month, and was not made to conceive afterwards. It therefore forms only an ex- ception to the rule. I have seen a few instances of fruitfulness where there was painful menstruation, without this membranous production, but where a few small coagula were discharged. But such cases are rare. Does this disease reside in the ovaria, or in the secreting sur- face of the uterus? I believe it has its seat in the latter; and that its being unfavourable to impregnation, *is not owing to any influence it may exert upon the ovaria, (for I have reason to believe that ova have been impregnated, but not finding the uterus in a condition to receive- them, have perished:) but to either the imperfect or the non-formation of the decidua. I believe the same surface furnishes both the menstrual secretion, and the ef- florescence called the decidua; it would seem then to follow, if it performed the first of these offices imperfectly, it would also the latter; and, consequently, the ovum would perish for. want of a proper nidus. This opinion is strengthened by the facts, that so soon as this wrong action is changed, the woman is instantly capable of being impregnated; or, in other words, fecundation becomes success- ful ; and also by the influence of camphor, a temporary change is induced in the secerning vessels of the uterus, and the formation of membrane is prevented. Were it necessary, I could illustrate both of these positions by very many cases; but, as it is the most PAINFUL MENSTRUATION. 129 remarkable I have met with, I shall confine myself to one of the former. In 1791, I was applied to by a lady, who had always suffered at her menstrual periods ; and who, at such times, discharged a number of membranous portions. She had been married nine- teen years without being impregnated. After due preparation, for she was very plethoric, I put her upon the use of the tincture of guaiacum; in this she persevered for three months. The first period after she commenced the use of this medicine, was one of prodigious severity; so much so as to make her resolve on aban- doning.it. I, however, persuaded her to persevere. The next pe- riod was better ; and the one after wras without pain. She con- ceived immediately after, and was delivered, in due time, of a fine girl. She took twenty-four ounces of the tincture.* As this disease is one of great interest—one, to use the lan- guage of Dr. Good, " the frequent returns of which imbitter the life of the patient, and effectually prohibit all hope of a family," we feel it a duty to give to our readers the advantage of every suggestion for its relief that may come from a respectable source. We therefore copy Dr. Mackintosh's views upon this subject in lis own language. " It always appeared to me, that there might be some mecha- nical cause for dysmenorrhcea ; but it was not till the year 1823, that I first entertained a belief it might be owing to the small size of the os uteri. In that year a medical friend presented me with a preparation of the uterus and its appendages, in which the os nteri was so small as scarcely to admit a hog's bristle ; since that period I have had many opportunities of investigating this inte- resting subject, and have now obtained many preparations taken from the bodies of individuals who died of different diseases, particularly of phthisis, and whose histories prove that they had laboured under dysmenorrhcea from the very beginning of their menstrual lives. In these preparations of the uterus, the orifices, instead of being shaped like the mouth of the tench fish, are either circular or nearly so, and some of them are so small as only to allow a bristle to pass; others are a little larger, admitting a small silver probe. " I am far from alleging, however, that dysmenorrhcea is al- ways produced by a small os uteri; on the contrary, I believe it may occasionally depend on inflammation of the lining mem- brane of the uterus, as well as on inflammation in the substance of the cervix uteri, and on the encroachment of tumours dimi- nishing the caliber of the passage through the cervix. I only maintain that the condition of the os uteri, above described, ac- * We could furnish very many instances of similar success from the use of the guaiacum—indeed, more than a hundred. 130 PAINFUL MENSTRUATION. counts satisfactorily for many cases of dysmenorrhcea,.—so far as my investigations have extended, I am inclined to say, it will account for the majority; although in candour I must mention, that one preparation in my possession appears to invalidate the evidence afforded by the others; in it, the mouth of the uterus is very small, and yet the woman to whom it belonged had had several children ; she died in a public establishment, but the his- tory of her menstrual life is unknown. " By this condition of the os uteri, not onLy are all the pheno- mena which take place in dysmenorrhcea most satisfactorily ac- counted for, but also the intractable nature of the disease, and the unsatisfactory result of every mode of treatment hitherto re- commended. The menstrual discharge, after it is secreted in the uterus, cannot readily escape, in consequence of the small size of its orifice : distention of the organ is the consequence, which, by exciting the contraction of its fibres, produces uneasiness and pain in the pelvic region. When the os uteri is very small, and the secretion viscid, or mixed with coagulated blood, shreds of membrane, or organized masses, then the distention becomes more considerable, and stronger contractions are excited. Some- times the action of the abdominal muscles is called into play, and bearing dowm or expulsive pains, are produced, resembling in every particular the pains of labour, and continue till the ex- pulsion takes place. Mr. Burns, in speaking of the disease, states, that it ' sometimes produces, besides uterine pain, spasmodic affection of the bowels, or violent bearing down efforts of the abdominal muscles, as if it were intended to expel the wromh itself.' " During these periodical attacks, inflammation of the lining membrane of the uterus, if it do not already exist, is sometimes excited, and in the end the sufferings occasion an entire break-up of the constitution. That dysmenorrhcea should be so intracta- ble, and the action of remedies so very unsatisfactory as to ren- der the disease an opprobrium to medical science, are not to be wondered at, if my views be hereafter found to be correct. Be- fore I had any opportunity of putting these opinions to the test of experiment, .they also appeared to me to be corroborated in a very striking manner by two circumstances:—1. By the action of the ergot of rye, which increases the force of the uterine con- tractions, quickly expelling the contents of that organ, thus short- ening the patient's sufferings materially; 2. By the admitted fact which has been already mentioned, that women affected in this manner, rarely, if ever conceive. The small size of the os uteri renders impregnation almost an impossibility, by offering a me- chanical obstruction to the passage of the semen into the cavity of the uterus, where it is proved it must reach, by the accurate experiments of that ingenious and distinguished physiologist, Dr. PAINFUL MENSTRUATION. 131 Blundell of London, as well as by other facts which it is unneces- sary to mention in this place. " These views appear to me to be farther supported by several preparations in my museum; in one of which the cavity of the uterus is divided into two compartments, by a strong transverse adhesion; in a second, occlusion of the passage exists at the upper part of the cervix, which has every appearance of having been produced by the irritation of a polypous tumour; and in, a third preparation, the os uteri became sealed up by inflammatory action; oh dissection, the uterus was found enlarged, and con- tained about two ounces of puriform matter. " Treatment of Dysmenorrhcea.—After the facts and obser- vations above mentioned were collected, my mind became occu- pied with devising the best means likely to cure the disease. Me- chanical irritation appeared to be the only remedy ; but I hesi- tated for some years to carry it into execution, or indeed, to pro- pose it, beyond mentioning it in my lectures, till the case of the young woman affected with amenorrhoea, [quoted at page 105,] presented itself in the year 1826. Since that period I have treat- ed fifteen cases of dysmenorrhcea, by dilating the os uteri, and have permanently cured all the patients: among these the two cases of amenorrhoea, formerly mentioned, are not included. Of the fifteen patients, eight were either young unmarried wo- men, or living in a state of widowhood; seven were married, and living with their husbands: of these seven, four subsequently fell with child. " The instruments employed to produce the dilatation are the common metallic bougies, of different sizes from that of the ordi- nary small silver probe to No 8, or 10. The operation is per- formed, (the patient lying in the position in which women are usually delivered in this country,) by introducing the fore-finger of the left hand till it reaches the os uteri, for the purpose of di- recting the instrument to the part, which is then to be gently in- sinuated by a rotatory motion, till it arrives at the fundus of the uterus; much force ought not to be employed, and little or no pain is produced by the operation. The unpleasant consequences which sometimes take place in treating stricture of the urethra by similar means, viz. shivering, followed by fever, occurred in two instances; the fever, however, was slight, and soon termi- nated by copious perspiration ; and in these, some days were al- lowed to elapse, before the instrument was again used. In two of the cases, 'the os uteri was sufficiently large, and well shaped ; but the passage became so narrow in the course, of the cervix of the uterus, that it required long-continued efforts before the small- est instrument could be introduced; but by perseverance the ob- structions were at last removed, and the patient cured. In one of these last two, menstruation was performed without pain till 132 PAINFUL MENSTRUATION. after marriage, when dysmenorrhcea occurred. The other was a young unmarried woman, who menstruated with ease for seve- ral years, but after long exposure to cold and moisture, the men- strual discharge became for a time suppressed, and ever after was performed with pain. The late Dr. Kellie, of Leith, was also consulted about this case, and had I not been encouraged by his advice, I should not have attempted the operation ; as on the pos- terior lip of the os uteri, several small elevations, like incipient tubercles, were felt. This woman called upon me eighteen months afterwards in good health, and stated, that she had not felt any uneasiness, or experienced any bad symptoms since the dilatation was effected. I will not doubt the accuracy of these cases, but only inquire what became of the recrements of the several discharges of the menstrual fluid, which must have accumulated, one would think, after years of regularity, though not of ease, at these times—I ask, what had become of them? It is too much to suppose it absorbed though some countenance is given to it, in cases of imperforate hymen, as when the patient has been operated on, so as to discharge what was accumulated ; the quantity thus dis- charged, has been much less than the aggregate quantity se- creted at the regular periods for years. Suppose a twelve month to have elapsed since the female began to complain, and we al- low for each menstrual period, say four ounces, there would be about 50 ounces thrown off, a quantity too great to be absorbed, from one menstrual period to another. " A lady, the subject of one of the fifteen cases, was also per- fectly healthy, and menstruated easily till the period of marriage ; but her health became impaired soon after, in consequence of her monthly sufferings. On making an examination, an enlarge- ment was discovered about half the size of a chestnut on the pos- terior surface of the cervix of the uterus. I undertook the operation in consequence of the urgent entreaties of her friends, who hap- pened accidentally to know of the happy results of which had at- tended it in other cases, but I held out little hope of .being able to do any good: notwithstanding which a striking improvement in her health soon took place; and, this, in the end, proved to be one of the most successful cases, for menstruation became easy, the tumour rapidly declined, and upon making an exami- nation in about twelve months afterwards, it could scarcely be felt. "None of the women operated upon had suffered for a shorter period than two years; some for three or fou<-; and others for ten. Of the four who subsequently fell with child, one had been mar- ried between seven and eight years, and was reduced to a shadow from constant ailments ; but after the operation, she recovered her health, strength, and flesh, and became pregnant at about the ter- PAINFUL MENSTRUATION. 133 tarnation of nine months from the date at which the bougie was used for the last time. " Another had been married three years, and had suffered con- siderably in constitution, with severe nervous symptoms every month, till at last she became entirely obstructed; and the abdo- men being enlarged, I was consulted upon the supposition that she was five months gone with child. From some circumstances which it is unnecessary to mention, I entertained a suspicion that she had deceived herself; and upon making an examination, when she supposed herself to be in the seventh month, ascertained be- yond all doubt that this was the case. In the process of time, the operation was performed, and the passage completely dilated; some months afterwards, impregnation took place, and I have since delivered her of two children at separate births. "A third case is that of a lady who had been married, two years, and who had had painful menstruation from the first ap- pearance of the discharge; she was in a miserable state of health, had taken a great deal of medicine, but only with temporary re- lief. Impregnation took place after the third menstrual period subsequent to the dilatation. " The subject of the fourth case had also been affected from the first of her menstrual life, and laboured under the impression that she -was therefore never to have a child. After dilating the passages with No. 6, bougie, menstruation took place with so much ease, that she supposed herself quite cured, and would not again submit to the operation. Several months afterwards, how- ever, she felt a return of the pain, the operation was again had recourse to, and the dilatation carried as far as it could be effect- ed with No. ]0, which was accomplished two days before her expected period. Menstruation took place freely, and without the slightest uneasiness; she subsequently fell with child, and was delivered of a boy." We are certainly much indebted to Dr. M. for his novel illus- tration of dysmenorrhcea, though we cannot suppose his patholo- gical views to be applicable to all cases of this complaint. We shall therefore take the liberty to declare, that his history of this complaint, amounts to no more than as a variety of dysmenor- rhcea, and that this variety is most probably but a consequence of the previous condition of the internal cavity of the uterus, or of its neck ; namely, the result of previous irritation or inflamma- tion ; though we are not prepared to deny, that it may have existed as an idiopathic condition of the neck of the uterus. Our reasons for thinking that this " mechanical cause of dys- menorrhcea," is but a rare and secondary cause, are, First, that in many instances the woman menstruates regularly and health- fully for a long time; but from exposure to cold; upon marriage; after an abortion, or sometimes a labour, this painful condition of 12 134 DECLINE OF THE MENSES. the menstrual process takes place—in neither of which do we see how the os tincae can be so reduced in size, as to be only suffi- cient to transmit a bristle ; unless we suppose that either of the causes named is capable of producing so much irritation or in- flammation, as to cause the disorganization .just named; and, if this be admitted, the dysmenorrhcea thus produced is but a con- sequence of the previous irritation or inflammation. Secondly, if his first reason be admitted, it must give us strong grounds for belief, that the degree of irritation and inflammation capable of disorganizing the neck of the uterus, might also be sufficient to in- duce painful menstruation without this disorganization ; and that when this disorganization has taken place, it could only add to the difficulties, and not be the exclusive cause of them. Thirdly, that this last suggestion is rendered not only highly probable, but is almost demonstrated to be true, by the effects of camphor in temporarily relieving pain ; and by that of the guaiacum, perma- nently removing it—for we cannot suppose that the action of either of these-substances, would remove the " mechanical cause of dysmenorrhcea." Yet as we have just observed, we have seen very many cases of dysmenorrhcea removed by the guaiacum, and impregnation follow in married females. Nevertheless, we gratefully acknowledge the value of Dr. M's cases and his mode of treatment; and we shall certainly attempt to follow it in cases that are of unusual obstinacy, and where the patient will yield to the remedy. We are, however, far from thinking that Dr. M. strengthens his cause by citing the action of ergot upon the uterus, as a proof of the smallness of the os uteri; or by a reference to the experi- ments of Blundell. For the benefit derived from the use of the ergot, (if any do arise,) is from its increasing the power of the fundus and body of the uterus, to expel the foreign body that is within it—and which only proves an increase of power in these portions of the uterus, and not in any way under such circum- stances, that the neck of the uterus is narrower than natural. And, as regards the experiments of Blundell, they are far from being confirmative of the necessity of the presence of the semen irt the cavity of the uterus, that impregnation may take place, except, perhaps, to those who have this particular hypothesis to sustain. Sect. V.—5. Of the Decline of the Menses. The nearer a woman approaches her forty-fifth year, (ctzteris paribus,) will be the risk of some irregularity in the menses: and as this period is more frequently the one at which any latent dis- ease of the uterus shows itself, it is always looked forward to DECLINE OF THE MENSES. 135 with much anxiety by women: Indeed, so replete is this time with horrors to many, that we may very justly suspect appre- hension to be the cause of some of the distressing symptoms, which sometimes accompany this interesting process of the hu- man uterus. Delicate women, and especially those who have lived idly, have this period of life arrive earlier than those of a contrary consti- tution, and opposite habits. We have already noticed, in our section on suppression, that this change sometimes takes place at a very early period of life, and this without leaving any injurious consequences behind it: and, on the other hand, we find many cases on record, where this discharge had continued with regu- larity to a much longer period than the ordinary one. Gardien mentions a case which fell under his own notice, where this eva- cuation continued with great exactness, until beyond the seventy- fifth year; others, still more uncommon, are mentioned by various writers.* The reason of this discharge leaving the woman at this time of life, appears to be founded in" the highest wisdom and bene- ficence ; it is to prevent child-bearing beyond that period, at which the mother would be capable, from the common chances of human life, of extending her care to her offspring; and, con- sequently, submitting her child to the doubtful management of strangers, or subjecting it to the waywardness or caprice of those, who could not feel a parent's affection, nor yield a mo- ther's devotion to its necessities at a time when its helplessness would most require the kindest offices. This change is sometimes effected so silently, that the woman scarcely notices her altered condition; at others, its approach is so gradual, as not to attract observation, until the diminished quantity gives warning that it is about to take its leave for ever; while, again, the irregularity, both in period and quantity, may be such, as justly to give alarm, as well as to produce the most serious danger. But, as a general rule, it may be observed, that when the wo- man has attained about her forty-fifth year, she finds her menses to become irregular, both in the quantity of fluid evacuated, and in the periods they observe ; being sometimes in advance, and at others not appearing until long after the accustomed time. The woman also finds some alteration has taken place in her general health ; she becomes pale, debilitated, and nervous ; arising, how- * I have had, very lately, a lady under my care, who menstruates with the most perfect regularity ; though she had laboured under a prolapsus of the ute- rus to a great extent for :-cvcial years. She is now in her sixty-fifth year. Her uterus is now effectually supported by a pessary, which has much improved her general healih. 136 DECLINE OF THE MENSES. ever, for the most part, from the too frequent returns of this dis- charge, or its too great abundance. At this time, also, the woman sometimes becomes the victim of a strange illusion, should the menses not have returned for several periods; for she now supposes herself to be pregnant, as her abdomen enlarges, as do the mammae ; her appetite becomes capricious, or she has strange longings, &c, the whole of the rational signs of this condition being present, even, in her imagi- nation to the motion of the child. This delusion is most com- mon to women who marry late in life, and who are very desirous of offspring; more, sometimes, we fear, from an anxiety to give a proof of their youthfulness, than from a wish to become mo- thers, at their time of life. But this youthful hope is soon to be destroyed—and, perhaps, for ever. For now the breasts lose their intumescency ; the morning sickness vanishes ; the swelling of the abdomen subsides; the imagined stirrings of the foetus cease, or the sensation becomes so unequivocal as to satisfy that it arises from the movement of wind ; and, to put every thing beyond hope, the menses return in overwhelming quantity, and thus the poor woman but too certainly becomes the butt of the unfeeling and the ridicule of the unthinking. It is, therefore, highly proper, that practitioners, and especially the younger part of them, should be put upon their guard in respect to this condi- tion of the patient, and not too easily yield credence to all her wishes may dictate, or absolutely to treat as an impossibility, a circumstance of which there is occasionally an example.* It seems that the apprehensions of this period of life have arisen mainly from the notions entertained of the final cause of the menses: namely, that it gives vent to peccant humours. But females should be made to know, that all this is purely the theory of the vulgar; as the menstrual blood is formed from the general mass ; and, consequently, if that be pure, the other will be ; there- fore, the idea is altogether ill-founded. But unfortunately, when- ever this discharge is less abundant than usual, the most serious fears are entertained, that there will be a retention of a portion, which will cause disease, either in the uterus itself, or in some other part of the body: hence, a diminished menstruous secretion is always more alarming to the female, than an unusual flow. But it may be well to remark, that there is a great difference between the cessation of this discharge, and the suppression of it. In the one instance, it is an event which nature has designed should take place, and is effected altogether by arrangements of the sys- tem itself; and, of course, one of its natural processes ; in a word, as much so as its commencement; but the suppression, from * Women have conceived at much later periods, and given birth to fine off, spring. One we knew at sixty. One case I witnessed. DECLINE OF THE MENSES. 137 some morbid agency, is in direct opposition to the intentions of nature, and will, of course, be followed by some baleful conse- quence, if it'continue beyond a certain period. The vulgar error, that "women at this period of life are al- ways in danger," is replete with mischief to the suffering sex: and I feel it a duty to declare, that they are not necessarily more obnoxious to disease at this, than at any other period of their ex- istence.* That they are sometimes liable to a disease at this time ; and that disease one of the most terrible in the long list of human infirmities, I admit; but must, nevertheless, insist, that Cancer, (the disease to which I allude, and tbe one so much dreaded,) is more rare in the uterus than in certain other portions of the body; for instance, the mammae; and, perhaps, I am within the truth, when I say, that there are three instances of the latter, for one of the former. If latent dispositions to disease, either in the uterus or other parts, become active about this period of life, it is not because the declining menses excite them; but because the disease is slow in developing itself, and is, perhaps, kept in check for a long time, by the menstrual discharge serving as an important evacuation; especially when the uterus maybe the seat of the complaint. In such instances, the foundation of the dis- ease was laid, perhaps, at a time when the menses were the most perfect, as regards period and quantity; consequently, they could have had no agency in its production ; but on the con- trary, from its frequently relieving the engorgement of the ves- sels, served to keep it in subjection for a long time; not as a spe- cific discharge, but as a mere depletion; or, in other words, that if an equal quantity of blood could have been by any other means as certainly abstracted from the uterus, the same favourable re- suit would have followed. Coincidences in the human system are so common, that they are frequently mistaken for cause and effect: hence, the cessation of the menstrual discharge, and the appearance of scirrhi and cancers, are considered as cause and effect. At this period of life, nothing will so effectually secure the wo- man against injuries which may arise from the irregularities of the menstrual discharge, as a well regulated regimen. By regi- men, in this place, we would wish to be understood, not only eating and drinking, but exercise of both body and mind, including the proper government of the passions ; in a word, every thing which relates to both moral and physical existence. * Indeed, it would seem that this period of female life is freer from diseases causing death, than almost any other. By some late observations made on the bills of mortality in France, by M. Boiniston of Chateauneuf, it appears that fewer women die between the ages of forty and fifty, than men, or indeed at any other period of their lives after puberty. And, farther, that if this change is effected. without much disturbance, that they lived not only longer than men, but are freej from morbid inconvenience. 12* 138 DECLINE OF THE MENSES. A well ordered course of exercise in the open air in well selected weather, and great simplicity of diet, is of the utmost importance to the female at this period of life, and should never be neglected, if it be possible to indulge in them. By these means the nervous, muscular, vascular, and lymphatic systems, are all preserved more certainly in equilibrium with each other, since they are the best calculated to ensure a reciprocation of their respective of- fices; and, consequently, to maintain that condition of the system, termed health. Hence, the justness of the remark, that the wo- men who live in the country, and exercise freely in the open air; who have fulfilled their duties scrupulously as mothers, by suck- ling their children, agreeably to the views of nature; who do not goad their systems by over-stimulating food and drinks ; who do not relax their bodies by too long indulgence in bed, have but little suffering at this period. From this it will follow, that a milk and vegetable diet, toge- ther with pure water as a drink: regular exercise, not carried to fatigue; keeping the bowels open by well-selected food, as the fruits of the season in proper quantities; the bran bread, if ne- cessary ; but not by medicine, unless absolutely required. Govern- ing the temper; restraining the passions, as well mental as ani- mal, will largely contribute to the safety and comfort of this pe- riod. All that we have just recommended, is calculated to place the system in a condition, by which it shall preseive its various forces ; have its irritability diminished ; itssensibilitv moderated; and pretty certainly prevent that condition of the blood vessels, most decidedly unfriendly to the general health at this time, called plethora. And, though last, not least in fair estimation, is an at- tention to cleanliness. The external organs should be washed with lukewarm water at least twice a day, and the whole body once a week, by going into a lukewarm bath. In using the bath, care should be taken to come out of it as soon as the purposes of cleanliness are answered. Our next concern is with the derangement of the discharge at or about the period of cessation ; this will consist, 1st, in a diminution of the proper quantity; and 2dly, in an excess of it. As regards, the first, I have already said enough when treating of the suppression of the menses; and, with respect to the second, it must be treated according to the rules prescribed for the ma- nagement of hemorrhage from the uterus from any other cause ; that is, first, to diminish the quantity discharging; secondly, to prevent an excessive return. The first indication is best fulfilled by rest; by cool air, and drinks; by cold local applications; by the acetate of lead and laudanum; and by the use of the tampon.* We should imme- See Chapters on Uterine Hemorrhage, and Menorrhagia. DECLINE OF THE MENSES. 139 diately confine a patient so circumstanced to a horizontal position; and strictly forbid motion of every kind, even turning in bed. We should admit cool air with freedom where practicable; and give neither nourishment, nor drinks, except they be cooled— the latter may even be iced. Cold, applied to the abdomen, is frequently useful in excessive discharges of this kind; the best mode of applying it, is by large bladders not quite filled with water, in which there is ice, if it be in summer, or during hot weather; cold water alone will be sufficient, if it be winter: during the use of this, care should be taken that the feet and legs be kept warm. We should also give, by the mouth, two or three grains of the acetate of lead, every hour or two ;' guarded with a sufficient quantity of opium, or laudanum, or a scruple of it with a drachm of laudanum, and two or three ounces of water, as an injection—this is to be repeated pro re nata. And, should these not control the discharge upon fair trial, recourse must be had to the sponge tampon. I have repeatedly seen the discharge of blood at this period of life, so enormous and so rapid, as to threaten almost instant exhaustion. When thus excessive, it can only be met successfully by the most prompt application of the most efficient remedies. Whether this disease show itself in the rapid expenditure of fluid blood, or in the repeated expulsion of large coagula, it must be opposed by the same remedies—these two conditions present no difference of indication, nor any essential difference in the complaint itself: the former, however, generally requires more prompt interference than the latter, as more blood is expended in a given time. The second indication must be fulfilled by blood-letting; by purgatives; by hemlock; and by tonics. Notwithstanding the immense loss of blood, which sometimes takes place suddenly at each period of return of this hemorrhage, it does not prevent the almost continual draining off of this fluid, even when its violence is much abated ; hence, we sometimes find a greater or less dis- charge almost always present: this renders the woman not only feeble, but keeps her mind in a state of extreme apprehen- sion, from one period to another. These two causes, namely, the excessive discharge, and mental anxiety, keep the system in a constant state of excitement; and if the pulse be examined, it will be found quick and corded. We are, therefore, under the frequent necessity of abstracting a few ounces of blood during the interval of each discharge; especially towards the approach of the period the disease has assumed for its movements,—this, however, varies in different individuals ; and in even the same individual, if any error have been committed in either diet or exercise. But when all things are equal, we find the period pretty certainly marked; and it may be every three or four 140 DECLINE OF THE MENSES. weeks; or sometimes even longer. I have known two or three violent cases, where the discharge returned every two weeks. To aid the vessels to contract, we should confine the patient to a strictly vegetable diet; or to a diet of milk, if this should agree with her : all kinds of liquor, and spices, should be forbidden; and exercise absolutely prohibited. The patient should sleep upon a mattress; and should be directed to repose herself upon it, or a sofa, as often as she may feel a little weakened, or fatigued by sitting up. The feet and legs should, however, be kept warm ; and, if habitually cold, should be rubbed two or three times a week with spirit or brandy, in which a quantity of the flour of mustard is mixed, or use the mustard bath. (See note to page 146.) The bowels should be kept open, by diet, if possible, as just suggested, or by the exhibition of some mild purgative, as rhu- barb, sulphur, magnesia, or any of the neutral salts. Against the use of aloes there is much clamour; but, I have some reason to believe, without just cause. I do not wish by any means to de- termine the point at this time ; as my experience in its use is yet too limited to decide with certainty, though my favourable im- pressions continue to be strengthened. I think it proper, how- ever, to direct the attention of the practitioner to it, that I may be aided by the experience of others, in determining the powers of this medicine—but I will relate what I know upon the subject, and leave it to the farther employment of this drug, either to con- firm, or destroy my present opinion. Folhergill and Gardien are decidedly opposed to its use. A lady, aged forty-two years, for whom I had prescribed al- most all the known remedies for the hemorrhage under conside- ration, with very little benefit, was told by some old woman, that the hiera picra was a certain cure in her complaint: she men- tioned this, and I very candidly stated my own, as well as the general prejudices against the principal ingredient in this com- pound ; but at the. same time, observed, that as the old woman who had recommended it, cited the cases of two or three ladies who were relieved by it, and who were known to her, it would be easy to make the inquiry, and, if it were as she stated, it would be well to give it a trial, as every thing else had failed—the medicine was warmly recommended by these ladies ; and she proceeded to make use of the old woman's prescription ; which was half an ounce of the hiera picra to a pint of gin ; of this a wine-glassful was directed at bed-time—it was taken, and the lady was completely intoxicated all night, and very sick next morning. Thinking the effects would next night be less severe, she again ventured on it, and with similar results. She was now determined to abandon it, unless some less ob- jectionable mode could be adopted for its exhibition—I pre- scribed it for her in the manner following: — DECLINE OF THE MENSES. 141 R Hiera Picra. gij. 01. Caryoph. gut. x. Sapd Venet gr. xij. Syr. Rhaei. q. g. M. f. pil. xl. • One of these was directed every morning, noon, and evening, unless they should prove too purgative—this did not happen, as the patient was of an extremely costive habit. She soon per- ceived, after she began the use of this medicine, a diminution of the discharge; and by the time she had finished the pills, pre- scribed above, it was so much reduced in quantity, as to give no farther uneasiness. Since this case, it is proper to state, that several of a similar kind have been under my care, with the same results from the same means. Several cases, of less severity, were entirely relieved after the use of the same formula: from this it appears, that in a number of cases in which this remedy has been prescribed, the patients got well; but the precise agency of the medicine remains to be determined by future observation. I am, however, convinced of the importance of pretty constant, but gentle purging, in this oftentimes tedious complaint. One of the most successful general remedies I have employed, is the extract of cicuta; beginning with a minimum dose, and increasing it gradually, but at the same time, as rapidly as the system will well bear. When decided marks of its influence, such as vertigo, headach, or sickness of stomach, begin to show themselves, the dose is not to be increased until they go off: when this happens, an increased dose may be given; and so on, until the complaint has so far yielded, as to render its farther exhibition unnecessary, or until we are convinced that it will not succeed in arresting it. I have thought this medicine most useful in those cases where the discharge was chiefly by coagula. I have used the secale cornutum in tincture, with great advantage, in some instances of this kind, though, by no means, so certain as in the more active uterine hemorrhages. A small tea-spoonful, every four or five hours, in sweetened water, has, in some cases, put an almost immediate stop to the discharge : in obstinate cases, it always deserves a trial. No class of medicine has done so much mischief in the com- plaint I am now treating of, as tonics—and this from a wrong view of the disease in question; for it has been treated as one of debility; consequently, all the most powerful tonics have been put in requisition for its cure. Bark, steel, wine, and all the bit- ters have again and again been unavailingly tried, and oftentimes the patient abandoned to the ravages of this disease, because it could not be conquered by tonics—the opposite mode of treat- ment, with such views, would necessarily be considered as death to the patient, and of course, would not be employed. 142 DECLINE OF THE MENSES. I well recollect a case where three pounds of bark had been taken in less than two months, with a proportionate quantity of the elixir of vitriol, to the manifest increase, of the disease: this patient was afterwards entirely cured, by an extremely low diet, gentle purging with neutral salts, quiet and repeated blood-let- tings. I must, therefore, caution the young practitioner against the use of tonics in such cases, though they may be attended by absolute weakness in the muscular system; for the state of the vascular system alone is to be attended to; and here a corded pulse must not be mistaken for a weak one, because it may hap- pen to be a small one. But how shall we reconcile the contend- ing opinions of the pathology of this complaint, and that of the suppression of the menses with each other? It is insisted on, by many that it is the debility of the extreme vessels that prevents the formation of the menses when they are suppressed; to over- come this, tonics and stimulants are advised. In the memorrhagia of this period of life, the cause of the too abundant flow is debility ; and tonics and stimulants are here recommended to restrain the excess of discharge! With respect to the preparations of iron, I have perfectly con- vinced myself, that they can never be usefully employed during the active state of any hemorrhagy: in my hands they have pever failed to do mischief: I have not used them, therefore, for many years, in the cases of which I am now speaking. The use of wine, I am also certain, has done mischief: it is port wine alone, however, that has any reputation in such cases; and this has arisen from its possessing a slight astringent property^-but this must also be strictly forbidden. The bitters will fall under a slighter censure than the barks; because they are generally much less powerful: the same objections, however, attach to them, but in a minor degree. Tonics are only admissible where there is nothing but debility to contend with ; they may then be advantageously employed, in properly regulated doses. The diet may now consist of more generous living; and when well ordered, and properly pursued, may be looked upon as the best possible tonic. Hitherto, I have been considering the severer forms of this complaint; I shall now say a few words upon the occasional ir- regularities of the menses, both as to period and quantity. The periods of return may be anticipated, or protracted ; and the quantity may be very small, or more or less excessive ; or it may employ a great many days for its evacuation, without the aggre- gate quantity being very great. I have constantly advised against any interference at this period of life, for mere irregularity, or ir- regularity with a diminished discharge; and for this plain rea- son that no other inconvenience is experienced: and this is so trifling, as not to merit consideration. But if, with the irregu- DECLINE OF THE MENSES. 143 larity, the discharge be too abundant, I treat it as directed already for hemorrhage, and try to prevent the recurrence, by bleeding a little before the expected return, a low diet, and purging with the neutral salts: these means rarely fail to give relief. When a great many days are employed in the discharge, or as the women term it, " being almost constantly unwell;" and where the aggregate quantity may not greatly exceed the common monthly amount, I have frequently succeeded by the tincture of rathany in two-drachm doses, three or four times a day. Gardien speaks in very high terms of the " rathany." He thinks it merits more confidence than the alum, the sanguis draconis, the kino, the nutgalls, or catechu. He says that M. Ruitz used both the extract, and the decoction of the root of the rathany.* The ex- tract should be given in doses of half-drachm or a drachm. In severe cases, it may be given to the amount of two drachms a day.f Agreeably to M. Ruitz, the second or third dose rarely fails to produce the desired effect. The remedy should be con- tinued some time after the discharge has ceased ; but the quantity may be gradually diminished. To prevent the nausea which its bitterness sometimes creates, he advises the mouth to be rinsed with lemonade. Frequently bathing the parts with cold water; abstaining from too much exercise; and refraining from a stimu- lating diet, are of much consequence to the cure. The alum whey y has often been useful in similar cases, and deserves a trial; the sugar of lead, in small doses with opium, given daily for some time, has many times answered every end4 In every form of the disease under consideration, I have thought, that very decided advantage has constantly resulted from injections of the solution of the acetate of lead thrown up / the vagina several times a day ;§ except during so profuse a flow of blood, as to render the use of the tampon necessary.|| It may * We allude here only to such cases, as have no organic lesion to account for their irregularity; we shall notice the other aberrations in other places. + I have, of late, substituted the extract for the tincture, and give it in the fol- lowing form:— Jfc. Ext. Rathan. gij. Pulv. Rhsei. 3ss. Syr. Rhsei. q. s. M. f. pil. il. Of these, two are directed to be takm every morning, noon, and evening. It will be seen that I do not give it in any thing like as large doses as M. Ruitz, having found the quantity prescribed above to answer; I, however, should not hesitate to give ii m much larger quantities, if it were necessary. t The prejudices against the use of the sugar of lead appear to be ill-founded: we have given it very often, without witnessing any inconvenience, except in one instance; in this case it had been too long continued: it produced obstinate vomiting. § The injections should be made of two drachms of the sugar of lead, to about a pint and a half of water. || I lately succeeded iu arresting a constant «nd long-continued flow, by injec- tions of warm alum waUr. A half ounce of alum to a pint of water, was used. 144 DECLINE OF THE MENSES. also be proper to remark, that the sponge, or tampon, should not be suffered to remain within the vagina longer than ten or twelve hours at a time. When taken away, it should be carefully wash- ed with soap-suds; and before it is again returned, it should be imbued thoroughly with vinegar ; or, if it can be procured, with the pyroligneous acid: on this account, there should always be two pieces of sponge. We have already adverted to the fact, that if there be any latent disposition in the system to produce scirrhus, or to convert scirrhus into cancer, that it most frequently manifests itself at this period of life ; hence, as before observed, the dread the woman has of the " disappearing of the menses." And this is especially the case, when the uterus is the seat of the affection. We have also declared, that this manifestation of disease, at this time, is not the direct consequence of this change in the uterine surface; .but because a powerful local means of preventing congestion in that organ, is now removed by the menstrual fluid not being formed to relieve the engorged state of the uterine vessels. It is highly probable, that the congestion which always pre- cede the menstrual discharge, would continue to take place from time to time, though the menstrual secretion might be interrupted; and this congestion not being relieved as before, may induce a part already strongly disposed to diseased action, to take on in- flammation, and hastily develope scirrhus, or cancer. On this account, it is important that females should so regulate their re- gimen, as to prevent any thing like undue excitement in the arte- rial system ; for this end it is necessary to reduce the quantity of nourishment; to adopt a properly regulated system of exercise, to govern, or control moral influences. By these modes, we are persuaded that the predisposition to these dangerous affections can be kept long in subjection. And, as the disposition of the system at this period strongly inclines to plethora, this state must be carefully guarded against, by every means capable of such an effect. Therefore, besides the rules suggested for the " regimen " of the woman, she must lose a few ounces of blood from time to time, if the pulse and other symptoms declare this state to be present, or if there be a well marked tendency to it. The blood may be abstracted from the arm upon common occasions ; but if there be pain in the re- gion of the pubes, back, hips, and rectum ; and especially if this be of the lancinating kind, accompanied by a sensation of heat about the seat of the uterus, it should be taken by leeches, or by cupping, as near the parts as it can well be drawn. The top of the sacrum, just over the pubes, the groins, or the labia puden- di, are the best places.* The bowels must be gently, but regu- * For the last two years, we have directed the leeches to be applied to the in- side of the thigh, about its centre ; so also, for the cupping. It is rury much le«s« DECLINE OF THE MENSES. 145 larly purged by neutral salts; and the woman should be confined to a very strict diet; she must also avoid all kinds of exertion during this commenced state of excitement. The patient should be attentive at the same time to cleanliness, as before directed ; especially, as will most probably be the case, if these symptoms be attended by leucorrhcea. If these measures be rigorously adopted, add steadily persevered in, there is much reason to believe, that this congestive condition of the uterus will be much relieved; and, of course, the evils arising from it dimi- nished, if not altogether subdued. A variety of other affections show themselves at the period we are now considering; such as eruptions, erysipelatous inflamma- tions, rheumatic pains, swelling of the lower limbs, violent head- ach, and a great variety of nervous or hysterical symptoms. None of these require any peculiarity of treatment, except that the loss of the menses, and the tendency to plethora, must always be kept in view. It must, however, be remarked, that though hysterical symp- toms are wont to disappear about this time, and to be sometimes even violent, owing to an augmented sensibility of the nervous system, yet this complaint almost always disappears, so soon as the system becomes accustomed to the change in the nature of the circulation, and its more general determinations over the other parts of the system. It is highly important, that the cutaneous circulation and sen- sibility be properly preserved; for this reason, the woman should avoid all causes which may tend to impair them; such as cold damp places; too humid an atmosphere; too thin, or wet, or damp clothing, or partial draughts of air. To main- tain an equality of excitement of the circulation, she should wear flannel next her skin, and carefully protect her feet and legs, by shoes of a proper thickness; and stockings of a proper quality. Should she be habitually subject to cold feet, she should employ the mustard bath at least twice a week, so long as this symptom continues.* inconvenient, and is certainly, to say the least, as efficacious. I think, we have paid too little attention, in this country, to the practice of the French physicians upon such occasions ; they almost always apply leeches at a distance from the af- fected part, upon a well-founded belief, I am inclined to think, that a revulsive effect is thus produced. * The mustard bath is made by putting two or three tables-spoonsful of the flour of mustard, to a gallon of warm water. The feet are to be put in this just before getting into bed for the night, and rubbed until they glow. 13 146 MENORRHAGIA. CHAPTER VII. OF MENORRHAGIA. By this term, we would understand an immoderate discharge of fluid blood, properly so called, or coagula, or both, from the internal cavity of the uterus; recurring at the menstrual period, and following the secretion termed the menses. I have already said, that this discharge consists of blood, pro- perly so called, in contradistinction to the fluid yielded by the internal uterine surface every lunar month, called the menses. When treating of the catamenia generally, the difference between the menstruous fluid and the circulating blood, was insisted on ; and it is important, that this distinction be preserved, that two different conditions of the uterus may not be confounded.* It will probably ever remain a matter of doubt, whether the blood which is expended in menorrhagia, be from the same ves- sels as furnish the menstrual fluid, or from a distinct set, which may terminate upon the internal uterine surface; nor is it, per- haps, at this moment, of very great consequence to determine, since it would not lead, with our present knowledge, to any prac- tical good. Reasoning, perhaps, would be against this identity; and would tempt us to believe, that the blood of hemorrhagy does not proceed from the same vessels which furnish the menstrual fluid ; for menorrhagia is always, so far as we have witnessed, preceded by the regular menstrual discharge ;f which it would be but rational to suppose, would effectually relieve any engorge- ment that might be supposed present at this time; provided this accumulation were confined to the vessels concerned in the pro- duction of the menstrual fluid. * Gardien evidently confounds these two conditions, both by the caption of his chapter on this subject, (de la menorrhagia ou flux immodire des regies,) and by his text. t Under the head of menorrhagia, we do not include those hemorrhagies which arise from a lesion of the internal surface of the uterus, or a portion of its proper substance, as in open cancer, or other ulcerations of this organ. We confine our- selves to that discharge of blood which follows or accompanies the menstrual action. We pretend not to account for this condition of the uterus; we only know the fact, that it takes place; and that the woman may be liable to it so long as the menstrual periods continue, be these longer or shorter. Women are, therefore, obnoxious to this state of hemorrhagy, during a great part of their lives, that is' during the whole menstrual period; for we have no evidence that this takes place after the congestion of the uterus, (so necessary for the menstrual secretion,) ceases to take place; though hemorrhagies from lesion, and some other causes do very often happen after this time. MENORRHAGIA. 147 Besides, did this flow of blood proceed from the same vessels as the menstruous fluid, we should be at a loss to understand how a hemorrhage should take place from vessels, after disten- tion was diminished by the evacuation of a portion of their con- tents ; which must be the case, did the vessels which ordinarily furnish the menstrual blood, also yield that of menorrhagia. But, if we suppose that a distinct set of vessels is concerned, we can more readily understand how they might be forced, or in- duced, from any given local cause, to open themselves, so as to pour out blood; since their distended condition may not be re- lieved by the catamenial discharge ; for it is not difficult to con- ceive, that the whole uterus may be in a congestive state at this time. Gardien, (Traite complete d'Accouchemens, vol. i. p. 289,) declares, that " so great a relation exists between menorrhagia and the menstrual flux, that it would be difficult to determine where the one ends and the other begins." Again: "In fact, all spontaneous hemorrhages have the strongest analogy with the menstrual flux. The phenomena which accompany the issue of blood, are absolutely the same in both cases; only, in menorrha- gia, the flow partly belongs to an original law, while that of he- morrhages is accidental," p. 289. It is evident from these passages, that he looked upon both dis- charges to be the common blood of the system; yet, it is noto- rious they differ widely in many particulars. The one is the result of a secretory process; the other is blood which has escaped from confinement, by the rupture, or the opening of the vessels which contained it. Now, were it true that the men- strual fluid, and the blood thrown off in menorrhagia were the same, there would be no difference between the menstrual flux and menorrhagia, except in the quantity of blood which might be expended: and, consequently, that menorrhagia is nothing but an excessive secretion of the menstrual fluid; or that the menstrual fluid is nothing but proper blood. Mr. Hunter declares, " it (the menstrual fluid,) is neither si- milar to blood taken from a vein of the same person, nor to that which is extravasated by accident in any other part of the body; but is a species of blood changed, separated, or thrown off from the common mass, by an action of the vessels of the uterus, simi- lar to that of secretion, (see p. 55,) by which action the blood loses the principle of coagulation, and, I suppose, life." Dr. Good* observes upon this subject, that, " as this distinction has not been sufficiently attended to, either by nosologists or physio- logists, many of the diseases occurring in the present arrange- * Study of Medicine, vol. iv. p. 30. Amer. Ed. 148 MENORRHAGIA. ment, (his own, under Paramenia,* have been placed by other writers under a genus named Menorrhagia, (a morbid flow of blood alone,) from the menstrual vessels. And we have here not only a wrong doctrine, but the formation of an improper genus; for menorrhagia is, correctly speaking, only a species of the genus Hemorrhagia." We have just intimated, that, as we are at present ignorant of the agency of remedies upon the different portions of the uterine system, a knowledge, whether the blood expended in menorrhagia be from the vessels which prepare the menstrual fluid, or from a distinct set of vessels, would be of little consequence in a practi- cal point of view; yet the time may arrive, and that soon, when such knowledge might be highly useful. For, at the present mo- ment, we are acquainted with the influence which the ovaria ex- ert over the internal surface of the uterus in the production of the menstrual fluid; and, consequently, that it maybe essential in the various deviations in the formation of this fluid, that the restorative remedies be addressed to these bodies; whereas, if a different set of vessels from the menstrual yield the blood, the cure might require remedies that would exert an influence upon the extreme vessels of the uterine surface. At first sight, it may appear idle to anticipate the possession of remedies that would exert an exclusive control upon each por- tion of the uterine system. Yet even the present history of the Materia Mediea will justify the expectation. The ergot, for in- stance, manifests its action upon the fibres of the body and fundus of the uterus, and not upon the neck; the sugar of lead acts upon the extremities of bleeding vessels; the spirits of tur- pentine, upon the mucous surfaces; mercury upon the salivary glands, &c. &c. Is it then, unreasonable to, hope wre may soon be in possession of substances, whose action shall be confined to the ovaria or to the internal surface of the uterus? for until we do find such specifics,\ our practice, in the inordinate flow of the menses, and in menorrhagia, will be rather uncertain. * "Morbid evacuation, or deficiency of the catamenial flux."' Amer. Ed. t Every substance wbich can exert an influence upon the animal system, causes its own peculiar mode of action ; and from what we already know, there is every reason to believe, that each organ belonging to the human fabric, has appropriate stimuli in a state of health, or counter-agents in a state of disease, among the va- ried productions of nature; and that these stimuli, or counter-agents, are capable of changing the mode of action of such parts, on which they are destined to act. If this be true, how important is it that the peculiar action of every substance should be closely watched when administered to the living animal ? It is only by such attention to the influence of medieines, that remedies can be discovered, and properly classed; and it is by the same kind of scrutiny that an individual article of that class, shall, at one time, or occasion, merit a preference over every other individual of the same class. To prove this, we need but refer to every day's ex. perience, in the choice of cathartic?, emetics, astringents, t time to abstract blood, we think, is a few days before the discharge, provided the pulse be active at this time : if it be not, let it be watched, and when it is found to be acquiring strength, let the blood be taken then, and in sufficient quantity to reduce both the size and vigour of the artery ; for bleeding is useful in such cases, in proportion to the contraction it produces in the vessels. If the pulse rise only near the period for the renewal of the hemor- rhagy, blood must then be abstractedly all means, and in larger quantity than at the other periods just indicated. For if this direction be not attended to, very lit- tle advantage will be derived from the operation, as the desired object, (the con- traction of the vessels,) will scarcely take place as those of the uterus are so insu- lated, and independent of those of the general system. I have thought I derived much advantage, at these times, from the application of leeches to the small of the back ; for eight or ten ounces abstructed by them, seems to have more control over the uterine circulation, than double that quantity taken from the arm. t Dr. Porta recommends "tannin" in menorrhagia, in doses of three grains, every three hours; and is led to the following conclusions in regard to its use:— 1. That whenever the uterus is the seat of irritation, which gives rise to an active or hypersthenic flooding, and also when this discharge depends upon a chronic metritis, this medicine acts specifically upon the uterus. 2. But when acute metritis gives rise to menorrhagia, the inflammation must be subdued by copious and sufficient blood-lettings. 3. But when menorrhagia proceeds from any organic alterations in the uterus, this medicine has no efficacy. 4. That a preference should always be given to this medicine in the treatment of menorrhagia, as it is very prompt in its effects: it produces no unpleasant symptoms ; and the stomach bears it well even in a state of irritation."__Archiv. Gen. from the Annali Univ. de Med. April, 1827. It may be well to observe, that "tannin" in its pure state, is very difficult to procure, and, consequently, in that condition cannot be well employed, in general practice. It certainly abounds in the Rad. rathanae ; therefore the extract of this substance, is perhaps as good a form as any we can employ. We have already mentioned this substance, when treating of the decline of the menses, page 143. MENORRHAGIA. 155 If this make the stomach sick, or if nausea and vomiting attend, which sometimes happens, it may be administered in the form of enema, as follows: a scruple of the acetate dissolved in two ounces of warm water, to which must be added a tea-spoonful of lauda- num. Should this be discharged soon, it may be repeated. We, however, from late experience, prefer the vinous tincture : of the secale cornutum; twenty drops in a little sweetened water, every hour until uterine pains are produced. The medicine is then suspended until this irritation passes off: it is then to be re- peated until similar effects are produced ; but given at longer and longer intervals. Cold applications, consisting of equal parts of whisky or brandy, and vinegar, should be applied over the pubes, and re- newed as soon as it becomes warm. In warm weather, the addi- tion of ice is very important. The best mode of applying the cold mixture, is by cloths wrung out of the mixture; or by means of a large bladder partially filled. If the latter be used, cold water is a's good as the mixture just named, as the fluid does not come in contact with the skin; its whole virtue being in its cold- ness. Late experience, however, teaches me to consider the tinct.,/ secale cornutum vin., as the remedy most to be relied on. If * given in tea-spoonful doses, morning, noon and evening, in some sugar and water until the discharge again makes its-appearance, it will be found to have abated the ensuing discharge very much; ] and if after this, the discharge should continue, the tincture must be continued, care must be taken that the drug is fresh as possi- ble ; as it is ascertained that this remedy will not preserve its activity more than two years, after being kept dry and in a glass ground stopper bottle. The plan just detailed is intended only for such cases as are attended by a profuse and threatening discharge ; for, in ordinary cases, the sugar of lead, as prescribed above, answers every pur- pose without the cold application. We deem, however, the other caution important, even in very moderate cases; as very slight errors will sometimes create a great deal of mischief. Rest, cool > air, a very low diet, and cold drinks, should be always insisted on, if we expect a permanent cure, even in cases where the patient does not think it important to lie by. Where the discharge is very profuse and alarming, which sometimes happens even with young girls, but more especially with women pretty well advanced in life, and the means above recommended have not proved sue- . cessful, the tampon must be had recourse to. The variety we have just described, is generally of much easier management than the second ; which consists " in a mere local determination to the uterus, producing an engorgement of this organ ; but which does not implicate the general system, except 156 MENORRHAGIA. from the waste of strength it .occasions, when the discharge is profuse, or long continued." The variety now under consideration, is most common to women of an irritable and feeble constitution ; and where, agreeably to Gardien, there exists an accumulation of vital power towards the uterus. This variety, like the one just spoken of, is accompanied by some pain and heaviness in the uterine region; heat and some- times itching in the pudendum. The pulse is small, and rather frequent; the extremities disposed to become cold; the face pale, and sometimes cachectic; the appetite feeble ; the tongue fre- quently found furred, especially in the morning; palpitation of the heart; and respiration hurried upon motion, &c. The indications in this variety, are, to destroy or diminish this congestive tendency of the uterus; and to moderate, or interrupt the unnatural discharge. The first indication is to be fulfilled by equalizing the^ circula- tion as much as possible, by determining it towards the surface; by well-regulated exercise ; by wearing flannel next the skin; by keeping the lower extremities warm; by a nutritive and easily assimilated diet; abstaining, however, from stimulating condi- ments and drinks ; by preventing constipation, by even purging with aloetic medicines;* by diverting the current of blood to some neighbouring part, by dry cupping the small of the back, and blistering the inner side of the thighs; and by the application of leeches to the groin, or inner part of the thighs. This last re- medy is found to be particularly useful, when used three or four days before the expected sanguineous eruption: three or four ounces abstracted in this manner is every way sufficient. The mustard bath is a very good remedy in such cases. Emetics, and especially the ipecacuanha emetics, are thought to be useful in this variety of menorrhagia: they were first proposed by Dr. Bryan Robinson for hemorrhagy, and have since been recom- mended in menorrhagia ; but of these, we can say nothing decisive from experience. If at all useful, in such cases, it must be just before the menstrual eruption ; for, during the flow, we never re- member to have seen vomiting abate the discharge when it came on spontaneously, though it may have been pretty severe. Taking a grain of the sugar of lead with a little opium, three or four times a day in the absence of the discharge; or drachm doses of * We have in several cases of menorrhagia, in women somewhat advanced in life, found great advantage from the hiera picra as a cathartic: it may be used agreeably to the following formula :— 9r. Hiera Picra, - - 3j. Sapo, Vcnet. - - gr. viij. Syr. Rhaei. q. s. m.—f. pil. xx. One or two of these taken every night, until the bowels are found free. See p. 141. SIGNS ACCOMPANYING PREGNANCY. 157 the tincture of rathany, or the extract, as directed at page 143, , will be found highly useful. To fulfil the second indication, the means are precisely the same as recommended in the first variety; with this exception, that if the discharge be long continued, we may employ the dry- cupping and apply blisters. In both varieties, we have often found decided advantage from injections per vaginam, made of the solution of the acetate of lead, of sufficient strength—that is, two or more drachms to a pint of v lukewarm water. Half of this, or one-third, may be thrown up the vagina by means of a syringe, three or four times a day. In all cases of menorrhagia, opium is found highly useful, when combined with small portions of ipecacuanha ; and should always v be exhibited, as soon as the pulse will bear its stimulus. It should be certainly given at night, if pain prevents sleep ; or even during the day, if necessary. « Gardien makes a third variety of menorrhagia ; namely, " a spasmodic." Of this variety I can say nothing; nor do I believe in its existence; the only evidence of the species, agreeably to him, is, that menorrhagia is sometimes relieved by opium, or other antispasmodics. CHAPTER VIII. OF THE SIGNS WHICH USUALLY ACCOMPANY PREGNANCY. In a work treating exclusively of the diseases peculiar to the female, we have thought it important that the experienced prac- titioner should be well acquainted with what are termed the ra- tional signs of pregnancy; and for the following reasons :— 1st. Because pregnancy often influences our prescriptions, in both-the acute and chronic diseases that may accompany this con- dition. 2d. Because the physician's opinion may decide the fate of a female in a court of justice when she wishes to take advantage of the privileges which pregnancy claims, when she may have for- feited her life to the laws of her country by her crimes. Or, 3d. Where the duration of human gestation may involve the character or property of individuals. Therefore the value of the signs of pregnancy should be as well ascertained as the nature of things will permit, that error may not be committed in our prescriptions; and that the innocent may not be injured, or the guilty absolved ; consequently, in a medico- 14 158 SUPPRESSION OF THE MENSES. legal point of view, a knowledge of the symptoms about to be considered, is every way of great importance. As soon as impregnation takes place, various parts sympathize, either directly or indirectly, with this condition of the ovarium. These sympathies, or disturbances, are generally so uniform in their nature, and so regular in their appearance, that they have been considered as evidences of pregnancy: the first, and most usual, is the interruption of the menstruous discharge ; secondly, nausea, and vomiting; thirdly, enlargement of the breasts ; fourth- ly, the areola? round the nipples; fifthly, the secretion of milk; sixthly, the enlargement of the abdomen; seventhly, the increased size of the uterus; eighthly, pouting out of the navel; ninthly, spitting of white frothy mucus; tenthly, salivation. Although almost every pregnancy has nearly the whole, or the greater part of the signs we have just enumerated, yet their union may not in a given individual case, so positively decide this con- dition as to render it free from all doubt; especially where the sub- ject may become an object of judicial proceeding; and where life, character, or property, may be involved in the consideration. On this account, chiefly, we will spend a few moments on each of these reputed signs of pregnancy. Sect. I.—1. Suppression of the Menses. Few signs of pregnancy are more equivocal than the suppres- sion of the menses, and should never be relied on, farther than that sign is entitled to. Dr. Rigby is very emphatic on this sub- ject, in his System of Midwifery; (p. 97,) he says, " The diag- nosis of pregnancy, is a subject well worthy of the student's most serious attention ; for he will of course be liable when in prac- tice, to be called to give his evidence before a Court of Justice, under circumstances, when the responsibility will ever be of the most serious and not unfrequently of the most fearful nature, the more so, as the old custom of impanelling a jury ' of twelve ma- trons' to determine whether the woman be quick with child, has fallen deservedly into disrepute." "Numerous cases are on re- cord where a false diagnosis in women convicted of capital of- fences, has led to the most lamentable results, and where dis- section of the body after death has shown that she was pregnant." A case is related by Baudelocque of a French countess, imprison- ed during the French revolution, who was accused of carrying on a treasonable correspondence with her husband, an emigrant; she was ordered to be examined by two of the best midwives in Paris, and they declared hex not pregnant. She was accord- ingly guillotined, and her body taken to the School of Anato- my, where it was opened by Baudelocque, who found twins in SUPPRESSION OF THE MENSES. 159 (he fifth month of pregnancy."—Dr. Rigby's Syst. of Midwifery, p. 98. Am. Ed. The suppression of the menses, in a married woman, or in a woman who has had illicit commerce with a man, may justly give rise to the suspicion, that impregnation has taken place; and, as a general sign, may safely be looked upon as one of the most unequivocal that may present itself; yet a variety of causes, independently of pregnancy, may produce the same effect, both in the married and in the unmarried woman: 1st. Exposure to cold and damp at the time the menses are about to appear, or immediately after they have shown themselves. 2d. Certain chronic affections, as phthisis pulmonalis, scirrhous liver, or other visceral obstructions. 3d. The operation of certain pow- erfully depressing passions, or emotions of the mind ; some imper- fection in either the ovaries or the uterus itself. 4th. Accidents by falling, or severe blows; and, lastly, the precocious cessation of this function.* If, then, the absence of the menses do not positively evince pregnancy, will their presence prove that it does not exist? This question would, unquestionably, be answered in the affirmative by Dr. Denman, and, perhaps, many others ; not because they have not seen coloured discharges from the vagina during preg- nancy ; but because, from a preconceived notion of the functions of the uterus, they deny these discharges to be menstrual. In declaring women may menstruate after impregnation, I have no favourite hypothesis to support; nor am I influenced by any affectation or vanity, to differ from others ; neither do I be- lieve I am more than ordinarily prone to be captivated or misled by the marvellous ; for I soberly and honestly believe what I say, and pledge myself for the fidelity of the relation of the cases I adduce in support of my position. Nothing can be more vague and unsatisfactory than Dr. Den- man's definition of menstruation: namely, "from the uterus of every healthy woman, who is not pregnant, or who does not give suck, there is a discharge of blood, at certain periods, from the time of puberty to the approach of old age." Now, from this definition it would necessarily follow, that if a woman men- struate, she must be in good health ; but the experience of every day is against this conclusion. Again, if a woman has a dis- charge of blood while she is suckling, she must, by the terms of this definition, be either no nurse, or this discharge is not men- struous blood. Dr. Denman would certainly agree to this last * Dr. Lacnck relates a remarkable case of this kind, in which a young lady received a fall down some steps while the menses were flowing, by which they were in^tmtly arrested, and continued to be so during a considerable time. La- cock on Hysteria. See also note, p. 119. I saw, as I mentioned, a similar in- stance. 160 SUPPRESSION OF THE MENSES. deduction, but what proof has he to support this belief? So far as my own, and the experience of many others go, I should say none. I wish to be understood to mean, whenever I use the terms, menstruous discharge, menstruous blood, menses or any other designation, that legitimate discharge from the uterus, which would, under the best circumstances of health in general, or con- dition of the uterus in particular, constitute this important func- tion in its most perfect form—I do not mean to include discharges of blood, properly so called, and properly so being, as coming within my views and meaning of the above terms. I employ the terms named above, to express the result of a peculiar action of the internal surface of the uterus, but which differs widely from the common circulating fluid, called blood; and precisely what Dr. Denman wishes to be understood to mean, when he speaks of " menstruation." The only argument adduced by Dr. Denman in support of his hypothesis, is, " that, if a woman menstruated, while pregnant, she must very often miscarry, as a part of the ovum must neces- sarily be detached from the uterus at each period." I would ask, why a part of the ovum must be necessarily detached to give issue to this discharge ? I see no reason why this should be so ; as I am persuaded, that this can happen without any such con- sequence. Dr. Hunter, Dr. Denman himself, Mr. Burns, Baude- locque, &c* all declare, that for the first two or three months, the inferior portion of the uterus, and more especially the neck, are not always occupied by the decidua, but are left as free, and as unembarrassed, as before impregnation : of this I have no doubt; and it is from this unoccupied portion, that the menstruous dis- charge takes place. If it be said, that this surface is insufficient in extent to yield the quantity that is ordinarily discharged, I would answer ; First, I am not contending for the quantity, but the quality of the eva- cuation. And I admit, that, when this evacuation takes place during pregnancy, it is not so abundant as it usually is under other circumstances. Second. That the following fact will show, how capable a small healthy portion of the internal surface of the uterus is, of yielding a quantity of menstruous blood. My friend, Dr. Coxe, gave me a diseased uterus, in the cavity of which there was a healthy portion of surface, not exceeding in size a common thumb-nail; and from this surface was yielded, at every menstruous period, a quantity of fluid ; and which, as far as could be detected by its sensible properties, was of a perfectly healthy quality. * " En general, elles, (les regies,) se suspcndent durant la grossessf, et Tallaite- ment; mais il est des cas ou leur ecoulemenl continue dans ces cireonstanees; re- lativement a la grossesse, il se borne ordiimrement aux premiers mots, rare-raeBt se soutient il jusqu' a l'accouchement."—Frank. SUPPRESSION OF THE MENSES. 161 Again, I well know a number of women who habitually men- struate during pregnancy, unlil a certain period; but, when that time arrives, menstruation ceases; several have menstruated until the second or third month ; others longer; and two until the seventh month; the last two were mother and daughter. I am certain there was no mistake in the cases to which I now refer. My interrogatories were numerous, and the answers bore all the marks of candour: first, the menses were regular in their returns; not suffering the slightest derangement from the impregnated con- dition of the uterus; secondly, from two to five days were em- ployed for their completion ; thirdly, the evacuation differed in no respect from the discharge in ordinary; except, they thought it less abundant; fourthly, there were no coagula in any one of these discharges; consequently, it could not be the common blood, or the blood of hemorrhagy ; fifihly, in the two protracted cases, the quantity discharged regularly diminished after the fourth month, a circumstance, not perhaps difficult of explanation. I may also cite, in favour of my position, the authority of Heber- den, Hosack, and Francis.* With regard to nurses menstruating, every accoucheur must be familiar with the fact, as it is of frequent occurrence; happening ten times, perhaps, to the other once. Here the same difficulty does not exist; for the uterus is now unoccupied: and the only matter of surprise is, that it does not more frequently occur. Though I have strenuously contended for the fact, and attempted an explanation of it, yet I am well persuaded it is but an excep- tion to the rule, and not an ordinary arrangement of nature. As it is sometimes of consequence to determine an incipient pregnancy, it is proper to notice every thing relative to this important subject. We will, therefore, state Mr. Nauche's obser- vations on this subject. Some years since this gentleman en- deavoured to show, that the urine of every pregnant woman con- tained a substance that he denominated Keisteine, which sepa- rates from it, and shows itself in the form of a pellicle on its surface, and considers it as a valuable diagnostic sign of this state. This was several years ago, and but little notice was taken of it, until Mr. Tanchou, of Paris, recently published his observations on it in " Lancette Francaise." They are as fol- low : "He examined the urine of twenty-five pregnant women, and in every case he detected the presence of Keisteine.—The follow- ing is the description he gives of the changes which the urine during pregnancy exhibits, and of the characters by which its pe- culiar ingredients may be recognised. " The urine of a pregnant woman, collected in the morning, is * Francis's ed. of Denman, p. 231. 14* 162 SUPPRESSION OF THE MENSES. usually of a pale yellow colour, and slightly milky in appearance; it is not coagulable by heat, or by any of the tests which indicate the presence of albumen. Left to itself, and exposed to the air after the first day, there begins to appear suspended in it, a cot- tony-looking cloud, and at the same time, a flocculent whitish matter is deposited at the bottom of the fluid. These phenomena are not of constant occurrence, and, moreover, healthy urine sometimes exhibits analogous phenomena. From the second to the sixth day, small opaque bodies rise from the bottom to the top of the fluid; these gradually collect together so as to form a layer which covers the surface: this is Keisteine. It is of a whitish or opaline colour, and may be aptly compared to the layer of greasy matter which covers the surface of fat broth, when it has been allowed to cool. Examined by the microscope, it exhibits the appearance of a gelatinous mass, which has no determined form. Some small cubical crystals can be perceived in it, when it has become stale. " The Keisteine continues in the state we have now described, for three or four days; the urine then becomes muddy, and mi- nute opaque bodies detach themselves from the surface to settle at the bottom of the vessel; the pellicle thus becomes soon de- stroyed. " The characteristic feature, therefore, of the urine during pregnancy consists in tbe presence of Keisteine. It deserves, however, to be noticed, that the urine in some cases of extreme phthisis pulmonalis, and also, of vesical catarrh, will be found to exhibit on its surface a layer of stratum which is not unlike to that now described as peculiar to the state of pregnancy. But with proper attention we may easily avoid this mistake. The stratum in the cases alluded to, does not appear so quickly on the surface of the urine as the Keisteine; and also, instead of dis- appearing, as it is found to do in a few days, it (the former) goes on increasing in thickness, and ultimately becomes converted into a mass of mouldiness. " Of twenty-five cases, in which Mr. Tanchou detected the pre- sence of Keisteine in the urine, seventeen occurred in women who were pregnant from four to nine months, four in women who had quickened, and who considered themselves as labouring under dis- ease of the womb, and the remaining four in patients who had been under treatment for casual complaints—one for sciatica at the Hotel Dieu, another for ascites in the city, a third for an ulcer in the neck at La Prtie, and the last had been cauterized twice a week for a pretended disease of the uterus.—In none of these cases had the existence of pregnancy been suspected, although in every one of them the fact was soon placed beyond a doubt." Amer. Journ. Med. Sciences, for Feb., 1840., p. 484. In one extraordinary case, which fell under my notice in 1791, SUPPRESSION OF THE MENSES. 163 the contrary of suppression took place at pregnancy : a woman applied for advice for a long-standing suppression of the menses; indeed, she never had menstruated but twice. She had been married a number of months, and complained of a good deal of derangement of stomach, &c— I prescribed some rhubarb, and steel pills. About six months after this, she again called to say " that the medicine had brought down her courses, but she was more unwell than before ; her sickness and vomiting had in- creased, besides swelling very much in her belly ;" I saw that this was pretty much distended, and immediately examined it, as I suspected dropsy—but from the feel of the abdomen, the want of fluctuation, and the solidity of the tumour, I began to think it might be pregnancy, and told the woman my opinion. She now became anxious to understand her situation exactly, and submit- ted, for this purpose, to an examination per vaginam ; this proved her to be six months advanced in pregnancy : after this time, she had the regular returns of her catamenial period until the full time had expired. During the period of suckling, she was free from the discharge: she was a nurse for more than twelve months; she weaned her child, and, shortly after, she was again surprised by an eruption of the menses, which, as on the former occasion, proved to be a sign of pregnancy. Whether this peculiarity pur- sued her still farther, I cannot say ; as she removed from the neigh- bourhood, soon after the birth of her second child. Whether there was a periodical discharge of a colourless fluid in this case, as a compensation for the regular menses, I am un- able to say, as I did not examine the woman on this point, not having, at that time, the same interest as now, in such minute in- quiry. I merely state the main facts, though they bid defiance to calculation, and almost to example, Deventer* being the only author, so far as I know, who has furnished a similar example. Sect. II.—2. Nausea and Vomiting. Nausea and vomiting, though a very usual concomitant, is very far from being a certain sign of pregnancy ; it occurs some- times where the menses have been delayed by other causes: it may, however, be considered as adding to the general testimony in proof of this condition. Should the child die while in utero, the vomiting, for the most part, ceases immediately. * Chapter XV. p. 65. 164 AREOLAE. Sect. III.—3. Enlargement of the Mamma. Enlargement of the mammae is a very common attendant upon genuine pregnancy, though it is not uniformly so—I have known a number of cases where they did not swell even at the latter periods of gestation ; nor was it until after delivery, that they gave evidence of capacity to perform their ordinary functions: on the other hand, I have known them to enlarge considerably, where the menses were interrupted from other causes than preg- nancy.* Sect. IV.—4. Areola. .The areolae, which are ♦sometimes formed round the nipples, must be considered as equivocal in any but a first pregnancy : in this case did areola? form, I should place great dependence upon them ; for, so far, I have not been deceived. They do not, however, always present themselves; and may not be easily de- tected even when formed, in very dark-skinned women : there is always, I believe, an enlargement of the little sebaceous glands which surround the nipples, wThen areolas encircle them ; and they, as far as my observations go, serve to strengthen the sus- picion of pregnancy. So far as I recollect, this blush is not mimicked by obstructed catamenia, or from any other cause than pregnancy. It is possible that they may attend a false concep- tion or mole; but of this I have no experience. In a second, or other pregnancies, I do not place the same reliance upon this sign ; as a trifling irritation, or other causes, I believe, may pro- duce them ; or they may, as I have often noticed, be absent alto- gether. The marks I have been speaking of, must not be con- founded with the permanent stain left around the nipple after a woman has suckled a child ; and great care should be taken to conduct this inquiry in such a manner as to give no false im- pressions. Dr. Ingleby considers the areola? as a proof of preg- nancy. When the nipples are to be examined, the woman should open her bosom so as to expose the whole breast; she must not be suf- fered to draw it above the margin of her clothes by placing her hand beneath it—in doing this, the nipple oftentimes is irritated by the pressure of the fingers, which gives a newr character to the appearances. I have, in a number of instances, detected pregnancy by this examination, where the patients insisted their * We have met with this symptom in a number nf cases: a swelling and ten- derness takes place in simple obstruc'ion, and we have known it accompany the menstrual discharge. In cases of the latter kind it appears to be habitual. FORMATION OF MILK. 165 irregularity proceeded from cold or other causes. It must, how- ever, be remembered, that the absence of these areola? does not prove the woman unimpregnated. In one case I detected pregnancy when it was not suspected: a lady who had been several years married without becoming pregnant, sent for me to examine her mamma, which she said, had a tumour in it. As soon as I saw the breast my atten- tion was challenged to a more particular examination. The areola? was so extensive and deep toned, and the little glands were so enlarged, and prominent, that it immediately struck me, that besides the small tumour, (which was nothing more than but one of the glands of her breast, swelled or enlarged,) she was pregnant; I mentioned my suspicion—she laughed at me, as did the husband;—but time proved I was right, much to their joy. Sect. V.—5. Formation of Milk. The formation of milk in the mamma?, is coeval, in some preg- nant women, with their swelling; while in others it is not formed until after delivery. When this secretion takes place, it is looked upon by the vulgar as a certain sign of pregnancy; but I have oftentimes known this fluid, (or at least a fluid bearing all the marks of the first formed milk,) plentifully secreted without preg- nancy, merely by the interruption of the menses. It has been produced in women past the period of child-bearing, and even, it is said, in men* by the repeated application of a child to the nipple. It has also been produced in a girl of eight years old, as we are informed by Baudelocque. (See his very interest- ing case, Vol. I. page 219.) I once knew a considerable quantity of milk form in the breasts of a lady, who, though she had been married a number of years, had never been pregnant; but who at this time had been two years separated from her husband. She mentioned the fact of her having milk to a female friend, who, from an impression that it augured pregnancy, told it to another friend, as a great secret; who in her turn mentioned it to another friend, and thus, after having enlisted fifteen or twenty to help them keep the secret, it got to the ears of the lady's brother. His surprise was only * Tim flowing case is in proof of this assertion: it is communicated by Mr. Heber Ohnse, of New Hampshire. A Mr. James Hildreth, of Hopkinton, New Hampshire, was, about three years since, (Dec. 9ih, le»34.) from the abundant secretion of milk in his ri«hi breast, enabled, by pressing it. with his fingers, to project milk fom the nipple two or three fit t. Mr. Chase declares he has seen him do so often at the young people around him. He was a blacksmith by trade, and a muscular, robust man, some- what dissipated, but not sa much so as to interfere with his. business. He was about thirty ye-jrs of age, and the father of several children. \ 166 ENLARGEMENT OF THE ABDOMEN. equalled by his rage; and, in a paroxysm, he accused his sister in the most violent and indelicate terms, of incontinency, and menaced her with the most direful vengeance. The lady, conscious of her innocence, desired that I should be sent for, forthwith; and insisted her brother should not leave the room until I arrived: some time elapsed before this could be accomplished, as we were several miles from each other, during the yellow fever of 1798. During the whole of this time she bore his threats and revilings, with the utmost exemplary patience and silence. I at length arrived ; and, in the presence of the brother and a female friend, she informed me of what I have just stated ; and said her object in sending for me was, to submit to such an examination as I might judge proper to de- termine, whether she were pregnant or not—she would not per- mit her brother to leave the chamber; and I conducted the ex- amination without his withdrawing. This thing turned out as I had anticipated, from the history given at the moment, of her previous health. I pronounced her not pregnant; and she died in about eight months after, of phthisis pulmonalis, in which dis- ease the obstruction of the catamenia is not an unfrequent occur- rence. Sect. VI.—6. Enlargement of the Abdomen. The enlargement of the abdomen, perhaps, is one of the most equivocal of the enumerated signs, since it may take place from so many other causes as, 1st. Dropsical affections, of either the abdomen, uterus, or ovaria.* 2d. A chronic disease of the ova- ria, or uterus itself. 3d. A retention of the menses, from some accidental cause preventing their flow.f 4th. Enlargement of al- most any of the abdominal viscera. 5th. The simple obstruction of the catamenia. For these reasons, but little reliance can be placed upon this circumstance alone, or even when combined with several others. For I have had the pleasure, in several instances, of doing away any injurious and cruel suspicion, to which this enlargement had given rise. Within a short time, I * Dr. Blundell relate? the following interesting case, which should be kept in recollection, as a beacon to shun a similar error. Dr. Hi.i^hton w;is sent for in consultation with a distinguished London surgeon, to a case supposed to be ascites, for which the patient was to be tapped the next day. Dr. Haighion suggested that this swelling might be a dropsy of the uterus, but no particular examination was made to ascertain this. During the night, the sac containing this fluid gave way, a " flood of Huid was discharged, and the ab- domen collapsid rapidly, a foetus not larger than the first joint of the finger escaped, the woman escaped the paracentesis and did well."—Princip. and Prac. of Obstet. p. 78. t See Miss F's. case, in Essays on various Subjects connected with Midwifery, page 337, by the author. ENLARGEMENT OF THE ABDOMEN. 167 relieved an anxious and tender mother, from an almost heart- breaking apprehension for the condition of an only, and beauti- ful daughter, on whom suspicion had fallen, though not quite fifteen years of age. This case, it must be confessed, combined several circumstances which rendered it one of great doubt; and without having had recourse to the most careful, and mi- nute examination, might readily have embarrassed a young practitioner. This young lady's case was submitted to a medical gentleman, who, from its history and the feel of the abdomen, pronounced it to be a case of pregnancy ; and advised the sorrow-stricken mother to send her daughter immediately to the country, as the best mode of concealing her shame. Not willing to yield to the opinion of her physician, (a young man,) and moved by the positive denials of her agonized child, the mother consulted me. The history of the case was thus briefly given by the mother: "Her daughter commenced, between twelve and thirteen, to menstruate, and con- tinued to do so, regularly, until late last fall ;* at which time she had a very smart attack of the prevailing epidemic; of this she was, however, relieved by the usual remedies; but since which time, she had never menstruated ; she gradually swelled in the belly ; her stomach was much affected, especially in the morning; and the breasts were a little enlarged." I examined the mamma?, and found them a little tumid, but without areola? ; the abdomen was much enlarged, tense, and hard, in consequence of a large tumour which was confined to the left side of this cavity, and which could be easily traced throughout its right and inferior margin, and proved, (at least in my opinion,) to be an enlarged spleen ; no tumour was found in the pubic region; consequently, the uterus was not found en- larged ; the navel w-as sunk ; and upon an attempt to pass the finger into the vagina, I found so much evidence of her conti- nency, that I did not persevere, being perfectly satisfied, from the condition of the parts, that she was a virgin. I unhesitatingly, and with no common degree of pleasure, declared the poor child to be free from the charge, so heedlessly and cruelly preferred against her. Sect. VII.—7. Increased Size of the Uterus. An increased size of the uterus, especially in young women, either married or single, will necessarily create a suspicion that it may arise from pregnancy ; particularly if its surface, as dis- tinguished through the abdominal parietes, be uniformly round, smooth, and elastic; and if there be combined with these marks, « 1832. 168 ENLARGEMENT OF THE ABDOMEN. several of the rational signs of pregnancy—but it is far from being infallible. This distention of the uterus may arise, 1st, from a dropsical state of the uterus ; 2dly, from diseases within its cavity, as tumours, or excrescences ; 3dly, from moles, or false concep- tions, or hydatids; 4thly, from a retention of the menstruous dis- charge from the occlusion of the os tinea?, &c. The case refer- red to, of Miss F., is strictly in point; and was one among others, where injurious surmises were, for a long time, most cruelly en- tertained.* Sect. VIII.—8. Pouting out of the Navel. Pouting out of the navel, if it takes place only proves that there is something behind, which makes it protrude ; but it by no means follows, that it is the uterus distended by pregnancy: I believe it invariably takes place in pregnancy after the sixth month, or sometimes even earlier; and I think the following conclusions may pretty safely be drawn frorri this condition of the navel: 1st, If the woman be pregnant, it will, by its projection, indicate the advancement to be at least six months ; yet the woman may be ad- vanced to the fifth or a little beyond it, without this part under- going a change; 2dly, If this part protrude, it will by no means follow without the concurrence of other signs, that the woman is pregnant; for this may happen from any cause, independently of pregnancy, that is capable of distending the uterus to a size equal to the sixth or seventh month; as in ascites, when the abdomen is much stretched; from sanguineous sarcoma; from hydatids; chronic enlargements of the liver, and, perhaps, of some other of the abdominal viscera. When this part does not protrude, we are not to conclude that the woman is not pregnant; as it requires the presence of the uterus behind it, to make it appear; and, therefore, whatever is capable of preventing its presence immediately be- hind the navel, as insufficient development, or its sinking unusu- ally low in the pelvis from the extraordinary size of this cavity, is capable of interrupting this protrusion. Sect. IX.—9. Spitting of Frothy Saliva. Spitting of very white frothy mucus, is by no means a constant * Since this period, I have met with a case very similar to that of Miss F'h. in a married lady, but who had never been pregnant. This case, naturally enough, was looked upon as one of pregnancy, as there was no apparent incapacity—all the rational signs of this condition were present ; and it was supposed that the pa- tient was in her seventh month of gestation. On the fifth of May, 1830, she was suddenly surprised by a large flow of a fluid resembling blood, but in which there was neither coagula, foetus, nor placenta. The abdominal intumescence quickly subsided, and the patient was very soon relieved of all the symptoms which re- sembled pregnancy. SALIVATION. 169 attendant upon pregnancy; but when it does occur, it very cer- tainly points out this condition. This saliva is very tenacious, and very difficult to deliver from the mouth ; it is extremely white and a little frothy; and, when discharged upon the floor, assumes a round shape, and about the size of a shilling piece : hence the ex- pression, that the person is " spitting English shillings, or cotton;" and, so far as I have remarked, it is almost a certain sign of pregnancy. Sect. X.—10. Salivation. Salivation, like the sign just mentioned, is not a constant at- tendant upon pregnancy, except in a very moderate degree; in- deed it is not very rare, though it seldom exists in excess: but, when it does happen, it very decidedly points out this condition —I do not remember to have observed this symptom from any other state of the uterus.* From what has been said, it appears that the rational signs, (as they have been termed,) of pregnancy, may exist in stronger or weaker combination, without proving it unequivocally ; though they may leave little or no room for reasonable doubt of its ex- istence. There is, then, but one mark, by which pregnancy can be absolutely determined—and that is, the movements of the foetus itself within the uterus. In judging of this, we are not to rely upon the ipsa dixit of the woman, as she may be deceived, or have motives to mislead ; upon this point, therefore, we must de- termine for ourselves. Upon this point Dr. Blundell furnishes us with the following curious facts: "I know an instance of a lady, possessing more than average intelligence, the mother of twelve children, who was led by certain abdominal movements into an erroneous persuasion that she was again pregnant; for spasms of the abdominal mus- cles, and flutters of the bowels, may now and then be mistaken for the movements of a child. It ought, moreover, to be known, that some women possess the power of similating the foetal move- ments, by the action of the abdominal muscles, so exactly, that even an experienced accoucheur might be deceived. A female who possessed considerable skill of this kind, formerly exhibited her talents in this town (London,) for hire; she was visited by * Sinre writing the above, I have met with two instances of salivation in fe- males, which was not produced bv pregnancy, or anv other known cause. One was extremely profuse, ;i nd lasted full three weeks, in defiance of all applications. The fluid was nearly tasteless, and wns without the lightest odour: it ceased gradually, and I may saysp< ntane usly; for noremed* that was used, appeared to make the slightest impression upon the discharge. This affection seemed to arise from some condition of the stomach, ns much n usea attended. The other was less profuse, and more obedient to remedies—a strong infusion of cinnamon ai pea red to afford complete relief, though it was altogether unavailing in the other instance. 15 170 OF QUICKENING. Lowder, Mackenzie, and some other celebrated accoucheurs of the day, and after satisfying themselves that the uterus was not enlarged, they made the usual examination of the abdomen, when they all agreed, that the movement was so exactly analogous to that of the foetus, that no distinction could be clearly made, adding, if there had been no internal examination made, they should, judging from this only, have satisfied themselves that the woman was with child." To do this, it is necessary to place the hand upon the bare ab- domen, and wait for the motion of the child ; or we may endeavour to provoke it, by having the hand either hot or cold, according to the season, as recommended by Morgagni; and as has been often practised successfully by myself. Should the weather be hot, we should have the temperature of the hand reduced by cold water, or ice; or, if the weather be cold, have the temperature raised, by placing the hand in warm water for a short time. By these means, we rarely fail to excite the foetus to action; and we may succeed in having it, even pretty frequently, repeated, by repeating the same means. Of this fact I am perfectly certain; but, to account for it, is beyond my ingenuity. By touching per vaginam, we may ascertain, that the uterus contains a solid body within it: but we cannot by this method, determine whether it be a living being, or an imperfectly organized mass. Will the absence of all motion within the uterus determine the woman not to be pregnant, when a sufficient number of the rational signs combine to render it more than probable that she is ? I must answer this question in the negative; as instances have oc- curred to others,* and one to myself, where the motions of the child were never perceived, during the whole period of utero-ges- tation. In such cases, an examination, per vaginam, will aid much; especially at the latter period of pregnancy—the state of development of the uterus; the feel of the substance contained in it; the condition of the os tinea?; the height of the fundus, &c, will, when taken into consideration, and found perfectly to cor- respond with the woman's history of herself, prevent any serious error in our estimate. Sect. XI.—11. Of Quickening. By quickening we are to understand the first perception the woman has of the child's muscular action. It is presumable, that it has in a very feeble manner exerted itself very often before it is or can be noticed by the mother; and the moment at which this action becomes obvious to her, must be at different periods of pregnancy, in different women, owing to the greater or less » Levret, as quoted by Baudelocque, Vol. I. p. 240. OF QUICKENING. 171 strength of the foetus ; the quantity of the liquor amnii; and the sensibility of the uterus itself. I once knew a lady of great ner- vous sensibility, who constantly perceived the motions of her children at twelve weeks; others are longer, and may be said to be at every period between the twelfth week and seventh month —the medium period is the most common ; and when I declare the most usual to be at the fourth month, I am, perhaps, as near the truth as can well be ascertained.* An anonymous writer in the Medical and Physical Journal for June, 1812, under the name of" Medicus," has puzzled himself, besides appearing willing to puzzle every body else, by a learned attempt to explain the cause of quickening by physical and meta- physical reasoning upon the subject. He evidently confounds two circumstances totally distinct, (if one of them really has an existence,) in their natures, under one general term; namely, the first perceptible motion of the foetus, is confounded with a sup- posed sudden change in the uterus, at the period the fundus usually appears above the superior strait. The disposition to syncope, which is sometimes felt by women at about the fourth month, he calls quickening; and declares it to be owing to the sudden escape of the uterus from restraint to liberty, by mount- ing above the brim of the pelvis, and there enjoying greater free- dom and repose. He will not admit that any motion of the child constitutes quickening ; but that essentially depends upon the change of position of the uterus itself. He rejects the common and " ancient" explanation of quickening, for the following rea- sons:— 1st, "The sensation of quickening, (by which he does not wish to be understood to mean any muscular action of the foetus,) is not constant and universal ; some women never experience it, others with some of their children only. 2d. It has a distinct character from any subsequent motion of the child ; no woman ever admits that it resembles, in the slightest degree, the struggles of the foetus. 3d. This sensation is never repeated in the same pregnancy, which must happen if it arose from the motion of the child. 4th. It is totally incomprehensible that any motion of which the foetus is capable, in the fourth month, should communicate such a sensation to the mother, as to produce deliquum animi."f The whole of these arguments go to declare, that when the uterus suddenly overcomes any restraint to its passage out of the * See Chapter on the T<.rm of Utero-gestation, in System of Midwifery, by the author. + We were much surprised to find this notion of''quickening," adopted by Mr. Morley, a lute writer, " upon the symptoms of pregnancy, &>•." We think it probable, that this gentleman will be induced to call things by their right names, when he has more experience to aid him. 172 OF QUICKENING. brim of the pelvis, the woman is wont to feel faint; and he con- founds this feeling, if it exist, with the sensation which all wo- men, (as a general rule,) experience, after the foetus has acquired sufficient strength to make itself felt; and which increases in force, and is multiplied in frequency, as gestation advances ; or, in other words, he calls the sensation created by the uterus sud- denly rising above the superior strait, quickening; but declares it to be distinct from the motions of the foetus—in this I most fully agree ; as I do not believe that the uterus is ever so sud- denly elevated into the abdomen, as to produce the sensation of faintness. I am, by no means, convinced of this sudden eleva- tion of the uterus, by the inquiries I have made of women, (who, one would suppose, were the best judges upon this subject.) My inquiries, however, have resulted in the establishment of the following facts :—1st. That all women experience, some sooner, others later, the sensation, which they term quickening; 2d. In some, this feeling is accompanied by a disposition to faintness, or rather of sinking, as they express it; and this is experienced, in some few instances, whenever the motion of the child is repeated, until after the fifth month ; 3d. That those who " quicken" very early, are most obnoxious to this enfeebling sensation ; 4th. That, when the feeling of faintness comes on, they are certain it is always produced by the motion of the child itself; 5th. That none have ever been sensible of any disposition to deliquum, but from the stirrings of the foetus. These facts are conclusive, that the sensation in question, is the result of the muscular agitations of the child ; and that the explanation of " Medicus," is at variance with this opinion ; con- sequently, not calculated to explain the phenomenon. Besides, the circumstance mentioned by " Medicus," of the sudden erup- tion of the uterus from the pelvic cavity, has no existence; and even if it were true, I do not see why this change of position is to be confounded with the absolute stirrings of the foetus. If he can make out his position, that the uterus suddenly surmounts certain difficulties in its attempt to rise higher in the pelvis, and that this is accompanied by deliquum animi, it is well ; but for the sake of precision, and of logic, do not let him confound it with quickening. Besides, there is a want of ingeniousness in the statement of facts by " Medicus ;" for we are yet to discover, that any one has explained the term " quickening," by saying it was owing "to life being suddenly imparted to the embryo,"—this would in itself be absurd, and contrary to all belief upon the subject; for I do not hazard much, when I say, that there is no one at present, nor perhaps ever has been, who supposed that the em- bryo did not possess life from the instant it obeyed the stimulus of the male semen for development; and for this plain and sim- OF QUICKENING. 173 pie reason ; that if it were not alive, it must be dead ; and if dead, it must be cast off by the womb, as an extraneous substance. There must be a period when the embryo is not sufficiently de- veloped, to move; another when this can be but feebly, and im- perfectly performed ; and another, when it can move with suffi- cient force to give evidence of this increase of power; and this moment is instantly recognized by the mother, who then says, she has " quickened ;" and that this novel sensation should be ac- companied by novel effects, and even sometimes by syncope, is no way surprising. The older writers merely wished to be un- derstood, by the term quickening, that moment at which the em- bryo gave the first physical proof of life ; and not the moment it received it. That an abatement of the severity of the symptoms of preg- nancy takes place about the period of "quickening," I am well convinced ; and that this takes place with greater certainty, when the uterus can repose itself upon the anterior portion of the pel- vis; y»t I am unwilling to admit, that this change is owing to the sudden rise of the uterus above the brim of the pelvis, as is de- clared by " Medicus :" 1st. Because, I do not know that this has ever taken place as a natural arrangement; and 2d. Because if it did, it might create the unpleasant sensations agreed upon by "Medicus." To me the melioration of symptoms at this period, appears to depend upon two circumstances mainly ; 1st. Upon the uterus being enabled to repose upon the symphysis pubis and its neigh- bourhood ; therefore, no longer liable to be depressed in the ca- vity of the pelvis, by the often repeated impulses of the abdomi- nal viscera. 2d. To the sensibility, and irritability of the uterus, being diminished, by the frequent repetitions of the child's mo- tions; in this obeying the law, which seems to govern every other portion of the system as regards the operation of stimuli, by becoming less and less sensible to them, in proportion to the fre- quency of their application ; hence, parts pretty uniformly sympa- thizing with the uterus when impregnated, wiUcease to do so, or will do so in a more moderate degree, as that viscus shall be it- self less affected. From what has been said, it will be evident, that much diffi- culty exists in determining that condition of the female called " pregnancy." We have endeavoured to show, that the " rational signs" of this state are particularly liable to error; and, there- fore, that where it becomes highly important to determine this point they are not to be absolutely relied upon, however strongly they may be marked, or however numerously they may be com- bined. In the more early advancement of this process, even to the fourth month, the difficulty of arriving at entire certainty is acknowledged by all who have any experience upon this subject; 15* 174 OF QUICKENING. and, that the one so much relied upon by Baudelocque and many other experienced accoucheurs, namely, the motion of the child, has lately been looked upon as doubtful by Mr. Morley. He says, it is possible for wind or other intestinal motion to be mistaken for the motions of the child.* Now, this we declare to be impossi- ble to the experienced accoucheur, who has been attentive to this part of the practice ; though we acknowledge it to be every way probable, to the inattentive and inexperienced practitioner. Mr. Morley appears to have fallen into this mistake from the opinion he has so inconsiderably adopted, of the cause, or rather the na- ture, of " quickening ;'- namely, the-ascent of the uterus through the upper strait of the pelvis, instead of the motion of the child, by the exercise of its muscular powers within the uterus, as has already been noticed above. The accoucheur who has ever ex- perienced the stirrings of a foetus in utero, cannot mistake the movement of flatus for the motion of the child ; therefore, after the fifth month, we think there can be little difficulty in distin- guishing the pregnant condition of the womb ; but up to that time, it is constantly involved in much doubt. But fortunately at the present time, the uncertainty just spoken of appears to be removed, by the discovery of the heart's motion, and the noise of the placental arteries, by means of the stetho- scope, by Kergaradic ; and since verified by a number of practi- tioners, especially by J. C. Ferguson, A. M. M. B.,t and Dr. Kennedy.I Both these gentlemen find, that the double beat of the child's heart can be distinctly heard through the uterine and abdominal parietes, and this as early as between the second and third months; and proportionably stronger, as gestation advances. The following rules for the use of the stethoscope appear to be very satisfactorily established :— First. That the instrument can be advantageously used, over the patient's common clothes; but that it is better to have but a single covering over the abdomen, and the patient lying down.§ Second. That in the early months, the instrument must be ap- plied immediately above the pubes—and though the iliac arteries may give the " bruit soufflet," as well as the uterine and placen- * Dr. Blundell informs us, that the motions of the child in utero can be by the designing so similated, as to deceive those who have had a vi ry enlarged experi- ence in midwifery: in (roof of this, he informs us t'»at a woman in London, de- cieved both the experienced lecturers, Lowder am) Mackenzie, and tbey honestly confessed they would have been imposed upon, had they not ascertained, by an ex- amination per vaginam, that the uterus was empty.— Principles and Practice of Obstetricy, p. 156. The case is referred to in pajre 169. t See Dublin Med. Trans. Vol. I. part 1, New Series. t See Dublin Hospital Reports, Vol. 1. § Forlere recommends the application of the ear to the naked abdomen, when it can be done with propriety, as the sounds are then more dUinct. OF QUICKENING. 175 tary arteries, yet they can never resemble the double stroke of the heart; nor can they be well heard, except in the groin; whereas, the other may be heard over some extent of the abdomen ; espe- cially in the more advanced stages of pregnancy. Third. That the beat of the foetal heart, agreeably to Mr. Fur- guson, may be heard in almost every region of the abdomen. Fourth. That the beat of the foetal heart is not always heard in the same place in the same individual; that is, it maybe found at one point to-day, and at another to-morrow, owing, doubtless, to the change in the position of the foetus itself. Fifth. That the pulsations of the child's heart are often double that of the mother's; and its double beat is well and distinctly marked.* Sixth. That a foetal heart, not exceeding in size a hazel-nut, can be distinctly heard to beat by the stethoscope. The value of this discovery, in a medico-legal point of view, as well as oftentimes in the common routine of practice, need not be commented on. While on this subject, it maybe well to mention, that Dr. Bec- caria thinks he has discovered a new symptom, by which preg- nancy in the early months is very certainly detected. This author thinks he has observed, in many instances, during several years' practice, a painful pulsating sensation beset the woman, in that portion of the skull which Gall terms the organ of amativeness ; this feeling is accompanied by giddiness upon the least motion of the head. Such females as feel this pain, are suddenly seized with it, and without premonition. It continues some time, and is followed by sleepiness, which being yielded to for a short time by the patient, she awakens free from pain, and with a great ap- petite. This pain returns daily, at about the same hour, for about eight days. It leaves the patient spontaneously, and.without the aid of art. This symptom manifests itself without being accom- panied with the usual signs of pregnancy, and without the woman suspecting herself to be in this situation.—(See Amer. Jour, of Med. Sci. for May, 1831.) * Mr. Furguson found, in one instance, the beats of the mother's heart SO, and that of the Icetus 136. In another, mother's 90, foetus 130. In another, the mo- ther's were 100, and the foetus's but 28. 176 GENERAL CONDITION OF THE SYSTEM DURING CHAPTER IX. OF THE GENERAL CONDITION OF THE SVSTEM, AND THE EFFECTS OF CERTAIN REMEDIES UPON IT DURING PREGNANCY. Dr. Denman seems rather unwilling to call the various affec- tions to which the female is liable from impregnation, diseases. He says, " The state of pregnancy is an altered, but cannot with propriety be called a morbid state." We are of opinion, that pregnancy is not necessarily a disease, but that the impregnated uterus very frequently induces it in other organs of the body, from a strong sympathetic influence, though it may be free from dis- ease itself. The uterus being occupied with the rudiments of a new being, agreeably to the arrangement of nature, cannot properly be said to be in a morbid condition: on the contrary, it is essential to the object of this condition, that it preserve almost inviolate its health- ful integrity. For if the uterus become diseased, in the strict meaning of the word, the intentions of this condition, will, almost to a certainty, be frustrated. It therefore has a decided power over other parts, by exciting them to diseased, or at least de- ranged action, while it preserves itself in the most healthful state. Indeed, the healthful state of this organ, seems necessary to the power it has, of calling other parts into sympathy. This is abundantly proved, by the fact, that the process of ges- tation goes on, as a general rule, best, when certain, or what are termed the rational signs of pregnancy, are present, and even in full force : such as nausea, vomiting, salivation, heartburn, swell- ing of the breasts, &c. &c, and, consequently, proving pregnancy to be a healthful condition. This is a fact almost universally ad- mitted by the writers upon the subject of midwifery. " It is a popular observation," says Dr. Denman, "confirmed by expe- rience, that those women are less subject to abortion, and ulti- mately fare better, who have such symptoms as generally attend pregnancy, than those who are exempt from them," p. 225. Is it not then certain, that the uterus is in the best health, when it excites the various parts concerned in the affections just enumerated ? and when it does not move them to sympathy as above stated, that it is performing its functions less healthily: since it may be excited to action, and very often is, in the ab- sence of these symptoms, to abortion ? For habitual aborters, are PREGNANCY, AND THE EFFECTS OF REMEDIES. 177 very rarely attacked with the more common affections belonging to pregnancy.* The uterus, when impregnated, produces commotions in vari- ous degrees, in other portions of the system, while it preserves itself in the most healthy condition, as if these various sympathies were intended to divert all evil from it, that the great object of nature, (the propagation of the species,) should not be circum- vented with too much facility. Very frequently, in civilized life, and not uncommonly in savage life, the "breeding symptoms" are very often called forth; now, it is not reasonable to suppose that all the severe sufferings to which the pregnant! woman is subjected, can be idly instituted, without a physical end, or a moral purpose! It cannot be that the severe privations, and the absolute evils of gestation, should have been intended as an afflic- tion without an object! The sympathies called forth by pregnancy, though they are, strictly speaking, but chains of morbid actions, so far as the parts immediately affected are concerned, yet they are not, like most morbid actions, called forth by a morbid cause; and we must still insist, that pregnancy, abstractly considered, is not a disease. For we have already shown, that the uterus, the part most im- mediately and extensively concerned in the process of gestation, must preserve its healthy powers, that this function shall not cease. It is, therefore, unlike any other process in the human body ; for it seems to provoke disease in other parts, in order to preserve the perfection of its own operations. The disturbances arising from impregnation have the tendency to prevent plethora, or to divert excitement. And these object^ are chiefly effected through the agency of the stomach, the part most generally subjected to this kind of vassalage. Hence, nau- sea, vomiting, loss of appetite, disgust, or loathings, or longing for certain unnutritious substances, &c. These affections are in- stituted, that the quantity of circulating fluids may be lessened, and excitement diverted ; and thus prevent the evils so sure to attend that condition of the system, called plethora. - Now, if the subjects be closely examined, it will pretty generally be found, that the sympathetic affections are violent, in proportion to the necessity of subduing this state of fulness, or uterine excitement. We may be told, that many women " breed" without any, or but very few of the affections which commonly attend pregnancy. This is admitted; but in such cases there is, perhaps, no necessity for instituting this subduing process; as there may be little or no tendency to the fulness spoken of. * It mu't, however, he admitted, that there are exceptions to this rule ; we have seen several instances of extreme sickness of stomach, vomii ing, &c, attend, when Ihe patients have aborted, and this repeatedly. 178 GENERAL CONDITION OF THE SYSTEM DURING Generally, the women who are exempt from this common penalty, are those who possess great physical powers, and are in the habit of constantly employing them. In these cases, the same end is answered by another means. The excitability of the sys- tem is expended by the regular application of the stimulu.s of exercise; and, consequently, that state of irritability of the mus- cular and vascular systems, so injurious at this period, is pre- vented. Besides, people who employ their physical powers in useful exertion, have few provocatives, save that of regular ex- ercise and regular rest, to produce appetite; no artificial condi- tion of the stomach is created; they satisfy their cravings by a simple but nutritious diet; and no more blood is formed, than is sufficient for the exigencies of the system. In these cases, also, the irritability of the uterus never becomes so excessive, as where the contrary life is led. For the uterus, being a muscle, participates, like the other muscles of the body, in the general benefit derived from healthful and regular occupa- tion and exercise. The nervous system has less mobility, for the same reason ; of course, the uterus will be less disposed to be thrown into contraction, by the application of either physical or mental stimuli; consequently, there will be less disposition to abortion. With those who lead indolent lives, and who feed luxuriously, the case is very different. In such, more blood will be irfnde, than can advantageously be employed; consequently, there will be " plethora"—and not only plethora, but augmented irritability; and therefore, a liability on the part of the uterus to be thrown into contraction, by smaller causes, sometimes, than ordinary. Now, should such females*not be visited by the common affec- tions of gestation, the liability to abortion will be increased in proportion to the disposition of the system to become plethoric. Hence, the truth of the remark, that "those women are less subject to abortion, and ultimately fare better, who have such symptoms as generally attend pregnancy, than such as are exempt from them." We know a lady that is easily provoked to abortion, who can tell soon after the stopping of her catamenia, whether she will carry her child or not, by the state of her stomach. If she have no morning sickness, vomiting, loss of appetite, or disgust, she is certain to abort. She has now acquired sufficient knowledge of herself to prevent this accident; and whenever she faithfully acts up to the dictates of her reason and experience, she is sure to carry her child safely. If after the interruption of her menses, she do not become af- fected with the common consequences of impregnation, she in- stantly reduces the ordinary quantity and quality of her food ; drinks nothing but water; keeps her bowels soluble ; and some- PREGNANCY, AND THE EFFECTS OF REMEDIES. 179 times but not always, loses a little blood; (but this, never with- out the advice of her physician;) uses very little exercise, lest she produce fatigue; in a word so conducts her regimen as to very much reduce, if not entirely prevent, plethora; and she so manages her physical exertions as not to convert them into un- usual stimuli to her nervous and muscular systems. But, at other times, when she becomes pregnant, and has the ordinary accompanying signs, she takes no extraordinary trouble to regulate the condition of her system, as she finds they are al- most always sufficient to subdue the tendency to plethora. But should she feel headach, or other marks of fulness, she loses a little blood, or eats less? During pregnancy, the system is in a state of constant stimula- tion from this very cause. First, there is the stimulus of disten- tion constantly operating, from the first six weeks to the full pe- riod of utero-gestation. This is the most obvious in the first few months; and, for this reason, the uterus yields with more reluc- tance at this, than at any subsequent period, either from its own specific density, or from the smallness, as well as feebleness, of the distending cause within.* Hence, in the first few months of pregnancy, the sympathetic affections are more violent than at the after periods. 2d. Joined to the stimulus of distention, is that disturbance which is, and must be, consequent upon the change of position of all the abdominal viscera, and which is sometimes very considerable. (See section on the pain in the right side of pregnant women.) 3d. The constant, though not uniform pressure upon the intestines, both above the fundus, and below its posterior and lateral portions, giving rise sometimes to many unpleasant symptoms; such as cramping pains, from the unequal distention of the bowels; constipation; diarrhoea; &c.| * So reluctantly does the uterus yield at this period, sometimes, that much in- convenience is experienced on the part of the patient, from severe alternating pains in this part, which are tranquillized with difficulty, by blood-letting, opium, &c. At other times, it absolutely refuses to yield farther than a certain point; con- tractions are excited,"aud the ovum eventually expelled—this is one of the causes of abortion. t "There is every reason to believe that thet uterus, and, therefore, its cavity is not enlarged solely by the distending power of the ovum; as, in c^sesof extra-ute- rine pregnancies, it has been known to be much larger than in the natural state, and to be lined with the decidua."—Review of Dewees on Females. N. Amer. Med. & Surg. Jour. Vol. 111. p.. 3f)L». In reply to the above critic, it is but necessary to observe that I have no where asserted that the increase of Uie uterus was owing solely to the distendinor power of the ovum. 1 have only declared that the uterine cavity was enlarged by the ovum ; and that it is, in every way, evident, as the most perfect relation between them is constantly established, after a certain period of pregnancy. Now, if the ovum do not make room for itself, it must be evident some other power must exist for this purpose. Can any other power be pointed out ? Isit not clear, to demonstration, that the ovum is the agent, when, if this be broken, and the liquor amnii riis- chargid, that the uterine parietes contract to the altered size of the ovum ? No, say8 the reviewer; for "the uterus is found to be much larger than in the natural 180 GENERAL CONDITION OF THE SYSTEM DURING The combination of these causes, keeps the system in a state of constant excitement; the pulse is, therefore, almost always acce- lerated. The nervous system directly, and the arterial indirectly, afe always found to bear stimuli ill. Hence, in their exhibition at such periods, there is much caution necessary. The young practitioner should never lose sight of the im- portant fact just mentioned, if he expect to be successful in the treatment of the diseases of the female, at such periods. We have known many errors committed for want of due attention to this state of the female system: some of greater, and others of minor importance; but all errors of this kind should be avoided with great care. To show the susceptibility of the system to stimuli at this pe- riod, in some cases, we will relate one instance of many of a simi- lar kind, which have fallen within our own knowledge. Mrs. ----, pregnant with her sixth child, and at the eight month com- plete of utero-gestation, complained suddenly of sickness, accom- state, in cases of extra-uterine pregnancies." Can the reviewer bring any case of extra-uterine pregnancy, where the «f the uterus in a natural or healthy pregnancy. The reviewer farther declares, •' it is not correct to assert that the greater suffer- ings of the woman, in the earlier periods, dep nd upon the stimulus of distention being greater at that time; as, in some individuals, these sympathetic affections appear before we have any proofs of the ovum having reached the uterine cavi- ty."—Ib. To this logic we would enly answc, th m, if th're lie "no proofs of the ovum having reached the uterine cavity," there can certainly be none that it has not; and, consequently, we have as much right to the positive assump'ion, were it in any way important to our views, as the reviewer has to the negative. B it this is of little consequence. We believe we arc borne out by all physiologists,-when we assert that later than thirty days has never been fixed for the ovum to gain possession of the uterine canity; and we believe that all observation enfirms the declaration, that sooner than this, the rational signs of pregnancy never appear; indeed, six weeks is very early for these symptoms to manifest themselves. Nor is it of any kind of consequence to the subject in question, whether the distention of the uterine cavity be effected by tt>e ovum, or by any other agency, since the reviewer himself admits that the uterus increases, even in extra-uterine concep. tions. The ovum, however, must always be regarded as infinitely the most' com. mon cause, and was consequently chosen to illustra'e the princip'e contended for. And we may arid, that when fie signs of pregnancy appear earlier than is here staled, they are the exejpions to this rule. PREGNANCY, AND THE EFFECTS OF REMEDIES. 181 panied by a distressing sensation of the stomach ; she was advised by a young practitioner of medicine, who happened to be present, to take a little pretty strong brandy and water; which he accord- ingly prepared, and gave to her. She had not swallowed the mixture more than fifteen minutes, before she felt the distressing sensation increase, though the nau- sea was abated; at the same time she experienced a confusion, and severe pain in the head, which seemed more concentrated in the forehead, immediately above the eyes; a dimness, or rather a temporary loss of sight, with strong twitchings in the muscles of the arms and legs. The physician, as well as the family became alarmed lest this should eventuate in a " fit;" and we were requested to see the lady immediately. When we visited her, she was labouring un- -der the above named symptoms, and which had been gradually increasing from the beginning of the attack. We found her with an accelerated pulse ; a flushed face, and considerable confusion of intellect. The remedy, in such a case, could not be mistaken. Her arm was immediately tied up, and blood abstracted, until her head and senses were perfectly re- lieved : it did not, however, require more than fourteen or fifteen ounces of blood to effect this. She had nor eturn of any unplea- sant symptom after that evening. So much does pregnancy modify the affections of the system, that even the sensations called nervous, can rarely be relieved by the usual remedies, however successful they may have been with the same patient at other times ; but under different circumstances. The common symptoms by which hysteria shows itself, such as palpitation of the heart; a sense of suffocation ; difficulty of swal- lowing, &c, can rarely be controlled by the common remedies, unless they are anticipated by a bleeding of a greater or less ex- tent. This should be borne in mind : for success will not follow the use of remedies, without attention be paid to it. But the susceptibility ^of the system to stimuli during preg- nancy, is more evident when the woman is attacked with an acute disease ; such as fever. To relieve her, at this time, is found more difficult always, than at any other; for the system is now so susceptible, so disposed from the circumstances of preg- nancy to maintain morbid action, that remedies of the most ap- propriate kind, succeed with difficulty. And if it be attempted to accelerate convalescence by tonics, even of the mildest sort, they are almost sure to disappoint the practitioner, if they should not even recall the disease. Nothing, perhaps, shows the difficulty of employing tonics during pregnancy, more than the want of success of the Peruvian bark in intermittents. In substance, we scarcely ever succeed in arresting the paroxysms, as we might calculate to do in ordi- 16 182 OF BLEEDING DURING PREGNANCY. nary cases, unless its exhibition has been succeeded by very ample depletion. We have seen a number of instances where an intermittent has been quickly converted into a remittent, by the exhibition of the bark. Indeed, it is hardly ever safe to trust it even after very liberal evacuations. The sulphate of quinine, however, is less objectionable,, or less treacherous. In a wrord, we rarely use tonics of the more powerful kind, in the convalescence of females, after acute diseases, when compli- cated by pregnancy, especially in the earlier months. After the fifth month, up to the full period, the system is less irritable. For soon after quickening, almost all the sympathetic affections begin to moderate; and sometimes, nay, very often, cease alto- gether. This, it is probable, is owing to the following causes;—1st. From the uterus now making greater demands upon the system at large for blood ; from the increased size of itself and foetus ; and consequently, relieving, in a degree, the state of plethora. 2d. By the system having become more familiar to the peculiar stimulus of pregnancy, from its long continuance. 3d. To less irritation being experienced by the greater disposition of this organ to be distended. For, after the fifth month, the resistance of the fundus and body is less; 1st. From its increase of vascu- larity ; and, secondly, from the ovum augmenting in power. Hence the melioration of symptoms after the fifth month. We will now consider the effects of certain remedies during gesta- tion. 1st. Of Bleeding during Pregnancy. From what we have said, it follows that the female constitu- tion, during pregnancy, has great susceptibilities, and even pecu- liarities, which are highly important to be known and regarded, especially when prescribing for an acute disease. The process of sanguification is much more rapid during this period ; as all the functions of the body are more quickly performed. Hence, at this time, they bear so well the loss of blood ; hence, the more frequent necessity of abstracting it; and hence the difficulty of overcoming the morbid actions of the system at such times. There is, very often, much clamour raised against this opera- tion : the depletion of the pregnant woman. This is sometimes so great as to render it extremely difficult to subdue their dis- eases.* This prejudice, for so it truly is, is founded upon false views of the functions of the uterus, and the economy of the fceitus, * The young or inexperienced practitioner must not be betrayed into over bleed. ing in cases of pregnancy, by the sizy appearance of the blood; for such is the i idomitable nature of the blood vessels, that the blood would appear sizy to the last drop in the body. OF BLEEDING DURING PREGNANCY. 183 during the period of utero-gestation. It is imagined, that every ounce of blood the mother loses deprives the foetus of a certain portion of it; consequently, that we should be very sparing of this fluid, that we may not rob the foetus of its due quantity of nou- rishment. On this account, the clamour of friends frequently arrests the lancet, when its employment is most essential to the welfare of the mother. There are few mistakes of greater magnitude than the one just noticed ; and, though founded in error, it has, nevertheless, often prevented, or very much interfered with the free and unbiassed practice of medicine. It very often causes the young practitioner to abandon some of the best established principles in the prac- tice of his art; namely, 1st, that women bear the loss of blood better, when pregnant, than at any other period ; and 2dly, that all the acute diseases by which they may be attacked require a more extensive use of the lancet. If, then, the interference of friends interrupt the free exercise of the judgment, the practitioner is reduced to the office of a nurse ; for it is not he who prescribes, but the friends of the patient; while all the responsibility rests upon his shoulders. We have known much mischief produced by yielding to these mistaken views of the animal economy, at this time. It should be recollected, that the circulation through the uterus, has most wisely been rendered almost independent of the contin- gent condition of the general circulation of the system ; and that no one viscus in the body is so little influenced by changes in this important function, as this organ, during the whole period of utero-gestation. The uterus contrives, if we may use the expres- sion, to make its demands upon the general mass always success- fully ; or, at least, so long as there is any thing to ask for; hence, when almost every other organ is but sparingly supplied, we find the uterus abundantly furnished. Who, in the practice of mid- wifery, has not seen a fully-developed foetus yielded by a mother in the last stage of a wasting disease, like phthisis pulmonalis, and where the quantity of circulating fluids was extremely dimi- nished? Is it to be supposed, then, in such, and in similar cases, that this could have happened, had the uterus had no more than a common participation in the distribution of the blood ? Certainly not; since the quantity in every other portion of the body was re- duced, by being deprived of part of their usual supplies. But it may be said that the uterus, in this respect, only enjoys the pro- perty of amassing supplies, in common with other viscera; let this be so ; it is not a part of our present purpose to inquire into it: all that we insist on at this moment is, that the uterus abso- lutely possesses this power. 184 OF PURGING DURING PREGNANCY. We may be told that, the foetus is by no means so secure as is represented, when the mother suffers considerable losses of blood ; and they will attempt to illustrate this, by showing that the child often perishes from uterine hemorrhages. This is true ; but it does not interfere with our remark; for we have not said that the uterus cannot be exhausted of blood, if blood be taken directly from it, as in floodings: we have only declared, that when this fluid is drawn from the general system, as in bleedings per- formed for the relief of disease, that very large quantities might be abstracted, without making the uterus give up any portion of what it absolutely possesses ; and this is strictly true. But, on the other hand, it must not be supposed that pregnancy, merely as such, requires blood-letting. This error is as great as the one we have just attempted to remove; for we make it a constant rule in practice to discountenance blood-letting, unless there exist some inconvenience or disease to demand it. 2d. Of Purging during Pregnancy. The pregnant woman does not bear purging so well as one who is not so: or rather, if this operation be carried very far, there is a risk of producing abortion, owing to the strong consent between the uterus and rectum. Hence, the occurrence some- times of this 'accident, from a profuse diarrhoea, or a violent dysentery. Therefore, some caution is required, in treating the diseases of pregnant females by purging; for if carried to a great extent, it may do mischief. But let us be understood exactly on this head, lest we deprive females of the advantages of this re- medy, in the acute forms of disease. We mean that a pregnant woman would not bear, with safety, as much purging, as if she were not pregnant; yet she bears it with advantage, when car- ried to a considerable extent, especially if tenesmus be not ex- cited, either by the quality of the drug employed, or by the acci- dental severity of the operation of a medicine, otherwise gene- rally eligible. In a word, we believe that a pregnant woman will bear, without risk, any common or necessary degree of purging, unless she be prone to abortion. We should suggest caution in the choice of purgative medi- cines, rather than forbid the employment of this evacuation, as a remedy; for, with the pregnant woman, much depends upon the selection. AH such as act with great force upon the bowels, should be avoided; such, for instance, as are classed among the drastic purgatives, as scammony, gamboge, colocynth, aloes, &c. ; because each of these produces, during its operation, great irritation in the rectum, and very frequently excites tenesmus. OF EMETICS DURING PREGNANCY. 185 It is this peculiar irritation which renders any cathartic unsafe that might produce it; no matter to what class of cathartics it may belong; for, if castor oil, magnesia, or any other mild ca- thartic were to produce this effect, it would be as equally improper, as any of the drugs prescribed above. Hence we see abortion frequently occur from dysentery ; and but very rarely from diarrhoea, however profuse. Cases of habi- tual abortion, which are preceded by severe diarrhoea, might be considered as exceptions to this rule ; but this is, perhaps, more specious than just. For in all the instances which we have wit- nessed of this kind of diarrhcea, there was more or less tenesmus accompanying it; and it is with us a doubtful point, whether this diarrhoea is not, in such cases, a concomitant, rather than a cause. For there is no fact better established, than that there exists a strong sympathy between the uterus, (and, perhaps, the mouth of this organ particularly,) and the rectum. We witness this oftentimes in the commencement of labour; during its pro- gress ; or towards its termination. We have more than one patient, whose labours always com- mence with diarrhoea; that is, so soon as the os uteri is stimu- lated to dilatation, the bowels yield. Now, in abortion, there must always exist some irritation at the os uteri, or it would not yield to the impulses of the fundus and body of this organ, for it is by no means a mechanical operation. And so soon as this nisus is perceived, (for the uterus prematurely throwing off its contents, is a kind of tenesmus of this organ,) the rectum sym- pathizes with the uterus, and a diarrhcea, with tenesmus, is pro- duced. If this be objected to, by saying, that abortion is sometimes prevented by the application of opium to the rectum, thereby removing the disease, or quieting the irritation which invited the action of the uterus; we would answer there is not the smallest proof from this circumstance ; since the sympathy between these parts is reciprocal; and, consequently, when a remedy is applied to the one it will influence the other. In proof of this, how often do we successfully apply remedies to the rectum, when we mean its effect shall be felt by the uterus alone ! We believe, then, it is not so much the frequency of the dis- charges from the bowels produced by the operation of purgative medicine that does the mischief in- pregnancy, as the peculiar, and oftentimes severe irritation it produces in the rectum. 3od can be abstracted with more rapidity and certainty from this part, than from either the back or abdomen. Besides, its revulsive power may have a salu- tary influence. TREATMENT OF CARCINOMA UTERI. 243 individuals concerned. As regards ourselves, we have but too frequently had cause to lament this overweening delicacy, as we are certain, in many instances that have fallen under our notice, cures might have been performed, where only relief, and that sometimes but temporary, was procured. So far, it has been our misfortune to have, in no instance, a single compliance with this prescription; but we do not despair that we may yet overcome this injurious reluctance. 2. Purging. This should never be omitted ; for there is no one remedy that we can employ in this deplorable disease, that is of such decided efficacy as purging. It not only comports with the general ob- jects to be fulfilled, but it removes a prodigious source of irrita- tion. In conducting this process, however, regard must be had, 1st, to the quality of the purgative; 2d. to the extent to which this must be carried; and, 3d. to the effects it produces. ]. It is not a matter of indifference, which of the purgatives we select for the purpose of affecting the bowels, in the disease under consideration. Such should always have the preference, as will sit best upon the stomach; that will operate without pain, and afford copious discharges of fluids from the intestines them- selves. Such are the neutral salts; they therefore merit the pre- ference. The sulphate of magnesia alone, or combined with an equal weight of the magnes. alb. ust.; phosphate of soda; the Seidlitz powders; crem. tart, and the flor. 6ulp. in equal quanti- ties; and the sulphur and magnesia. Next to the neutral salts, we may place rhubarb, or rhubarb and aloes; the castor oil, the magnesia alone, &c. Mr. Clarke recommends, " when saline purgatives do not agree with the stomach, but excite vomiting, an additional quantity of acid may be given with them: thus, eight or ten drops of diluted sulphuric acid may be added advantageously," p. 227. We have known a saturated solution of the sulphate of soda, or of magnesia in small doses, repeated every morning, or every other morning, continue to agree with the stomach admirably, for months together, and move the bowels freely two or three times a day, without either nausea or pain. This solution must be taken in the quantity of a large table-spoonful, early in the morning, before eating ; and, contrary to expectation, it sits well upon the stomach. This solution is not, however, always sufficiently powerful to keep the bowels soluble; when this happens, a little calcined magnesia must be added. Where those medicines would be dis- gusting, the phosphate of soda, the Seidlitz powders, the cream of tartar and brimstone, or brimstone and magnesia may be substi- 244 TREATMENT OF CARCINOMA UTERI. tuted. The castor oil occasionally may be resorted to, but it does not, in general, answer well, when continued for a long time. I have mentioned rhubarb, as the next best general carthartic: this is a valuable medicine in almost all cases, where a perse- verance in purgative remedies is absolutely necessary, as it very seldom requires an increase of dose if it be regularly adminis- tered. But it happens with it, as with every other medicine, that it will sometimes, though rarely, lose its effect: when this happens, it should be combined with aloes. The following is the formula I generally employ:— R. Gum Aloes sue. ^ss. Pulv. Rhaei. 5j. 01. Caryoph. gut. iv. Sapo Venet. gr. viij. Syr. Rhaei. q. s.—M. f. pil. xxx. One of these is to be taken every night, or every other night, as they may affect the bowels. This form rarely requires an increase of dose, unless the bowels are rendered costive by opium, which is very likely to happen, as this drug must be used in this complaint; if this happen, two or three of the pills may be required. It is familiar to us, that aloes is generally prescribed in all cases where the uterus yields blood too frequently, or in too large a quantity ; but we believe this to be an ill-founded prejudice. We have used the pills now prescribed, in several instances of this complaint with entire success, as regards the object for which they were ordered ; namely, to gently purge the bowels; and, certain- ly, without increasing the inconveniences under which the patient was labouring. It happens not unfrequently, that the bowels become obstinately costive; nor can they be made amenable to common remedies, even in large doses: this condition is most unfortunate for the patient; for it not only deprives her of the advantages which con- stantly result from purging, but aggravates by a mechanical agency all the evils of her situation. In such cases, the bowels should be emptied by mild injections, when they can be thrown up the rectum; this sometimes, however, is a matter of great dif- ficulty, but they should be made to act rather by their bulk than by their quality. The common stiff pipe, attached to a syringe, is but ill-calculated to succeed in cases where the rectum is par- tially obliterated by the enlarged uterus pressing against it: a flexi- ble tube should always be used, when this difficulty occurs. 2. The extent to which purging must be carried, is next to be considered. It will readily occur, that this process should have a limit; or much mischief must ensue; indeed, its very objects would be frustrated. The use of purging is, to solicit large serous discharges from the intestines, with a view to relieve the TREATMENT OF CARCINOMA UTERI. 245 engorged state of the pelvic viscera: and at the same time, not to weaken the system too much, by its excess; consequently, if purging be carried too far, we shall have the following incon- veniences to contend with; 1st, the body will be unnecessarily debilitated from the excess of discharge; 2d, we shall have mu- cous discharges, instead of serous, which will be attended by griping pains; 3d, instead of lessening the congestive tendency of these parts, it will increase it, by producing a sub-inflammation of the intestines; 4th, we should increase the activity of the inflammation in the neck of the uterus, by the mechanical pres- sure of the sigmoid flexion of the colon and rectum, in the act of passing the feces. Therefore, more than two or three easy stools per day, have ever proved both inconvenient and injurious, by the dislurbances they create during their passage. 3. Regard must be paid to the effects purging produces. This must be determined, 1st, by, whether the discharges are attended with much pain during the operation, or immediately after: if they are, the number of discharges must be diminished; unless the pain arise from the costive condition of the bowels; 2d, by, wheiher these discharges produce faintness, or other decided t signs of weakness: if they do, they should be moderated; or, if judged proper, even suspended for awhile. 3. Abstemious Diet. There is no disease, unless it be one very much more acute, that so decidedly suffers aggravation from errors in diet, as the one under consideration. We have known severe and long-con- tinued pain, to follow an apparently slight error in diet. For, it would seem evident, that, if any expectation be entertained of curing, or even alleviating this complaint, that diet, like every thing else remedial, should be made conformable to the great in- dications ; namely, to diminish the quantity of circulating fluids; and to abate, both locally and generally, arterial action. Therefore, the most bland articles must be selected for this purpose; as milk, and vegetables. If milk agree with ihe patient, as a general article in diet, it should be used in preference to almost any other: it may be taken, a little reduced by water, three times a-day, with bread, rice, Indian, or rye mush, or un- bolted wheat flour mush; but especially the last, as there is almost always costiveness. The fruits of the season, tapioca, oatmeal, sago, Indian meal gruel, &c, may also be taken, the rennet whey, where the whole milk disagrees; in a word, almost any vegetable, that is neither stimulating, nor of difficult assimilation. h is well known, that food may offend by its quantity, as well 21* 246 TREATMENT OF CARCINOMA UTERI. as by its quality; and though we have admitted a great variety of vegetable substances, it must be understood, that those must be moderately indulged in; otherwise they may offend by their quantity. ~ . The influence of this course of diet is much more efficient than we might at first be willing to admit; but the fact is unquestion- able, that it almost immediately relieves pain, after it has been adopted. Mr. Clarke very well observes, that " the quantity of food taken should be very moderate; lest, not being digested, it should disturb the functions of the alimentary canal, and become the cause of fever; or lest, being digested, it should add to the quan- tity of blood, and improperly increase the vigour of the system," p. 229. The patient, it must be remembered, must be forbidden, at the same time, every kind of stimulating drink. Wine, spirits, and fermented liquor of every sort, must be prohibited with even more rigour, if possible, than animal substances, as food. Spices, or any other condiment, must be considered as coming under the same ban. " All local stimuli should of course be avoided. Sexual inter- course must, therefore, be improper." Clarke, p. 229. 4. By Cleanliness. Nothing can compensate for the want of cleanliness; yet, in this case, some care is required, to conduct it with advantage. In the history just given of carcinoma, it was observed, that there was an increase of vaginal discharge. This, if permitted to accumulate, or suffered lo undergo the changes which heat always effects upon the fluids when thrown off from the systems would become offensive, and highly acrid; consequenlly, would increase ihe irritable condition of the cervix uteri, from its prox- imity, and even contact with it. It therefore behooves the female to keep these parts extremely clean, by frequent ablutions with lukewarm water, or flaxseed tea, as well as deterging the vagina with the same material, by means of the female syringe. Many have thought to improve the efficacy of these mild applications, by the addition of certain medicaments; but, we believe, that advantage has rarely, if ever been gained, by this practice; unless a subsiance has been ex- pressly added to destroy the fcetor of the discharge, by its che- mical agency. If the disease has proceeded to ulceration, the smell sometimes becomes almost insupporlable ; for now a quantity of blood is almost constantly issuing from the ulcerated surface, which, TREATMENT OF CARCINOMA UTERI. 247 becoming putrid, gives out so pestiferous a gas, that few can sup- port its presence without great aversion, or even nausea. The patient herself becomes much annoyed by this stench ; often so much so, as to deprive her of both appetite and sleep; she quickly becomes debilitated, even sometimes to exhaustion, from this cause. All her evils are increased by the pervading influence of this odour; her digestive powers are so weakened, as to reject the little sustenance a wretched appetite allows her to take: and the-effort to puke may renew a hemorrhage, which had been but a short time before arrested with difficulty. We once witnessed a very sudden death from this very cause : care should, therefore, be taken to guard against it. > It becomes, on this account, a matter of much importance to diminish this fcetor, both mechanically and chemically; mecha- nically, by frequent washings with warm water, or the flaxseed tea ; and chemically, 1st, by carbonic acid gas ; 2d. by lime ; 3d. by the pyroligenous acid ; and, 4th. by the chloride of lime, or soda. 1st. By the carbonic acid gas. • We have enabled several patients to derive much comfort, as well as temporary relief, from the extrication of this gas within the cavity of the vagina, by means of a flexible tube of sufficient length and size, attached to the mouth of a bottle, in which there "*is mixed, diluted sulphuric acid, and the carbonate of lime. This may be introduced into the vagina several times in the twenty- four hours. In two or three instances, this substance has relieved the severity of pain whenever it was employed, as well as di- minished the offensiveness of the discharge. 2d. By lime. Lime may be usefully employed in two ways ; and both may be used at the same time. First, lime water, a little warmed, ^nay be thrown up the vagina by the syringe, several times a day. 0 Qne of the best forms-we have tried, is, where a portion of quick lime is slaked in an infusion of chamomile flowers, and permitted to settle clear before using it. The second is, by placing the caustic lime in various parts of the room, or even under the bed- clothes. For this purpose, it should be broken up into small portions, and renewed every twTo or three days, or so often as it is perceived to slack. 3d. By the pyroligneous acid. The defecating power of this acid is no less certain than sur- prising ; and for the purposes now in view, is one of the most valuable articles of the materia medica. This substance, like the lime may be used in two ways. First, as an injection, in' weak solution ; we cannot give any exact directions for its strength, since it varies, as do the feelings of different patients, and even of the same patient at different times. It should at first be made 248 TREATMENT OF CARCINOMA UTERI. verv weak, and used warm, as directed for the other injections; its strength must be increased, as the feelings of the patient may permit;Remembering, the stronger it can be used, the more cer- tain is its control over the putrid exhalations. It may, at. the same time be used in its concentrated form, by wetting a folded towel with it, and placing it over the external parts—this is to be renewed when dry. The cheapness of this article enables the patient to indulge in a liberal use of it. 4th. By the chloride of lime or of soda in solution, as an in- jection per vaginam, beginning with a feeble solution, (a drachm of either to the pound of water,) and gradually increasing the proportions as the parts may become accustomed to the applica- tion. 5. By rest. Rest is a sine qua non in this complaint; whether it be in its incipient stage, or at a more advanced period of its progress. But by rest, do not let us be understood to mean absolute confinement lo bed. By rest, we mean the indulgence of a horizontal position for the body, without intervening exercise. This auxiliary acts by equalizing the circulation; by diminishing its force; by ab- stracting the stimulus of motion ; by preventing the consequences of the pressure of the abdominal viscera upon the fundus of the uterus, and thus avoid irritating the cervix ; and in cases where hemorrhage attends, by permitting the coagula, which arrests for the time the bleeding, to remain undisturbed ; thus preventing the renewal of it. It may be well to caution the young practitioner against too much anxiety for the occasional discharges of blood, which are almost sure to take place, sooner or later, in this disease; he should regard them for a time as so many leechings, from which the patient derives much immediate comfort, if not eventual benefit. Upon the same principle, he should not attempt to arrest the purulent discharge from the vagina, by the employment of astrin- gent or stimulating injections. W^e have already directed strict attention to cleanliness, by means of simple warm water: with this, there can be no fear of doing mischief by any stimulating property. But medicated injections of an astringent nature, must be forbidden ; unless it may be the occasional use of a very weak solution of the acetate of lead—from this injection we have thought advantage was derived by its sedative influence, to the irritable neck of the uterus. Tonics are ever inadmissible in this complaint. Mr. Clarke concludes his remarks on the treatment of this dis- ease by observing, " In treating this disease, as no cure is known TREATMENT OF CARCINOMA UTERI. 249 for it, the practitioner must be satisfied with palliatives, and not be anxious to restore the vigour of the body, which might aggra- vate tbe disease again. Still, let it be remembered, that, by a strict attention to management, and an unwearied perseverance in the means suggested, all the cases of the disease may be relieved ; in many, the farther enlargement of the tumour, or progress of the thickening, may be prevented; and if the author was not afraid of deceiving himself, or of deceiving others, he would venture to express a belief, that in a few instances, the disease has altogether subsided," p. 235. The consolation which this last suggestion affords, should be constantly kept in mind ; as it holds out a strong inducement to both patient and practitioner, to persevere in the use of the reme- dies pointed out; shows that this formidable and loathsome dis- ease may occasionally be prevented from running its terrible career; and restores a useful individual to society. We are equally persuaded with Mr. Clarke, that in instances of the en- largements under consideration, we have succeeded in entirely removing them by the plan laid down. And farther, that, from the success of such cases, strong inducements are held out to the timid sex to make known at an early period, any unpleasant feel- ings they may experience in these parts, that the fairest chance may be given to perseverance in pfoper and well-devised reme- dies. And to the practitioner, it offers an inducement to exertion in the cause of humanity. For the most part, after ulceration has commenced, the patient suffers much from the violence and peculiarity of the pain, which now is almost sure to attend. This is so constant, especially at night, as to deprive her almost altogether of rest. There is no alternative now, but the employment of opium, or other narcotics, which but too soon lose their influence, however we may attempt to maintain it by increasing the dose ; and the patient thus early becomes deprived of the only solace art can give her. But in this state of carcinoma, the same regard must be paid to the general state of the system, as in its first stage. For, not- withstanding absorption has commenced, and ulceration is pro- gressing, the system becomes implicated, and the arteries are found to be much excited. A high sympathetic fever is produced, accompanied by a hot dry skin, and almost insatiable thirst, to- gether with a sense of intense heat in the stomach itself. This burning aggravates all the other symptoms, by its intensity and pertinacity ; sleep is interrupted, and the patient will sometimes almost starve, rather than take food at the risk of increasing this sensation. This feeling sometimes proceeds from acidity ; when this is the case, absorbents or antacids should be given: and the frequent use of small quantities of good sweet cream, is almost sure to afford at least temporary ease. OjQ TREATMENT OF CARCINOMA UTERI. The pulse, under these circumstances, is always, we believe, excited ; and in a degree that requires the loss of blood, either from the arm, or from near the part. Some may entertain fears of this remedy from the appearance of weakness which the pa- tient discovers; but this must not create alarm ; for the state of the system declares its propriety. Indeed, nature seems to offer this relief, by producing a hemorrhage from the part, which hardly ever fails to afford it. Besides, it is sure to place the system in a more favourable condition for the operation of nar- cotics, to which, at this stage of the disease, we must always have recourse ; and happy is the patient, when she can obtain a truce to suffering, by their agency; for the pain is generally so severe and protracted, as to quickly destroy their power. For this purpose, we believe it will be found, that opium, in one form or other, is the only one that can be relied upon for any length of time together. Much, however, has been said in praise of several other nar- cotics, besides opium, in the disease in question ; such as the belladonna, the hyosciamus, the stramonium, and the hemlock. WTe are sorry we cannot add any testimony in their favour. In our hands they have fallen far short of the anodyne powers of the opium ; and have constantly failed to merit the high enco- miums which have been bestowed upon them. I am happy to find myself supported in this experience, by Dr. Chauffbrd'.* After pointing out the great abuses committed by persisting a long time in the use of narcotics, he observes, '• The violence of pain often forces us to the administration of narcotics : but do not let us forget, that in such cases, two or three grains of opium will succeed better to calm it, than forty grains of the other extracts. I have seen eight grains of opium, in a terrible cancer, afford more complete comfort or relief, than two drachms of the extract of aconite, and this without worrying the digestive organs or disturbing the intellectual faculties in any like degree: and also much more promptly. This substance, (opium,) would procure some moments of refreshing sleep, which could not be obtained from the other." This is truly a matter of regret; as it abridges our resources at a period, when so few can be commanded, yet when so many are required. So frequent and so uniform have been our disappointments, that we neither consider the belladonna, hyosciamus, stramonium, nor the hemlock, as substitutes for opium. And though altogether aware, bow unfriendly some of its properties are to many con- stitutions, yet we cannot, as a general remedy, give it up for any other, with which we are acquainted. Every preparation of opium is not equally objectionable ; the * Mcmoire sur l'emploi et Tabus des medicaments stupeflants lea plus usitea.— Trans. Med. &c. for July, 1330. TREATMENT OF CARCINOMA UTERI. 25l common laudanum is, perhaps, the most so of any ; even more so than in its solid form. The least, (if we except morphia,) is the acetated tincture of this drug; or what is commonly called "the black drop." In this form, several of its unfriendly tendencies are obviated altogether; and almost always, are very much dimi- nished. It is seldom followed by headach or nausea ; nor does it constipate the bowels, in any like degree, as the laudanum. It, therefore, always merits the preference, when it can be com- manded ; and when it cannot, much of the inconvenience of the laudanum may be avoided, by mixing the doses with sweetened vinegar; or by the addition of a few grains of the carbonate of soda or potash.* It has been a usual practice in carcinoma, to give the cicuta in increasing doses. We have thought that we have sometimes derived a temporary benefit, but we have never witnessed a permanent advantage from it, to whatever extent we have car- ried it. We have thought, however, that opium was more cer- tain to give relief from pain, while the patient was using the hemlock, that when she was not under its influence. We have frequently found in the same patient, that opium would procure rest at one time much more certainly than at another, even under the same circumstances, as far as could be determined. Why this has happened, we cannot pretend to say; but when opium has failed, we have found camphor, in libe- ral doses, would oftentimes succeed. Indeed, we have several times found, that the camphor was a valuable addition to our slender means of procuring rest, in cases of severe pain from ulcerated carcinoma; and this especially where opium disagreed, or had worn itself out. We have also, in several instances, found that the spirit of turpentine, in twenty drop doses, has also pro- cured sleep, when it could not be obtained by opium. The same may be said of the liq. anod. Hoffm. in tea-spoonful doses.f When opium either disagrees, or its efficacy is waning, giving it in the form of an enema, has very often a most happy effect. When employed in this way, a treble dose of the laudanum, in two ounces of warm water, should be given at a time; and re- peated, pro re nata. • Since the above was written, we have become possessed of a preparation of opium that bids fair to supersede almost all the others; namely, the "denarco- tiscd laudanum." This is prepand from opium, that has been divested of its narcotinc. It sits most kindly up. n the stomach; and is very rarely followed by the att-r consequences of the common laudanum, even in those, who are generally obnoxious tn them. Morphia itself < ffers a valuable resource ; it is very certain in its effects, and is not usually follow d by the inconveniences of the other prepara- tions. It may be given either in substance or in solution ; one-sixth of a grain, is about equal to one grain of opium, or thirty drops of laudanum. t Care ;-hou1d always be taken that this substance has been faithfully prepared, See note to page 213. 252 TREATMENT OF CARCINOMA UTERI. When the stomach becomes affected, the case is always more deplorably for reasons easily imagined. This rarely takes place as a sympathetic affection, until ulceration has commenced; and when it does, it goes on, pari passu, with the ulceration, and be- comes even more distressing sometimes, than the original com- plaint. We have but a sorry choice of evils, when this condition ol the stomach exists; for"we are generally obliged to give up a system of diet, which is best calculated to mitigate the uterine sufferings, for one which is better adapted to appease a rebellious stomach. We must give up the vegetable course of diet, for one of animal substances, that we may tranquillize this organ; and we must also neutralize the predominating acid, by the various antacids, or by the sulphuric, or nitro-muriatic acid, in small, but often repeated doses. One of the best sitting substances that we have found, when the stomach is extremely irritable, is rich sweet cream; this must be given by the tea-spoonful: and repeated every fifteen or twenty minutes. We shall conclude this account of carcinoma, with giving an extract from Mr. Clarke's work, so often mentioned. We do this, because his remarks upon this terrible disease are judicious, and bespeak the experienced practitioner, as well as the man of feel- ing. Moreover, there are some views of the disease which are novel', and a part of practice and resources, that is not sufficiently familiar to the American practitioner. We have preferred giving his opinions and suggestions in his own language, to condensing them, though at the risk of being blamed for so long a quotation, by those who have not yet met with the disease. But, from the practitioner who may have such a case in hand, and whose re- sources are nearly exhausted, we fear no such censure : on the contrary, we are sure we shall receive his thanks for any new suggestion that will, for even an hour, relieve his suffering patient. " The management of the discharge from carcinomatous sores, is a circumstance deserving the best attention of the surgeon. This discharge appears to have the poverof converting the neigh- bouring parts, to which it is applied, in some instances, into sores of a similar character to that by wdiich it was itself secreted; and there is reason to believe, that the spreading of carcinomatous ulceration may be greatly retarded by the employment of those substances which absorb or remove the ichorous fluid secreted by them. Common aphthous sores, which frequently arise in the vestibulum of women, who have long laboured under diseases of the female organs, may also possibly be converted into malignant ulcerations. These observations especially apply to carcinoma- tous ulcerations of the internal parts, in which the discharges are TREATMENT OF CARCINOMA UTERI. 2^2 more likely to be retained, than where the disease attacks exter- nal surfaces. If it were only that the fcetor attending such sores would be removed by cleanliness, attention to this circumstance would be of great consequence, inasmuch as the patient's health, and that of such persons as may associate with her, will be less likely to suffer, that when constantly breathing an impure atmo- sphere. • « " Of all the modes of applying water to sores at the upper part of the vagina, none is so effectual as the use of the hip-bath; in the employment of which, the water is brought into contact with the sore without any risk of infusing the latter. By these means, the object of maintaining cleanliness is not only obtained, but-a soothing application is made to an irritable surface ; the carefully injecting warm water into the vagina,'by a syringe^ or the agi- tating the water with the hand, will render it more likely to remove any portions of coagulating lymph, or thickening matter, which may adhere to the inside of the vagina. The heat of the water employed, should depend upon the feelings of the patient in some measure ; but, generally speaking, it may vary from about eighty- six to ninety-four degrees. Where the patient is too weak to bear the exertion of being put into a hip-bath, her hips may be brought over the edge of the bed, and warm water may be care- fully injected into the vagina by a small'syringe. The quantity of the discharge is frequently increased by the means above-men- tioned, but the comfort which the patient will derive from it, will abundantly compensate her for any debility which may be pro- duced by the remedy ; and excruciating attacks of pain, are some- times rendered very sufferable, by a frequent recurrence to it. Strong decoction of carrots, sometimes used-for the same purpose, has the happiest effects. Warm w'ater may also be made the 'vehicle for a variety of sedative applications, which are found by experience to tranquillize all irritable sores; and, in some, to ex- pedite the healing process. Amongst the different applications for this purpose, the extractum conii, or eXtractum hyosciami, may be mentioned, either of which may be employed in the pro- portion of about three or four drachms to a pint of water. Solu- tions of opium, or of extract of poppy, may. also be used ; of the former, two drachms; of the latter, half an ounce may be dis- solved in each pint of water. Starch or mucilage of quince-seed, form' good menstrua for these applications; their adhesive pro- perty enabling them to cling to surfaces to which they are applied.- Three or four ounces of either of these fluids, impregnated with sedative substances, may be thrown into the rectum, in those cases where relief is not obtained by their application to the vagina ; but when opium is used for this purpose, the practitioner should be very careful to watch over its effects,- as1 it has some- times happened that unpleasant consequences have arisen from 22 i54 TREATMENT OF CARCINOMA UTERI. the application of this drug to the rectum, such as vomiting, syn- cope, cold extremities, and irregularity of circulation. The action of the absorbents of the rectum is, in all probability, in these cases, increased by the inflammatory process which exists in the vicinity; besides which, the action of the rectum itself is temporarily taken off, so that the enema will probably be retained during a considerable length of tinae. Plasters and liniments into the composition of which opium enters largely, will sometimes be found serviceable in allaying pain, and are useful auxiliaries in a disease, in which all the resources of the practitioner may be re- quired to diminish the suffering of the patient. " There are some applications which produce a sedative, or a stimulating effect, according to the strength of which they are used. A very diluted mixture of acetic acid, or of nitric acid in water, will form a soothing application to an irritable part, whilst in different proportions, they will become highly irritating. Either of the lotions mentioned beneath may be employed. R. Acidi acetici, - - - -. gss. Aquae distiliatae, - - - Oj.—M. f. Injectio. Or, R. Acidi nitrici, - - - - gutt. x. Aquae distiliatae, - - - Oj.—M. f. Injectio. Or, R. Liquoris plumbi acetatis, gj. Acidi acetici, - - - - 311. Sp. Vinosi. ----- 3j, Aquae distiliatae, - - - gxvss.—M. f. Injectio. " If the discharge should become so profuse, as to induce great debility, injections which possess an astringent power, must be sought for. R. Decocti corticis granati, - - Oj. Sulphatis alluminae - -. - ^ss.—M. f. Injectio. Or, R. Zinci sulphatis,.....^ss. Aquae distiliatae, ----- gxv. Tinct. Rino. ------ ^j.—M. f. Injectio. " If the discharge should assume a sanguineous appearance, it should be considered how far it would be safe to permit its con- tinuance. If the patient should be in great pain at the time, it may be right not to restrain it hastily, unless the patient's strength should have been previously much exhausted; but if it should appear desirable to diminish the hemorrhage, the astringents which have been before recommended, may be employed,0and their strength may be increased, or the following may be tin- ployed in their stead:— TREATMENT OF CARCINOMA UTERI. 255 R. Argrnti nitratis, ----- gr. x. Aquae distiliatae,.....Oi—M. Or, R. Cupri sulphatis,.....gss. Decocti cinchonae, - - - - Oi.—M. "Respecting internal remedies, although no one has as yet discovered any medicine capable of removing the-disease, it may not be too much to state, that there is scarcely a medicine of any class which may not, in some way or other, or at some period or other, be useful in this complaint. Various are the symptoms which may arise ; various must be the means of obviating them ; and he will be the best practitioner, who best understands the adaptation of these means to their end. To point them out here, would be an endless labour, and a waste of the reader's time. " It may be sufficient to observe that the patient should be treated upon general principles, bearing in mind, on the one hand, the hitherto intractable nature of the malady, and on the other, the sufferings of humanity, which call loudly for relief. " Pain, the great evil of life, is the symptom by which the pa- tient will be most distressed ; and, happily, in the sedative class of medicines, there are to be found many capable of re- lieving it. " It should be a rule of practice, never to exhibit a sedative of great power, -when a milder will produce equal relief; because the disease is one of long duration, of increasing suffering, and every medicine will at length fail in producing its effect. " Hyosciamus and conium maybe amongst the first employed, and the dose of each may vary from three to eight, or ten grains; larger doses have been exhibited ; but the object is not to know- how much of these or of any other drug can be taken with im- punity, but how much is necessary to produce the desired ef- fect. If they are wantonly employed, the patient will be exposed to another set of symptoms, arising from a disturbed state of the stomach, and of the brain ; as flatulence, heartburn, eructations, delirium: the necessity for the exhibition of these medicines, must regulate not only their dose, but the frequency of their exhibition. " Extractum stramonii is another serviceable remedy in allay- ing pain, and it may be given in doses of a grain. The writer is not in the habit of exhibiting belladonna, having once seen a patient nearly destroyed0by two small doses of it. Other practitioners, however, have employed it, it is said with advantage. Mr. Brodie has informed the writer, that he has seen the happiest effects produced by a suppository contain- ing extractae belladonnas, gr. j. in cases of irritable bladder, and also of carcinoma of the rectum. Perhaps, therefore, in those instances, in which the administration of other sedatives is un- 256 POLYPUS OF THE UTERUS. availing, it may be advisable to administer the above medicine in the form alluded to. t "As the symptoms become more pressing, and as the sufferings of the patient increase, still there will remain to the practitioner one resource, and to the patient one solace, in opium, by means of which, her distresses may be alleviated, and her passage from this world to another, rendered less agonizing. It will not be sufficient simply to prescribe a dose of opium, at stated intervals; that dose must be proportioned to the necessity for its use ; and the skilful combination of it with other medicines, and the selec- tion of its different preparations will call forth the happiest efforts of the practitioner: in one case opium in a solid form, will be found to agree; in another the tinctura opii, of the pharmacopoeia will better answer the purpose; in the third, the preparation known by the name of black drop ; in a fourth, the liquor opii sedatives of Mr. Beattie, will quiet the patient, and at the same time produce the least disturbance in the system ; whilst the irri- table state into which some patients fall, will be most successfully diminished by the very small quantity of opium which enters into the composition of the tinctura camphorae composita. " In the greater number of painful diseases, which call for the use of opium, less care is required ; but the sympathy of the sto- mach is so actively called forth, when the uterus is the seat of this disease, that it will be capriciously inclined towards one me- dicine, whilst it receives another with great comfort and advan- tage. If, as always happens towards the close of ulcerated carci- noma of the uterus, vomiting should come on, the combination of spices with opium, will render this medicine more agreeable to the stomach. The julepum menfhce, cinnamon water, and, in some cases weak brandy and water, will form the best vehicles for the different preparations of opium; sometimes a mixture of confectio opiatae and spiritus aetheris sulphurici compositus, given in peppermint water, in small doses, at short intervals, will relieve, in an expeditious and certain manner, the vomiting, singultus, and eructation, more effectually than any other combinations of medicines." Sect. III.— Of the Polypus of the Uterus. This disease of the uterus, the author has never seen ;' he is * Since the period stated above, T have seen several cases of " polypus of the uterus," one of which was fatal. Mrs.----, aged forty-five years, was attacked with pains resembling labour. Aft' r they had continued with more or less seve- rity for thirty-six hours, I was requested to visit her. I found her labouring un- der powerful pains, which were almost without intermission, and of great Ibrce. It immediately examined per vaginam, and found a tumour of the size of a child's POLYPUS OF THE UTERUS. 257 therefore under the necessity of drawing his account of the poly- pus from the experience of others. He has«endeavoured to give a faithful history of this complaint, by consulting those he esteems to be the best authorities upon this subject; namely, Levret, Denman, and Clark. It would seem to be fairly presumable, that this disease is of more rare occurrence in this country, than in Europe ; since, in the practice of the gentleman just named, many cases have oc- curred ; while in this, the experience of a number of gentlemen whom I have consulted, has not furnished one. This would also seem to call in doubt, one of the causes assigned for the produc- tion of this disease; namely, injuries which the uterus may have sustained during labour; for it is to be presumed, that were this a common cause, the American women would have a greater claim to polypi, than they appear to have. Dr. Denman says, " The cause of polypi is supposed to be some accidental injury done to the part at the time of labour or otherwise; but more commonly, it is a spontaneous disease, pro- ceeding from a certain disposition of the constitution, or of the part itself; as those who have a polypus of the uterus, are apt to have excrescences from other parts; and they sometimes exist in those who have never been pregnant, and even in virgins."— Introd. Francis' Ed. p. 123. Mr. Clarke defines polypus lo be an " insensible tumour attach- ed to the internal part of the uterus, by a small neck, forming a disease of a very important character," p. 243, vol. i. This definition does not exactly correspond with the history given of this complaint by Dr. Denman: he says, " Some of them hang by a small pedicle, and others have a broad basis, especially at their commencement,"* p. 123. Nor is it so satisfactory as the head at seven months, occupying, or rather advancing through the vagina. £>us. pecting the nature of the tumour, and fearing it would invert the uterus if it did escape from the os externum, I opposed its passage, with all the strength I conld make to bear upon the part, but without success, for in defiance of all opposition, the tumour was pushed without the vulva. It was attached to the uterus by a short neck, and the tumour had inverted this organ upon its escaping from the vagina. I endeavoured lo restore the mass, but without success, as the parts were so extremely sensible, that the woman could scarcely support the slightest touch. The tumour soon became blackrand very offensive; the woman had been exhausted by a long-continued discharge of blood of some months' standing, to- gether with a considerable hemorrhage during the effort the uterus made to dis- lodge the tumour: she died the next day.- Leave could not be obtained to examine the body, as it was in extremsly hot weather, and was to be removed some dis- tance into the country. * A lady from Savannah, Georgia,, consulted me for a polypus of the uterus, in July, 1830. Upon examination, it proved to be mmall, and its pedicle very slim. It was seized by two fingers and the thumb, and drawn down to the os externum ; in doing this the tumour separated at its attachment with the uterus—it caused no pain, nor did the smallest hemorrhage follow: as I have not heard from the lady since, I presume she has suffered no farther inconvenience, though she had been very much reduced previously by repeated hemorrhage from this tumour. 22* >>58 POLYPUS OF THE UTERUS. definition of Levret: he makes it "an indolent circumscribed tumour, more or less salient, resembling a fleshy or fungous ex- crescence, covered by the membrane from which it takes its rise, and which is of greater or less thickness."—Obscr. sur la Cure radical de pleusiers Poly, de la Matrice, &c, p. 2. Levret makes, three species of uterine polypi: but this is cer- tainly an unnecessary distinction, since his species are derived from the situation of the polypus in the uterus, and not from a difference in their organization ; therefore, properly speaking, it is a mere difference of location. He says his first species, which he declares at the same time to be the most common, has its origin or attachment from the fundus of the uterus; the second, which is less frequent, takes its origin from the neck of this organ; and the third, which is the most rare, has its pedicle attached to the margin of the orifice of the uterus, p. 14. He has given plates to prove the different locations of these tumours, which we have copied. See Plate IV. These substances are vascular in different degrees; and, agreeably to Levret, the veins are large in proportion to the arteries. The latter becomes varicose in that species, which is confined within the cavity of the uterus, or has its origin from its fundus. The first species of Levret, is always attended, at a certain period, by hemorrhage; and is of course always accompanied by an increase of size of the uterus. A sense of weight, or bearing down, is experienced, of more or less intensity, as the polypus may be large or smaH. It ia of uncertain size; and may employ a longer or shorter period for such a growth as shall be either very troublesome, or strongly engage the woman in a consideration of her situation. It occasionally grows very large, and distends the uterus so much that it can be distinctly felt above the pubes. When it acquires this volume, and, oftentimes before, there is found a dis- charge from the vagina, which in the commencement is serous; but may soon become purulent and sanguineous. If a ringer be introduced into the vagina, the os uleri will be found- open to an extent much beyond its natural size; and will permit the point of the finger to penetrate the cavity of the uterus, in which a substance will be felt of greater or less firm- ness, and of-different degrees of inequality. The finger, if it be made to pass a sufficient distance within the womb, can be turned round the. body, which, the uterus seems to enclose. This examination may be followed by a very small, or a very large flow of blood. Since the above was written, I have heard from her husband, who assures me she is perfectly welK POLYPUS OF THE UTERUS. 259 The woman is almost always troubled with a discharge of blood which at times seem to assume a periodical movement; or it may only be more abundant at certain periods, while a con- stant but moderate flow fills up the interval. Pain of a periodi- cal kind sometimes ensues; and this may be so long continued and severe, as to force the tumour from the cavity of the uterus into the vagina, and even through the os externum.*—When this takes place, it is generally mistaken for the uterus itself, and has been called by many a descent of this organ. The following case will show the nature of this disease. Mrs. B. had suffered from time to time nearly eighteen months with a profuse^ discharge of blood from the vagina, for which much had been done, but to no useful purpose. She was about twenty-three years of age, had had two children, and was pre- viously to these discharges of a good constitution. She came to this city to place herself under my care—at this time, she was very feeble, and almost bloodless, as she had suffered a most pro- fuse hemorrhage a few days before. By an examination per vaginam, I discovered a polypus about the size of a walnut, the pedicle of which was within the uterus. I begged the assistance of my friend Dr. Horner. We applied a ligature without diffi- culty close to the os tincae around the neck of the tumour—it separated in about four days without any unpleasant symptoms, though the patient laboured under the fever from excessive hemor- rhage, for nearly two weeks. This, however, yielded gradually ; and she returned home free from disease, and continued to im- prove up to the last account we received of her.f It is this condition of the polypus, which has given rise to the absurd stories related by many of the older authors, especially Cesalpinus, iEtius, Paul- Eginetta, Carpi, &c.; of the uterus having been amputated, and the woman conceiving afterwards. Levret, sur Polypus Uterine, p. 29. The mechanism of the expulsion of the polypus, is very simi- lar to that of an abortion ;| that is, the os uteri is gradually, but * See Dr. Denman's cases at the end of this chapter ; and the case just related, page 257. t Since writing the above, I have met with several cases of polypi, all treated with the happiest effect by ligature. X The explanation of Levret, of the mechanism which nature employs when she attempts the expulsion of this species of polypus, is so ingenious, and so con- formable to the general laws which- govern the uterus, that we cannot resist the temptation to transcribe it at length. '• Le polype uterin de la premiere espece ayant une fois pris naissance au fond de la matrice par quelque cause que ce puisse etre, croit peu a peu sans que la femme ni le chirurgien meme s'en appercoivent; en effet, lorsque la malade se plaint pour la premiere fois, en ne peut d'abord decider si la cause de son mal est un polype ou toute autre maladie: car il n'y a dans les premiers tems aucun signe characteristique de son existence. "Ce corps etranger ayant-acquis avec le terns plus de volume,oblige la matrice 260 POLYPUS OF THE UTERUS. successfully opened so far as to permit the extrusion of this sub- stance. When this takes place, the body of the polypus is with- out the os uteri, while its pedicle maintains its attachment to the inner surface of the uterus itself. If it be examined now, it will appear to occupy the vagina, and might be supposed to proceed from its surface; yet, by a careful search, its pedicle will be found to be within the uterus, and the os uteri surrounding it entirely, as a sphincter; and as such it acts, agreeably to Levret. The polypus has been suddenly discharged from the cavity of the uterus, by falls or other violence. He says, that this species, " hemorrhage is necessarily a con- sequence ; but that it never appears, until the body of the tumour has in a great measure freed itself from the orifice of the uterus, and until it begins to extend itself into the vagina; then the sphincter of the uterus, (that is, the os uteri,) compresses the ex- tepnal veins of the polypus ; in consequence of which, these veins become varicose, and finally burst; and their rupture gives rise to a hemorrhage, which is renewed at irregular periods," p. 25. It does not appear to disturb the economy of gestation or in- terfere with the process of labour in some cases; Dr. Churchill gives an interesting account of a labour that was successfully terminated, but which had a fatal termination, owing to a poly- pus in the uterus; we will relate it in his own words. "The patient after a natural labour, appeared for awhile to be going on well. In a short time, however, a flooding came on, resisting all the usual means for arresting uterine hemorrhage, and in eight or ten hours the patient died. Upon examining the uterus after death, there was a large cellular polypus, descending from the fundus, and which it w-as evident had prevented the due con- traction of the uterus. No vessel could be detected in the poly- pus."—Churchill on the Principal Diseases of Females, p. 191. a se dilater, quoique, par degres trcs-insensibles; mais comrne Pattache de cette tumeur occupe, dans tous le* tems, au fond de la matrice bien moins d'espace que le placenta d'un enfant en quelqu' etat d'accroissement que soit ce dernier, toutes choses neanmoins etant d'ailleurs egales, il faut, non pas que le fait dilater l'arriere. faix dans la grossesse ; mais que les parois de ceviscere se pretent un peu, de meint de son fond, a cette puissance dilatante etrangere. Or il n'est point en ces cas de loix naturelles a sa destination qui sollicitent les parois de cette organe; elles doivent done resister: le polype doit etre comprime ; il doit done aussi s'allonger plus au moins, & raison de son plus ou moins solidite. Alors il s'insinue dans le col de cet organe, parce qu'il y trouve moins de resistance. Parvenu ausphynctcr de 1'orifice, il le force peu a peu, et s'introduit dans le vuide qu'il s'y pratique, comme le feroit un coin : enfin l'extremite du polype ne trouvant plus rien que le gene s'etend en avant etau large dans le vagin, et la tumeur prend plus ou moins de volume, selon que le permeltent mille diverses circonstances, que sont plus aisees a conceivoir qu' a. detailler. " Le pedicule ne peut pas s'etendre au large comme le resle de la tumeur, 1'ori- fice dc la uterusqui souffre un espece de violence, le comprime, lc polype est done comme etrangle en cet en droit: il faut qu'il prenne la figure pyriforme, de la naissent les varices; e'est la vraie cause de 1' hemorrhagie, p. 38. POLYPUS OF THE UTERUS. 261 These frequent bleedings, if not relieved by the removal of the tumour, eventually exhaust the woman ; but rather by their per- tinacity, than by their immediate excess; yet examples are upon record, where a sudden hemorrhage has destroyed the woman im- mediately. Levret, p. 30. These polypi seem not in general to do injury to the proper substance of the uterus; for several relate, that this organ was found sound after deaths occasioned by the wasting hemorrhages from the surface of the tumours. Levret, p. 42. Agreeably to Levret, the signs of this species of polypus are, " whenever we examine a woman, who has been labouring under a discharge of blood from the vagina, or of a falling of the womb, whether they are both found together, or separately, if we find in the vagina a pyriform body, the insulated top of which passes through the orifice of the uterus, without destroying its circular form, we may always with certainty be assured, if we except pregnancy, that it is a polypus attached by its pedicle to the uterus, and that it is in the most favourable condition for the liga- ture," p. 48. See figure 1. Plate IV. In the second species, the finger cannot pass entirely around the pedicle, as in the first; and the point which opposes the finger making its circle, is a little above the orifice of the uterus, and is found to be the pedicle of the polypus, inserted on the outside of the neck of the uterus. The os uteri may also be felt. See fig. 2. Plate IV. This species is not commonly accompanied by hemorrhage, because the pedicle does not become strangulated, as in the first; but there is an increase of vaginal secretion. This species, never- theless, is a genuine polypus. The third species is thus distinguished: when there is in the vagina a moveable tumour, with a narrow neck attached to the orifice of the uterus, but in such a manner as to leave the orifice free, we may be pretty certain, that it is a polypus of this kind. In this case, the mouth of the uterus will be obliquely situated, as regards the axis of the vagina, in consequence of that part of the neck of the uterus to which the tumour is attached, descending a little lower than the other portions of it, from the weight of the tumour. This species is not necessarily attended by hemorrhage. All these species have but one common remedy ; namely, ex- tirpation by ligature. In the first, it will be seen, that this remedy cannot be applied, until the tumour has descended into the vagina, and consequently will not admit of a cure, until that event takes place. It would then seem desirable that this escape of the tumour from its confinement, should be promoted, if possible, so soon as it shall be determined that there exists a polypus within the uterus. But how shall it be ascertained, that there is a tumour in the cavity of the uterus, since no particular symptoms mark 262 POLYPUS OF THE UTERUS. this condition until it fall into the vagina? There maybe a great difficulty in distinguishing this condition at such a period ; but we are informed, before this takes place, the woman suffers pain resembling labour ; and when pregnancy cannot account for these pains, nor dysmenorrhcea, it might be well to examine the patient per vaginam. In such an examination, the tumour might be felt, making its way through the os uteri: if so, it would be every way desirable to facilitate its progress; and for this purpose I would ask, what would be the probable effect of the secale cornutum ? The uterus will also be found enlarged, and may be felt above the mons veneris ; at least this will be the case for a certain pe- riod ; or until the tumour shall pass, either in part or altogether, through the os uteri. Nothing illustrates the routine of practice so well as the recital of cases ; and no cases can be more interesting and satisfactory than those related by Dr. Denman. We shall, therefore, tran- scribe them for the benefit of those who may not have the advan- tage of possessing his work; as well as conveying to such in per- spicuous language, the histories of several highly useful cases, treated with all the ability, that that great metropolis, London, could furnish. Case First. " A single lady, twenty-two years of age, had, for a considera- ble time, been subject to frequent and profuse returns of uterine hemorrhage, which resisted all the means that could be devised for her relief, and at length reduced her to a state of great weak- ness. Dr. Turton, (whose worth and continued friendship to me, I am happy on every occasion to acknowledge,) was the physician who attended; and he, suspecting some local disease, desired I might be permitted to make inquiry. I discovered a polypus, not of a large size, lying low in the vagina. When I came to pass the ligature, there was much embarrassment from the state of the parts, any injury to which I was solicitous to avoid. On the fifth day from the time of my passing it, it came away ; but the poly- pus could not be extracted without much caution and trouble. There was no return of the hemorrhage; she soon recovered her strength, and in a few months was married. She has since had seven fine children, with safe and easy labours. This polypus weighed four ounces." Case Second. " Another young lady had long suffered from frequent uterine hemorrhages, together with most violent pains recurring in the POLVPUS OF THE UTERUS. 263 manner of those of labour. High up in the vagina, just cleared through the osuteri, I discovered a small polypus, round which a ligature was with difficulty passed. The late Mr. Hunter was with me at the time. When I began to tighten the ligature, she complained of very severe pain, and presently vomited. The ligature was immediately slackened, but on every future attempt to draw it tighter, the symptoms were instantly produced. After many trials, I was obliged to desist altogether, leaving the liga- ture loose round the polypus; merely to keep up in the mind of the patient, some faint hope of benefit. The health of this patient was very bad when I first saw her, and in about six weeks from the time of the operation, she died." " Leave being given to open the body, the uterus was found inverted, and the ligature to have passed over the inverted part, which occasioned all the symptoms before mentioned. This polypus could not have weighed more than one ounce, and had a very short, if it could be said to have a stem ; so that the ute- rus could not in this case have been inverted mechanically, but by its own vehement action, excited to expel the polypus, which, like any other extraneous and offending body, was a perpetual cause of irritation." Case Third. " Many years ago, I visited a lady, who had for a long time suffered greatly from various uterine complaints, and was sup- posed to have a cancer in the uterus, of which a general aspect gave very strong indications, but on examination I found a large polypus in the vagina. The late Dr. Ford, than whom no one was more intelligent or expert in practice, was in consultation with me. I passed the ligature and drew it tight, confidently ex- pecting a happy termination of* the case. The stem of the poly- pus was very thick, and it required eight or nine days' action of the ligature to divide it. When I had removed the polypus, I was very much mortified to find a new substance, nearly the size of that which had been taken away, in the vagina. Her health being very infirm, it was thought advisable for her to go a short distance in the country, for the chance of establishing her health, before another operation. But a colliquative diarrhoea with aphthae, came on ; she gradually declined, and about the end of the month she died. " Of this repullulation, if it were such, I have never seen any other instance, so early after the operation ; and it might be attri- buted, 1st. to the thickness of the stem ; or, 2d. to the slow decay of the stem ; or, 3d. to a cancerous disposition of the uterus; or, 4th. to a large portion of the polypus remaining in the uterus ; besides what was discoverable in the vagina. If a case similar 264 POLYPUS OF THE UTERUS. to this were again to occur to me, I should certainly act more speedily with the ligature, and however reduced the patient might be should feel justified in passing the ligature on the second ex- crescence, as affording the only chance of saving the patient; but this is, perhaps, to be considered as an instance of the great mis- chief done to the constitution, by too long delaying the opera- tion." Case Fourth. "A lady, about sixty years of age, who had several children, had, with violent pain, frequent hemorrhages from the uterus, so profuse as to bring her at each time of their return into the greatest danger. When she permitted me to take an examina- tion, there was no polypus in the vagina, but the uterus was much distended, and the os uteri being opened nearly to one third of its circurrlference, I could discover within, and pressing upon it, a tumour of apparently a very large size. In the course of a few weeks, an immensely large polypus dropped into the vagina." Her health was much reduced, and the extirpation of the polypus appearing the only chance of saving her, I made many and stre- nuous attempts to pass the ligature, but without success. I then procured a large and different instrument, like that used in tying the tonsils, but with this I was also foiled. In my endeavours to pass this instrument round the polypus, the surface was abraded, a blood vessel of a considerable size was wounded, and there was a loss of blood which rendered the patient still more weak. After a few days without any instrument, I gradually introduced my hand into the vagina, got the ligature over the polypus, and then tightened it. Dr. Orme and Mr. Croft were with me at the time. But many complaints came on, and she died in a few days, be- fore the pplypus could be extirpated. " The blood vessels which convey nourishment to a polypus, probably bear a relation to its size, and must, of course, be some- times very large, so that in passing the ligature, it behooves us to be very careful that we do not wound the polypus ; and, perhaps, in every case when the polypus is large, it would be better, if possible, to introduce the hand, for the conveyance of the ligature, than to use the instrument. Much will also depend on the tex- ture of the polypus, which is sometimes so slight as to resemble an injected and corroded liver or kidney. I remember a case in which, though I only took a common examination, and the usual caution, so violent a hemorrhage was occasioned, that I thought the patient would have died instantly. Were a case similar to * In this case the secale cornutum would most probably have succeeded in ex- pelling the tumour, and should always be tried in such cases. POLYPUS OF THE UTERUS. 265 this to occur to me again, I should be disposed to try the effect of styptic injections, deferring any attempt to pass the ligature, till I had seen the effect which would be produced by them. " The three preceding cases are the only ones among a very great number, in which I have not been successful; and I have judged it right to state them thus circumstantially to set others upon their guard, and to prepare them for the possibility of dis- appointment. " In the museum of the late Dr. Hunter, there is a large poly- pus from which an engraving was made, and by the register it appears, that after many attempts to pass the ligature, without success, this patient died. Perhaps by a knowledge of the causes of the miscarriages of others, (as in case 4th, just recited,) sub- sequent trials, even in the polypi which are of the largest size, may be more fortunate. I have very great pleasure in relating the following case, whieh was lately under my care." Case Fifth. u A foreign lady, who was born, and had lived the greatest part of her time, in a hot climate, applied to me. She had had every day, for more than three years, a very considerable dis- charge of blood from the uterus, together with others of a diffe- rent kind and complexion, by which her strength was very much reduced. She had been attended by different gentlemen, who had not given any decided opinion of the nature of her disease. When I first examined her, I was indeed very much surprised; for not only the whole vagina was filled up with a fleshy sub- stance, but the os uteri was as completely dilated as when the head of a child is passing through it, and the cavity of the uterus appeared to be much distended and filled with the same substance. I at first hesitated whether I should make an attempt to pass the ligature, as I could not reach the stem of the substance, but after deliberating on the state of the patient, who must soon perish, unless relief could be given, and knowing that if the ligature could be passed, I should have the power either of proceeding, or of stopping, on the appearance of any untoward symptom, I deter- mined to make a trial. The first and second attempts to pass the ligature were fruitless, but I at length conveyed the ligature beyond the bulk of the tumour, and far beyond my reach, by means of a piece of thin cane, notched at the end. The ligature being daily drawn gradually tighter, was at liberty on the sixth day. The external parts were unusually contracted, and as any endeavours to bring away the polypus at that time must have failed, it was left in the vagina to soften and decay. On the ninth day after the ligature was come away, she had pains as regular 266 POLYPUS OF THE UTERUS. as those of labour ; and when the os externum became somewhat dilated, I laid hold of a portion of the tumour, first with mv fin- gers, and then with a small sharp pointed hook, favouring the expulsion of it as well as I could, during the pains, by which it was at length propelled with considerable force, after a labour of four hours' continuance. From that time to the end of five weeks, there was not any discharge of any consequence. Then she menstruated regularly, and returned home in perfect health. " This polypus, which was the largest I ever saw, was put into the hands of Dr. Baillie, who saw the patient during the opera- tion. It weighed two pounds and three ounces ; so that, allowing for its decay, perhaps it could not originally have weighed less than three pounds. But the violence of the symptoms does not always depend on the large or small size of the polypus. "When polypi are too large to be extracted without much dif- ficulty after their separation, no harm can arise from their re- maining some days in the vagina, as I have found in several instances; and their bulk hourly lessening by decay, their ex- traction is rendered more easy. " These cases lead to an observation on the difference between what is properly meant by the term polypus, and excrescence. By the former is to be understood, those excrescences that arise distinctly from the uterus or vagina ; and by the latter, a morbid enlargement of those parts. The first of these generally admits of extirpation with safety and advantage ; but the latter, though they admit of extirpation, and even promise success, cannot, with propriety and safety, be removed." Case Sixth. miS.\Yer5 ""^r0 M[S- ^ in January> 1833> wh0 ™s losing much blood every few days from the uterus. Upon examination per vaginam, the mouth of the uterus was more open than natural, admittingthe point of the finger to pass a little distance within k without difficulty : the whole neck was larger than usual, but nearly of the ordinary length.. Rest, a restricted antiphlogistic diet was ordered, with injections, per vaginam, of pretty strong ead water ; that is, two drachms of the acetate, to ffeiss. of water, three or four times a day. These would seem to control the hemorrhage temporarily, but they would recur, at short intervals, wJ^ V67k v?\ e/ertions- The cici^> in increasing doses together with liberal doses of the extract of Rathany, were steadily SZ'f^'i?^ so^u.^gree of advantage as regarded the qt*>tity of discharge. This plan was persevered in until August ■ aHms time, an alarming discharge took place so as almost to exhaust my patient. On an examination, now, the neck of the MODE OF OPERATING FOR POLYPI. 267 uterus was found much enlarged, and it immediately occurred to me, that this enlargement was owing to a concealed polypus, making its way through it: with a hope of ending this work, I ordered thirty drops of the vinous tincture of the secale cornutum every four hours. In the course of 48 hours, slight uterine pains were produced, which were permitted to continue for two days, and were then checked by morphia; at the end of a week, they were again renewed, and so on at intervals, for two months. On touching the mouth of the uterus now a smooth round body, of the size of a large cherry, was perceived at its extremity, which, to my great satisfaction, confirmed the opinion I had given: the hemorrhage was now very much diminished ; and could always be stopped by a small tampon of sponge. In this manner things went on for several months, the substance gradually pro- truding itself, by the occasional use of the tincture of ergot, and eventually, by December, 1834, the uterus freed itself of a poly- pus, as large, nearly as a goose-egg, forming a neck or pedicle of considerable thickness, more than an inch in diameter. I applied the wire ligature, and the tumour fell off on the eleventh day; no unpleasant symptom attended its application or followed its separation: my patient is rapidly recovering from the im- mense loss of blood, during a period of more than two years' con- tinuance. " The late Dr. Hamilton, of Glasgow, obliged me with the drawing of a polypus which weighed one pound and four ounces, and had dropped through the os externum, inverting and drag- ging along with it the fundus of the uterus. The patient died. Had the nature of this complaint been understood in due time, it would, in all likelihood, have been possible to have tied and ex- tirpated it, before it had occasioned so much mischief. It is an example, among many others, of the impropriety of waiting till the polypus is excluded through the os externum, before we at- tempt to tie it; an opinion which some have entertained. Sect. IV.—Mode of Applying the Ligature for Polypi. We shall give Mr. Clarke's mode of applying the ligature, with our own experience upon this plan. He directs, that previously to performing the operation, the rectum of the patient should be emptied by a clyster, or the in- testinal canal may be cleared in its whole extent by a mild pur- gative. For a short time before the commencement of the ope- ration the patient should be kept in the upright posture, that the neck of the tumour may be more within reach. " As the tumour possesses different degrees of convexity in dif- ferent cases, and as the distance of its neck from the os externum 268 mode of operating for polypi. is very various, the practitioner must be provided with two or three rods of different lengths, made of flexible metal, so as to be capable of being adapted to the shape of the tumour. The author's brother, the late Dr. Clarke, has contrived a brass rod, which, being received into a hollow handle, is capable of having its length altered as each case may require ; and by this means the multiplication of instruments is rendered unnecessary. " A silver cannula, of a length sufficient to reach from the neck of the tumour to the distance of an inch, or an inch and a half from the os externum, should be prepared ; and near the extre- mity which is to hang out of the external parts, there should be placed two small shoulders, round which the ends of the ligature may be twisted. A sort of windlass has been recommended for this purpose in the cannula ; but this is quite unnecessary, and renders the instrument more complicated. " The ligature should be made of waxed silk, of such a thick- ness, as neither to cut the neck of the tumour, nor to break, nor block up the cannula.* In order to pass the ligature through the cannula, a long piece of thin brass wire should be ready. This is absolutely necessary; because, when the ligature becomes slippery and pliable, it will not be possible to push it through the cannula. The patient should be placed upon a bed. She should lie upon her left side, and her knees should be drawn up towards the abdomen. If the external parts should not be readily dila- table, they should be dilated. The forefinger of the practitioner's left hand, (previously oiled,.) is now to be carried through the vagina to the neck of the tumour. The brass rod (previously prepared with the ligature, and its curvature adapted to the shape of the tumour,} is to be passed up by the right hand to that part of the neck of the tumour where the forefinger of the other hand is placed. The ligature is then to be secured by the finger, and the brass rod is to be carefully carried round the neck of the tumour, till it comes to that part where the ligature was secured. The practitioner is now to secure also under his finger, that part of the ligature which has been carried round the neck of the * We are convinced, from late experience, that a double silver cannula, rather longer than it is ordinarily made, armed with a piece of fine steel well annealed wire, is much the simplest and best instrument. We have tried the rods,.but did not succeed in applying the ligature. We merely mention the fact, without under- valuing Mr. Clarke's instrument. The failure may have been owing to our own mal-adroitness rather than to the want of suitableness in tbe instrument itself. We, however, succeed with difficulty with the long silver double cannula. We think the following advantages attach to the cannula and wire. First, its whole powers are more at the command of the operator. Secondly, the loop can always be enlarged or diminished at pleasure. Thirdly, it can be more easily removed, or have its location changed, if this be necessary. Fourthly, any degree of pres- sure can be made, by a pair of pliers, that may be deemed expedient. Fifthly, the tumour is more completely strangled, and consequently, will be soon detached by ulceration. Sixthly, it requires but one instrument. MODE OF OPERATING FOR POLYPI. 269 tumour, and the rod is to be carefully withdrawn. In some cases, it will be found more convenient to steady a part of the ligature with the rod, and to carry the other part of the ligature round the neck of the tumour with the finger. In doing this part of the operation, great care is to be taken not to include any part of the os uteri. Before the ligature is tightened, the patient is to be desired to inform the operator if she feels pain; because, if the tumour only is included in the ligature, no pain will be felt. " The two extremities of the ligature which hang out of the os externum, are now to be drawn through the cannula, by the piece of wire, (which had been previously doubled, and carried through the cannula, so as to form a noose projecting from it,) and after the cannula has been gently passed up to the neck of the tumour, they are to be drawn tight, and are then to be twisted round the shoulders of the cannula, where they are to be made secure. The ligature, therefore, should be long enough to encircle the neck of the tumour, to be carried through the cannula, and a suf- ficient length of it should remain to be affixed to the shoulders of it. More than one ligature should always be prepared, lest that which is first used should become too slippery to be managed. " After threading the eye of the rod, one extremity of the liga- ture is to be twisted once or twice round the instrument, whilst the other hangs loose. The patient should be made acquainted with the shape and situation of the instrument, that it may not be liable to be removed when she gets up to make water. She is also to be desired to remain constantly upon her side, and should not be allowed to move from one side to the other, unless when the practitioner is present. For want of attention to this caution, there is reason to believe that the cannula has been inadvertently pressed against, and its extremity pushed through the uterus of the patient, so as to occasion her death. In the engraving given of the polypus cannula, there may be seen a contrivance, by means of which this accident may be prevented. The cannula is made of the same diameter from one end to the other, and a spiral screw is cut upon it. To this spiral screw is adapted another screw, placed in the centre of a kind of shield, which, (when the ligatures are fastened,) is to be placed in contact with the external parts. The shield in the plate is of a circular form ; but in women who are corpulent, it may be more convenient that its shape should be oval. " The patient is now to be left, and great care is to be taken by the nurse that the cannula is not moved when the contents of the bladder are expelled. "Every day the practitioner is to examine the state of the liga- ture ; and as often as it is found at all too slack, it is to be tightened. The mode of tightening it requires particular attention. If the cannula should happen to be long, the practitioner should not hold 23* 270 MODE OF OPERATING FOR POLYPI. the end of it whilst he tightens the ligature; lest with the force used, the ligature should cut through the neck of the tumour, and the other extremity of the cannula should be forcibly and suddenly pushed by the left hand against the internal parts of the woman. In order to avoid this accident, the cannula should be firmly held close to the external parts of the woman, which prevents the pos- sibility of mischief being done. If the cannula with a ligature is employed, it is next to impossible that this accident should hap- pen. "A syringeful of warm water should be thrown into the vagina every day, when the ligature is tightened, in order to wash away the putrid discharge. " The time at which the ligature will come away, will depend upon the thickness and firmness of the neck of the tumour, and the tightness with which the ligature is at first applied. The neck of the tumour sometimes is cut through in four days; sometimes ten or twelve days will elapse between the application of the liga- ture and the removal of the tumour, and occasionally the separa- tion of the tumour will take up nearly three weeks, but this is an uncommon occurrence. "The neck of the tumour being destroyed, the tumour itself is to be brought away by the practitioner. This will be accom- plished in some cases with ease, by one or two fingers intro- duced into the- vagina. If the polypus is large, or the external parts contracted, a single blade of a pair of midwife forceps may be used. If the size of the tumour should be such as not to be easily removed by these means, the crotchet may be fixed into it, and in this way it may be brought along. The palm of the hand should always be kept opposite to the beak of the insfrument: so that if it should slip, the parts of the woman may not be injured by it. " The cavity of the vagina, should 'afterwards be cleansed, by injecting some tepid water, and this should be repeated during several days. "The mucous and bloody discharge seldom continue long after the extraction-of the polypus; but if any should' remain after a week or ten days, some astringent injection should" be thrown into the vagina three or four times a day. "As the ligature is-applied around the neck of the tumour, a part of the latter may remain between the ligature and the uterus. In consequence of the application of the ligature, this part putre- fies, and eomes away mixed with the discharges. In one case in which the author extracted a polypus from the uterus, he found that the os uteri had nearly recovered'its natural size at the end of five days from the time at which the ligature came away; that at the end of fourteen days it was impossible to ascertain that V CAULIFLOWER EXCRESCENCE. 271 any disease had existed in, the parts; and upon the sixteenth day, the patient menstruated.. " It has been recommended*, after the application of the liga- ture, that the tumour should be cut off' with a knife; but there does not appear to be any necessity for doing this, particularly as no harm arises to the patient from, suffering it to remaia till it falls off. Besides which, mischief might be done with a knife carried high into the vagina, and it is by no means certain that the tumour will not be more likely to return. "It sometimes happens that the ligature and canula fall out of the vagina when the practitioner is not with the patient; for which event she should be prepared, lest this occurrence should create alarm. Whenever this happens, it is obvious that the neck of the tumour is destroyed. " The food of the patient should be simple, easy of digestion, and nutritious. If the bowels should be confined, a clyster of warm gruel may be thrown into the rectum. If the stomach should be irritable, a. saline draught in a state of effervescence may be given, with a few drops, of laudanum ; and if the patient should complain of pain from long confinement to the same pos- ture, a sufficient dose of opium should be taken to procure rest. " The cause of debility being removed, the patient generally quickly recovers her strength; but as an, auxiliary, a draught con- sisting of a decoction, of bark, with sulphuric acid, may be taken three times a day. Sect... V.—Of the Cauliflower Excrescence.. This is a disease of the uterus that the author has not seen. He has, in several instances, witnessed considerable discharges of a watery kind from the vagina, which he anticipated might be this disease ; but, upon examination per vaginam, they did not prove to be so; nor could the cause of such profuse discharges be accounted for:, they all were relieved by astringent injections, the tincture of cantharides, the bals. copaiv., &c* * I lately witnessed a case of profuse and acrid diseharge of water from the va- gina, which .resisted all the remedies I employed, and eventually terminated in death. The neck of the uterus, when.examined per vaginam, was much thickened, tender, and opened so much as to permit the finger to pass. The whole uterine mass seemed to fill up the lower portion of the pelvis, and appeared to be attached to the whole of the surrounding parts, so firmly, as to be immoveable in the pelvic cavity, by any force which could be applied by the finger. There was also a con- siderable hemorrhage from time to time; and when this was not present, the watery discharge was constant and copious. The patient appeared to sink from the profuseness of this discharge. She laboured under this complaint about six months. Leave could not befpbtained to inspect the body. There was not, at any time of her illness, any rising of the fundus above the pelvis; or, in other words, thero was.no distention of this organ, to.leadito the sus- picion, that its cavity might be occupied by hydatids. ■212 CAULIFLOWER EXCRESCENCE. The late Dr. John Clarke, of London,' we believe, was the first who described this disease. In this country it must be ex- tremely rare, or our experience, we think, would have furnished us with a case. It may almost be looked upon as among the in- curable diseases of these parts, though considerable relief has been experienced, at different times, by the application of the ligature, &c. This disease has taken its name from its strong resemblance to the cauliflower. "The surface is granulated and it consists of a great-number of small projections, which may be picked off' from the surface, as the granules may be detached from the ve- getable." Clarke, p. 59. The whole of this excrescence is co- vered by a membrane of an extremely fine texture ; from the sur- face of which, an aqueous fluid is poured in great quantity; and thus gives a particular character to this disease. This tumour occupies, for a long time, the upper part of the vagina, as it is the product of the os uteri; it, however, gradually, nay, sometimes very rapidly, enlarges so much, as to fill up the whole of the vaginal cavity; and occasionally, even to protrude beyond the labia. This extension of the disease gives an oppor- tunity to examine its texture, and to ascertain its colour. Its texture is so extremely delicate, as to be injured by the slightest violence; and, when this has been done, a discharge of florid, arterial-looking blood, immediately follows; the quantity of which will be in proportion to the extent of lesion the tumour may have suffered. The appearance of the tumour is of a bright flesh colour; giving evidence of great vascularity, with very little solidity of structure. This tumour possesses no sensibility, and is one of the rare in- stances of great vascularity, being unaccompanied by exalted feeling. In no instance is the structure of the vagina involved, so far as observation has yet extended. It may originate from the whole circle of the os uteri, or only from a portion of it; hitherto it has never been traced within the uterus. Mr. Clarke thinks the growth of this excrescence, is, in some measure, influenced by the capacity of the vagina; increasing more rapidly in capacious, than in restricted vaginae. Hence, in married women, who have borne many children, the tumour increases very rapidly; and, on the contrary, " the pressure of the sides of a less capacious vagina, as in single women, will greatly tend to control its enlargement, acting like a bandage."— Clarke, p. 61. 4 * See his paper, in Transactions of the Society for the Improvement of Medical Knowledge, 1812. CAULIFLOWER EXCRESCENCE. 273 It would seem that the enlargement of the tumour, at least, when it is so large as to protrude beyond the labia, occasions inconvenience by its mechanical pressure ; as the parts immedi- ately in contact with it, will not unfrequently ulcerate. It is not ascertained what gives rise to this disease; conjecture even seems at bay. The mechanical violences of labour, are al- together insufficient to account for its production; for " married women, who have never been pregnant; nay, single women, are liable to the complaint, in whom no violence can have been of- fered to the os uteri," p. 62. " It cannot be traced to any syphilitic cause. The common prostitutes of this metropolis, (London,) are by no means more liable to it, than any similar number of women in different sta- tions of life. The disease as often arises in the strong and robust as in the weak; in persons who live in the country, as those who inhabit large towns; in those whose situation in life obliges them to labour, as well as in those, who from their rank in society, sometimes consider them privileged members of it. " No period of life, after the age of twenty, seems to be exempt from the disease. The author has known it fatal at the age of twenty; and he has met with the disease at different periods of life up to old age."—Clarke, p. 62. We have noticed above, that the blood which escapes from the tumour, when it has been injured, has the marks of arterial blood, indeed this excrescence seems to be but a mass, or congeries of arteries and veins. A very remarkable circumstance attends this disease ; namely, its disappearance after death. Mr. Clarke declares, "No one has seen a tumour, resembling a cauliflower excrescence, in the dead body," p. 63. It seems that so soon as life ceases, the whole tumour shrinks, and leaves nothing which resembles itself. All that can be perceived of the former tumour, however large it may have been, is " a soft, flaccid, slimy, whitish substance, re- sembling the foetal portion of the placenta of a calf, after it has been macerated in water," p. 66. Notwithstanding the extremely vascular nature of this excre- scence, it has hitherto resisted every attempt to inject it; and, " though the uterine vessels were abundantly filled with the in- jection, the fluid escaped from its surface as fast as it was thrown in from the pipe of the injecting syringe. Many attempts had been made by different practitioners to procure a specimen of this disease; but all had failed, until Mr. Clarke was fortunate enough to remove one of these tumours on the third day after the application of a ligature. So soon as it was relieved from the vagina, it was put into alcohol: it was from this specimen, that his beautiful drawing and engraving were made. See plate IX. 274 SYMPTOMS of cauliflower excrescence. Sect. VI.—Of the Symptoms of this Complaint. This complaint begins by an aqueous discharge from the va- gina: this is but little attended to in the beginning; nor, indeed, until the quantity rendered obliges the woman to protect herself against its excess. But as this profusion is not attended with either pain or stench, she neglects herself, until her health yields to this undermining disease. As a general rule, the quantity of watery discharge is in proportion to the surface of the tumour. The water evacuated in this way, may be altogether transpa- rent or colourless: or only occasionally tinged with red, upon the yielding of a small vessel; the quantity of water may be so small as not to create any great inconvenience, or it may be so excessive as to require constant attention. Sexual intercourse is always followed by a discharge of blood ; even common exer- tions may be succeeded by a similar hemorrhage. Thus, cough- ing, sneezing, or straining at stool, will sometimes be followed by a great loss. The watery discharge diminishes, in proportion as the san- guineous increases. From these multiplied discharges, the sys- tem becomes very much debilitated, and the body wastes, but not to great emaciation; the stomach becomes dyspeptic, and the belly tympanitic. Hysterical and nervous symptoms super- vene, to aggravate the distresses of the already oppressed pa- tient Effusions now take place, and both local and general dropsy but too certainly follow. Sometimes the sufferings of the patient have an unexpected and fatal termination, from the profuseness of the hemorrhage, which may have suddenly assailed her. Sect. VII.—Of the Prognosis. Mr. Clarke is of opinion that the tonicity of the vagina will have a decided influence upon the progress of this complaint; which must consequently influence the prognostic. He says, " As the enlargement of vessels in other situations is much in- fluenced by pressure, so it will be found, that the compression of the sides of the vagina will greatly retard the growth of this tu- mour. Now, as the quantity of the watery discharge depends upon the extent of surface the tumour presents, and as the danger of the patient is in proportion to the quantity of the discharge, it follows that whenever the vagina has lost its tone, and the tu- mour has thereby been little subject to compression, the prognos- tic to be given to the friends of the patient, as to the probable treatment of cauliflower excrescence. 275 duration of life, should be less favourable than when the sides of the tumour are supported by the sides of a more contracted canal. Added to this, the very pressure of a contracted vagina, is an evidence that the constitution still possesses a considerable de- gree of vigour : so that the capacity of the vagina, in this instance, as well as in many others, is by no means a bad criterion of the strength remaining in the constitution. '• When the tumour occupies only a small part of the os uteri, the opinion to be given should be more favourable, than when the whole circumference of the opening is involved in the disease." " The symptoms, in some cases of the disease, are diminished. more easily than in others ; of which circumstance no knowledge can be obtained until the experiment has been made; the greater the effect, therefore, which local remedies produce in controlling the discharge, the longer will the disease continue, caeteris pari- bus, without destroying life." Sect. VIII.— Treatment of the Cauliflower Excrescence. This disease, like some others of the uterus, if let alone, never cures itself. The debilitating nature of the discharges, with which this complaint is always attended, will soon exhaust the woman that may be the subject of them—the watery, from the excess of its quantity, and the sanguineous, from the importance of its quality, though it may not be profuse. Unfortunately, this complaint, in its commencement, does not excite as much alarm as its mischievous tendency should create. It were desirable, that females should be better acquainted with the symptoms, which forerun and accompany many of the dangerous diseases to which they are unavoidably liable, were it always safe to com- municate to them such information. But, unfortunately, the ima- gination exerts such influence over the happiness of mankind, as to render it extremely doubtful, whether more would not be lost, than gained, by such knowledge: it must, therefore, be left to contingent discovery for the present, as it has been hereto- fore. From the nature of the formation, or rather organization, of this species of tumour, it is evident, that its extension or diminu- tion will very much depend upon the state of the circulating sys-: tern both as regards its excitement, and its quantity of blood : and experience appears to have proved, that nothing keeps it in sub- jection like controlling the force of the arterial system ; and no- thing is so effectual to this end, as lessening the quantity of blood ; directly, by bleeding ; and preventing its accumulation, by a well- regulated diet. Blood may be abstracted from the arm by the lancet; or it 276 TREATMENT OF CAULIFLOWER EXCRESCENCE. may be taken by cups, or by leeching, from about the sacrum or thighs : this will diminish the quantity of blood immediately pre- sent, and will afford relief. But this benefit will be transient, if new accumulations be not prevented, by severely restricting the patient toa very bland and unnutritious diet. The articles of diet must be not only void of stimulus, but should also be but little nourishing. If this be not attended to, no good can result from the abstraction of blood ; on the contrary, it may be even inju- rious, as the excitability of the system is increased, by the loss of it. Mr. Clarke appears to prefer local, to general bleeding. He also prefers cupping, to the application of leeches ; but without assiging any reason for the preference: we cannot see why either would not do. Mr. Clarke says, " The diet should be of the mildest kind, such as puddings, white fish, and vegetables." In this country, we should look upon " puddings and white fish," as very substantial fare ; and would be far from the articles we should select as pro- per for a woman in this situation. Were we to direct upon such an occasion, we would confine the patient to black tea, thin cof- fee, and stale bread, for tbe meals of morning and evening; and vegetables alone for dinner. These may consist of rice, the po- tato, tiie turnip, the parsnip, the carrot, the tomato, and the ripe fruits of the season. We might permit a little variety, by allowing rennet-whey, butter-milk, baked or roasted apples, thin vegetable jellies, as that of the tapioca, rice, or arrow root. Her drink should absolutely be water, bailey water, molasses and water, toast water, or thin flaxseed tea. A recumbent posture must also be insisted on, or but little advantage will be derived from the attempts made to reduce the force of the circulation. But it should be remembered, that it is not a matter of indifference on what the patient reposes ; it should be either a good elastic mattress, a sacking bottom, or a sofa. A feather bed would be directly injurious, by maintaining too much warmth about the pelvis. And Mr. Clarke insists, that, " if the patient be married, she should be separated from her husband's bed; to which she should never return." An unceasing attention should be paid to the state of the bow- els; a loose stool should be procured daily. When this can be effected by diet, it is always best it should be. For this purpose, the bread which the patient eats should be made of unbolted wheat flour; or this may be made into mush, and eaten with molasses. Indian meal gruel, sweetened with molasses, has also a favoura- ble effect upon the bowels. But should these be found insufficient for the purpose, the pa- tient may chew daily a little of the root of rhubarb : or take equal TREATMENT OF CAULIFLOWER EXCRESCENCE. 277 parts of creraor tartar and the flour of brimstone, made into an electuary by molasses. The lenitive electuary alone, or a little increased in power, if necessary, by a small addition of powder- ed jalap, is oftentimes very effectual. Equal parts of calcined magnesia, and the flour of brimstone, is a very certain laxative. The solution of the sulphate of magnesia in small doses, taken be- fore breakfast, is also very certain. At all events, costiveness must be avoided. Should it, however, accidentally occur, it should be removed in the most gentle manner; for the strong efforts of the abdomen must be avoided. This will be best done by very mild injections, such as warm molasses and water, thin soap suds, making the quantity such as will ensure their opera- tion, rather by their bulk than their stimulus. Mr. Clarke speaks in high terms of cold applied to the outside of the pelvis; and by injections of cold fluids within the vagina. The former to be applied by sponges, and the latter by the female syringe: these to be repeated twice each twenty-four hours. With a view to diminish the size of the tumour, Mr. Clarke recommends astringent applications. For this purpose, he ad- vises the sulphate of zinc, in the proportion of four or five grains to the ounce of water; or alum, in the proportion of ten or twelve grains, with a little of the mucilage of gum Arabic; or alum and the tincture of kino, as follows ;— R. Infus. lini, f xv. Aluminis, gij. Tinct. kino, gj.—M. Or, R. Cupri sulphat. grs. x. Aquae Flor. Samb. Mist camphorae, ^vj.—M. He gives several other formulae, much of the same character, but we think of no more efficacy. He suggests, with much pro- priety, the necessity of great care in throwing up these injections into the vagina, lest the extremity of the pipe should break a por- tion of the tumour, and occasion a bleeding. The round-headed pewter female syringe is the best for this purpose ; and even this should be introduced but a litttle way beyond the os externum. If the tumour has so far increased, as to appear at the os ex- ternum, or just within the labia, it is advised, that the as ringent fluids should be used by means of a common earthen butter boat; the woman having her hips elevated during the operation.* And when the tumour has actually protruded, Mr. Clarke directs "compresses dipped in an astringent fluid, to be applied to it; or the surface may be lightly touched with a soft sponge wetted with it," p. 98. 24 278 TREATMENT OF CAULIFLOWER EXCRESCENCE. As this complaint is sure, sooner or later, to be attended by great debility, the woman should be supported by tonics when this occurs. The sulphuric and muriatic acids are recommended for this purpose, with the infusion of orange peel, or of rose leaves, with great confidence, and, we believe, justly: at least we think they agree better than any other tonics we have tried, in wasting diseases. Bark in decoction, is also a favourite remedy with most prac- titioners, but it is sometimes difficult to restrain its effects on the bowels. The sulphate of quinine has not the same tendency to , pass through the bowels, as the bark, in substance or in decoc- tion ; it, therefore merits the preference. The decoction of the cascarilla, (cortex Eleuth.) has an admirable effect sometimes, where the bark is indicated, but cannot be used. Of the general plan of treatment now laid down, Mr. Clarke speaks in the following terms. " The author is justified in re- peating, that, by a strict attention to, and compliance with, the rules above suggested, nearly every case of this disease may be made tolerable; and, perhaps, such a change wrought in the size or the actions of the excrescence, in a few instances, as to remove all the symptoms, p. 104. He confirms these hopes by the re- cital of several successful cases. The ligature, however, he considers as an important auxiliary. It is to be applied, as recommended for the polypus of the uterus. He declares, however, that more care is necessary in its appli- cation in the one case lhan in the other; the cauliflower excre- scence being so very liable to bleed, when any violence is offered it. The shield recommended for the polypus, is not so necessary in the cauliflower excrescence, as the tumour will be cut through in a much shorter time. The objection to the use of the shield in this operation is the possibility that the weight of it may tear through the tumour, before the blood has coagulated in the ves- sels above. "After the removal of the disease, (tumour,) it is recommended that the vagina should be washed out with cold water, and that a solution of alum, in a strong decoction of oak bark, should be thrown into the vagina twice or three times a day, and the ex- ternal orifice blocked up with a dossil of lint, so as to prevent the too sudden escape of the fluid. " A weak solution of the nitrate of silver, or of the sulphate of copper may be preferable, in some instances, to any other injec- tion: it may be used in the following proportions: — R. Argenti nitrat. grs. xij. Aq. distillat. ^xij. f. sol. Or, R. Cupri sulphat. grs. xviij. Aquae rosae, f xij. f. sol." HYDATIDS OF THE UTERUS. 279 A piece of lint, wetted with either of these solutions, may be introduced, and placed against the diseased portion of the os uteri. "By such means, a slight inflammation maybe excited in the blood vessels, so as to produce a consolidation of the parts diseased ; and thus the regeneration of the tumour may be more tardy. "However favourable appearances may be in that part of the uterus which can be examined by the finger, there may exist out of reach, and consequently without the knowledge of the practi- tioner, morbid changes of structure, which may, of themselves, prove fatal," p. 112. We have chosen to quote the opinions of Mr. Clarke upon the subject before us, pretty much at large, as his experience quali- fies him to give directions for the management of this disease, which our entire ignorance would not justify. The high stand- ing of this gentleman, as a successful practitioner, adds much value to his practical directions, and what enhances these opi- nions still more, is, that they are altogether free, from learned parade, without elucidation; and of ingenious speculations, with- out practical improvement. Sect. IX.— Of Hydatids of the Uterus. By hydatids, is understood a congeries of vesicles of various sizes, containing a transparent lymph; attached to the internal face of the uterus, and with each other, by filamentous footstalks, much resembling a bunch of grapes. These vesicles differ in size, from the smallness of a pin's head, to the size of a walnut. They are looked upon as animals of extremely simple organiza- tion, and functions.* Of their origin we know nothing, and * This disease Ins been long known to physicians; for it is said that jEtius has distinctly alluded to it, yet the cause/and the precise nature of the product, is still unsettled. Valcsneri lo ked upon this product, as an enlargement of glo- bules or pouches, which he says he has discovered by the microscope to belong1 to the lymphatic vessels of the placenta, chorion; and amnios, as a natural arrange- ment; but which from some morbid cause, have enlarged themselves. Desor- meaux, aided by the microscopical observations of Velpeau, (a) ha« taken nearly the same view of the subject as Valesneri. While Percy looks upon them as ani- mals, and to be the tcenia liydatigena of Pallas, and declares, (6) ihat he has seen them move, when exposed to the aciion of salt and vinegar. While Madame Boivm (c) reverts to ihe old doctrine, that the vesicular mole, as she terms it,does not consist of hydatids, but is bona fide a degeneration of the impregnated ovum. For she declares, that this vesicular cluster is covered by a membranous expan- (■> Third. The initial symptoms of the " irritable uterus, are not those of nervous mobility, though these symptoms are almost sure to follow, if the disease persist for a considerable time. Fourth. The symptoms laid down by Dr. A. are virtually the same as those to which the inflamed spine gives rise, and which affection, agreeably to Mr. Tate, produces the hysterical pheno- mena. These symptoms, however, do not necessarily belong to the " irritable uterus," but may be looked upon as purely nervous, and arise out of a morbid condition of some other part, or may be the result of an " irritable uterus." Dr. A. thus cautions upon this point— . " Whenever a female complains of a pain under the left breast, with or without palpitation or pulsation of the heart; of pain in the right hypochondrium ; in the situation of the left or right colon; or acute pain generally over the whole belly, or in the region of the bladder or kidneys—always be upon your guard ; and if, upon inquiry, you find few or many of the constitutional symptoms I have described, together with uterine irritation, as show by pain in the pelvis, in the loins, or in the thighs, before or during the flow of the catamenia ; by too frequent or too profuse menstrua- tion ; or by leucorrhceal discharge: I say, when you find such an assemblage of symptoms and circumstances, your suspicions will amount to a high degree of probability that the complaint is not of an inflammatory nature," p. 31. . Now these very symptoms, we must repeat, Mr. Tate declares to belong to the inflamed spine. We must, therefore, say, that when these symptoms prevail, that neuralgia is either combined with, or is existing independently of the " irritable uterus;" for we are of opinion, that the " irritable uterus " may exist in its gravest form in a state of combination with neuralgia, or it may be present without this complication, and exist independently. We think this opinion is abundantly confirmed by the symptoms enumerated by Dr. A. as constituting, or as arising from " ute- rine irritation ;" but which, as we have just said, Mr. Tate claims for inflamed spine. Such as a pain seated under the left breast, or under the margin of the ribs of the same side ; or pain under the margin of the ribs of the right side ; pain in the course of the ascending and descending colon ; pain affect- ing the whole abdomen; pain in the region of the stomach; and, lastly, pain in the region of the kidneys; sometimes extend- ing down the course of the uterus to the bladder, p. 22. Now, in our opinion, the first five of the symptoms do not belong to the pure, or idiopathic, " irritable uterus." First, because we have known them to be absent in several instances of exquisite- IRRITABLE UTERUS. 291 ly formed " irritable uterus;" 2dly, because they are constantly present in hysteria, where the uterus may be in a perfectly healthy state—for we have witnessed them in women who bear healthy children ; bat we have never known conception to take'place in women who labour under " irritable uterus." And the last enu- merated sign belongs more properly to the carcinomatous, than to the "irritable uterus." Fifth. Dr. A. makes very young females liable to the disease which he describes; now, we, have seen the " irritable uterus " only in women who had arrived near, or had passed, the middle period of life.* Diagnosis.—The " irritable uterus" may be distinguished from a neuralgic condition of this part by the following important par- ticulars. 1st. In neuralgia of the uterus there is an entire absence, at least, as far as we have observed, of the general, or what we have termed the constitutional symptoms, especially the evening febrile movement. 2d. There is seldom, (nor is there ever, neces- sarily,) a vaginal, or leucorrhceal discharge ; if it be present, it may have been habitual, and have existed before the neuralgic attack. 3d. There is no preternatural heat in the vagina. 4th. Nor is the uterus so sensible to the touch, unless it be examined during the painful continuance of the paroxysm, and then, per- haps, it is even more exquisitely sensible than it is in the pure " irritable uterus;" besides, in neuralgia, the pain is less constant, but is more violent during the paroxysms, and these pretty con- stantly observe periodicity, but which the " irritable uterus" is free from. 5th. In neuralgia, a paroxysm may be suddenly in- duced by passions or emotions of the mind, which is never the case in the " irritable uterus," though the latter is susceptible of great, and occasional augmentation of pain, through the medium of the circulation, by errors in diet, or improper exposure. The " irritable uterus " is, however, more frequently confound- ed with prolapsus uteri than with any other complaint, as the local symptoms of the latter are a miniature representation of the former. And as the womb is almost sure to descend more or less in the " irritable uterus," this precipitation has been supposed * Since the above was written, I have been consulted by letter, in the case of a young lady, only eighteen, who, I have not the smallest doubt, is labouring under "irritable uterus," and forms an exception to the general rule of the period of life at which this disease may show itself. All the symptoms that mark this disease are present, even to the prolapsed state of the uterus. This is a case of great in- terest, as it occurs in a young person, who, in other respects, enjoys a fair propor- tion of health; but which will, and must very soon, be destroyed, if this terrible affection be not speedily removed. There is, in this young lady, a strong scrofu- lous tendency, with some development. We have recommended absolme rest; a milk and vegetable diet; the rhubarb pill; occasionally, leeching or cupping; the iodine, and injections of the solution of the nitrate of silver, on the faith of its influence upon certain inflamed surfaces in other parts cf the body. 292 IRRITAELE UTERUS. to be the cause of all the inconveniences experienced ; and hence, the frequent failures of the pessary when it has been applied for the relief of the prolapsus. Nay, sometimes serious and perma- nent injury has been done by this instrument in these cases, with- out the practitioner being exactly aware why mischief should be caused by a machine that had been so often successful, in cases so apparently alike. Consequently, it is a matter of much moment, that the two affections should not be confounded ; we would, therefore, sug- gest the observance of the following precautions, when an exami- nation is about to be made per vaginam, for prolapsus uteri. First. Let the patient be placed upon her back with the knees drawn up. Second. Let the parts be well lubricated, that no pain may be excited by the introduction of the finger, lest a wrong conclusion be drawn from the complainings of the patient. Third. After the finger has possession of the vagina, a gentle search should be made for the neck of the uterus, and when found, the patient's attention should be solicited, to the degree of sensation produced by touching it; the portion of the body of the uterus immediately above the neck, and the sides of the vagina—inquire if there be any extraordinary sensibility in either of these parts; and if there be, in which of the parts it resides; and if either of these parts be morbidly tender, the pessary must not be intro- duced, until this has been abated by suitable means. In this case the patient will be labouring under " irritable uterus," and not a simple prolapsus. Besides,in the "irritable uterus," the prolap- sus is not always permanent—but sometimes only so in the erect position of the body, as in standing. " The " irritable uterus " has also been confounded with carci- noma of this organ, when it has been about to throw off' its indo- lent condition, and to commence the ulcerative process. But the "irritable uterus" is easily distinguished from the carcinoma, by the neck of the uterus, in the latter, still retaining the original marks of carcinoma ; as a thickening of the whole of its substance; by its having a cartilaginous feel; by its being shorter ; and the os tineas being more open than natural; by tumours still occupy- ing the neck, and pelvic portion of the body of the uterus ; by a pretty abundant and sometimes constant discharge of a serous fluid, which may be occasionally tinged with blood, and the almost entire filling up of the vagina, by the increased size of the uterus. The " irritable uterus " has also been confounded with dys- menorrhcea, but from this functional derangement of the uterus it is easily distinguished. First. In dysmenorrhcea pain is only felt during the menstrual action ; whereas, in the other, the suf- fering is more or less constant, though subject to occasional ag- gravation, and this of a severe kind, at other than the catamenial IRRITABLE UTERUS. 293 * periods. Secondly. The " irritable uterus " is not necessarily attended by dysmenorrhcea, nor is dysmenorrhcea usually attended by this irritable condition of the uterus; for we have seen very many instances to the contrary. Pathology.—We have already declared our belief that this dis- ease consists in a chronic or sub-acute inflammation of perhaps all the tissues, that compose the neck of the uterus. The pathologi- cal condition of the womb, in this complaint, has, however, never been ascertained, by post mortem examination, as it very seldom, or perhaps never, of itself, destroys the patient. It were much to be desired, that an examination be made, should opportunity present—as we are of opinion, that more derangement of struc- ture would be found in some cases, than appears to be allowed to exist by either Dr. Gooch or M. Genest, for we have met with several cases in which the size and' form of the neck of the uterus was much altered from its natural condition. Indeed the admis- sion of Dr. G. and M. Genest would seem to declare the same thing. Dr. G. admits that "the neck of the uterus is slightly swollen," (p. 312,) though he denies a change in its structure. M. Genest declares the same thing; indeed, the latter seems but to have copied Dr. G. in his account of this disease. It is true, he has seen the disease, and appears to have been attentive to its phenomena: yet we would be rather disposed to question his ac- curacy, as he mentions that this disease continued during the whole of a pregnancy, that terminated happily. Now, as far as we have had opportunities of noticing this disease, (which have been many,) we have never known a single instance of impreg- nation in a patient labouring under the " irritable uterus." We admit that, in an unmixed or idiopathic neuralgia of the uterus, very little, if any, derangement of structure takes place ; from which circumstance, we are disposed to believe, that when >his undisturbed condition of the womb is met with, it betrays the neuralgic form of this disease. Dr. Gooch will not admit the uterus to be in a state of chro- nic inflammation. He says that chronic inflammation like the acute, is always " a disorganizing process ;" but if we are not very much in error, a chronic inflammation may exist for an almost indefinite period, in some instances, without any very manifest derangement of a part; and that there is some derange- ment in the "irritable uterus," we are, from many observations, very certain—besides, there are present in this affection all the common characters of inflammation—as heat, swelling, and pain; but whether there be unusual redness also, we are not prepared to determine. We are, therefore, disposed to believe that the conclusion of Dr. Gooch is rather hasty; for, indeed, his attempt to support his opinion is rather by analogies than by pathological observation. 25* 294 IRRITABLE UTERUS. He says, "The disease which I am describing, resembles a state which other organs are subject to, and which, in them, is deno- minated irritation. Surgeons describe what they call an irritable tumour in the breast. It is exquisitely tender; an ungentle exa- mination of the part leaves pain for hours ; it is always in pain ; but this is greatly increased every month, immediately before the menstrual period. Although apprehensions are entertained of cancer, it never terminates in disease of structure." "Mr. Bro- die describes a similar slate in the joints." It chiefly occurs amongst hysterical females ; it is attended by pain ; at first with- out any tumefaction; but the pain increases, and is attended with a puffy, diffused, but trifling swelling; the part is exceedingly tender; this assemblage of symptoms lasting a long time, and being often little relieved by rerjnedies, occasions great anxiety, but " there never arise any ultimate bad consequences." " The disease," says Mr. Brodie, " appears to depend on a morbid con- dition of the nerves, and may be regarded as a local hysteric affection." " These painful states of the breast, and of the joints, appear to be similar to that which I have been describing in the uterus ; similar in the kinds of constitutions which they attack; similar in pain; in exquisite tenderness; in resemblance to the commencement of organic disease ; and in proving ultimately to be only diseases of function," p. 318. Now, we would ask, if the condition of the parts here described, and that of the portion of the womb, implicated in the disease we are treating of, were identical, would it prove, that the symptoms to which they give rise do not depend upon a modified inflamma- tion ? Does the attempt to illustrate the condition of apart in- volved in disease, by adducing the inexplicable phenomena pre- sented by diseases of other parts, (however strong their analogy may be,) throw any light upon its pathology ? Is not the patho- logy of" the irritable breast," or, " certain affections of the joints," as entirely unascertained, as the situation of the structure involved in the " irritable uterus?" Does any definite pathological condi- tion of a part present itself to the mind, by saying, that the phe- nomena of the diseases offered as illustrations depend " upon a morbid condition of the nerves, and may be regarded as a local hysteric affection ?" or, in other words, is our knowledge of the pathology of the " irritable uterus " any way advanced by de- claring, it is the same as in a " local hysteric affection?" Who has demonstrated the condition of either the brain or the nerves, which give rise to the phenomena of hysteria; of the glands of the mamma in " the irritable tumour of the breast," or of the joints, in the disease of these parts, as described by Mr. Brodie ? Has it been proved, that the affection of a part called inflamma- tion, (either acute or chronic,) has no agency in the production of the symptoms which characterize the several diseases just named ? Certainly it has not. IRRITABLE UTERUS. 295 Does Dr. Gooch's denial, that the " irritable uterus" depends upon a chronic inflammation of the neck, and perhaps a portion of the body of the womb, derive any support from Dr. Anderson declaring the same thing? We think not. In fact, whilst Dr. Gooch denies the presence of inflammation, he at the same time furnishes us, in the history of his cases, with sufficient evidence, tjiat this condition of the parts concerned, really exists. Thus, in relating the history of the disease in ques- tion, one of his patients, he says,— " In the lowest part of the abdomen, or a little lower even than that internally, she first felt a sense of heat; to this Was speedily added a sense of throbbing, then a sense of distention, as if there was a tumour within, which gradually expanded till it felt ready to burst: then began spasms ; these she described as shooting, or electric shocks, darting from the tumour up into the abdomen ; they recurred every five or ten minutes, making her start with such violence as to shake the bed. I have been in the adjoining room when she has been in this state, and have perceived the shock; between the spasms, she felt what she called a convulsive pain. Nothing relieved these spasms, but a small local bleeding; she has used fomentations, simple, and medicated, for many hours, hip baths, opium in draughts, and in injections, without relief; but as soon as four or six leeches were applied, and had drawn blood, the spasms, distention, throbbing, and heat, speedily sub- sided, leaving a dull permanent uneasiness. The uterus was so tender, that the examination of it was torture, and left severe suffering for hours,"* p. 335. Need better proof be given of the inflammatory nature of the irritable uterus than the treatment of this case? Certain sensa- tions of spasms accompanied this complaint; the sensations are described as consisting of local heat, throbbing, and expansion, to a feeling like bursting; the spasms as shooting or electric shocks, darting from the uterus up into the abdomen, which we are in- formed neither opium nor other means would appease, though persisted in for hours, yet were " instantly relieved by four or six leeches!" Causes.—The remote causes of this very tedious and painful affection are involved in great obscurity—indeed it may be ques- tioned whether any satisfactory, remote or predisposing cause has ever been assigned, though we are in possession of a number of the exciting. These consist chiefly in severe fatigue, or other bodily exertion, as it almost always shows itself, after this has taken place, where predisposition has existed. Dr. Gooch says— * We have never met with such an exquisite degree of sensibility in the genuine nncomplicated irritable uterus, as is here spoken of; where this has existed, to the extent described by Dr. Goocb, we have always had reason to suspect neuralgia was added. 296 IRRITABLE UTERUS. " In one patient it came on after an enormous walk during a menstrual period ; in another, it was occasioned by the patient's going a shooting with her husband, not many days after an abor- tion ; in a third, it came on after standing for several hours many successive nights at concerts and parties; in a fourth, it originated in a journey in a rough carriage over the paved roads of France; in a fifth, it was attributed either to cold or an astringent lotion, by which a profused lochia was suddenly stopped, followed by intense pain in the uterus ; in a sixth, it occurred soon after, and apparently in consequence of matrimony," p. 314. It is evident that the causes here enumerated were only exciting causes; in none do we discover the predisposing, if we except the instance of abortion. It is more than probable that this effort of the uterus may be one of the common predisposing causes of the "irritable uterus;" we at least can say, that three of the severest cases we have met with were preceded by abortion. But, if abortion be admitted as the predisponent, it must also be granted that there may be many other causes, as we witness the " irritable uterus," in the unmarried, and in the widowed female, where abortion has had no agency. Dr. Gooch says, his " patients had previously manifested signs of predisposition to it; they were all sensitive in body and mind, many of them had been previously subject to the ordinary form of painful menstruation." He then adds, with a view, we pre- sume, of conveying some idea of the pathological condition of the uterus, that " the disease seemed to consist in a state of the uterus similar to that of painful menstruation, only permanent instead of occasional," p. 315. Upon these observations, we beg leave to offer a few remarks, that our experience in the affection under consideration has sug- gested. First, It by no means accords with our observations, that those who are " sensitive in body and mind," are more ob- noxious to the " irritable uterus" than those of an opposite tem- perament—for we have seen this disease in its most aggravated form in the hale and robust, and especially such as were of the sanguine temperament. Secondly, That no analogy exists be- tween that state of the uterus which gives rise to dysmenorrhcea, and that in which consists the "irritable uterus." For dysme- norrhcea is owing to a certain pathological condition of the in- ternal and secreting surface of the uterine cavity; whereas, in the " irritable uterus," some change has been produced in the parenchyma composing the neck of this organ, and to which the disease is confined, agreeably to Dr. Gooch's own showing. Thirdly, As we do not know in what manner the inner lining of the body and fundus of the uterus is affected, to produce painful menstruation, so we cannot be enlightened in regard to the pa- thological condition of the neck, while labouring under the con- IRRITABLE UTERUS. 297 dition we are treating of. Fourthly, In dysmenorrhcea, the pain that accompanies the secretion of the menstrual blood, is not caused by any particular condition of the secreting organ, ab- stractedly considered ; but to the changes wrought upon this fluid itself during its elimination, causing it to remain within the uterine cavity, until it becomes, to all intents and purposes, a foreign body, and requiring the aid of uterine contraction to expel it—hence the pain of dysmenorrhcea, and, consequently, between if, and that attended upon the " irritable uterus," there is not the slightest resemblance in either kind or cause. Fifthly, Were there the strongest resemblance between the pathological condi- tion of the internal surface of the uterine cavity, and that of the neck of the uterus, in the two affections under consideration, we should not profit from the analogy, as Dr. G. has not pointed out the condition of the former, that we might benefit from its resem- blance to the latter. Dr. Gooch insists that the " irritable uterus " is " a disease of function, and not of structure," p. 316. We would ask of what function ? For Dr. G. admits that the menses continue to be dis- charged, though not in the most healthy manner; but we have endeavoured to show, that there is no necessary connexion be- tween the discharge and the disease in question—for we have seen them, as we have observed before, altogether independent of each other. And, if it be not the catamenial function to which he alludes, we are altogether at a loss to what other to assign it. Treatment.—Would it were in our power to say, that the treatment of the " irritable uterus" were as well understood, and as void of difficulty and uncertainty, as its obstinacy and seve- rity render it desirable ; for were we candid, we must honestly confess, that the contrary of this is nearer the truth. This diffi- culty, however, does not arise so much from the indomitable na- ture of the disease, as from the length of time required to over- come it, and the privations to which the woman must submit who looks forward to its cure. Patience becomes exhausted, and confidence in the efficacy of remedies is too quickly destroyed ; for relief is not only almost always tardy, but is too often uncer- tain ; especially with patients whose circumstances and avoca- tions will not permit them to fulfil any plan^ however judiciously laid down, or however important its adoption may be to their welfare. We have just declared, that relief in this disease is almost al- ways tardy ; for however judiciously remedies may be advised, or however faithfully they may be applied, they are far from being uniformly speedy in their effects: in this opinion we do not stand alone ; for it is the declaration of the several authorities we have quoted above, and but too certainly confirmed by our own expe- rience; months, nay years, are sometimes required to accomplish 298 IRRITABLE UTERUS. a cure ; and if this be effected even after a very long trial of means, the woman may felicitate herself that she has been able to procure health, even at so great a price. In no disease does recovery so much depend upon the conduct of the patient herself, as in the " irritable uterus." The patient must make up her mind to a long and irksome confinement to bed; she must consent to, perhaps, the frequent use of external applications and internal remedies, and submit to a system of diet or abstinence that will not bear infraction with impunity, if she expect to recover from this painful, wayward, and perplexing affection. All this should be fairly and candidly stated and the patient's mind should be duly impressed with the absolute neces- sity of perseverance, and of the penalties that will await neglect, or that will follow infringement. On the part of the practitioner, much caution, as well as pru- dence is required, that no ill-founded hopes may be raised, or that the patient may not be unnecessarily sunk to despondency. He should not make a false estimate of the persevering nature of the disease, from its apparent mildness, at the moment of its investi- gation ; nor be too suddenly elated, at the seeming success of his plan; for the symptoms of the "irritable uterus" are not uni- formly severe, or constantly obstinate, yet there is, perhaps no disease of the female system more wayward in its intensity, nor more liable to recurrence, from either neglect or imprudence. He should be well aware of a truth, proved by multiplied expe- rience—that no affection brooks trifling with so bad a grace as the "irritable uterus;" and that all departures from prescribed rules, is almost sure to be followed by penalties, much beyond the seeming importance of the trespass. $ut, notwithstanding the unyielding nature of the disease of which we are treating, much may be done towards its relief, if we cannot always promise its removal; and we are rather dis- posed to believe, that the difficulty of its management arises very often from the impatience, the imprudence, or the circumstances of the patient, rather than from the insurmountable nature of the disease itself. The first prevents the best application of the reme- dies ; the second may defeat their best operation ; and the third will perhaps interrupt their due employment. Having thus pointed out some of the difficulties inseparable from the manage- ment of this disease, and suggested certain cautions, that must never be lost sight of during this treatment, we will now pro- ceed to detail all that experience has hitherto suggested for its relief. The therapeutical means will consist, first, of rest; secondly, of bleeding both general and local; thirdly, of purging ; fourthly, of blistering, or of the employment of rubefacients; fifthly, of narcotics; sixthly, of injections per vaginam ; seventhly, of re- IRRITABLE UTERUS. 299 gimen; eighthly, of the application of the pessary; and, lastly, of tonics. Of Rest.—A steady and persevering repose of body is a sine qua non in the treatment of a confirmed "irritable uterus." By rest, we are to understand almost absolute quiet in a horizontal position. The patient may make her election as regards the substance on which she is to repose : it may be a bed, a mat- tress, a couch or sofa; or she may occasionally vary either of these, provided these changes are neither made too often, nor too suddenly, nor at the expense of the patient's own exertions. The patient, for instance, may be carefully removed from either her bed or her mattress, to a couch or sofa, and this daily, if she choose this change, but she must preserve the horizontal position under all circumstances. She must not sit up even in the bed, or on the mattress or sofa, even for a short time, as this slight indulgence is almost sure to be followed by an increase of pain, or other inconvenience; a fortiori, she must not be permitted either to stand for any time upon her feet, or to walk. Nothing shows the extreme sensibility of the uterus, (or rather a portion of it,) more decidedly, than that augmentation of pain, which almost instantly takes place from an erect, or even a semi- erect position, and which obliges the woman, almost instinctively, to return to a horizontal one. All her unpleasant symptoms are suddenly increased; especially the throbbing sensation, which, as we have declared above, so particularly characterizes this disease. This infrease of pain most probably arises from two causes: first, from the uterus being obliged to sustain much of the wreight of the abdominal viscera; and, secondly, this position retards the return of blood from these parts. At first, the confinement to bed is extremely irksome ; but the patient should be encouraged to perseverance, by the assurance that this unpleasant sensation will wear off in a short time; and that she will not only become reconciled to the horizontal posi- tion, but will absolutely covet it, from the immediate and certain relief she will experience by returning to it after having sat up for a few minutes, or, sometimes from even attempting it. The cause of this increase of pain we have endeavoured to explain above. Of Bleeding.—First, we shall say a few words upon the occa- sional necessity of bleeding from the arm or foot. We would employ general bleeding only under two circumstances of the system—first, where the circulation is vigorous; the pulse tense or chorded ; where there is much pain, and especially in the ab- domen, accompanied by cough or headach. In such cases we would abstract blood from the arm, to an amount that would afford relief even during its flow, did this require but eight or ten ounces, or a much larger quantity: for we have uniformly 300 IRRITABLE UTERUS. found that the proper abstraction of blood from the system at large, in the beginning of our treatment, was sure to be followed by advantages that could be procured in no other way—besides, if we draw blood in sufficient quantity at first from the arm, we need rarely repeat this operation ; while, at the same time, its abstraction gives a more decided efficacy to other remedial means. Secondly, should the symptoms enumerated above be attended with a sparing menstrual discharge, we would abstract eight or ten ounces of blood from the foot, and this should be repeated five or six days before the next menstrual period, if the first has not succeeded. But the " irritable uterus" will require the abstraction of blood from parts near the seat of the affection, and this again and again —the parts hitherto selected for this purpose, have been the sa- crum, or the abdomen ; but multiplied experience has convinced me, that as much advantage, to say the least, but we really think much more has followed, when the blood has' been drawn from the inner part of the thighs, three or four inches below the vulva: it may be drawn from one or both thighs at the same time, by either cupping or leeching, and should be repeated every four weeks, a few days before the menstrual period, until pain, &c, are much abated, or until the patient can bear to be placed upon her feet, or even walk, without much inconvenience or discomfort. Four or five ounces may be drawn at each time. We have had, within the last year, a number of exquisitely formed cases of this disease; and we are happy to state, that if: blood be abstracted by leeches, immediately on the womb, to the amount of four, five, or six ounces, (as the inflammation may be more or less attended by a high degree of sensibility of the ute- rus,) the most decided advantage will quickly result. This ope- ration is one of less difficulty in its execution than would, at first sight, be supposed. The greatest difficulty is lo get the patient to submit to it. It gives less pain than leeching from an exter- nal surface. We have seen several cases of irritable uterus yield to this plan, and the other means, diet, rest, &c, in a very short time, and much more completely. A tube is introduced into the vagina, through which the leeches are conducted to the neck or other portions of the uterus. The after bleeding is generally more considerable than from the skin. The application of leeches to this organ is a great improvement in the management of any of its affections. In judging, however, of the diminution of pain, it must be kept in view, that the effects of long confinement in a horizontal posi- tion be not mistaken for the consequences of the change of posi- tion upon the affected parts. We should, therefore, inquire into the nature of the existing feelings, and compare them, both in degree, and in their nature, with those that really belong to the IRRITABLE UTERUS. 301 disease. To aid us, therefore, in forming a correct judgment upon this important point we should, from time to time, make a careful examination per vaginam, with a view to determine the existing degree of sensibility in the neck of the uterus, and the several portions of the vagina. By doing this, we shall be able to determine the exact impression we are making upon the dis- ease ; and, consequently, thereby ascertain the extent of neces- sity for perseverance* In making this estimate we must never fail to take into consideration the state or degree of the "throb- bing sensation " we have mentioned, as particularly belonging to the diseise. By this, very much may be learned ; for, if this feeling do not diminish with the sensibility, we may be certain that the affection has only made a truce, but has not retrograded ; while, on the other hand, we may be assured, that, in proportion to the abatement of this unpleasant feeling, is the abatement of the disease itself. Purging.—>-There is no one of the remedies proper in this disease so difficult to manage as purging-^-for there is no do- ing with or without it, as the bowels in this complaint are al- ways either constipated, or too easily made free, and either con- dition is sure to aggravate the suffering. In this opinion I am happy to be supported by the experience of Dr. Gooch. But, notwithstanding these difficulties, it is every way important that the bowels should be moved once a day ; neither less nor more ;— and for this purpose nothing answers better than the simple rhu- barb pill. Blistering and Rubefacients.—We afe much at a loss to deter- mine the exact value of blistering in the " irritable uterus," as it has in some instances, we have thought, proved useful, while in others, we have feared it has proved mischievous; on the whole, therefore we are distrustful of this remedy. But not so of rube- facients, or vesicating with the tartar emetic ointment. We have uniformly found the mustard bath of great utility in this disease, as there is a prevailing coldness of the feet and legs. This hath should be used whenever the coldness of the feet claims attention, be this daily, more seldom, or oftener. The ointrrient should be applied to a pretty large surface of the abdomen twice a day, un- til a pretty extensive vesication is produced, and repeated from time to time, as the vesicles may heal, and as the urgency of the symptoms may require.* * We have frequently had cause lo lament the tardy effects of this ointment, though pretty well aware of the causes-. The first iss the adulteration of the tar- tar emetic; and the second, from the imperfect manner in which the ointment is prepared, we were, therefore happy in meeting with M. Mialhe's directions for making it. As the efficacy of the ointment depends upon the minuteness of the division of the tartrite of antimony, M. M. recommends that " a saturated solution of it be made in cold water, and that it be then precipitated with alcohol: a very small quantity of the latter will suffice, he says, to precipitate the tartar emetic 26 302 IRRITABLE UTERUS. Narcotics.—Agreeably to our experience much caution is re- quired in the use of narcotics, at least of opium ; for, to this drug only, in one form or other, do we fly, when it is proper to sub- due pain by this means. Much mischief, we are persuaded, has been done by the too free use of this medicine, when exhibited to abate pain (coute qui coute,) when the disease has been mis- taken, or not well understood. For, as we have persuaded our- selves that the disease is inflammatory, we can readily understand why opium has done mischief, or why, at least it has not proved always successful. This opinion must not be taken for a prejudice, or as one founded upon an hypothesis ; for the medicine flas failed in other hands, as is abundantly proved by Dr. Gooch's cases. Yet there is a period at which there is both propriety and advan- tage in the use of opium—and this is, after the general febrile symptoms have been removed or abated, and when the local ones are diminished in intensity. The neck of the bladder, and the whole tract of the urethra, are sometimes in a highly sensitive condition, and give much pain, especially in the effort to pass water; for the relief of which, much benefit has been derived from smearing the parts just men- tioned, morning and evening, with the following ointment, con- ducted to the parts by the point of the patient's own finger. R. Ext. Belladon. ... jjiss. Cerate simp, reeen. prerarat. - §j.—M. When this period arrives, we do not hesitate to give opium, laudanum, black drop, or preferably the sulphate of morphia in adequate doses at bed time, or oftener, if suffering require. Opium may be given with much advantage in either of the forms now mentioned, in enemata, as well as by the mouth. But we .should carefully watch the influence of this medicine upon both the general and local symptoms; and if either be increased after its exhibition, or, in other words, if it fail in procuring relief, the quantity should be diminished, or it should be withheld altogether, until the system be farther relieved of its susceptibility to stimuli. To prove how important an attention to this circumstance is, we need only refer to the case we have related from Dr. Gooch, where opium, and many other means were employed, without benefit; yet the patient was almost instantly relieved by the application of a few leeches. In a word, if opium is to be useful, it must only be employed under a reduced state of the arterial system. Of Injections.—Under this head, we will comprehend, first, such as will deterge the vagina, and, at the same time, sooth the in the form of a powder of extreme tenuity. The precipitate is to be collected on a.filter and dried. Two drachms of this, mixed with an ounce of simple cerate, will make a very active ointment"—Amer. Journ. of Med. Sciences, for February, 1831, p. 522. IRRITABLE UTERUS. 303 uterus: of this kind, is lukewarm flaxseed or slippery elm bark- tea: a quantity of this should be thrown up the vagina, by a syringe of sufficient size, three or four times a day, or oftener, if suffering be considerable, either from pain, heat, or throbbing. The injection should be retained for some time by applying a cloth to the vulva, so as to prevent its too early escape. The other is sedative—and may be composed of eight grains of opium dissolved in a pint of hot water, and carefully strained—an ounce of this may be used after the other injection has removed itself. Quere, as more or less leucorrhcea pretty uniformly attends this disease, might not a weak solution of the nitrate of silver be used with advantage, as this remedy is known to exert a tranquillizing influence upon certain inflamed surfaces ? We have found the "throbbing" much relieved by introducing a small piece of sponge saturated with equal parts of laudanum and water, within the os externum. Regimen.—The diet of the patient should be most carefully at- tended to, and made to conform to the general indications; namely, to abate inflammation, and to relieve pain ; therefore, an antiphlogistic regimen, strictly so called, should be constantly ad- hered to, and persevered in, even for some time after the ap- parent removal of the disease—for, as noticed before, no dis- ease bears imprudences bworse than the one of which we are treating. Of the Pessary.—It frequently happens, that the uterus will re- main prolapsed after the sensibility of the uterus is removed— when this is so, much advantage will be derived from the use of a well-adjusted pessary. Attention, however, should Be paid, that it excite no pain, or other inconvenience, by its presence ; if it should, it must be instantly removed, and not reapplied, until the parts have acquired a more natural state of feeling. Tonics.—Much injury is frequently done, by the too early use of this class of remedies—in several instances we have witnessed severe relapses, by attempts to give strength to the body ; they should, therefore, be withheld for a long time, or perhaps more safely, altogether, in very susceptible systems. In two instances, where the stomach had suffered much, great advantage was found from the use of the posphate of iron, given from six to ten grains, three times a day. We have selected two or three cases, that the general and local symptoms of the " irritable womb " may again be brought into view, and that the common routine of practice may be the better understood. In making this selection, we have not been govern- ed by any peculiarity they exhibited, or because there was any particular departure from the ordinary mode of treatment; they have been chosen with one exception, (the third,) because they weje considered as fair instances of the " irritable uterus," and 304 IRRITABLE UTERIS. exhibited the most usual train of symptoms, as well as the most uniform mode of treatment. Case I.—Mrs.-----, aged thirty-six, the mother of five chil- dren, had been labouring under the following symptoms several months before we visited her; namely, a constant tenderness immediately behind the mons veneris, which was converted into acute pain by any sudden exertion of the body, especially by walking up stairs, or going down. The pain experienced upon such occasions, was of a lancinating kind, and of great severity ; and when once provoked, would continue from one to two or three hours, suffering, however, a gradual abatement daring this time. This pain was constantly excited if she sat upon a hard substance, and she was therefore obliged to guard against this inconvenience, by placing a soft cushion over the hole of a pierced chair. She found that emotions of the mind, if suddenly induced, would have the effect, though in a more moderate degree than some other causes. Coughing or sneezing was sure to create great suffering. Upon examination per vaginam, the uterus was found considerably lower than natural; its neck was exquisitely tender, and larger than common^-the os tinea? very closely shut, and the part of the body of the uterus within reach of the finger, as well as the vagina, were extremely ten- der ; so much so, indeed, as to render the examination a very unpleasant operation—slight leucorrhcea, of a milky appearance ; the whole neck of the bladder was enlarged and tender, with frequent desire to pass urine, accompanied with a disagreeable sensation in the bladder, and the whole tract of the urethra. The urine "was high-coloured, sparing, and deposited largely. The menstrual discharge was pretty regular in its recurrence, proper in quantity, and employing about six days for its com- pletion. This discharge was announced always by tenderness in the mammae ; a sense of fulness in the region of the uterus, with a feeling as if the uterus were constantly sinking lower in the pelvis—there was no dysmenorrhcea, nor any discharge of coagula. The head was. very frequently attacked by severe pain, espe- cially on the back part of it. This became worse almost always in the afternoon, at which time a slight febrile exacerbation was sure to take place, though the pulse was always excited beyond the natural beat—it was corded, and not large ; the skin dry, and, where covered, the heat was above the natural temperature. The hands, feet, and legs, constantly cold ; the bowels constipated, but easily urged to diarrhoea ; the appetite pretty good, though variable, and the digestion not bad. The tongue very slightly furred, and paler than natural. She was ordered to observe a horizontal position ; a strict an- tiphlogistic regimen ; to lose ten ounces of blood from the ayn ; IRRITABLE UTERUS. 305 the mustard bath for the feet and legs every other night; luke- warm flaxseed tea injections per vaginam three times a day; a rhubarb pill every night at bed-time; and to forego matrimonial privileges, as extreme suffering was always experienced from their indulgence. This plan was persevered in for three weeks without any re- markable change, save a general improvement of feelings. The uterus and every thing else remained pretty much as at the com- mencement of the plan. Four ounces of blood to be taken by leeches from the inner portion of the thighs—every thing else as before. After the third month had elapsed, there was an evi- dent melioration of symptoms; especially of the uterus and the surrounding parts—their sensibility was much diminished, and the leucorrhcea abated—during this time leeches had been applied three times ; the bowels kept daily open, and the urine was dis- charged less frequently, and with more freedom, but it still de- posited considerably. Injections of a weak solution of the acetate of lead, (two grains to the ounce,) were ventured on ; leeches to the thigh, as before ; rest, diet, and the rhubarb pill, as before.-- At the expiration of three months more, symptoms were much improved; the plan had been persisted in with great fidelity and patience. Injections of the solution of opium, were now substi- tuted for those of the lead—a sixth of a grain of morphia was ordered whenever pain became severe ; for this had never failed to attend, in a greater or less degree, though^ with, much less se- verity and frequency than before. This lady was once blistered on the sacrum, but with such doubtful effect, that it was never repeated. At about this time the tartar emetic ointment was rubbed upon the lower part of the abdomen until a copious crop of pustules appeared, and with manifest advantage. It may be proper to observe, that this application can only be serviceable, we believe, after the violence of the disease has abated—it may be repeated in three or four weeks after the first, if the sensibi- lity of the neck.of the uterus be not subdued-—we never use this ointment in the beginning of the treatment. It now appeared that the disease was more certainly under the control of the remedies already mentioned, and was daily abating in severity—the leucorrhcea entirely disappeared, nor has it returned. At the end of thirteen months the patient was en- tirely well, though weak from long, confinement, &c, and was now, and not until now, permitted to sit up: after this was tried a few days, and apparently with advantage, she was allowed to walk in her chamber, and rapidly gained strength by the indul- gence. It was, however, soon found, that the prolapsed condi- tion of the uterus was offering considerable inconvenience ; and as the parts had entirely recovered their• natural condition, a 26* 306 IRRITABLE UTERUS. pessary was introduced with very prompt and decided advan- tage, and the patient is now enjoying a very comfortable state of health. Case II.—It will not be necessary to detail the symptoms of this case; as they bore an entire resemblance to the one just re- lated. There were, however, certain points of difference ; namely, the patient had been labouring under the affection for several years, but had. not derived the slightest benefit from what had been, done for her relief. It was looked upon as a disease of de- bility, and the severe sufferings were supposed to be caused by spasnr—hence,, bark, steel, cold bath, sea-bathing, opium, hem- lock, henbane, stramonium, warm bath, blistering, salivation, twice repeated, &c, &c., were had recourse to, but to no other purpose than to increase debility, without diminishing suffering. In this case, pain was not so violent, but there was more leucor- rhcea, and more profuse menstruation. This lady was confined to her bed from extreme weakness when we first saw her—the febrile affection was more distinctly marked, and great obstinacy of bowels.. General bleeding was not employed in this case; with this exception, it was treated like case first; but fortunately in this instance the patient was entirely restored in seven months. In this case, like the former, the pessary was employed from the period just mentioned. Case III.—This case differed from the two now related, in three important points; first, the menses were very irregular in their, returns, and, always attended by hemorrhagy, to a very con- siderable degree ; coagula. were expelled in great numbers, and after each spell the patient was left much debilitated, though she for the most part kept about; secondly, there was profuse leucor- rhcea of a purulent appearance; and thirdly, the neck of the ute- rus was very much larger than, we had ever witnessed before, and its sensibility was very great. The same general plan was adopted, and: the patient was. very much relieved at the end of about five months, though not altogether well. When we_examined. the uterus last, its neck was reduced to its natural size, and had lost nearly all its morbid sensibility. We have had: some reason to regret that the plan which had-so far relieved the. disease, had.not been persevered in three or four months longer, as.there was every reasonable expectation that it would have proved still more beneficial. Notwithstanding the success, that attended the cases just re- lated, as well as many more that we could mention, it is but fair to acknowledge, there have been others, in which no such benefit was received, though remedies, generally speaking, were faith- fully, used, and every.reasonable precaution taken to ensure suc- cess. From.re.cent experience, Lhave found the Iodine of great ser- UTERINE HEMORRHAGE. 307 vice in this indomitable disease, but never to be a decided remedy; but much relief has been found from it; so much so, that patients believed they were getting well fast, but it seemed to have an in- fluence so far and no farther. It was given, in the form of Lugol's tincture, No. 3. It was commenced by ordering six drops every morning, noon, and evening, in some sweetened water, and in- creased very gradually to thirty drops. It abated many of the symptoms very sensibly, especially the pain and constant uneasi- ness that was felt in the vagina, and rendered coition when it was indulged in much more tolerable. CHAPTER XVI. QN UTERINE HEMORRHAGE." The mode I shall pursue in treating this subject, will be, First, To consider very briefly the nature of the connexion of the ovum, with the internal surface of the uterus. Secondly, To investigate the causes which may impair this connexion, and-thus expose the surface from which the blood is derived". Thirdly, To examine into the mode of action of these agents, in affecting this lesion. Fourthly, To point out the several periods of utero-gestation, at which this lesion may take place—and trace the various con- sequences which may result from it, al these several periods. Fifthly, To notice the modes of treatment at these different stages, and-under these various circumstances.. Sect. I.—1. The Connexion of the Ovum with the Uterus. Soon after the ovum is deposited within the cavity of the ute- rus, we find it connected- through the whole extent of its surface, with the internal face of this organ. The uterus and ovum mu- tually contribute to this end ; on the part of the womb, we find it produce a soft spongy substance, called decidua ; on the part of the ovumj we discover its external covering, or chorion, shooting * Of this dwease, the unavoidable species, we have thought, only belonged pro- perly to midwifery; consequently, that which arises from the "implantation of the placenta to the mouth of the uterus," is: not treated of here, only the accidental variety. 308 UTERINE HEMORRHAGE. out innumerable vascular fibres—and both, when united, seive as the bond of union between the ovum and the uterus. The efflorescence on the uterine surface, like that which covers the ovum, is decidedly vascular; and seems that these minute vessels interlock with each other after a certain period, and this so firmly, that they cannot be well separated without rupture. Therefore, should a portion of the ovum be detached in the earlier months, the quantity of blood that will issue, will be commen- surate with that surface; especially, if it be from the body or fundus. And, as a general rule, it may be said, that the quan- tity of blood which may be expended, will be in proportion to the advancement of pregnancy. Sect. II.—2. The Causes which may tend to destroy this Connexion. If we consult authors upon this subject, we shall find a variety of causes enumerated, as capable of destroying to a greater or less extent, the connexion between the placenta and uterus—and it is agreed, by far the greater number, that no considerable he- morrhage can occur unless this happen. In enumerating the remote causes of hemorrhage, I shall only name such as are most generally believed to be capable of this effect, either before or after delivery. Before delivery: 1st, too short a funis; 2d, mechanical vio- lences; 3d, passionsor emotions of the mind ; 4th, plethora ; and, after delivery, 1st, atony; 2d, spasm ; 3d, humoral engorgement; 4th, unequal contraction of the uterus; 5th, inversion. Though all these causes have been assignedfor the diseases we are considering—still, it is sufficiently difficult of explanation how some of them act to produce it. When violence of any kind is-offered a pregnant woman, and she miscarry, or. is prematurely delivered, the cause, from its force or extent, appears, at first sight, capable of the end ; and there, all investigation ceases. It may not, therefore, be time ill-spent, .to inquire into their respective agencies. Sect. III.—3. Mode of Action of certain of the remote Causes. And, first, too short a cord. It was the opinion of La Motte, that the cord may be naturally or accidentally too short—and that in either case, it might be the cause of hemorrhage. He gives a case purporting to-be illustrative of this assumption—but con- fesses it was the first, and only one, he ever met with. The bleeding proceeded from one of the umbilical vessels, at a portion which was folded into a kind of knot, and which yielded, from UTERINE HEMORRHAGE. 309 the accidental shortness of the funis. Levret met with a similar instance. And BaucTelocque also mentions a remarkable case of this kind.* It must, however, be confessed by all conversant with the practice of midwifery, that though this may be a cause of hemorrhage, it must be a very rare one—or the extensive practice of these three celebrated authors, would have furnished more examples. Secondly, mechanical violence: Thirdly, passions, or emotions of the mind: Fourthly, plethora. Each of these causes may pro- duce uterine hemorrhage ; and perhaps all have. However, the mode in which they effect this, is not so well understood as it deserves to be—the whole of these causes have one common operation upon the system—they all induce increased force of circulation ; and this is generally considered sufficient, under certain circumstances, to produce the evil in question. It has been thought, that whatever gave an increase of force or velo- city to the circulatory system of the mother, must almost neces- sarily, in consequence of the large size of the hypogastric and spermatic arteries; the short distance they have to travel be- fore they arrive at the uterus; and their great increase in that viscus as gestation advances, very much effect the condition of the ovum within its cavity—and, that the arterial vis a tergo must act mechanically upon the ovum; and by mere force of circulation drive it from its connexion with the uterus. That plethora must also act after pretty much the same manner—and as a proof of this, it is said, that the periods at which the menses are wont to return, are those at which the abortion is most readily provoked: for, at these times, though the uterus is impregnated, and this discharge has ceased, still the blood is sent in greater abundance than usual, until the demands of the embryo are such as to employ it, without suffering the vessels to become en- gorged. Now, if a mere increase of circulation were all that is required to effect this end, no woman would escape aborting, who might labour under high arterial action—thus, fevers of all kinds would he followed by this accident; but this is contrary to all expe- rience. I am obliged, then, to suppose that something more is necessary than an invigorated circulation. I have said, that something more is required than an increased force of circulation, to effect a separation of the ovum in the early months, or of the placenta in the more advanced periods of pregnancy—and that something I believe to be uterine con- traction ; as, without this, I am at a loss to understand the modus agendi of the remote causes. I shall not pretend lo say how the causes just enumerated in- * Midwifery, par. 1084. 310 UTERINE HEMORRHAGE. duce this action—though I am certain that this effect is produced through their agency, and for the following reasons: 1st. Because mere circulatory impulse appears from the anatomy of the uterus and ovum, to be inadequate to this effect—since neither abortion, nor premature delivery follows as a consequence, when this con- dition has been present in its highest degree. 2dly. Because contraction, in every instance, is essential to the separation of the placenta, whether in cases of abortion, pre- mature labour, or delivery at full time. 3dly. Because we frequently detect this cause, by the presence of pain, hours or sometimes even days, before the eruption of blood; and because, so long as this contraction continues, hemor- rhage will not cease, unless we diminish the bulk of the ovum, or interrupt its return by proper remedies. Where the ovum is about to be cast off, either in the early or later periods of pregnancy, or where there is no chance of its preservation from the effect already produced upon it, contrac- tion becomes useful, though originally the cause of the separation and hemorrhage, as it proves the healthy disposition of the uterus ; at least so far as this circumstance is concerned. By it, the ovum is completely separated, and cast off; the bleeding put a stop to, and the woman secured from danger. Contraction and pain are now to be contended with, as well as the bleeding; and these always increase the difficulty of cure. Therefore, it may not be amiss to inquire how far we may have a control, or whether we have any, over uterine contrac- tion after it has once been called into action. The no small authority of Mr. Burns is against me when I say, I think we have ; though confessedly, it is difficult of subjection. Yet, as it is a matter of high consequence to ascertain the truth upon this subject, I hope to* be forgiven if I differ from this respectable writer. He says, "When abortion is threatened, the process is very apt to go on to completion, and it is only by interposing before the expulsive efforts are begun, that we can be successful in preventing it; for whenever the muscular contraction is uni- versally established, marked by regular pains, and attempts to distend the cervix and os uteri, nothing, I believe, can check the process." That it is a matter of uncertainty, whether we succeed in our .attempts to arrest uterine contraction after it is " established," must be acknowledged. But that it is never attended by success, I cannot concede ; nor should the principle be inculcated, as it paralyzes exertion, and makes us withhold from the suffering female, an attempt which rarely fails to give at least comfort. My experience would, I think, in more instances than one, de- clare that I have been rewarded ; and should our attempts fail nineteen times out of twenty, we are surely not justified in with- UTERINE HEMORRHAGE. 311 holding them. I therefore make it an invariable rule, to treat the case as if success were to follow. There is one case or condition, I acknowledge, with which I never interfere, under the slightest prospect of success; and that is, where the process of gestation has ceased ; of the signs of which there is but one absolutely certain ; namely, where the breasts have become tender and tumid, and then pretty suddenly subside. It would here be a forlorn hope to administer remedies with a view of retaining the ovum. I am disposed to believe that this circumstance is the Only one which marks the loss of life of the ovum with sufficient certainty ; it is perhaps the only one that is unequivocal; since all others may be said to be deceptive. This mark was known to Hippo- crates ; and has, I believe, ever since this time, stood the test of experience. So long, then, as this sign be absent, I do not relax in my attempts to preserve the ovum. It must, however, be con- fessed, that I have known the ovum to be cast off, where this symptom was wanting. Yet I am persuaded, in each of these instances, that the ovum preserved its vitality almost to the last moment; and that its expulsion was owing to the indomitable nature of the contractions of the uterus: I think this* has obtained most generally with women who are in the habit of miscarrying. I do not stand alone in my opinion upon this subject. Puzos, (Mem. de l'Acad. de Chirur. vol. i. p. 203,) declares, that neither pain nor hemorrhage necessarily produces abortion. La Motte, (Obs. 305,) gives an instance where the woman went her full time, after the orifice of the uterus was considerably di- lated. And above all, I may cite Mr. Burns, himself, for an ex- ample most strictly in point. (Princip. of Mid. ed. 2d, p. 195, in a note.) He relates, with seeming belief, that cases have occurred of twins, one of which has been expelled, while the other re- mained, and the " action of gestation," as he happily terms it, was still maintained to the proper period.* Now, this clearly demonstrates, that after muscular action has been "universally established," it can be suspended for a con- siderable time if this be so, under the circumstance of one foetus being expelled, and the uterus, by a cessation of action, permit a second to remain until the proper time, I should expect it, a fortiori, when the uterus is not so extensively, or so powerfully excited. The remote causes which I have hitherto been tracing, may with propriety be considered as contingent, or accidental in their application and influence. But one still remains to be noticed, * Indeed, our periodical Journals have lately, in a number of instances, fur- nished us with cases, proving thai the uterus may expel a fetus prematurely, and then become passive, Hntil a twin was matured, or in a condition to be expelled with advantage to itself. 312 UTERINE HEMORRHAGE. which must be regarded as absolute in its effects, whenever it may chance to exist—I allude to the implantation of the placenta over the mouth of the uterus. The knowledge of this particular location of the placenta, is of modern discovery—and, perhaps, Levret is the first, who decided- ly taught this doctrine. Mauriceau, La Motte, and others be- fore his time, met with the placenta in this situation, but they ?11 believed it was a mere falling down of this mass to the mouth of the uterus, after its entire separation from the fundus. But, when thus placed, flooding is inevitable; for the order of development of the uterus, is so uniform, that a deviation can only result from accident, or such a combination of circumstances, as very rarely happens ; we can then with absolute certainty de- clare, that when the placenta is unhappily situated over the mouth of the uterus, a flooding, towards the latter periods of gestation, must happen—hence the propriety of the term " unavoidable," for this kind of hemorrhage. During the first six months of utero-gestation, the body and fundus alone yield to the distending power of the ovum: after this time, the neck is called upon, (if I may so term it,) for its proportion, as the other parts of this organ seem to refuse any farther supply; in consequence of which, it, in its turn, becomes distended; and, in this act, a portion of the placenta is neces- sarily removed ; and a bleeding, according to the extent of injury, or the number of vessels exposed or ruptured, ensues. After discharging more or less blood, the hemorrhage may cease; or it may be so reduced in quantity, as to excite little ap- prehension. But this is a false security—it is sooner or later re- newed, either by a farther stretching of the neck, by the augmen- tation of the ovum, or by the removal of the coagulum, which had, until now, stopped the bleeding. In this manner may things proceed, until near the last stage of pregnancy—or the extent of separation may be such, or the size of the vessels exposed be so large, that the woman's life is in- stantly jeopardized, and from which she can only be protected by the most prompt and efficient remedies.* Sect. IV.—4. The Periods of Pregnancy at which Hemorrhage may take place. There is no period at which hemorrhage may not take place, after the first month of pregnancy; since, it is presumable, that after the fourth or fifth week, a union, more or less strict, is * For a particular account of this cause of hemorrhage, and its mode of treat- ment, see Bystem of Midwifery by the author. UTERINE HEMORRHAGE. 3l3 formed between the ovum and the uterus, by means of the cho- rion and the decidua. It must, therefore, necessarily follow that a separation may be effected, and, if this happen, a bleeding must ensue. Until about the fourth, or between the fourth and the fifth month of gestation, this separation may happen to any por- tion of the ovum ; as, up to this period, the placenta, or what is to become placenta, completely surrounds the ovum. As a general rule, then, we find the danger from floodings in proportion to the advancement of pregnancy ; because the vessels are larger, and will, in a given time, yield a much greater quan- tity of blood—though the chance of hemorrhage taking place is greater in the earlier months. Puzos says that abortions under the fourth month are rarely fatal; and this observation, perhaps, would be confirmed by the experience of almost every practi- tioner ; provided a sufficiently early attention may have been paid to it. It must, however, be confessed that it is very difficult to esta* blish any certain rule upon this subject, since I have seen symp* toms as alarming attend an abortion of six weeks, as I have wit- nessed from a premature labour of the seventh month ; or, indeed, at any other period. It may, however, with confidence be ad- vanced, that alarming symptoms do not show themselves as quickly in the early as in the latter months; and, of course, we have much more time for the employment of proper remedies. We shall now consider the mode of treatment. In pursuing my inquiry into this part of my subject, I shall endeavour to be as explicit as the nature of the subject will admit; for I can only establish general principles, and modes of management; as, per- haps, each individual case will present a shade of difference ; and the treatment of this shade of difference, whether important or otherwise, must be very much left to the good sense and judgment of the practitioner. I, however, trust, at the same time, that little embarrassment will be experienced, as the indications and their fulfilment will be so distinctly pointed out, as to render the one pretty certain, and the other without much ambiguity. With a view to perspicuity, I shall divide the consideration of floodings into the several periods at which they may appear, and the remedies into their nature, or supposed mode of action. The. peculiarities of each period will be pointed out: by doing which, we can establish more clearly and certainly the mode of treat- ment. The nature of each remedy shall also be considered, and the period at which it is more especially indicated ; together, with its mode of action, and the degree of confidence to be placed in it. In the division of this part of my subject, I shall nearly follow the arrangement of Dr. Denman, as it embraces every essential variety of period at which hemorrhage, as a consequence of ute- ro-gestation, may take place. This will consist of four periods. 27 314 UTERINE HEMORRHAGE. 1st. That period at which the ovum is entirely surrounded by the decidua and decidua reflexa : this will comprehend the first four or four and a half months of pregnancy. 2d. Into the remaining period of utero-gestation. 3d. Into the period between the birth of the child, and the expulsion of the placenta. 4th. Into the period subsequent to its expulsion. This division is by no means arbitrary: it is founded upon principles and circumstances that must not carelessly be lost sight of, if we wish either to understand the nature of the disease in question, or become acquainted with its most successful mode of treatment. For instance, until after the time pointed out in our first division, it would be highly improper, under almost any cir- cumstance, to pierce the ovum with a view to the discharge of the liquor amnii; yet, at the second period, it may become an es- sential remedy. In the third, the woman's safety may depend upon the immediate delivery of the placenta. And the fourth, upon procuring the tonic contraction of the uterus; and each of these distinctions should be well understood, for upon them is the conduct of the practitioner to be regulated. First Period. Until the period of four and a half months, or even to the fifth, the ovum, when separated entire from the uterus, appears to be an ovular, spongy, fleshy mass; it bears evidence of attachment to the parietes of the uterus, in every point of its surface—and it would seem to show, that at any one part of this, it may be sub- ject to separation; and this separation will necessarily constitute a solution of continuity of more or less vessels; and a consequent hemorrhage. I have just intimated that this separation may be at any point of the ovum ; but the effects will be in some measure different, as it may happen near the neck, at the body, or at the fundus of the uterus. If the separation happen at the body or fundus, the blood proceeding from the lesion, must increase the mischief, by separating other portions of the connecting medium of the ovum and uterus, before it can issue from the os tinea;; it will, therefore, follow, that when this takes place, the chance of arresting a flooding, and preserving the ovum, must be diminished in proportion to the destruction of the connecting medium. But when the disunion takes place near the neck, the mischief will be less serious, though the discharge may be very abundant. It has been thought by some that the os tincae was always soon affected in cases of hemorrhage threatening abortion. But I am disposed to think that the uterus has been supposed to be open merely because clots were expelled from the vagina—bu: this is by no means a proof of an open condition of the os uteri; UTERINE HEMORRHAGE. 315 for the coagula are always, perhaps, but certainly much the most frequently, formed in the vagina, when an ovum occupies the ca- vity of the uterus. Of this the most decisive proof can often be given, in the very early months of pregnancy, by a mere survey of the size of an expelled coagulum; for many times, it is five or six times the bulk of the uterine cavity. But little information can be derived from an examination of the state of the uterus in the commencement of a flooding at this time; for the os tinea? may be completely closed for a long time, in some instances, though the ovum may be eventually cast off; while in others, it may be naturally a little open, without offering additional risk to the embryo. But I may safely declare, when the neck of the uterus is dis- tended, so as to resemble in feel the extremity of an egg, that abortion will sooner or later take place, however small the open- ing of the os tincae may be. In this case the uterus is thrown into complete action, and the extension of the neck of the uterus, just spoken of, is the effect of these contractions. There is another mark equally unequivocal; and to which it may be proper now to advert, namely, the cessation of morning sickness; a diminu- tion of the abdominal tumour; but, above all, the mammae be- coming painful and distended with milk, and these pretty quickly followed by flaccid breasts. In both of these cases, all attempts to save the ovum will be unavailing; and our whole care must be directed to the state of the flooding. Nor is the quantity of blood expended, in itself, however exces- sive, positive evidence that abortion will take place ; especially when unaccompanied by pain—for I have repeatedly seen a very %large waste, without any other evil attending; while, on the con- trary, I have witnessed the expulsion of the ovum with the loss of a very few ounces, when accompanied by pain.* As a general rule, perhaps, it may be said that flooding following any violence, more certainly ends in abortion, than those which come on silent- ly and slowly, without any apparent cause. No reliance should be placed upon the opinion, that a mode- rate discharge of blood from the vagina during pregnancy, is use- ful by removing topical plethora.f On the contrary, we should look upon every appearance of this kind with great suspicion, and treat it as if it were to become decidedly mischievous. There- fore every sanguineous discharge from the vagina of a pregnant woman, should be treated with the utmost care—all the essential * Pain accompanying flooding, should not make us abate our endeavours to save the ovum, liut under the circumstances stated above, for I have seen it preserved; while I have witnessed several instances of ova being cast off, where neither pain nor flooding accompanied the expulsion. t Kok says, that local plethora is a cause of hemorrhage. (See Pasta, p. 275 316 UTERINE HEMORRHAGE. indications for hemorrhage should be instantly complied with; and no time should be lost by temporizing. The essential indications are 1st, to arrest the bleeding; 2d, subdue pain, if present; and 3d, prevent a recurrence of the he- morrhage. These three points are constantly to be kept in view, as the preservation of the ovum, or even of the woman, is dependent upon their fulfilment. Therefore, whenever a woman is attacked with hemorrhage from the uterus, the sooner it be arrested, the better: every known remedy of efficacy is to be employed in suc- cession, should the antecedent ones fail of success; and every ad- vantage must be given to these means, by the patient and her attendants, by a strict adherence to the directions enjoined. It would be in vain for the physician to prescribe, if either the pa- tient or attendants run counter to his instructions; and in no.case, perhaps, is their observance of more decided consequence than in the complaint we are now considering. One of the first steps to be taken, is to command the most per- fect possible r§st of body and of mind. The patient should be placed upon a mattress, sacking-bottom, or even the floor, in pre- ference to a feather-bed. The room should be well ventilated; the patient very thinly covered; her drinks, toast-water, cold balm-tea, lemonade, ice-wa.ter, &c.—No stimulating substance of any kind should be permitted. Care should be taken, even in the administration of food and of drinks, that the patient does not exert himself to receive them ; she should be strictly confined to a horizontal position. Her food should be of the same general character as her drinks—.such as thin sago, tapioca, gruel, or pa- nada—in neither of these should wine, or any other liquor, find admission ; they can be rendered agreeable by lemon juice, sugar, or nutmeg. All animal food, or the juices of them, in the com- mencement of a flooding, should be forbidden. Let whatever is given, be given cool. Absolute rest of every member of the body should be enjoined. The officiousness of nurses and of friends very often thwarts the best directed measure of the physician, by an overweening de^ sire to make the patient " comfortable." This consists in changing of cloths, " putting the bed to rights," or altering her position ; all this should be strictly forbidden. Conversation should be pro- hibited the patient; and all company excluded. Much mischief is sometimes done by the talking of the by-standers; for they, for the most part, delight in the marvellous, and relate the histo- ries of cases every way calculated to appal, the already too much alarmed patient. This kind of gossiping should be peremptorily forbidden, even at the risk of giving offence, rather than permitted, to the certain injury of the sick. Having established a proper system for the repose of the pa- UTERINE HEMORRHAGE. 317 tient, and the government of the attendants, we should next de- termine the propriety of blood-letting—this becomes very often of high importance; especially at this division of our subject: plethora is a usual attendant at this time ; nay, may be, as I have hinted above, the very cause of the alarm. Blood should be taken from the arm in a quantity proportionate to the force of the ar- terial system ; remembering we do little or no good by the ope- ration, if we do not decidedly diminish the force of its action ; let the pulse rather sink under the finger than otherwise ; its re- petition must be regulated by circumstances; recollecting, how- ever, that hemorrhage is sometimes maintained solely by exalted arterial action; as the following case will very clearly show. I was called to Mrs. B. in January, 1796, whom I found much exhausted by uterine hemorrhage, in the fourth month of gesta- tion. She had several days previous to my visit, returns of flooding, which were little attended to. The usual means were now employed, and for the time, the discharge was arrested : this was early in the morning of the 16th. She remained verv well until 5 o'clock, P. M. At this time she had a return of flooding: I was instantly sent for; and> living but a few steps from the patient, was very quickly at her bed-side. She was found to be flooding very rapidly ; the pulse was very active ; and the eruption of blood appeared to have been preceded by a slight rigour, followed by high arterial action-; she was instantly bled from the arm, until there was a reduction^ in the force and fre- quency of the pulse; and the abdomen covered with ice and snow. So soon as this took place, there was-an abatement of the dis- charge : this condition was followed by slight alternate pains in the back, shooting towards the pubes. Forty-five drops of lau- danum were now given ; and strict injunctions left, that the patient should be kept as quiet as possible ; and in case of return of the flooding, that I might be instantly apprized of it. 17th, A. M. The patient was found- free from fever, and almost free from dis- charge ; she continued so until about 5 o'clock, P. M., when the whole scene, as mentioned before, was renewed; she was again bled; subjected to the application of the ice: and the laudanum was repeated for the same reasons as yesterday. 18th, A. M., 8 o'clock, I was called suddenly to my patient, as she again had a return of fever, with hemorrhage; she was again bled, &c. In this manner didN matters proceed for several days; it was now found, that the arterial* exacerbations observed no regular period ; but whenever they did occur,.there was uniformly a re- turn of the flooding; and would continue during this state of ex- citement. With a view to interrupt this condition, or to abridge it as much as possible, Iplaced a young gentleman at the patient's bed-side, with orders to bleed her the moment he perceived an in- crease of pulse ; this was accordingly done; and from each bleed- 27* 318 UTERINE HEMORRHAGE. ing decided advantage was discovered. The loss of five or six ounces of blood was sure to put a stop to the uterine discharge, in the course of a few minutes; and sometimes would prevent its appearance, when it eould be very promptly used. By proceed- ing in this manner until the 23d, the patient was entirely freed from this distressing complaint. She was bled seventeen times; and lost, by computation, one hundred and ten ounces of blood in the course of seven days. She gradually gathered strength, and was safely delivered at the proper time. The acetate of lead should now be given, in doses and frequen- cy, proportionate to the extent of the discharge. From two to three grains may be given, guarded with opium, every half hour, or less frequently, as circumstances may direct; or in case the stomach be irritable, a very efficient mode of exhibiting it is, per anum—twenty or thirty grains may be dissolved in a gill of wa- ter, to which must be added a drachm of laudanum, and this be repeated, pro re nata.; or we may give the extract of rathany with great advantage, in the manner already recommended at p. 143, only the quantity should be repeated, every hour or two. If pain attend) opium should be given until a decided impres- sion be made upon the uterine contractions; or until its exhibi- tion appears to be totally unavailing. Should the discharge be profuse, the application of equal parts of cold vinegar, and spirit of any kind may be applied to the region of the pubes ; or what is still better, a large bladder, two-thirds filled with ice and wa- ter: the tampon should be introduced without farther delay. For the discharge from the uterus, when very profuse, will not always yield to these remedies; and if it do not, it will very soon become highly alarming. To save even a few ounces of blood, is always desirable; and sometimes it is highly important; should the means just recommended fail in moderating, or stop- ping the threatened symptoms, no time should be lost in employ- ing the tampon. The best, I believe, is a piece of fine sponge of sufficient size to fill the vagina. Lt should have pretty sharp vinegar squeezed from it several times, with a view to clean it, and to have it imbued with this acid; it may then be intro- duced into the vagina, and suffered to remain until its object is answered. Previously, however, to the introduction of the sponge, it will be well to examine the state of the neck of the uterus and the os tincae; their condition will very much govern our decision and prognostics. Should the one be found entirely closed, and the other of its original shape, we may, notwithstanding the pro- fuseness of the discharge, and even the presence of pain, still en- tertain a rational hope of preserving the ovum ; but if, on the con- trary, the form of the neck be altered, and the mouth opened, we are pretty certain it will sooner or later be cast off". But neither UTERINE HEMORRHAGE. 319 of these conditions is to effect our conduct, as regards the hemor- rhage ; for this is to be stanched, though we are certain the em- bryo will be lost. Much error is sometimes committed, under an impression that the ovum must be expelled ; and that nothing can be done advan- tageously for the woman, until this be effected. I have known a hemorrhage suffered to continue, almost to the exhaustion of the patient, because pain was considered essential to the throwing off the ovum, though on each return of it, a large coagulum has been expelled ; or the discharge has been augmented by injudi- cious manual attempts to aid the expulsion of the ovum. Both of these mistaken methods cannot be too severely reprehended— one for blameable supineness ; and the other, for rash inter- ference. Whatever may be the rapidity of the discharge in such cases, it is ever under command, so far as my experience will warrant the assertion, by the use of the tampon. This should be instantly resorted to ; and its effects W'ill be quickly perceived.* I deprecate with mucL earnestness, frequent and unnecessary touching. This is not only injurious, by fatiguing-lhe patient, but by removing coagula, that may be important to the stopping of the hemorrhage. This should, therefore, always be avoided ; except at such times, as it may become necessary to ascertain whether the mouth of the uterus be yielding to the influence of pain. It therefore can only be necessary in such cases as are, or have been accompanied by uterine contractions. I also must seriously forbid all attempts to remove the ovum, so long as the greater part of its bulk is within the cavity of the womb ; lest its covering be broken,.and the liquor amnii evacu- ated. We must let no false theory get the better of multiplied experience ; all the latter goes to prove (he impropriety of such a procedure ; for it is agreed by the most enlightened upon this subject, that it is mischievous to effect it, and unfortunate, when it spontaneously happens. The reason is obvious. The embryo is expelled, but its involucrum is retained ; in consequence of which, the flooding is perpetuated, and much pain, and other in- convenience, if not danger, are experienced, before it is thrown off from the uterus. I must therefore repeat it as a rule, that the ovum is never to be pierced before the commencement of the fifth month,f unless the flooding is very profuse^ the pains very urgent, and the os uteri pretty wall opened.. *" Dr. Meigs informed me, however, of a ease that fell under his no'ice, in which the discharge continued in an alarming quantity, though a tampon had been em- ployed. In such a case it might be well U> make a piece of sponge occupy the os externum completely, and its escape prevented by continued pressure against it with the hand. t Burton, and some others advise the rupturwgof the ovum, even at the second month—than this, nothing can be less conformable to either sound reasoning, or good practice. 320 UTERINE HEMORRHAGE. In this advice I depart from the very high authority of Baude- locque, with whom it is not very safe to differ: he recommends this to be done always after the third month; provided the mem- branes do not tear of themselves. But very ample experience has convinced me, that it is safer to preserve them so long as the os uteri remains closed, be the pains ever so frequent or power- ful, or the flooding ever so profuse ; for the one maybe diminished by opium, and the other arrested by the tampon. And if no pain attend, it almost becomes criminal to do so ; since the ovum may, by the use of the tampon and the other remedies above suggested, be preserved. I have ever found, in such cases, that much effort is required to expel the secundines; nor will we be much surprised at this, when we recollect the strong disposition the mouth of the uterus has to close itself at this period of utero-gestation. Indeed, I have repeatedly witnessed most alarming floodings from the placenta engaging in the mouth of the uterus ; and am certain, that they arose from the presence of the placenta, as the discharge always ceased, so soon as this mass was removed. When the hemorrhage is contained in this manner, the pla- centa should be removed as quickly as possible ; but this is the difficulty. At the early periods of pregnancy, (those compre- hended within the first five months,) the uterine cavity is too small to admit the hand, or even a couple of fingers; indeed, sometimes, not even one ; therefore, any attempt to deliver it by the hand alone, must almost always fail. If this mass be entirely within the uterus, or even nearly so, the os uteri will be found most generally so much closed, even at the fifth month, as to prevent the introduction of the finger to hook down the placenta; and as we descend from this to the second month, or lower, it will certainly be so small, as to prevent the intromission of even one. Whenever this is attempted, (especially by the experienced,) it is almost sure to end in disappointment. Sometimes a portion of the placenta is felt without the os tincae ; and should its greater bulk be so situated, we can sometimes remove the whole, by pressing it between two fingers, and withdrawing it; and thus put a stop to the discharge; but it is rare that we are so fortu- nate.* In such cases, I have employed, with the most entire success. a small wire crotchet. This instrument is very simple in its con- struction, as well as in its mode of action.f * From some late experience, I am induced to believe, that the ergot, if given at this time, will often supersede the necessity of the "crotchet." It must, how- ever, be borne in mind, that it is only in cases in which we cannot command the removal of the placenta by the fingers—that is, where this mass continues to oc- cupy the uterine cavity, or but very little protruded through the os tincae. t The drawing I have given of this instrument,.is upon a reduced scale; the- reduction.is one-third. I consider this much more simple than the piuee a»faux /:.;:'// UTERINE HEMORRHAGE. 321 The manner of using it is as follows:—The forefinger of the right hand is to be placed within, or at the edge of the os tincae; with the left, the hookedt extremity of the crotchet is conducted along the finger, until it be within the uterus; it is now to be gently carried up to the fundus, and then slowly drawn down- wards, which makes its curved point fix in the placenta : when thus engaged, it is gradually drawn downwards, and the pla- centa with it. The discharge instantly ceased, in every case in which I have used it. In all the instances to which I here refer, I am persuaded the women's lives were saved. In illustration of what I have just urged, I will relate one of the cases of the several that have fallen immediately within my notice. I was called to Mrs. H-----, on the 3d of August, 1807 ; she was at the third month of pregnancy, and was flooding violently ; pains were fre- quent and severe ; large doses of the acetate of lead and opium were ordered, together with cold applications externally—the mouth of the uterus was a little open ; the ovum protruding; quiet, cold drinks, &c. were ordered. I now left my patient, and returned at twelve o'clock, three hours after the first visit—the hemorrhage not abated ; pains increased; the os tincae more di- lated, and the ovum more tangible. At three o'clock, P. M., the ovum opened spontaneously, and the embryo escaped—flooding violent; pains trifling; syncopes frequent; pulse very small and quick ; the placenta in part engaged in the os uteri—a stimulating injection was ordered, with a hope it would bring away the placenta. Four o'clock, P. M., the injection failed in the object for which it was given ; hemorrhage continues; syncopes fre- quent; pulse scarcely perceptible. The placenta was now re- moved by the wire crotchet; the flooding ceased instantly ; the subsequent symptoms were very mild. Sometimes, when the ovum has opened, and the embryo escaped, but has left its involucrum behind, the hemorrhage may not be violent, but may be of long continuance ; at least it will be as long as this mass remains. In such cases, where time is not so precious to the safety of the woman, I have, in several in- stances of this kind, administered the ergot in twenty-grain doses, with very decided and prompt advantage. The peculiarity of this period consists in the ovum not having the transparent membranes formed ; and the practice founded upon this, as a general rule, is never to break the walls of it. germe,. as. proposed by Levret, and recommended by Leroux and Baudelocque; or that of Burton, for the same purpose. 322 UTERINE HEMORRHAGE. Second Period. This comprises all the time from the fourth and a-half, or the fifth month, to the entire completion of utero-gestation. The woman is liable to hemorrhage during any part of this period, by the action of any of the remote causes already enume- rated ; and in proportion to the advancement of pregnancy, will be the risk from flooding, as the quantity of blood thrown out in a given time, is, caeteris paribus, greater and more difficult to arrest. Therefore, when a woman is attacked with a discharge of this kind, however moderate it may be in the commencement, we have no security against its increase, at any after-moment— she is to be carefully watched, and most fully advised. We should insist upon compliance with the rules directed for the first period, and we must employ the remedies already proposed, as early as the nature of the case may require. I have already intimated, that a hemorrhage from the uterus during pregnancy, can only happen from a portion of the pla- centa being detached. It will follow that the issue of blood will be in proportion to the extent of surface so exposed; to fhead- vancement of pregnancy, and the force of the circulation. Now, as the advancement of pregnancy is greater in this, our second division, than in the first, the chances for a more profuse dis- charge of blood, are increased in an equal proportion : hence it is agreed upon all hands, that the risk the woman runs is very great; so great, indeed, sometimes, as to be very speedily fatal; since, we can have no influence over the extent of separation of the placenta, nor always have control over the force of arterial action. The indications, however, are precisely the same, as for the " first period ;" but their fulfilment is not always effected after the same manner. It is my practice, in cases of a threatened flooding, during pregnancy, or when, from the rapidity of the discharge, the woman's strength would be quickly exhausted, to use, in addition to the means just mentioned, the tampon. I have already said, I have found fine sponge the best; but where this cannot be pro- cured, fine flax, or very well picked tow, or old linen, may be substituted. When the latter substances are chosen, they should be used in portions of moderate size, and well moistened with sweet oil, or melted lard—they should be introduced one by one, until the vagina is completely filled; the whole may be secured by a compress and T bandage. This latter precaution is not necessary when a sponge is used, if the piece be of proper size. From its compressibility, it is introduced without the least inconvenience, UTERINE HEMORRHAGE. 323 if previously prepared as directed; and I believe it promotes coagulation quicker than any other substance, from its numerous cells giving speedy passage to the finer parts of the blood. It almost instantly puts a stop to the hemorrhage; and in some instances, I believe I was entirely indebted to it for the preserva- tion of the lives of my patients. Some object to the employment of the tampon : they say there is danger of local inflammation from the use of vinegar; but ex- perience has proved it to be futile. The mode of action of the tampon in stopping hemorrhage is precisely the one nature employs, when she alone effects this end. A coagulum is formed from the tampon to the mouths of the bleeding vessels, and thus puts a stop to, or very much dimi- nishes, the farther issue of blood. It would seem, from all we know upon this subject, that there is a strong disposition in the cut or divided extremity of a blood vessel when at rest, or nearly at rest, to form a coagulum within itself, for the purpose of put- ting an end to the farther issue of blood; hence, the importance of coagula at the mouths of the bleeding arteries; the formation of which is the first step towards spontaneous suppression. Puzos,* many years since, had pretty nearly the same notion upon this subject: he said, that the coagula acted as corks to the mouths of the bleeding vessels. The internal remedies for the suppression of uterine hemor- rhage, when successful, must act by disposing the blood to co- agulate more speedily; or immediately, upon the open extremi- ties of the bleeding vessels, so as to induce them to contract. Hence, the almost universal employment of that class of medi- cines called astringents. Leroux,+ however, forbids them in uterine hemorrhage, after delivery; but he does this upon a wrong principle. He says, " Dans l'haemorrhagie uterine violente qui succede a l'accouchment, ils ne peuvent etre d'aucune utilite. Pour s'en convaincre, il suffit de se representer la route qu'ils sont obliges, de suivre avant de parvenir ou lieu au leur pour- rait etre utile, le temps qu'ils mettent a parcourir ce trajet, et les changemens qu'ils eprouvent avant d'y arriver." In like manner, from their mode of action, LeakeJ objects to the use of astringents or styptics in this complaint; and upon no better ground, I think, than Leroux; for I know that certain of * "Os sages precautions ont snspendu souvent, et quelquefois ont fait cesser des pertes de sang accompagnees de petits caillots : non pas en soudant, pour ainsi dire, a l'interieur de la matrice les portiones du placenta separ6es, mais en donnant le temps au sang arretc a l'embouchure des vaisseaux de'sy cailleboter, et d'y former de petis bouchons moules sur leur diameter capables d'arreter le sang." (Mem. de l'Acad. torn. i. p. 211.) t Observations, &c. p. 209. t On Child.Bed Fever, vol. ii. p. 301. 324 UTERINE HEMORRHAGE. them, as the sugar of lead, (especially,) produces sometimes the most decided and prompt effects, let its mode of action be what it may. In many instances, it exerts a control over the bleeding ves- sels, as sudden as the ergot does upon the uterine fibre ; and, from the extent and certainty of this action, we might be tempted, without doing much violence to the delicacy of medical specula- tion, to call its action specific. In a word, we may justly ques- tion, whether any internal remedy can be successful in uterine hemorrhage, which does not exert an action somewhat specific. But neither internal remedies, nor external applications, should be exclusively relied upon, longer than is decidedly consistent with the safety of the patient; for neither astringents of any kind, nor the tampon, can be availing in all cases; and when they fail, there is but one resource, namely delivery; the consideration of which brings us to the other modes employed by a large class of practitioners, for stopping uterine hemorrhage; namely, those who consider delivery the only resource. Sect. V.—Delivery considered as a Mode of arresting Hemorrhage. From the time of Mauriceau and Dionis to the present mo- ment, the number belonging to this class is very considerable ; and if numbers merely were to be considered, the weight of evi- dence would be in favour of their practice. The want of proper knowledge in treating uterine hemorrhage by other means; the fatal rapidity of its termination sometimes, where rupturing of the membranes, or delivery, was not performed, or where a feeble plan had been pursued ; the occasional success of delivery, toge- ther with the strong probability of uterine contraction after this organ is emptied, and the influence of this contraction in arrest- ing the bleeding, has but too easily, and too generally, found ad- vocates for its almost exclusive employment. Thus, La Motte* thought it impossible to restrain hemorrhage, when the placenta was detached in part or entirely, but by the extraction of this mass; Dionis declared we should not defer the delivery of the foetus, if blood in great quantity, and without interruption, escaped from the uterus.f Mesnard advised delivery, if there was a flood- ing sufficient to cause fainting ;J and Heister§ and Puzos|| were of the same opinion, &c. &c; for it would be easy to multiply authorities, to considerable extent, to the same end. * Traite des Accouchemens, Obs. 216. t Pasta, p. 170. II Mem. de l'Acad. vol. i. p. 224. t Des Operations, p. 249. § Surgery, part ii. p. 957. UTERINE HEMORRHAGE. 325 The advocates for delivery as the only means of arresting he- morrhage, may be divided into two classes; first, those who paid no regard to the condition of the uterus when the operation was undertaken. The second, those who evacuated the liquor amnii previously to delivery, with a view to promote the contraction of the uterus, and by this means put a stop to the flooding; the latter may he subdivided into three: 1st. Those who did not regard the situation of the os tincae, when they ruptured the membranes; and if this operation did not immediately succeed, entered the uterus with the hand, by forced means, and imme- diately effected the delivery.' 2d. Those who, having torn the membranes and gained the feet, were contented to bring them to the orifice of the uterus; and then trust to the natural efforts to perform the delivery. 3d. Those who never pierced the mem- branes, but when the mouth of the uterus was either dilated or dilatable; and who, after rupturing them, permitted them to escape gradually, and finish the delivery slowly, or waited for the efforts of nature. From the improvements which midwifery has received within the last fifty years, I should not have expected to meet with an advocate for indiscriminate delivery, at the present day; yet in Meygrier, we find that advocate. That the most mischievous consequences have followed the practice of those who compose the first class,* we have the authority of Pasta,f who deprecates the practice as both cruel and dangerous; of Kok,| who says he has seen it followed by inflammation of the womb; of Leroux,§ who declares it to be dangerous to both mother and child; of Baudelocque,|| who insists that nothing can justify the accou- cheur, who persists to deliver while the neck of the uterus retains its natural thickness and firmness. And I may add my own ex- perience, as I once witnessed death, as the consequences of such a proceeding. The method pursued by those of the first division of the se- cond class, is not free from serious inconveniences, and is, per- haps, scarcely inferior to the first, as the same violence must al- most necessarily be committed. The plan of the second division of the second class, (which I shall, in conformity with custom, call Puzos' method,) is far from being the one most conformable to the principles of the art: since, in its performance, great vio- lence is frequently obliged to be resorted to. * Among the first class, may be reckoned all the accoucheurs prior to the time of Mauriceau. To the second class, and the first division of that class, belong Mauriceau, Dionis, La Motte, Deventer, &c. &c. To the second division, we may plice Puzos, Smellie, Delourie, &c. &c. And to the third, we have Leroux, and most of the late writers upon midwifery. t Vol. i. p. 132. * Pasta, p. 276. § P. 241. II Vol. ii. p. 90. 28 326 UTERINE HEMORRHAGE. The objections to this scheme are, 1st, that every flooding during pregnancy, is not necessarily followed by delivery ; but if we adopt this method, it must, within a short period, take place, and this perhaps, to the destruction of the foetus. 2d. Because the mouth of the uterus may be so placed as to render this operation very difficult, if not impossible; especially when the uterine orifice is still very thick and rigid; for Puzos* himself confesses, he was an hour or more before he could pierce the membranes; and this was a loss of most precious time to the patient, as the flooding still went on, and he began to despair of the success of his method, from the excessive loss of blood, and was fearful he should be Obliged to have recourse to forced de- livery. 3d. That the hemorrhage does not always cease after the rup- ture of the membranes; but, on the contrary, sometimes becomes more violent at this operation. 4th. That the presentation of the child, if it be preternatural, and the presence of the placenta over the mouth of the uterus will render this method ineligible. 5th. It is sometimes impossible to make a forced delivery; es- pecially, from the fifth to the sixth and a half month ; of this La Mottef gives one example, and Smellief another—and I once saw a similar failure. And, above all, they have not pointed out any alternative when this plan shall have failed. It is only upon the method of those who compose the third divi- sion of the second class; or those who never pierce the mem- branes, but when the os uteri is dilated or dilatable, that we can safely place reliance, in cases of severe flooding. It may be asked, what are we to do in cases of profuse he- morrhage, at any period from the fifth month to the full time, when the discharge threatens the life of the patient, and when the os uteri is closed and rigid ? Are we supinely to witness her death, rather than employ some violence to relieve her? Certainly not. If there really were no other remedy, forced deli- very, with all its disastrous consequences, might be justifiable; but as we have the power of plugging the vagina, and prevent- ing the farther issue of blood, we should have immediate recourse to it: and this plan, so far as I have witnessed, has not failed ; and this experience is so supported by that of Leroux, as to entitle it to entire confidence. By this means, time is permitted to the natural agents of delivery for the performance of their duties; and this is done, for the most part, with both certainty and success. The importance of the tampon is, perhaps, never so clearly * Mem. sur. les Pertes, &c. p. 336. + Obs 452 X Collect. 33, No. 2, Ob. 1. UTERINE HEMORRHAGE. 327 demonstrated, as when it is employed in cases where the flooding has proceeded to almost complete exhaustion, and where every ounce of blood is of immense value. In such cases, (before de- livery,) I have seen it arrest a profuse flow in almost a moment, and where the farther loss of a few ounces, must have been fol- lowed by death. Syncope, and even convulsions, have ceased upon its application. Though it be confessed, that after the failure of the remedies, recommended for the suppression of hemorrhage, as the appli- cation of the tampon, &c, there is but one means left in our pos- session, (namely, delivery,) by which the flooding can be arrest- ed, and the life of the woman preserved,—yet it may be asked, is there no condition of the patient, in which it would be im- proper to attempt this besides the rigidity of the os uteri ? To this, I answer, yes,—I would say, that a woman reduced to the last extremity of weakness, but with a suspension of the discharge, should not be meddled with, so long as the hemorrhage is kept in check. But suppose the same degree of weakness, with a continuance of the flooding, to exist; should we in such case, attempt delivery ? I have no hesitation in answering this in the affirmative:—but, previously to the operation, the condition of the patient should be candidly stated to her friends; it must be undisguisedly de- clared to them, that no undue calculation should be made of the benefit of delivery ; but, as this operation offers the only possible chance of relief, it might be adopted. We maybe encouraged to do this, as it now and then happens, that the woman recovers, under such circumstances, contrary to all expectation. Hitherto, I have said nothing of opium as a remedy in uterine hemorrhage ; the reason is simply this—it has never merited the smallest commendation in my hands ; for it has never been at- tended with the slightest success; of course, I cannot be of opi- nion, that it deserves the encomiums which have been so lavishly bestowed upon it by Dr. Hamilton and others. I have read, dis- passionately, and with care, Dr. Stewart's book upon this subject; and have cautiously examined the cases detailed by him; but they have not afforded me the slightest ground to believe, that the opium had any agency in arresting the floodings for which it had been so liberally administered; the cessation uniformly appeared to be the result of the natural powers of the system in general, and of the uterus in particular. That it is sometimes beneficial, previous to delivery, in allaying pain, and in this way putting a stop to farther mischief, I most freely confess; but I cannot yield any thing more. I am not alone in this respect: Dr. Denman seemed to entertain the same opinion; and Barlow has advanced similar sentiments. It may be proper to say a few words upon the subject of cold 32S UTERINE HEMORRHAGE. applications, as no remedy has been more extensively employed, or more constantly abused. Cold, as a means to arrest flooding, is in almost universal employment, is usually one of the first re- sorted to, and the last that is abandoned—it has acquired so much popularity among the vulgar, as to render it unsafe for the repu- tation of the practitioner, who has omitted it in his treatment ot this complaint. But, though confessedly an agent of great power, it has never- theless its limits of usefulness; and beyond which, it should never be urged—for its efficacy is very much confined to its influence over the circulating system, by diminishing its vigour, and abating its velocity, though it may also act as a stimulant to the uterus when its shock is first perceived, and thus induce contraction; but its greatest value seems to be, in controlling arterial action. After these ends are answered, it is truly doubtful, whether it should be farther persevered in; at least, its utility is very much diminished. I employ it very liberally ; and sometimes, if the case be urgent, even at a very low temperature—in general, the best mode of applying it, is by a large bladder, as has already been directed— but, in very sudden and alarming cases, I have caused it to be teemed from a height upon the abdomen ; and this method of using cold, from its promptness, and the extent of its effects, has a'very decided preference. But if the pulse flag, and the woman be much exhausted, I not only forbid it, but have a warm blanket, or other warm articles, to supply its place. During the use of cold water, &c, to the abdomen, warm applications should be made to the feet and legs ; a bottle or jug of warm water well corked, is one of the best and most handy: this last direction should never be omitted, when the feet and legs are preternaturally cold. We, also, should be particularly careful not to wet the bed and clothes of the patient, if it can be possibly avoided, as it creates much inconvenience, by rendering her situation extremely unpleasant, besides obliging her to be disturbed, that dry things may be substituted. The injecting of cold water, cold alum-water, the solution of the acetate of lead, the introduction of ice into the vagina, and even into the uterus, &c, have been practised ; and, it is said, with advantage. The merits of such applications must rest upon the authority of those who recommend them ; for I confess I have no experience in either of them ; nor should I be tempted to rely upon them in very pressing cases.* It may be proper to observe, in addition to the remedies and modes of proceeding pointed out in this division of our subject, * See chap, on "Unavoidable Uterine Hemorrhage," in the author's System of Midwifery, for a variety of means lately proposed for the relief of hemorrhage. INFLAMMATION OF THE UTERUS. 329 that in certain cases of uterine hemorrhage, the forceps are the only means to be employed or relied upon. They are exclusively indicated, 1st, Where the discharge is threatening, and the labour well advanced; but where the membranes have been long rup- tured, and the uterus is firmly embracing the body of the child or the head does not advance with sufficient rapidity to afford security. 2d, Where the head is low in the pelvis, and has escaped from the orifice of the uterus—in this case, turning must not be thought of, however recent may have been the escape of the waters; or, however moveable the head may be in the pelvis. 3dly, Where the uterine efforts are either feeble, or suspended ; and where the os uteri is sufficiently distended, but where the waters have been long discharged. 4thly, Where the head oc^ cupies the inferior strait; the orifice of the uterus sufficiently ex- panded ; the waters either recently or a long time expended; but where the natural agents of delivery would act too slowly for the safety of the patient.* 5thly, Where the natural powers are in- competent to the sufficiently speedy delivery of the patient; owing either to the ma/-position of the head, or to such a disparity be^ tween it and the pelvis, as shall prevent its timely expulsion. CHAPTER XVII. HYSTERITIS, OR INFLAMMATION OF THE UTERUS. There is more ambiguity, or at least, a greater want of pre- cision, in the accounts of the acute diseases which attack the puerperal woman, than in any others whatever. This does not arise from an absolute necessity; for they are neither obscure nor numerous. Those which attack the uterine system and its de- pendencies, have chiefly created the confusion; and this has mainly arisen from an overweening desire for great accuracy of distinction, without a corresponding power to give the signs by which each should be ascertained. Or in some instances, from a blameable generalization, making every febrile affection puer- peral fever. Thus, the disease now under consideration has almost always been confounded with puerperal fever; and the latter, as frequent- ly blended with the former: this has arisen almost entirely from * From late experience, we have reason to believe, that the secale cornutum may, occasionally, supersede the necessity of the forceps in this case : it should, at all events, be tried. 2S* 330 INFLAMMATION OF THE UTERUS. not allowing that puerperal fever is an inflammation of some one portion, or the whole of the peritoneum ; and in not thinking, or believing, that the proper substance of the uterus can be inflamed without necessarily involving this membrane ; though the latter may become so secondarily. On this account it will be proper to divide hysteritis into two species: the first we shall call the simple or pure ; the second, the mixed or accidental inflammation of the peritoneum, or superadded puerperal fever. The first we shall define to be, an inflammation of all or any portion of the proper substance of the uterus, except its peritoneal covering. The second where the latter is implicated with the former. It has been rendered highly probable, from the late ob- servations of Mr. Dance, and M. Tonnelle, that in hysteritis, it is the veins of the uterus that are inflamed, and constituting a ge- nuine phlebitis. Dr. Conquest says, " the substance of the uterus is sometimes infiltrated with pus, and becomes livid and spongy, or it may contain small abscesses; and the uterine veins, particu- larly those containing blood from the spermatic arteries, may be inflamed, and contain coagula or pus." Obs. on Puerp. Inflam. And M. Tonnelle says if proper care be not taken in dissection, it will be supposed abscesses of the proper tissue exist, when the vessels are only affected. Sect. I.—Species 1.—Causes. The causes which may produce inflammation of the uterus, are all, or any of the violences to which this organ may be ex- posed in the exercise of its functional powers, during the expul- sion of the child from those to which extrinsic aid may give rise, when its powers have been insufficient for the purposes of deli- very; from those which may arise from the artificial delivery of the placenta ; or those which may act independently of either but not readily cognizable. Under the first head we reckon, 1st, the long and reiterated efforts the uterus is occasionally forced to make, to overcome the resistance which opposes the expulsion of the child ; whether this arise from the rigidity of the neck of the uterus ; or of the external soft parts ; the construction of the pelvis; or the size or situation of the child. 2d. To violences committed in the use of instruments of any kind ; to injuries sustained in the act of turning ; or to ill-directed manoeuvres executed on the neck of the uterus in attempting its dilatation, or by too frequent handling. 3d. To lesions of the internal face of this organ, from a sud- den, rude and unnecessary interference in the separation of the INFLAMMATION of the uterus. 331 placenta ; or to the injuries it may sustain from a placenta that has been too adherent. 4th. To those which may arise from exposure to cold ; checked perspiration ; some secret influence of the air; improper regi- men, &c. 2. Symptoms. Whichever of the causes may have acted with sufficient force to produce inflammation of the uterus, we find that it generally betrays itself within the first five or six days after delivery. The woman complains of a pain at the very lower part of the abdomen, which gradually increases or can easily be augmented by pressure made immediately above the symphysis pubis. It is also increased by any motion which may disturb the repose of the uterus, as turning in bed : sitting up ; passing of water ; or going to stool. If the fingers be made to press upon the uterus externally, it will be pretty readily distinguished, by its size being greater than is usual at such a period after delivery; by its hardness, (which is very resisting,) and by its unusual tenderness. The pain which the woman feels is constant; or it may be oc- casionally lancinating ; but it is always greatest when the uterus contracts, and produces after-pains. From the after-pains, with which it is sometimes confounded, it may be distinguished by the latter being always alternate ; and when the contractions subside which produce them, the woman is altogether free from pain, until they are again renewed. There is no swelling of the abdomen in the commencement of this disease, unless it arise from the augmented size of the uterus itself; but which is never so great at the onset of the complaint, as to make it conspicuous. The abdomen does not participate, in the slightest degree, with the uterus, in simple hysteritis ;- hence, there is none of that tenderness, which is witnessed in pe- ritoneal inflammation, or puerperal fever. Sometimes there is a frequent desire to make water, attende with more or less pain: or there may be a retention of urine ; especially if mechanical aid has been required to effect the deli- very; and the passing of water is accompanied by a sense of heat or burning in the urethra and vulva. The urine is almost always high-coloured ; generally scanty, and will deposite a lateritious sediment. In judging of the urine, however, we must take care that the mingling of the uterine dis- charges with it be not mistaken for the tone of colour of the urine itself. 332 INFLAMMATION OF THE UTERUS. 3. Constitutional Symptoms. The symptoms which we have just enumerated, may be looked upon as strictly local, and such as would necessarily arise from an inflamed condition of the uterus ; but these symptoms exist but a short time independently of constitutional disturbance. Soon after pain, &c, as above described, is felt, we find the heat of the body very much increased, without, for the most part, the interposition of " chill." The head becomes painful, the face flushed, and very frequently there is delirium,* if the febrile irri- tation be not soon relieved. The tongue is white, much loaded, and Dr. Clarke says, dry; but this we have never witnessed at the beginning of the disease. It is true, there is less moisture than is usual in the mouth, and the little fluid there is, is more clammy than is common in fevers of an ordinary kind. This creates a great, and sometimes, almost an insatiable thirst. The pulse is full, strong, and hard; its frequency is not very great; rarely a hundred.-)- Dr. Clarke says, from one hundred to a hundred and twenty strokes in a minute. This we have never seen in the simple hysteritis ; nor does it become so, unless the disease is running on to a fatal termination. The stomach, we believe, is never much affected in the begin- ning of the disease ; certainly never, or but very rarely, provoked to vomiting. As the disease progresses, or rather as soon as the constitu- tional symptoms commence, the pain extends itself to the back, and down the thighs ; and sometimes, a pretty severe one is felt beneath the lower part of the ribs on the left side. As the lochia are interrupted to a greater or less extent in in- flammation of the uterus, it has been commonly supposed, that the disease is produced in consequence of that obstruction. But, as the lochia are nothing but evacuations of the blood, with which the uterus was filled, and with which it will continue to be filled, until the vessels of this organ and their open orifices contract so much, as to refuse to transmit more, the lochia must be looked upon as a discharge dependent upon the condition of these ves- sels, or rather on the degree of contraction of the uterus. Con- sequently, their being more or less abundant, must depend upon the state of the vessels which furnish them; and the state of these * It may be looked upon as almost a character of hysteritis, that delirium al- most always attends it; while, in the unmixed puerperal fever, of peritoneal in- flammation, it rarely occurs. t This is another peculiarity in hysteritis, as distinguished from peritonitis, and serves to show how much inflammation of particular structures influences the cir- culating system. There is no instance of pure hysteritis, so far as we have seen, in which the pulse is as quick, as it is in puerperal fever. inflammation of the uterus. 333 vessels must necessarily be influenced by other portions of the uterus, by the degree of inflammation. Now, the uterus when inflamed, swells; and'this swelling, in consequence of its effect upon the extremities of the exposed vessels, prevents the usual flow of the lochia ; and from which, two effects are produced : first, an accumulation of blood in the uterine vessels, which stretches them anew; and second, an aggravation of the inflam- mation from this distention, as well as augmentation of pain. We may assign another reason, indeed, for the lochia being less abundant at this time; which is, the tonic contraction of the uterus being suspended ; consequently, one of the causes by which the lochia are forced through the vessels of the uterus is with- drawn, and the quantity discharged will consequently be less. It must, therefore, follow, that the diminished lochia is but a con- sequence of this condition of the uterus, and not the cause of it. It would be as rational to say, because there is a sparing se- cretion of urine in nephritis, that this scarcity is the cause of the inflammation of the kidneys; or that a diminished quantity of bile is the cause of the inflammation of the liver in hepatitis. It is true, that the lochial discharge is highly important at this time to the uterus itself; since it unloads its vessels, and thus pre- vents the consequences that would most probably follow its over- exertions, as well as promotes the tonic contraction of this organ. But, as their existence altogether depends upon the degree of permeability of the vessels which open within the uterine cavity, their quantity and quality must necessarily be influenced by the condition of these vessels; therefore, the state of the vessels of the uterus may influence the lochia, but the lochia cannot affect the vessels of the uterus ; for they are not lochia until discharged from these vessels. The return of the lochia after they have been arrested, how- ever, is justly considered as a favourable sign ; and this circum- stance has been urged, as an additional argument in favour of their agency in producing this disease. But here the effect is evidently mistaken for the cause. The return of the lochia is only an evidence of the diminished resistance to the flow of blood at the extremities of the uterine vessels; and this lessened resist- ance is owing to the abatement of the swelling which had inter- rupted its flow ; and the reduction of the swelling is but a conse- quence of the retiring of the inflammation. Therefore, the lochia being diminished, or arrested, would tend to increase the inflammation that was the cause of this di- minution, or stoppage ; as there would now be an accumulation in the substance of the uterus, not only of all the blood sent there to supply the lochial discharge, but also that, which always at- tends upon inflamed vessels. And, on the other hand, when the cause which arrested or diminished the lochia, (namely, inflam- 334 inflammation of the uterus. mation,) was so far diminished as to leave the extremities of the uterine vessels free, which, by again transmitting their contents to the cavity of the uterus, would not only relieve the engorge- ment with which they were accidentally affected, but tend also to relieve the vessels of the inflamed portion of this organ; and in this way is the lochial discharge useful. In pure hysteritis, the mammae sympathize with the uterus much less than in peritoneal inflammation, or puerperal fever; for we must be permitted to use them synonymously. (See Chapter on Puerperal Fever.) On this account we never have an entire suppression of this secretion, as in puerperal fever, un- less the disease runs an unusually long course, or has peritoneal inflammation added, or combined with it. Indeed, in a number of cases we have seen the offices of the breasts remain undis- turbed during the whole continuance of the disease. This circumstance is worthy of notice; since it not only serves as a distinguishing mark between the two species of hysteritis, but also proves to us that the influence of the peritoneum, or some one portion of the genital system, has a stronger influence over the formation of milk, than the uterus proper itself. Is this the peritoneal coat of the uterus ? or is it only when the ovaria be- come involved, that this secretion is so decidedly interrupted, or suspended ? We believe it to be the latter. Does not this fact serve to account for certain discrepancies in the accounts we have of the inflammation of the womb, and of puerperal fever ? In one instance the disease is called hysteritis, though the secretion of milk was interrupted ; and in the other, denying the disease to be "genuine" puerperal fever, because this secretion was so little disturbed. In the first case it was a misnomer to call the disease hysteritis ; for so soon as peritoneal inflammation takes place, the disease is, strictly speaking, puerperal fever, though its cause may have been a preceding violent inflammation of the uterus, as we shall say more particularly, presently. In the second case, the disease has been refused the title of puerperal fever, because the mam- mary secretion was but partially disturbed, though a true peri- toneal inflammation existed. Thus, we find, that the epidemic fever described by Dr. Leake, as it appeared in the " Westminster lying-in hospital," was re- markable for the following peculiarities: first, the omentum be- ing the most common seat of the inflammation; 2d, the almost total exemption of the uterus, and its appendages, from disease : 3d, the little disturbance of the lactiferous secretion, as will appear from the following statements. In case V., " the uterus as well as the bladder, was perfectly sound, and without mark of inflammation, or rather morbid affec- tion ; (state of milk not mentioned.) In this case, " the omen- INFLAMMATION of the uterus. 335 turn was melted down." In case VIII., "the omentum was much inflamed ; but fhe greater part of it was destroyed by sup- puration." "She had milk in her breasts until a day or two before her death." " The fundus uteri seemed to partake of the general inflammation which had attacked the omentum." " The lochia was not defective, neither was there a want of milk till after the febrile attack." Case XL, " the omentum was suppu- rated, and converted into thick matter." " The substance of the uterus was sound." "The secretion of milk was moderate on the third day;" on the fifth, " her breasts subsided, and the milk suddenly disappeared." She died on the seventh day. Case XIII., " the omentum was destroyed." " The uterus had a na- tural appearance, and was perfectly sound." (The state of the milk not mentioned.) Case XVI., "the contents of the pelvis were sound.'* Milk not mentioned. In none of these cases is there any mention of the inflammation of the ovaria. The abdomen, we have said, does not swell in hysteritis; un- less it be merely in proportion to the increase of size of the uterus itself. This, however, we have seen pretty considerable, owing to confined coagula, but which has always subsided, so soon as these were expelled by the contractions of the uterus. Indeed, this circumstance alone produces much pain ; and, for a short time, even threatens most serious mischief: especially as this takes place while the uterus is labouring under inflammation, as we have had occasion more than once to see ; the sufferings then are very severe and even menacing* Under such circum- stances, we have known the uterus to acquire a size nearly equal to that at the seventh month of pregnancy. In this case the abdomen becomes very tender, and the system is always excited to fever; the pain is constant, and scarcely to be borne; for now the uterus is suddenly put upon the stretch, and this during its inflamed condition. But this state, as far as we have witnessed, does not continue long; for the uterus be- comes stimulated to contraction after being thus painfully dis- tended ; its mouth opens, and the coagula are either expelled by one or two efforts, or it may require a number for this purpose. After the removal of these offensive clots, the woman is greatly relieved, and she is rarely exposed to a second attack. In hysteritis, then, so long as the disease maintains the charac- ter of the first species, the abdomen may be considered as but little affected; nor does it suffer at any period of the disease, as it does in puerperal fever, either original, or induced; as, for in- stance, in the second species of hysteritis. On this account, the sufferings are not so severe, and the woman is enabled to change her position, without that intensity of suffering, which she expe- riences from the same effort in peritonitis. The bowels are variously affected; but in the beginning, as 336 INFLAMMATION OF THE UTERUS. in peritonitis, they are generally disposed to constipation; or this complaint may be ushered in by diarrhcea ; but this is rare, though no unusual attendant in the progress, or last stage of the disease, though it may become critical. The symptoms we have just detailed may be looked upon as constituting the first stage of this disease; or the stage of high inflammatory action, which may terminate either in resolution, or in suppuration. When this disease is about to yield, there is an alleviation of all the more distressing symptoms; there is a softening or reduc- tion of the uterine tumour, with an abatement of its tenderness ; the pulse loses its febrile and inflammatory character; it is less frequent; softer, and more yielding; the skin becomes relaxed, and disposed to become moist. Headach abates, and delirium, if it had been present, subsides; the tongue begins to clean, and the thirst diminishes; the lochia return, and their appearance changes to a more florid colour. The urine becomes more abun- dant, and less high coloured; the milk is more freely secreted, &c. But should the disease not have abated, either owing to its in- tensity, or the feebleness of the means employed, the inflamma- tion may terminate its suppuration in various parts of the proper substance of the uterus, and which are almost sure to be followed by death. Sometimes, however, there is reason to believe that the abscess opens within the cavity of the uterus, and escapes through the os uteri; in which case, the woman may recover. We have seen two or three instances, in which we believe this had occurred. A disposition to suppuration may be suspected, from the pulse becoming more irritated ; by its increasing both in frequency and quickness; by the skin being alternately partially dry and moist ; chills of more or less intensity, with dark flushings on the cheek, or cheeks: by the tongue becoming dry and red ; by the lochia escaping in a larger quantity, but very fetid ; in a word, the wo- man now sinks from irritative fever. Or, the inflammation may communicate itself to the peritoneal coat of the uterus, by pil- ing along the Fallopian tubes, or otherwise ; and thus adding puerperal fever to the inflammation of the uterus, making the second species. Species II. The mixed Inflammation of the Uterus, or accidental or Secondary Puerperal Fever. When the peritoneum, covering either the uterus, or its ap- pendages, becomes the seat of inflammation, the disease is called INFLAMMATION OF THE UTERUS. 337 by Dr. Clarke, a mixed case ; and is one of almost certain fata- lity. For we have an inflammation now besieging two very different tissues or structures, and its effects upon either may be sufficient to destroy life. This extension of inflammation may be always dreaded, when the first species remains unsubdued; especially after a vigorous treatment has been pursued; for it now betrays a disposition to run on to its second stage. This extension of inflammation to the peritoneum announces itself by the addition of several new symptoms, to the unpleasant ones belonging to the second stage of the first species; such as a great increase in the frequency of* the pulse; hiccough; tenderness, and swelling of the abdomen ; vomiting; an inability to lie, other than on the back; a total stop- page of the lochia ; a cessation of the mammary secretion; cold sweats ; muttering delirium ; a dry, husky, blackish tongue ; diar- rhoea, &c. When the disease, by its extension, becomes the second species of hysteritis, it may be considered as almost necessarily fatal: at least we recollect no instance of recovery. Nor is this surprising; since a highly dangerous complaint makes its appearance at a time the system is debilitated from the force of a previous disease, and the effect of remedies ; and is from these causes unable to support the farther use of means for its relief. The patient, there- fore almost necessarily dies. Dr. Clarke has furnished us with the appearance of the parts after death, in both species of inflammation of the uterus. He says, " Upon examining the bodies of women who have died under this disease, we have found little or no extravasated or secreted fluids in the cavity of the abdomen, when the disease has existed simply. The peritoneal surfaces have been also dis- covered free from disease in some cases; in others, however, the peritoneum, which covers the uterus, has been partially inflamed, and that covering the posterior part of the bladder. Inflamma- tion is often observed running along the Fallopian tubes, which when cut into, will be seen loaded with blood. The ovaria, too, are often affected in the same way. " The uterus will commonly be found very firm in its sub- stance, but larger than when naturally contracted. Upon cut- ting into the substance of the uterus, pus is often found, which, in all the cases I have met with, is situated in the large veins of that part.* Pus is also sometimes found in the cavity of the Fal- lopian tubes, and also in the substance of the ovaria, which are distended by inflammation and matter, so as to equal in bulk, in some cases, a pigeon's egg. * In these cases it is more than probable that the disease was a genuine phlebitis of the uterine veins. 29 338 INFLAMMATION OF THE UTERUS. " I have never had occasion to meet with any case in which mortification had taken place in any part of the substance of the uterus, except in one instance, where there was a gangrenous ap- pearance of the cervix; but it is to be remarked, that instruments had been employed in that case, by the gentlemen who attended the labour." Essays, p. 69. Treatment. The history of this disease, will suggest at once its general treatment. a. Of Bleeding. The high inflammatory character of this complaint, especially in this country, declares the necessity of the most ample deple- tion, and the most abstemious diet. Blood-letting must be employed to the full extent the system will well bear; or it will not, nor cannot be, successful. The extent of bleeding in this disease, must be regulated only by its effects; its quantity must ever be of minor consideration, so long as the symptoms continue to demand its repetition. Dr. Clarke says, "In the repetition of the operation, (bleeding,) we must be governed by the same circumstances, and the effect of the former evacuation upon the disease ; and it must be observed, that it will frequently be found necessary, not only a second, but a third time," p. 73. From the histories of the dissections of those who have died of hysteritis, it is evident that nothing but very ample blood- letting and other depletions, can prevent the fatal termination of this disease ; or, at least, prevent its ending in suppuration, from which the escape with life must necessarily be rare. And though this disease is declared by Dr. Clarke, to be, " of all the serious complaints which attack the woman in the puerperal state, the least fatal," he isnot to be understood to mean, that this is the case when this complaint is not badly treated. For immediately after, he says, " Every art which has a tendency in any manner to diminish the quantity of the circulating fluids, and weaken the action of the heart and arteries, should be employed, in order to subdue the inflammation at the very outset," p. 72. This exactly corresponds with our own experience in this dis- ease : we have, in every instance in which we have encountered it, abstracted blood, both from the system at large by bleeding, and also by large leechings upon the abdomen. With regard to blood-letting, our plan has generally been as follows : to bleed from the arm, until it produces sickness of stomach, at least; if INFLAMMATION OF THE UTERUS. 339 syncope take place, we have no objection. It will almost always be found, after this, that the fever and other signs of inflamma- tion will be much diminished ; but this, in many cases, will be of short duration ; for the system, if the bleeding has not been suffi- cient to "strangle" the disease, will react in the course of a few- hours, and pain, fever, &c, will again be renewed. Whenever this takes place, be the period longer or shorter, it is to be re- peated again and again ; nor do we know any reason for stopping, but the reduction of the disease. But our bleedings are not always renewed from the arm; for, as soon as we get the pulse pretty well down by this means, we have leeches applied over the parts nearest to the fundus of the uterus, and also to the vulva, in such numbers as shall abstract at least eight or ten ounces of blood, and encourage their after- bleeding by the application of moist warmth. Should these abstractions of blood not prove effective, and pain, fever, and other unpleasant symptoms continue; but especially, great pain and tenderness in the parts; if the pulse does not call for general bleeding, we repeat the leeching, nor stop until the end is an- swered, or until we are convinced our efforts will be unavailing, by the approach of the second stage, or by the addition of peri- toneal inflammation. Perhaps there is scarcely a disease which demands such ex- tensive bleeding as the simple hysteritis; several reasons concur to render this necessary, nay, indispensable. First, from delivery having lately taken place, the uterus is much engorged with blood, at the period at which it is attacked by inflammation ; its vessels, therefore, are still distended, and its whole substance in a highly irritable state ; consequently, a new quantity of blood is invited to its parietes. Secondly, owing to the insulated position and independent economy of this organ, it becomes very readily filled with blood, but parts with it, unless under particular circumstances, as in hemorrhages from this part, with great difficulty, or at least very slowly, as is proved by its bulk several days after delivery; con- sequently, large quantities may be taken from the general system without greatly influencing the quantity contained in the substance of the uterus. Thirdly, owing to the lax and distensible condition of the ute- rine vessels, they are readily restretched by any influx of blood; and consequently, they again become charged by a fresh quantity of it, which now becomes another cause of irritation (by disten- tion,) to the newly provoked inflammation; and thus inviting a greater flux of blood to this part. Fourthly, that when the uterus becomes thus re-filled, the ves- sels cannot be relieved from this engorgement, as the only agent by which their capacities can be diminished, and of course, this 340 INFLAMMATION OF THE UTERUS. state relieved, is now suspended, (namely, the tonic contraction of this organ:) hence the enlargement of this viscus in this dis- ease ; and hence it is a favourable symptom, when it diminishes in size, as it shows a return, of the tonic contraction, and conse- quently j an abatement of inflammatipn. All these circumstances show the necessity of blood-letting: and at the same time prove, that it will require much to be ab- stracted, before this particular condition of the uterus can be re- lieved. It also shows us the importance and propriety of local bleeding, by either leeching or cupping; as the blood abstracted by these means, acts with more certainty, as well as more promptly upon this part. b. Of Purging. To co-operate with bleeding, purging has been advised; this, to say the least, is a doubtful remedy. Dr. Clarke says, " neither can I recommend a course of purging, as serviceable in the in- flammation of the uterus, which follows delivery. It is always, I believe, right, in the first instance, to procure two or three stools ; but afterwards, it will be enough to preserve the regular motions of the bowels, by giving, from time to time, small quanti- ties of castor oil, or a little rhubarb, mixed with other medicines, which may be proper. The objection which I have found to long-continued purging is, it has always the effect of preventing that gentle perspiration, which, if it can be produced and kept up, will do more towards curing the disease than any remedy which I know," p. 75. The bowels should be kept open by the gentlest means: of these the clyster is the best remedy. This should be done daily at least. f c. Of Fomentations. Dr. Clarke recommends fomentations to the abdomen: we never advised them, for we have never seen them of the slightest use in hysteritis, and we have known them do mischief. They do mis- chief by the intensity of their heat; by their weight, by exposing the woman to chills; and, by keeping her constantly wet. They are particularly inadmissible in the early stage of this disease, as they increase the circulation by their warmth. In such cases of hysteritis as may be accompanied by after- pains arising from coagula within the uterus, which is known, as we have said, by its alternate movements, we have seen an ap- plication of dry, or merely moist substances, very useful; by INFLAMMATION OF THE UTERUS. 341 promoting the contractions of the uterus so as to expel these foreign bodies. The one we have most commonly used is the "tansy pan-cake." This is made by mixing flour and water together to the consistence of a batter, and adding to it a quantity of tansy: and then to be fried like a pan-cake; but made much thicker; (say half an inch,) when done, it is to be placed be- tween two cloths, and is applied to the abdomen. Under these circumstances, for which we recommend this application, it will, we think, be found highly useful: at least it has proved repeat- edly so with us. It certainly combines all the good properties of the fomentation, without its disadvantages; but let it be clearly understood, its employment is confined to the cases above stated; namely, where the uterus distended with coagula, produces much pain, and the ordinary efforts of this organ are found insufficient to expel them. The French are fond of fomentations, but we think too much good is ascribed to them. d. Of Blisters. It is very doubtful whether blistering the abdomen in cases of hysteritis is of benefit: we are at a loss, from what we have seen, how to decide ; their efficacy, if they possess any, is un- questionably very limited. Dr. Clarke and others are decidedly against their use, and we are rather disposed to coincide with them; not that we are satisfied they are injurious, but because we are not convinced they are decidedly useful, and because they are very inconvenient especially to such patients as may have diarrhoea. It is many years since we last used them; and we cannot venture to recommend them, They are too pertur- bating. e. Of Sudoriflcs. Our opinion of this class of remedies, may be collected from what we have already said on the subject of "perspiration:" we shall only add, that, in the early stage of the complaint, their powers are altogether inadequate to the state of the disease ; and, when it is on the decline, they are generally unnecessary. We have thought them occasionally useful, where the force of the pulse had been abated by the treatment, and nothing but a little feverishness came on in the evening, accompanied by watchful- ness and a dry skin. We think we have seen the occasional use of Dover's powder, given at bed-time in ten-grain doses, useful, 29* 342 INFLAMMATION OF THE UTERUS. But our rule is, never to rely upon them, to the exclusion of eva- cuants. f. Of Opium. In the commencement of the disease, the pain which sometimes attends hysteritis, has led to the free use of opium ; but it is al- ways unfortunate for the patient; for it never subdues the pain, and it is sure to augment the existing evils by its stimulus, and by its constipating effects upon the bowels. It is, therefore, clear, it is not proper in the beginning of the disease ; nor is it much more eligible in its decline, as it may interrupt the discharges from the bowels, at a time they may be much needed. In combination, as in Dover's powder, it may be now and then useful; but we think no decided advantage is gained by its use, unless it be to relieve some sudden symptom, as severe and unexpected pain in the bowels, from flatulency, or other causes, when the fever is pretty well under command; to moderate unnecessarily severe purging, or hypercatharsis, or to give temporary comfort to an exhausted or irrecoverable patient. Indeed, if depletion has been ample, there is very little use in the opium.* g. Of Emetics. Emetics have been thought highly useful in almost every com- plaint of the puerperal woman. From their reputed efficacy in peritoneal inflammation, as recommended by Mr. Doulcet, they have been thought useful in inflammation of the uterus, and, ac- cordingly, have been recommended in such cases. Our expe- rience exactly coincides with that of Dr. Clarke on this point, that they "constantly add to the pain, by the agitation they oc- casion, and the pressure made by the muscles on the inflamed uterus," p. 77. From all, then, that has been said upon the various remedies proposed for the relief of this disease, it will appear that our de- pendence is chiefly upon bleeding and purging. The treatment for the second species, or the mixed inflammation of the uterus, will be learnt under the head of Puerperal Fever. * Dr. Clarke is much in favour of opium in this disease; this, perhaps, arises from his not carrying bleeding and purging as far as we are in the habit of doing; the consequence is, that pain is much more permanent, in cases which have not been freely held, and may require, for temporary purposes, the aid of laudanum. Its indiscriminate use, however, cannot be too severely condemned, in diseases of high action. PUERPERAL FEVER. 343 CHAPTER XVIII. OF PUERPERAL FEVER. This term, by some, is now looked upon as generic; and should, therefore, be employed with more severe restrictions than it for- merly was. Dr. Conquest says, that " in reality it designates only a prominent symptom of disease, but which in ordinary usage, embraces complaints having little or no resemblance or connexion, either in their essential nature, their seat, or their treatment. For I fearlessly appeal to every cautious, intelligent, and reflecting man, whether the term is not, in daily use, equally to designate spasmodic and inflammatory affections of the peri- toneal investments of the uterus, and abdominal viscera ; inflam- mation of the muscular fibres ; inflammation of the veins of the uterus; phrenitis; irritative fever; diarrhoea; and spasms of the intestinal canal, so frequently confounded with inflammation."*— Observations on Puerperal Fever. If this statement be true, and we have no doubt but it is from the respectability of the authority, the term puerperal fever is used in Great Britain much more vaguely than in this country. And though our notions respecting this disease are not logically accu- rate, they are, nevertheless, more definite than they appear to be in England, agreeably to Dr. Conquest. For we do not believe, that any well-instructed practitioner here would agree to call all the affections enumerated above, by the sweeping term, " Puer- peral Fever." We have observed already, in treating of the in- flamed womb, that much confusion existed ; as both hysteritis and peritonitis were expressed by the same term ; though very differ- ent tissues were implicated in the two diseases: yet, with this admission, we are by no means prepared to say at this moment, that much practical mischief has arisen from this wrong location of the inflammation, as both, caeteris paribus, require very much the same treatment, though we profess to be warm sticklers for correct pathology. We will, therefore, at once, declare, that by puerperal fever we understand, inflammation of some one portion * For these reasons M. Tonnelle prefers the term puerperal fever to more spe- cific names, as we shall have occasion to say presently. Strictly speaking, puer- peral fever means a fever that may attack a woman in child-bed—and, as the term has no pathological meaning, it is preferred by the writer, as it will embrace all the febrile affections to which the woman may be liable after delivery, however faried their seat or nature. 344 PUERPERAL FEVER. or other of the peritoneum, which attacks women almost imme- diately, or within a few days after their delivery; and is distin- guished from every other affection of the febrile kind, by being always attended by a more highly accelerated pulse ; by a pain- ful soreness of the abdomen ; and with more or less distention, (after a short time,) of this cavity. This disease is frequently, but not always ushered in by a chill. For however much authors may disagree about the essential nature of this disease, its remote and proximate causes, or its mode of treatment, they, neverthless, one and all consent, to consider the marks just stated, to be its pathognomonic symptoms. And, perhaps, in no disease of the febrile kind, can so many peculiari- ties be enumerated, as almost constantly present themselves in this ; such as the highly accelerated pulse ; the failure in the secre- tion of the milk ; if it has not taken place previously to the attack of the disease ; its almost immediate arrest, if it has begun to be formed ; the diminution, or suppression of the lochia ; the consti- pated condition of the bowels ; the peculiar character of the alvine discharges ; the exemption, for the most part, from delirium ;"the loss of maternal feeling, &c. The fatal character of this fever is almost proverbial; Dr. Den- man declares, " it occasions the death of much the greater part of those who die in child-bed ;" and many others bear a like testi- mony of its dangerous tendency. Dr. Clarke declares, that three out of four die. "Perhaps there is scarcely a disease with which we are acquainted, whose consequences are more fatal than this; as far as I have observed, three-fourths of those who have been seized, have fallen sacrifices to its severity." Essays, p. 132. The accuracy of this statement may, at the present time, be very well questioned, if accuracy in pathology be strictly adhered to—for it is but just to suppose, that in the time of Dr. Denman and Dr. Clarke, and as it has almost ever been since, agreeably to Dr. Conquest, many other complaints, nay, almost all of the febrile kind that befell the lying-in woman, were called puerperal fever. This indiscriminate use of the term, is found much fault with, as we have just shown, by Dr. Conquest, while M. Ton- nelle prefers the term to peritonitis, or metro-peritonitis, as being more comprehensive ; and as it expresses nothing of itself—that is, that it has no pathological reference ; for he has satisfactorily shown that neither peritonitis, or metro-peritonitis, will express the pathological condition of all that have fever, or die in child- bed ; or by puerperal fever, if we employ the term specifically. Thus, M. Tonnelle found, that in 222 cases of puerperal or child-bed fever, the peritoneum was found affected in 193; the uterus and its appendages in 197. In 165 cases, the changes in the peritoneum and uterus were differently combined ; those of PUERPERAL FEVER. 345 tlie peritoneum simply were 28, those of the uterus were 29. In 79 cases, the alterations of the uterus were produced by simple metritis ; superficial ramollissement, 29 ; profound ramollissement, 20 ; inflammation of the ovaries, 58 ; with ulcers, 14;—total 190. Alterations in the uterine veins and lymphatics—pus was found in 90 instances in the veins: in 32 it was found in the lymphatics; and in 3, it was observed in the thoracic duct; with inflammation and suppuration of the inguinal and lumbar glands, in 9 instances, making 134;—total changes effected in the uterus, 324. Suppuration of the veins of the uterus, 32 ; with ramollissement or putrescency, 11 ; with metritis and ramollissement, 5 ; with peri- tonitis without any other alteration, 34; entirely insulated, 8;— total 90. Suppuration of the lymphatics with the veins, 20; with those of the uterus, 13 ; with ramollissement of the uterus with suppura- tion, 6 ; with simple peritonitis, 3 ; without any other alteration, 2 ;—in all 44. Inflammation of the ovaries with simple peritonitis, 29; with alterations of the uterus, 27 ; with simple metritis, 8; without any other alterations, 2;—in all 62.* It appears from these tables that the alterations of the uterus exceed by a little, those of the peritoneum, if taken collectively; but if taken alone, they very much exceed them. And that in 134 cases there was pus in the veins and lymphatics. It is difficult to assign the cause of the results observed by M. Tonnelle; for they differ, (if other observers are correct,) from what would seem to be the experience of others upon this point. As regards our own experience in autopsic examination, we are willing to take it at its absolute value, for our opportunities have been nothing, when compared with those of M. Tonnelle ; yet the little we have seen leads to a belief, that there must have existed some predominating cause for the very frequent lesions of the uterus itself; as we very rarely have witnessed any altera- tions in that organ, in the few bodies we have examined. Besides, neither Leake, Hulme, Clarke, Hey, nor Armstrong, have made the same observations. Nor do we think, that the result of hos- pital experience is always the best authority for the character of any disease, as this is known to be modified by local causes, how- ever inscrutable these causes may be. We are therefore much inclined to the belief, that peritoneal inflammation is very much more common in this country, than metritis, properly so called ; for, if the abdominal, or that portion of the uterus, that'is covered by peritoneum, be inflamed, and no other tissue of this organ, it * It is proper to remark, lest this table should appear to contradict itself, that tire reason of the whole amount of the two classes of a flections, exceeds in num- ber all the cases dissected, is, that in many cases peritonitis was complicated with metritis. 346 PUERPERAL FEVER. is to all intents and purposes, peritonitis, and not metritis. But be this as it may, the observations of M. Tonnelle are no less interesting than curious; and he has proved, that of the very many deaths of women in child-bed, a large proportion of them was not owing to acute peritonitis, as metritis and phlebitis of the uterus come in for a large share; at least this was found to be the case in hospital practice. a. History of Puerperal Fever. In Europe,* it frequently becomes the epidemic ; and when this happens, its ravages are sometimes truly awful, as its malignity is thought to be increased by the peculiar constitution of the air, which renders it epidemical. In this, almost all the writers upon this subject agree. Dr. Leake says, " It will always be found most fatal, when most epidemical, that is, during the distempera- ture of the air ; and least of all so, when it happens in healthy seasons, from accidental causes."—Obser. on Child-bed Fevers, p. 101. Mr. Hey and others declare the same thing. In this country, this disease very rarely presents itself as an epidemic ; the only record of this kind that offers itself to my recollection at this moment, is that of Dr. Jackson. He says, it prevailed "both in Northumberland and Sunbury, in this state, (Pennsylvania,) in the fall of 1817, and in the spring of 1818. And though treated evidently with both vigour and ability, about one half died.—Electric Repertory, vol. viii. p. 202. So far as we know, this disease has never appeared as an epi- demic in this city ; though sporadic cases have been more fre- quent at one time than at another. It has always, however, been a disease of great danger, and is sure to excite great alarm when- ever it may occur. It does not appear to attack the poor, more frequently than the females in the higher ranks of life; for when it occurs, one class seems as liable to it as another; if we can call any thing happening so rarely as this disease does with us, a liability. Yet, notwithstanding the infrequency of this disease in this place, it does not seem to invalidate the observation of Dr. Den- man, that " it destroys the greater part of the women who die * In the year 1746, this disease raged in Paris to a terrible extent, especially in the Hotel Dieu. It attacked only the poor women ; yet il was neither so vio- lent nor so common when they were delivered at their own houses, as when placed in the hospital. In this place it was remarked, that of twenty women who were attacked, scarcely one escaped. The character of the disease, according to the writers of that day, resembled in every particular the puerperal fever of Great Britain, and of this country.—Quoted by Clarke, in Essavs, p. 104. PUERPERAL FEVER. 347 in child-bed :" for when deaths occur in the puerperal state, this disease has its full share of them. But deaths in child-bed are comparatively of rare occurrence in this country, when contrasted with their frequency in Europe. This is partly owing to our not having a class of people, that exactly corresponds with the class called "the poor" in Europe; and among whom this disease commits dreadful ravages, and especially at the time it becomes epidemic. In Great Britain, it occurs perhaps more frequently as an epi- demic than on the Continent; the cause of this we cannot pre- tend to explain ; but such appears to be the fact. Mr. Hey and others describe this disease as an epidemic of frequent occurrence; and one that visits one district after another, without any appa- rent cause. Thus, he tells us, that " for some years past the puerperal fever has prevailed epidemically in different parts of Yorkshire." Again, that "it appeared first at Barnsley, twenty miles south of Leeds, where it was prevalent and fatal. It began there early in the year 1808, nearly two years before it became general in Leeds," p. 15. Again, " About two years before the fever which I am about to describe, made its appearance, a puerperal fever was epidemic in this town, (Leeds,) which was similar in its nature to that now under consideration; but it was more partial in its extent, afflict- ing only one district of the town, and being confined chiefly to the poor," p. 15. He farther states that there was a perpetua- tion of this disease " from November, 1809, to about Christmas, 1812," p. 16. These facts incontestably prove the frequency and the extent of the disease, (in England, at least,) when compared with this country; and the account given by Mr. Hey is but one of many of the histories of this epidemic, which has occurred in Great Britain. See Dr. Gordon,* Dr. Joseph Clarke,f Dr. John Clarke, &c4 We are, however, not to be understood to mean, that fevers do not occur in child-bed in this country; we only declare, that this particular fever is one that we very rarely see. The milk fever, the ephemeral fever, called the " weed," are frequently met with; for here, as well as elsewhere, improprieties during * See Dr. Gordon's account of the puerperal fever, when it appeared as an epi- demic in Aberdeen, in Scotland. t See Dr. Joseph Clarke's account as it appeared in Dublin in 1760. Duncan's Medical Comment, for 1790. It again appeared in Dublin in 1767. t See Dr. John Clarke's account of the low fever of child-bed, in 1787, and 1788. Mr. White's account of it at Manchester in 1761. Treatise on manage- ment of lying-in women, p. 165. Dr. Leake's account for 1770, as it appeared in the Westminster Hospital. Prac. Obs. p. 241. Mr. White's account as it appeared in Edinburgh in 1773. Tenon's account as it appeared in Paris from 1774 to 1781. 348 PUERPERAL FEVER. the first few days of confinement will be committed, and the pa- tient be subjected, in consequence, to the fevers just mentioned.* Besides, we have every now and then, inflammation of the womb, which sometimes passes for puerperal fever. In the account we shall give of this disease, we shall confine ourselves to that inflammation of the peritoneum that succeeds delivery. For we are of opinion, that this will embrace " the low malignant fever of lying-in women," as detailed by Dr. Clarke, as well as the disease described by Hulme, Kirkland, Leake, Denman, Gordon, Armstrong, Hey, &c. It is true, that, several of these include in their accounts, what they term an in- flammation of the uterus; as Hey and Denman; yet the simple inflammation of the uterus is a very different disease from puer- peral fever: so much so, in our opinion, that they should never be confounded ; and, for this reason, we have given them a sepa- rate consideration. b. Of the Predisposing Causes. Much diversity of opinion exists as to the remote or predis- posing causes of puerperal fever; especially when it may appear as an epidemic. Cold, moisture, labour itself, &c, have been assigned ; but it seems that nothing satisfactory has yet been ascer- tained upon these points. For M. Tonnellef has pretty satisfac- torily ascertained, that neither cold nor moisture can be looked upon as causes. For when this disease raged in " la Mater- nite," the hospital to which he was attached, as the pupil of the late M. Desormeaux, neither of these powers could have ope- rated as regards cold, it was observed, that though the disease was very common in January, which was very cold and dry, yet in December it was very rare, though this month was similar as regards temperature and dryness: and the agency of moisture appeared to be equally uncertain; for, in the summer, which was both cold and wet, cases were numerous, yet they were rare at other times, when the weather was similar: while on the other hand, they were very common during the spring, when the draught was very unusual in length and duration. In a word, the disease prevailed in its greatest extent during cold dry weather; in temperate weather, as well as during moist tem- perate weather—while at other periods of the year, when similar weather prevailed, the disease was neither more frequent nor * We consider the milk fever certainly, and the " weed" most probably, of ar- tificial origin; for we believe we are correct in sayiDg, where the nursing has been properly conducted, they never appear ; or if they do, it is very rarely. f Des Fievres Puerperales Observees a la Maternite de Paris. PUERPERAL FEVER. 349 more severe. Neither could the frequency or severity of the dis- ease be traced to a vitiation of the atmosphere of the hospital. Indeed, the disease prevailed in the most whimsical manner,— now existing extensively and severely, and then disappearing, and as suddenly reappearing. M. T. is decidedly opposed to the doctrine of its being contagious. And, with respect to the influence or agency of labour itself, in producing this disease, it would appear from the testimony of all the writers on puerperal fever, and in this M. Tonnelle agrees, that a difficult delivery has no greater agency in the production of this fever, than the most easy or the most natural* All that appears to be necessary to its appearance, is the emptying of the uterus; and even this is not always essential to its production, as instances have been recorded, where this fever manifested itself before delivery.* Besides, the male is unquestionably liable to peritoneal inflammation as well as the female; and when it occurs in them, the same general phenomena present themselves. Thus, Dr. Armstrong, p. 2, assures us, " it does not seem to depend upon the difficulty of labour, for in most of the women in whom it oc- curred, parturition was remarkably easy, and the placenta was cast off after a proper interval, and without more than usual pain. Nor was the lochial discharge, before the* attack, in any way ap- parently affected." Mr. Hey says, p. 21, " It is somewhat remarkable, that I have scarcely known an instance in my own practice, of this disease coming on after a preternatural labour. I do not mean to imply that such cases were more exempt from it than others, but so it happened ; and the fact shows that it was independent of any thing untoward in the labour. It has, on the contrary, most frequently occurred, within the compass of my experience, after the most easy and natural labours." But Dr. Clarke seems inclined to a contrary opinion, though not exactly satisfied with his own sentiments. He observes, " For some reason or other, there seems to be a great aptitude in the peritoneum to be inflamed in women after delivery, so that causes applied to the body, which generally have a tendency to excite inflammation of internal parts, seem to be peculiarly di- * A case of this kind occurred lately. A lady was delivered at 6 o'clock P. M., of a six months' child; she became extremely ill by the next morning, all the sad signs of puerperal fever declaring themselves : she died at 3 o'clock, P. M., of the same day—that is, twenty-three hours after delivery. It was the opinion of Dr. James, who saw the patient in consultation with Dr. Moore, that the fever had commenced before he saw her—the pulse at his first visit, being extremely frequent. Her labour was sufficiently easy for a premature delivery; but the patient sank rapidly until the moment of death. When I saw her, (9 o'clock A. M., fifteen hours after the birth of the child,) she was nearly without pulse, though she re- tained her senses; the abdomen was much swollen, and extremely distended—she died six hours after. I am of opinion that this was an instance of inflammation of the peritoneum preceding delivery. 30 350 PUERPERAL FEVER. rected in their operation, to this part, during the time of child-bed. Hence this disease, (the inflammation of the peritoneum,) is very frequent, and has been also called puerperal fever." " It has been conceived, that this predisposition might depend upon some change in the state of these parts, or of the cavity of the abdomen succeeding to the act of labour, or the contraction of the uterus. Yet it seems not to be conformable to the wisdom of nature, to construct parts so that the circumstances to which they must necessarily be exposed in a state of health, should either prove a predisponent, or an immediate cause of disease. More- over, the alteration of the state of the cavity of the abdomen, is so frequent an occurrence, and this complaint is comparatively so uncommon, that it is hardly credible that so many should escape, and so few be liable to its influence. " In some cases, the pressure made by the child's head, in entering the pelvis, against the peritoneum, either covering the cervix uteri,* or the bladder, may predispose to, if it does not actually produce the disease; and I believe it is often an occa- sional cause. It may be said, that this also would more frequently produce the disease, than we find in fact that it does. But, on the other hand, it should be remembered, that it is only in cases where the head is comparatively large, that so great a degree of pressure can happen, as to occasion the disease. Where the head is small, in proportion to the upper aperture of the pelvis, or is of the usual size, any violent degree of pressure can hardly take place, which is the reason why the disease does not occur after every labour." Essays, p. 81. Now, the hypothesis of Dr. Clarke is contradicted by almost every other writer; for they declare, that the severity of the act of parturition has no agency in producing the disease ; and Dr. Denman informs us, that " Women are certainly not attacked so often with this fever after difficult labours." Again, were this a cause, it should be an ever-acting one; yet, in this country, the disease is scarcely known, though the females of it have their share of children, whose heads are of full size, and which exert as strong a pressure upon the upper aperture of the pelvis, and, consequently compress the peritoneum as certainly and as power- fully, as in England, or other portions of Europe. We might readily multiply authorities to prove this curious fact; and from its.importance it should challenge the attention of the physician to an investigation of the cause of it; for we are not altogether satisfied with the explanation that Dr. Denman gives of this singular exemption; namely, "Because of the par- ticular care with which they are then managed." Were this the * Dr. Clarke has committed a little mistake in his anatomy : the cervix uteri is not covered by the peritoneum; it is only the body and fundus, that derive a ceat from this membrane. PUERPERAL FEVER. 351 cause alone, it would be easy to arrest the progress, or at least to mitigate the violence of this malady, by bestowing the same at- tentions ; especially upon those who have easy labours, while the disease was ravaging as an epidemic. Indeed, it would seem, that the public had some right to expect a practical illustration of the suggestion from the author of it; and we truly regret, that he had not turned his attention to it. c. Of Prophylactics. It is true, there appears from the practice of some, a founda- tion for the opinion just named above ; so far at least, as certain medical treatment comprises that peculiar care bestowed upon women who have had laborious labours, alluded to by Dr. Den- man ; for Dr. Gordon informs us, that when the puerperal fever raged as an epidemic at Aberdeen, a bolus composed of calomel and jalap, given in the morning, the day after delivery, either prevented the disease entirely, or answered the good purpose of anticipating the cure before the attack.—Treatise on Puerperal Fever, p. 100. This must certainly have been a most consoling fact to the physician, and a most important discovery to the afflicted, or those liable to be afflicted ; since a sure prophylactic was at hand, or a remedy in waiting, which was capable of disarming this terrible malady of its dangers. The only matter of surprise is, that after this discovery we should have heard any more of the dangers, or even of the occurrence of puerperal fever; for if the value of the remedy had been really as great, as the eulogium passed upon it declared it to be, we ought not. Mr. Hey has furnished us with his experience of the use of this remedy: he says, " In every case of accouchment, it was my practice to give a purgative on the day succeeding the delivery; which, if it did not prevent the disease, afforded some advantage in its cure," p. 154. Now, as Mr. Hey has not given us the proportions of success of this plan, we can only conjecture, that neither'its prophylactic, nor its sanative powers, could have been very great; since he constantly was acquiring patients, some of which he lost.* Nor does it appear from the history of his cases, that those who got well were indebted to the anticipating purga- tive alone, as blood-letting and farther purging were constantly had recourse to. From all we can learn from the testimony of Dr. Gordon him- * Indeed, Mr. Hey informs us, immediately after, p. 155, that "some of the worst cases in his practice, occurred after an excessive operation of the purga- tive." 352 PUERPERAL FEVER. self, and from Mr. Hey, who followed his practice, it does not ap- pear that the plan under consideration deserves the sweeping en- conium bestowed upon it by its inventor; that it was highly pro- per and very useful, we have every disposition to believe ; but that it ever prevented the disease, we very much doubt.* Indeed it would be extremely difficult to ascertain when it did prevent the onset of this disease ; for the fact amounts but to this nega- tive ; that some of the women who took it, escaped the disease; but this is no proof that the calomel and jalap prevented it; for it is not fair to presume, that every newly delivered woman would have had puerperal fever. Besides, were this power of preventing the onset, or of abating the force granted to the calomel and jalap, it still leaves the fact unexplained, of women, who must have had laborious labours, being less liable to this disease ; since, agreeably to the practice of both Dr. Gordon and Mr. Hey, every newly delivered woman was treated alike, as regards the exhibition of the purgative : yet, those who had easy labours were more certainly liable to puer- peral fever than those who had difficult times. From all this, it would appear that the subject is still open for in- quiry ; and we would earnestly recommend it to those whose practice will furnish them with opportunities to inquire into the fact, and endeavour to discover the cause why a tedious and pro- tracted labour should be any way instrumental in diminishing the liability to puerperal fever. For -wc may well a^1 how it is, that long suffering, and very certainly, lesion of some kind, and to various extents, should diminish the predisposition of this dis- ease, or abate the force of the exciting causes! Will a slight inflammation of the proper substance of the ute- rus, and of the vagina, which follow almost necessarily as a con- sequence of a long-protracted or preternatural labour, interrupt the tendency to peritoneal inflammation? Is this rendered pro- bable by other facts relative to this disease which are certainly no less singular, namely, that " not one instance has been ob- served, of any woman, who had an abscess in the breast, being attacked with this fever; nor of any who, in consequence of their labour, had such an affection of the bladder as to occasion a sup- pression of urine ?"f Denman, Introd. Francis's Ed. p. 574. * Mr. Hunter long since taught us, that we may cure a disease, but that we cannot destroy a predisposition. Even the anticipating purging cannot always be proper, if carried to any considerable extent. We see this illustrated in the practice of Mr. Hey, just alluded to; for the powerful operation of a cathartic may be and doubtless is sometimes, the exciting cause of the disease. t We do not mean that these facts should be taken for more than they are worth; for we are aware that different explanations may be given of them ; for, of the first, it may be said, that the woman who lives free from the disease long enough to have milk secreted, and an abscess to form, most probably had no pre. disposition to the disease, and would have escaped the fever, without the abscess,; PUERPERAL FEVER. 353 But notwithstanding the powers of a mercurial purgative have been in our opinion rather overrated, it is every way certain that it has been highly useful; we should, therefore, from both facts and analogy, recommend the adoption of the plan first suggested by Dr. Gordon, of purging briskly at the end of the first eighteen or twenty hours, or earlier, after delivery, whenever there was a tendency in puerperal fever to become epidemic, or where spo- radic cases were more than ordinarily frequent. d. Of the Seat of the Disease and its proximate Cause. Post mortem examinations have satisfactorily shown puerperal fever to consist in peritoneal inflammation. This inflammation does not confine itself to any one portion of this membrane. The mesentery, omentum, the liver, the mesocolon; in a word, every portion of the abdominal contents, may be the seat of this inflam- mation; nay, even the pleura and lungs have been found in- flamed; and we have shown by the tables of M. Tonnelle that the whole of the uterine system may be involved, even to the very vessels of these parts themselves, as the veins, lymphatics, &c. Before death, it is not uncommon for this inflammation to ter- minate in effusion ; hence the immense quantity which is some- times found within the abdomen ; and perhaps an evidence of some peculiarity of the lining of this cavity, since no other serous membrane pours out an equal quantity in the same time; nor does equal danger attend the inflammation of them. Mr. Cruikshank informs us that he has " taken away often forty or sixty pints of water, which had accumulated in the cavity of the abdomen, in the few days the peritoneal inflammation had lasted, during the usual species of child-bed fever." On the ab- sorbents, p. 116. Dr. Clarke says, " The first thing which, in the greater number of instances, (of dissection,) presents itself, is a collection of fluid in the general cavity of the abdomen, sometimes very large in quantity, inasmuch as I have often absorbed, by means of a sponge, several pints of it." Essays, p. 135. When effusion is extensive, the existence of a previous inflam- tion is less evident: this has led some to conclude, that this effu- sion was not the effect of active inflammation ; but rather the re* suit of a certain disposition of the vessels of the parts affected, essentially different from an inflammatory action. and, that the abscess was an only evidence of this want of disposition, and not of its being prophylactic. Of the other, it may be said that the freedom from this fever should be referred to the tedious and painful labour of which the suppression of urine was a consequence; and, therefore, that this symptom should not be con* sidered as having any agency in procuring the exemption, 354 PUERPERAL FEVER. It is easy to refine too much, and nowise difficult for a sturdy polemic, to deny the force of the most obvious facts. What but the resolution of inflammation yields such a quantity of fluid as is found after puerperal fever? what but inflammation giving out coagulable lymph will account for the interstices of the intestines being filled up ; their surfaces covered ; and their various convo- lutions connected in masses? what but an inflammation, and that of the most active kind, will give rise to such an acceleration of pulse; such immoderate heat; such intense pain ; such exquisite soreness, as almost constantly combine in the puerperal fever ? In a word, wre must repeat, what other condition of the blood vessels, than inflammation, induces them to give out so suddenly and so excessively, their fluids ? Besides, inflammation of the pe- ritoneum from other causes, is known to terminate in large effu- sions within the abdominal cavity ; the rupture of the uterus, if the woman should not die too soon, is always, we believe, accom- panied by a large effusion. Now, it is a fact, very well ascertained, indeed we had almost said, not disputed, that when the vessels of an inflamed surface proceed to effusion, there is an immediate reduction of that in- flammation ; nay, sometimes, a complete removal of it; so much so is this occasionally the case, that disappointment has followed the search for it, where there previously existed every evidence, but ocular demonstration. Had Dr. Clarke been sufficiently acquainted with this fact, or permitted it to have had its full weight, we would scarcely have consented to have agitated the following questions: I. " Does the fever in a puerperal woman, dispose the perito- neum to effuse the fluid, which, being of a coagulable nature, forms a coat on different surfaces ? II. "Does an inflammation of a small part dispose the whole of the peritoneum to throw out the coagulating fluid? III. "Does the inflammation precede or follow the effusion? If the latter, is the inflammation excited by a stimulating quality of the matter itself? or lastly, are the fever, the inflammation, and the effusion of fluid, entirely independent of each other, as to cause and effect, and are they only parts of one whole, which is a dis- ease sui generis? p. 157. If the first question mean, as we presume it does, that the fever in question may so act upon the peritoneum as to force it to effusion without any intermediate condition, as inflamma- tion, we would answer it in the negative, and for the following reasons:— 1st. Because we know of no instance of an effused fluid re- sembling the one found in the cavity of the abdomen, without the initervention of some altered condition of the parts concerned ; nor of any other fluid, to the same extent in the same space of PUERPERAL FEVER. 355 time. In cases of large collections of water in cavities, as in as- cites, &c, it is always very gradual; and seems to be rather owing to the defect of absorption, than to an increase of deposi- tion ; though in some instances there is strong reason to believe it to be the result of a previous inflammatory action. 2dly. Because, we know, when serous effusions take place in other portions of the body, that they are always preceded by in- flammation ; as in hydrothorax, hydrocele, hydrocephalus, &c.; and when they take place upon the surface of the body, as from blisters, burns, or scalds, we know that inflammation existed be- fore the effusion ; nor do we ever see it but as the result of highly excited vessels. 3dly. Because, in all instances of the resolution of inflamma- tion, by effusion, a serous fluid is thrown out; and when thrown out, the inflamed surface which yielded it, is always relieved from the excitement; either in part, or altogether. II. The second question we would answer also in the negative ; and for reasons that might be in part collected from the answers to the first; for, 1st, if the inflammation of a portion of the perito- neum could excite portions to effusion which are not inflamed, it would of course be admitting, that effusion can take place with- out inflammation, or that a sound part can perform the functions of a diseased one; a position we must entirely deny. 2dly. Were this admitted, it would be supposing that an inflamed surface, and one which is not inflamed, would yield the same fluid, which is contrary to all experience. III. To the third query and consequences, we would say, that inflammation always precedes effusion; and that the fever is but the result of the local inflammation. 1. Because a sense of soreness and tenderness, is always ex- perienced in some one portion of the abdominal cavity, before the fever is well formed ; and in the accounts we have of this fever, as it appeared in the Hotel Dieu, we are told that " after the escape of the waters, the uterus became dry, rigid, painful, and swelled, and that the lochia did not flow as usual." 2. Because the excitement of the arterial system, keeps pace with the inflammation of the peritoneum. 3. Because fevers from other causes have no tendency to pro- duce peritoneal inflammation; as milk fever, the weed, or even erysipelas ; consequently, that there must be a disposition in the peritoneum to take on inflammation after delivery.* * We may include, with much propriety, under the head of delivery, those in- stances of abortion, which have been followed by puerperal fever. Dr. Hull says, " It sometimes attacks women who have suffered an abortion, or who have been prematurely delivered, as well as those who have gone their full time of utero-ges- tation." Treatise on Phlegm. Dolens, p. 228. Mr. Hey also informs us, that he met with two cases of puerperal fever after abortion, p, 27. See note to page 349. 356 PUERPERAL FEVER. 4. Because, whatever excites inflammation in the peritoneum, by local irritation, as tapping, sometimes; rupture of the uterus; inflammation of the proper substance of the uterus, when it in- volves this membrane, &c, but not until then; extraneous sub- stances passing from the stomach and bowels into the cavity of the abdomen ; punctures or wounds in this cavity, give the same phenomena; proving beyond doubt that when this membrane is indisputably the seat of inflammation, the system at large sym- pathizes in the same manner as in puerperal fever. From these facts, and others developed by dissection, we have no hesitation to declare, that puerperal fever is an inflammation of the peritoneum. This inflammation always terminates in effusion or suppuration before death; and never, or but very rarely, in gangrene, so far as dissections have yet discovered.* Dr. Clarke says, p. 135, that " the inside of the uterus, or of the intestines, has not been found inflamed in any of those whom I have had an opportunity of ex- amining after death; much less have I found any signs of gan- grene or mortificatiCn." These are curious facts as regards this disease; and they are particularly valuable as coming from so veracious and candid a man as Dr. Clarke ; and completely esta- blishes Bichat's doctrine of the tissues; the disease which killed the patients he examined was " the low fever of child-bed," and had, agreeably to him, a strong tendency to " putridity," as his practice declares, and as on one occasion he avows, p. 115. For he expressly says, that " all the medicines which have been employed with a view to the diminution of an inflammation, have, in the course of my experience, failed in curing the dis- ease. It became, therefore, next an object, to try whether such as have a tendency to support the strength and diminish the irri- tability,' would be attended by better success. * Dr. Fordyce intimates, from the character of the symptoms, and the analogy of the circumstances, that we might suspect gangrene sometimes ; but there is no mention that this has ever taken place. He says, that " the suppuration is very different in its effects, from the suppuration which takes place in other inflamma- tions : for the pain goes off suddenly, and even the soreness sometimes, but the tumefaction continues; the pulse becomes more frequent; the strength is more depressed, and the patient is cut off in from six to twenty-four hours afterwards; so that from the symptoms it might be supposed, that gangrene had taken place in these cases." Hull, p. 234. And Dr. Leake says, in Case VIII. p. 197, "On opening the body, the inferior lateral portion of the omentum was found much inflamed; but the greater portion was destroyed by suppuration. Case IX. The greater part of the omentum was suppurated; the remaining portion much inflamed, &c. Case XIII. Great part of the omentum was destroyed, and converted into matter; what remained had be- come gangrenous:" this is the only mention made of gangrene by Dr. Leake, and the part being in this condition, must have been the result of previous inflamma- tion, but which had not relieved itself by effusion, and thns died. For he makes no mention of a fluid in the abdomen, but declares, that that portion of the omen- tum which is inserted round the great cnrvature of the stomach was considerably inflamed. PUERPERAL FEVER. 357 " As soon, then, as any very considerably increased frequency of the pulse is discovered, I believe that it is right to begin im- mediately with exhibiting the Peruvian bark very freely, and in as large quantities as the stomach will bear," &c. p. 162. Now, the mode of treatment here pointed out, declares the tendency to the typhoid, (or putrid) state, if you please, yet there was neither mortification nor gangrene discoverable in any portion of the cavity of the abdomen. ' Yet, the phlegmonous, the erythematous, and erysipelatous inflammations, when violent, will each termi- nate sometimes in gangrene or sphacelus. Dr. Clarke has endeavoured to prove, that the inflammation of the peritoneum of a puerperal woman, and " the low fever of child-bed," are essentially different diseases. But he has not been successful in this attempt, as may readily be proved, by comparing the symptoms he details as belonging to each, as well as the post mortem appearances, making allowances for seasons, locations, epidemic constitution of the air, and, consequently, the type which these will impose upon certain parts of the character of the disease.* In both of the diseases which he describes, (Essays, sect. III. p. 81, and Sect. VI. p. 102,) the peritonitic inflammation, and the puerperal fever, attack at the same period after delivery: they are both preceded, sometimes by rigour, and sometimes not. Both have a soreness, tenderness, and distention of the abdomen; in both, the pulse is accelerated in a remarkable degree, very soon after the tenderness of the abdomen is experienced. In both, the secretion of the milk is interrupted, if it has not been se- creted ; or if began to be formed, it is immediately suspended. In both, does the woman discover indifference to her offspring; in both, is the state of the stomach, the appearance of the tongue, the condition of the brain, the feel of the skin, &c, the same; or, * Dr. Clarke says, " It is very well known, that during the strong exertions of labour, every woman suffers a kind of temporary fever; or, in other words, the action nf the heart and arteries is very considerably accelerated. Now, if this should happen to a woman under the influence of the causes adverted to above, (namely, the epidemic constitution of the air, &c.,) and if, under these circum- stances, any occasional cause of fever should occur, such as exposure to cold, or infection, the disease thence arising will be most susceptible of that type, to which the system has the greatest aptitude," p. 152. And, to show his entire belief in the power of the air, he says, the epidemic disposition of the season must likewise always be taken into the account; otherwise, under these circumstances (of pre- disposition,) "the same disease would always arise, if the same occasional causes were applied, which is not the case," p. 151. He farther adds, p. 151, "Now the nature of the epidemic constitution, which had prevailed at the time when this disease was prevalent at Paris in 1746, and in London in 1787 and 1788, was a dispo>ition to diseases of debility ; with such a predisposition, if any diseased slate, especially fever, should appear in a parturient woman, it would almost certainly put on that character which the preceding history of this disease fully justifies." Now it is evident, that in such casts the nature of the disease is not changed, it is only the character of the type that is affected. 358 PUERPERAL FEVER. at least, they are without a marked difference in any respect. In both, does the pulse increase in rapidity, as the soreness and distention of the abdomen increase; and both have the same at- tending symptoms, and the same period for their fatal termina- tions. Both have the same kind of effusions. The differences observed in post mortem examinations are, in- deed, very trifling; in the inflammation of the peritoneum, "the appearances, upon examining the bodies of women who have died of the disease, have been those of inflammation of this mem- brane, covering the different viscera. Upon the whole, that of the neck of the uterus and bladder, will be found more generally inflamed than of other parts; nevertheless, there is no part on which inflammation is not sometimes found. The surface of the stomach, liver, spleen, omentum, great and small intestines, ute- rus, the internal peritoneal lining of the muscles of the abdomen, will, in their turns, or altogether, be found to partake of the dis- ease: and, as far as my experience leads me to judge, no part more than another."* " A very large quantity of fluid is generally collected in the cavity of the abdomen, resembling serum mixed with pus; bat it differs from both of them in this respect, that it is not homoge- neous in its texture, but intermixed with portions of a solid mat- ter, resembling pieces of the same solid matter as is found on the surfaces of the peritoneum, the nature of which will be more par- ticularly taken notice of hereafter," p. 88, Of the examinations he made of those who died of " the low fever of child-bed," he says, " The first thing which presents it- self, is a collection of fluid in tlie general cavity of the 'abdomen, sometimes very large in quantity; insomuch, that I have often absorbed with a sponge several quarts of it, It is of the same nature with that which I have described in a former section, (namely, the above,) as far as can be ascertained by its sensible qualities. There is something very remarkable in the smell of this fluid, which is peculiar to itself, and distinguishes it from any other fluid which I have ever met with in the human body, either in health or in disease.f Where it is in large quantity, all the sur- * Walter is said to have dissected more than five hundred (a) woman who had died in child-bed. He constantly found in those who died of puerperal fever, the peritoneum, throughout its extent, smeared with a pus like substance ; but never found the mucous or muscular structure implicated.-«-Med. Chirur. Journ. vol. iv. p. 420. t Is not this circumstance absolutely conclusive of the identity of the two dis- eases ? does not this peculiar smell of the extravasated fluids prove the sameness of the inflammation which yields them? and do not the various seats of ihe inflam- mation establish their kindred nature ? For Dr. Clarke informs us it was not confined, in either case, to any one particular part. (a) We liave, at a venture clianeed, the number to 500 from 5000, believing there must have been an error in the text from which we quoted. PDERPERAL FEVER. 359 faces of the viscera, and of the peritoneum generally, will be found covered with a crust formed of a solid part of this matter, re- sembling coagulating lymph. Its particles cohere but slightly, so that, by a little agitation, it will mix with the fluid matter. The parts lying under this coat or crust, are not always inflamed* If there be any interstices between the intestines, or the other viscera of the cavity of the abdomen, they are frequently filled with large masses of the same, making an accurate cast of such interstices. " The quantity of fluid extravasated, and of the solid part float- ing in it, or incrusted, is prodigious sometimes, when the disease has been of short duration, not exceeding two or three days. They seem also, as far as I am able to judge, to bear no proportion to the degree of inflammation, or the extent of inflamed surface; since we often find a large quantity of both, where the redness of any surface has been very inconsiderable, and by no means general. In most instances, there has been some slight degree of inflamma- tion in some part of the cavity of the abdomen; but it has not been confined invariably to any particular part." " Sometimes the peritoneal surface of the intestines, sometimes of the liver, and sometimes the investing membrane lining the muscles have been found partially inflamed ; but I have scarcely ever seen any extensive degree of inflammation in any case, and in some I could hardly say that there was any,"f p. 135. Now, the only difference we can discover from the histories of the dissection of the two diseases, is, that the neck of the uterus and bladder are generally more inflamed than other portions of the peritoneal surface: in every other respect, they are so faith- fully alike, as not to raise a suspicion of a difference. It is true, that Dr. Clarke, and, perhaps, others who may have embraced his opinions, might insist that there are other very remarkable differences; but we cannot view them in this light; since the ap- parent discrepancies can easily be accounted for, without the ne- cessity of supposing them unrelated to each other. We have marked by italics the points of resemblance. We will first notice, however, the coincidences of appearances; * Dr. Clarke's observation only amounts to this, that after effusion has taken place, redness is not always found : but this happens from a cause familiar to every practitioner; namely, that when inflamed vessels effuse serum, they become re- lieved, and the redness disappears. t " We have, indeed, been told, that in the dissections of some who are said to have died of this disease, (puerperal fever,) no appearances of inflammation have been discovered ; but I should suspect, that in such cases, some important appear- ances had been overlooked, or that error had been committed as to the nature of the disease, and probably in its treatment."—Denman, Introd. to Mid. Francis's Ed. p. 583. " Whatever be the cause of puerperal fever, the cause of death is the same in all its varieties; namely, abdominal inflammation."—Gordon, p. 117. 360 PUERPERAL FEVER. and then attempt to account for the seeming differences. 1st. In both cases, the extravasated fluid, agreeably to Dr. Clarke's own statement, are the same ; as he says, " it is of the same nature" in both instances. Now, let us ask, is it probable that dissimilar diseases of the peritoneal surface shall produce fluids alike in every respect, as far as can be determined by their sensible or chemical qualities? and especially as Dr. Clarke observes, that " there is something very remarkable in the smell of this fluid, which distinguishes it from every other fluid." Does not this fact satisfactorily prove, if that inflammation of the peritoneum called puerperal fever yields a fluid of particular qualities or pro- perties within the abdominal cavity; and if a fluid of precisely the same kind is found in the abdomens of those who die of" the low fever of child-bed," that the same action must have yielded both, and that they must be one and the same disease ? We think the force of this conclusion is irresistible. 2. In the inflammation of the peritoneum Dr. Clarke says, the surfaces of all the viscera in their turn, or altogether, may be in- flamed ; he says, that precisely the same thing happens, but not to the same extent, in " the low child-bed fever:" it is then the de- gree of inflammation, agreeable to this, and not the absence of it, in the latter instance, that constitutes the difference of the two cases, for we think we have rendered it more than probable from the nature of the fluids found in the abdominal cavity, that in both instances, they are the result of a similar inflammation. Having cursorily remarked upon the coincidences of the fevers, we shall attempt to account for their seeming discrepancies. I. Dr. Clarke tells us, that in the low fever of child-bed, a coat most probably of coagulating lymph, covers the whole, or a part of the abdominal contents; but the parts under this coat, or crust, are not always inflamed: whereas, in the fever from peritoneal in- flammation, this condition is obvious, especially about the neck of the uterus and bladdder; and no crust is noticed. This, at first sight, might lead some to suppose, that a very material difference existed between the two diseases; and espe- cially if they be not aware, that a number of causes may make a difference in the intensity of any given disease; but especially in one so liable to become epidemic, as puerperal fever. For the sporadic cases, of all such diseases as may become epidemic, are milder; and, consequently, more manageable, than when they be- come epidemic* If this be so, it can only happen from the spo- radic cases acquiring the intensity which the epidemic constitu- * This fact has ever been notorious in our yellow fevers. The histories of this disease, as it appeared in its several visitations in Philadelphia, show, that the an- ticipating cases, if they may be so termed, were comparatively mild, and that the malignancy increased in proportion to the continuance of the disease, or at least until the type was modified by cool weather or frost PUERPERAL FEVER. 361 tion of the air gives any particular epidemical disease. Thus, Dr. Leake says, that puerperal fever " will always be found most fatal when most epidemical; that is, during a distemperature of the air."—Treatise on Child-bed Fevers, p. 73. Mr. Hey says, " I am persuaded that this circumstance (the influence of the air) is deserving of the greatest attention; and that whoever attempts to cure an epidemic puerperal fever, by such means as are com- monly sufficient for the sporadic cases, will find himself greatly disappointed in the result," p. 13. It is to be remarked, that this difference between a sporadic and epidemic disease, is not confined to the puerperal fever; for it is incident to all the diseases, as we have said, which may be- come epidemical. This has frequently been experienced in the yellow fever, the dysentery, and the remittent and intermittent fevers of this country. It is therefore probable, nay, we believe, certain, that the spo- radic puerperal fever might furnish the description Dr. Clarke has given of the peritoneal inflammation, and the epidemical puerperal fever might afford the appearances recorded of " the low fever of child-bed," and yet be one and the same disease; that is, both caused by peritoneal inflammation. But without resorting to these suggestions, which may be by some looked upon as gratuitous, we will mention a fact familiar to every body who has paid attention to epidemics, which is, that the reigning disease may differ very essentially in type, at the dif- ferent periods of its visitations. Thus, no two yellow fevers, as epidemics, were precisely alike in this city. The fever of 1793, was very different from that of 1798; and that of 1797 different from both, as regarded the conditions of the system; and this, consequently, made if necessary to change our therapeutical views. Yet, in all post mortem examinations, they were found to resemble each other in so many important points, as not to leave a doubt of the identity of the diseases. Besides, an epidemical constitution of the air may exert an influence upon more than one disease at the same time ; and this fact gives the strongest evidence of a distemperature of the air. Thus, Dr. Gordon informs us,*that erysipelas, and the puerperal fever, " began in Aberdeen at the same time; and afterwards kept pace together; they Doth arrived at their acme together, and they both ceased.at the same time." Treatise on Puerperal Fever, p. 50. Dr. Clarke says, " Inflammatory diseases had been extremely infrequent; or, if they occurred at all, they were principally of the erysipelatous kind. Eruptive diseases, particularly those which are attended with great depression of strength, had at- tacked great numbers of patients. The ulcerous sore throat, with or without scarlatina, had been very general, both in Lon- 31 362 PUERPERAL FEVER. don, and also in the country at a distance from the capital. Most of the fevers had been of the low, nervous, and malignant kind, approaching to that type which has been by some called putrid," p. 115. " About the same period also, in some situations in the country, especially in low marshy places, the generality of patients under inoculation had recovered with great difficulty. Abscesses formed in the axilla?; large ulcers and sloughs took place, both there and at the place of insertion of the matter,"1 p. 116. Again, " The stimulus of her labour, (the woman whose case he is relating,) brought on a degree of fever, which degenerated in consequence of the nature of the then prevailing epidemic con- stitution, into a low type," p. 150. Yet, with all this evidence before him, Dr. Clarke insisted on the slight difference which he had observed between the sporadic puerperal fever, (for such were the cases of peritoneal inflamma- tion which he describes,) and " the low fever of child-bed," which was a puerperal fever, or an inflammation of the peritoneum, in an epidemic form, to be different diseases; and seriously admo- nishes the young practitioner not to mistake the one for the other. Every body familiar with the diversifying influence of an epi- demical constitution of the air, knows the variety of type it will force the same disease to assume, at the different periods of its visitations, or even in different situations. Some, who have no: been attentive to the influence of the cause just mentioned, and who neither recognise its existence, nor acknowledge its power, have been led into serious, and we had nearly said, absurd errors, on the subject of puerperal fever. Thus, Dr. Kirkland supposes that the genuine puerperal fever is never epidemic ; at least he says, " That the puerperal fever which has been observed in hospitals, is owing to some causes peculiar to hospitals;" and that when it occurs in such places, " it should be considered as an adventitious disease, happening to women in child-bed."— Treatise, p. 73. When we consider the circumstances under which females are placed, even in the best regulated hospitals, we are nowise surprised that the puerperal fever 'should be more common, and more fatal to them, than to patients in private life. That there may be, and most probably are, causes in hospitals, which pretty constantly operate in such a manner, as to gjve a peculiar type to a disease similar to that which an epidemic constitution of the air might effect, we have no hesitation to believe; since, in such situations, the disease is not only more Common, but is some- * Much more difference will be perceived between the small-pox under ordinary circumstances, and the form it assumed in the cases just stated by Dr. Clarke, than between " peritoneal inflammation," and " the low fever of child-bed," yet Dr. C. did not hesitate to call both " smallpox." PUERPERAL FEVER. 363 times exclusively confined to them. But in granting this,, it does not do away the possibility of its prevailing as an epidemic else- where. Indeed, the history of this disease as an epidemic, abundantly proves, that the situations remote from hospitals, or even from cities, have been visited by this fatal malady.* On this head Mr. Hey says, that " It must be allowed that the puerperal fever has occurred as an epidemic, most frequently in hospitals ; but if any proof were wanting that it may be epidemical, independently of any cause peculiar to hospitals, that proof is abundantly supplied by the instances of this fever which have occurred at Aberdeen and Leeds; where it was not confined to situation, rank, or cir- cumstances ; affecting alike the rich and the poor, the young and the old, the inhabitants of the town and of the country," p. 12. Besides we are quite at a loss to comprehend the meaning of Dr. Kirkland's appellation, " the genuine puerperal fever," if a distinction be intended by it; for a fever happening to a lying-in woman must be a genuine puerperal fever, if the peritoneum be inflamed ; or, if it be not inflamed, it must be some other variety of fever; therefore, a puerperal fever must be a genuine puer- peral fever, or it is no puerperal fever whatever. A spurious puerperal fever cannot exist: for, unless the peritoneum be in- volved in inflammation there is no propriety in the title ; and if it be, it cannot be other than genuine. But to return, Dr. Clarke says, that " the parts under the crust or coat," (of coagulable lymph,) " are not always inflamed;" this must be certainly understood to declare, that they generally are; and, if they generally are, the appearance of inflammation must produce a stronger resemblance to the peritoneal inflamma- tion, than he appears to have been willing to admit. Not that we consider this circumstance essential to the establishment of our position, that the peritoneal inflammation of child-bed wo- men, and " the low fever of child-bed," are one and the same disease. For, had Dr. Clarke told us he had never found " the parts under the crust or coat inflamed," it would not have permitted us to doubt for a moment the identity of the affections, for the reasons stated above. For this, and every other species of in- flammation, may throw out even large quantities of fluid under certain stages of its continuance ; but when it does, the inflam- mation which gave rise to the effusion, becomes relieved, either altogether, or in part, as this effusion may be more or less exten- sive, or as the inflammation may have been more or less exalted. * We have noticed above the prevalence of puerperal fever, as an epidemic in Northumberland in this state,) and its neighbourhood; situations very remote from either hospitals, or towns, of any considerable size. 364 PUERPERAL FEVER. These effects are familiar to every body ; for they present them- selves to us almost daily, in the consequences of burns, scalds, and blisters. II. We are led to suppose, that Dr. Clarke infers a difference in the two diseases under consideration, from the immense quan- tity of fluid found in the cavities of the abdomen of those who have died of the " low fever of child-bed," and which bears no proportion to the degree of inflammation, or the extent of in- flamed surface," and the extent of the inflammation and the smaller quantity of fluid found in the abdomen of those who died from peritoneal inflammation. Now, in our estimation this should show the most entire iden- tity of the two diseases, instead of proving a difference. For, in the one instance, there was a stronger disposition to effusion arising from the peculiarity of the inflammation, but which pe- culiarity was the result of an epidemic influence; and the reduc- tion of this inflammation kept pace with the profuseness of the effusion. In the other instance, the same circumstances obtained precisely; that is the abatement of inflammation was in the exact proportion to the effusion; hence, more inflammation and less effusion was discoverable in one case than in the other ; because, in the one case the extent of inflammation was less, or there was less disposition to effusion. . Physicians and surgeons have ever entertained their own no- tions as regards the type of every epidemic with which we are acquainted : and their mode of treatment must, consequently, be predicated upon such opinions. Thus, in the yellow fever of 1793, some physicians looked upon it as a " putrid fever, and, accordingly, treated it with bark, wine, and other stimuli; while others considered it slightly inflammatory in the commencement, but typhoid in its progress : these bled a few ounces on the first or second day; purged gently; and then used bark, wine, carbo- nate of ammonia, &c. Others looked upon it as a fever of high inflammatory character; to subdue which, extensive, and some- times repeated bleedings, profuse purging, and a strict antiphlo- gistic plan was pursued. Now, it cannot be supposed, that all these opinions were right; yet each attempted to support the pro- priety of his practice, by detailing such phenomena and effects, as were most likely to answer this end. Hence resort was had to dissections, and each found a justification of his practice as he supposed, in the post mortem appearances. But, after awhile, it was discovered, that the first plan was entirely without success; that the second had some, but it was very limited ; while the third was attended by a fair proportion of recoveries. Just so has it been with puerperal fever; for the rapidity of its march, and the strong tendency of the body after death to putre- faction, led to the belief that it could be no other than a putrid, or PUERPERAL FEVER. 365 typhoid fever; and the want of success in curing it, hy the reme- dies proper for such diseases, was not attributed to the improper nature of the means employed, but to the indomitable nature of the disease itself. Therefore, wrong pathological views led them, either to a feeble or inefficient practice, or to one decidedly wrong.* Dr. Clarke, intent upon advancing the interests of his profes- sion, and indefatigable in the duties which a large share of busi- ness constantly imposed upon him, attempted to remove the ob- scurities which seemed always to await this formidable disease, by making the various affections of the puerperal state conform to a certain classification. With this in view, he divides the de- rangements of the uterine system,! and the peritoneum, into the following classes:— 1st. Into the inflammation of the uterus and ovaria. 2d. The inflammation of the peritoneum. 3d. Cases of inflammation of the uterus, ovaria, and Fallo- pain tubes, or of the peritoneum, connected with an inflammatory state of the system. 4th. The low fever of child-bed, &c.J The doctor was solicitous that these several affections should not be confounded ; to prevent wThich, he admonishes the inexpe- rienced practitioner in the following words : " Before I close this part of my subject, I must beg leave to caution those of my readers, whose experience may have been short, to be very care- ful in distinguishing these diseases from cases of fever consequent to labour, occurring in debilitated constitutions, in large towns, * It is but just, however, to state, that the researches, of Tonnelle and Duplay, have led to the conclusion, that puerperal fever does not always consist of a purely inflammatory action—but on the contrary, that in " la Maternite," this condition was comparatively rare; hence, they have divided it into the inflammatory, ty- phoid, and the ataxic varieties. The typhoid was by far the most frequent, and the ataxic the most rare, while the puuly inflammatory, occurred but thirty-nine times in two hundred and twenty.two of the fatal cases examined by them. This, however, must only be received, as the reports of the type of the disease as it ap- peared in that hospital; and though no modifying circumstance could be discovered in that institution, yet it is every way certain there must have been one, and that this account will not serve as an infallible guide fur the treatment of this disease in this country. This peculiarity in the influence nf an hospital atmosphere, has been lately proved in the Pennsylvania Hospital of this city ; for the cases of puer- peral fever which presented themselves, were fatal in an unprecedented degree, yet this disease was confined to this place, as it did not occur in private practice, at least we did not meet with a single case. Yet even in the most frequent form of this disease, (the typhoid,) in the Paris Hospital, it wa,s acknowledged that the typhoid symptoms were preceded by an inflammatory stage, and this is all that we absolutely contend for. t By the uterine system, we would wish to be understood only such portion of it, as is within the abdominal cavity, or such parts as have a peritoneal covering. X Modern pathologists pay no attention to which part the inflammation makes its appearance—it is very essential to the production of puerperal fever that any portion of the serous or peritoneal coat be the seat. 31' 366 PUERPERAL FEVER. and in hospitals more particularly, where there is any disposition to epidemic complaints, which have a low tendency," p. 92. But, notwithstanding the apparent propriety of these divisions, and the earnestness of his cautions, he has not, in the smallest degree, facilitated " those whose experience may have been short," (and we may add, those whose experience has been long,) to dis- tinguish, with any profitable accuracy, the different conditions he has described. Nor is this to be wondered at; as he has, in the very threshold of his inquiry, created confusion by neglecting a most important part of his subject; namely, not informing us, in what, or from what, condition of the system this fever pro- ceeds. For it will be perceived, that notwithstanding his attempts at distinctions in this division of the seats of this disease, they are truly without differences ; as they are at last all resolvable, and this, strictly speaking, into peritoneal inflammation. In his first division, he declares the uterus and ovaria to be involved : now, it is obvious in this case, that the ovaria cannot well be inflamed to the exclusion (for we will omit the condition of the abdominal portion of the uterus) oftheir peritoneal covering, consequently this first division must mean "puerperal fever," if this fever con- sists of an inflammation of the peritoneum, as we have already insisted on. His second division, a fortiori, must be^considered as puerperal fever; since its distinctive mark consists in an " inflammation of the peritoneum." We have already noticed, p. 350, Dr. Clarke's attempt to institute a distinction between this condition of the abdomen, and the " low fever of child-bed ;" we shall, therefore, not repeat what we have said there. His third division is still more exceptionable ; because it insi- nuates, that an inflammation of that portion of the peritoneum which covers the uterus, ovaria, and Fallopian tubes, is different from an inflammation of other portions of this membrane; and he considers it necessary, that an inflammation of these parts should be distinguished from inflammation of other portions of the peritoneum, which' we hold to be impossible. And were it possi- ble, no kind of practical good could result from the discrimination. His fourth, appears to be in opposition to his own facts, or even reasonings. In this, he attempts to prove that " the low fever of child-bed " is not a peritoneal inflammation. We have already noticed this effort, p, 350. From what we have said, we think we may safely draw the following conclusions : first, that the distinctions attempted to be made, of an essential difference in the nature of the disease from the location of the inflammation within the abdomen, is without foundation. For it does not appear from all we learn from others, that the inflammation of puerperal fever is ever confined, v PUERPERAL FEVER. 367 strictly to any one portion of the peritoneum; and from Dr. Clarke's one acknowledgment, " The surface of the stomach, liver, spleen, omentum, great and small intestines, uterus, the in- ternal lining of the muscles of the abdomen, will in their turn, or altogether, be found to partake of the disease ; and, as far as my experience leads me to judge, no part more than another." See page 351. We must look upon the peritoneum as a unit; and that, when inflamed in any one part, the same general symptoms will arise; and that the whole of it is now liable, from this cause, to be in- volved in the same condition as that part: hence, if the inflam- mation commence at any given point, it may travel over the whole, or a great portion of its surface, or it may be confined to the original focus. A want of attention to this circumstance, has led all the wri- ters,* so far as we recollect, into the error of considering the in- flammation of the peritoneal covering of the uterus, as a distinct disease from puerperal fever, by calling it an inflammation of the uterus. In this, there is a great want of precision ; for the in- flammation of the uterus, properly so called, is a very distinct dis- ease from peritoneal inflammation. (See Chap, on Inflammation of the Uterus.) Dr. Denman very properly observes, " There is undoubtedly much difficulty in forming a just idea of a very complicated dis- ease; and in proportion to the difficulty, every attempt to make accurate distinctions, is deserving of commendation." To this we most willingly assent. But he adds immediately after, " but, however symptoms may vary from affections of particular parts, or in particular constitutions, there is but one essential nature of the disease ; and if we ha.ve a true notion of this, we have less reason to be solicitous about the cause, or the determination of the part originally or principally affected. For a similar treat- ment may be enjoined, with equal propriety, for an inflammation of the uterus, omentum, peritoneum, or intestines, or perhaps any of the contents of the" abdomen ; whether the disease re- main local, or a fever be produced by its influence being extend- ed to the constitution in general."—Introd. to Mid., Francis's ed. p. 565. Yet is Dr. Denman himself betrayed into a want of precision in the very next sentence ; for he says, that " the inflammation of the uterus is far less dangerous than an equal degree of inflamma- tion of any of the viscera of the abdomen, especially in the state * Dr. Armstrong might have been looked upon as an exception,- as he mentions " simple hysteritis;" did he not immediately after appear to lose sight of the dis- tinction, by following Dr. Denman and Dr. Raillie; especially the latter, who speaks of "inflammation of the uterus and its appendages," under the head of inflammation of the uterus.—Morbid Anatomy, p. 362. See also text below. 368 PUERPERAL FEVER. of child-bed; because the uterus readily admits of a return of the lochial discharge, which always affords relief, and sometimes cures the disease." Here we are at a loss to understand, whether by an inflamma- tion of the uterus, it is intended to include its coverings, or to strictly confine the inflammation to the substance of the uterus without its covering being involved. We are, however, inclined to believe he meant the whole mass of this organ, from what im- mediately follows : " because the uterus readily admits of a return of the lochial discharge, which always affords relief, and some- times cures the disease."—Ib. We shall merely remark upon this last passage, en passant, that Dr. Denman has evidently mis- taken an effect for a cause. For in inflammation of the uterus, the lochia do not return until this condition is relieved ; and if the inflammation be relieved by any cause, so as to permit the lochial discharges to return, it is evident that the reduction of the inflam- mation is the cause of the return of the lochia, and that the dis- ease is subsiding, but not a proof that the lochial discharge is the cause of the diminution of the inflammation; for this discharge would not take place, unless preceded by this reduction of inflam- mation, though it may ultimately contribute to this end by its continuance. Dr. Armstrong, however, quoted the above passages different- ly: he makes Dr. Denman to say, " when simple hysteritis takes place," &c. But this reading of Dr. Armstrong is entirely gra- tuitous ; for there is no mention made of the simple inflammation of the uterus, by Dr. Denman ; and this is the very fault we com- plain of. Nor does Dr. Baillie discriminate any better: for, in speaking of the inflammation of the uterus, he says, "the inflam- mation is sometimes confined to the uterus itself, (evidently meaning it as a whole,) or its appendages;" and that he means to distinguish this organ from its neighbouring parts, is indisputa- ble ; for he adds, " but the peritoneum in the neighbourhood is most commonly affected, and frequently over its whole extent." That is, (as we understand it,) when- the uterus is inflamed, the neighbouring peritoneum is also most commonly inflamed ; con- sequently, if this be so, it is, to all intents and purposes, puerperal fever, and not a simple inflammation of the uterus. It would, in our opinion, be always best, when post mortem examinations are related, in which the fundus of the uterus is found inflamed, to say, that the peritoneal covering of the uterus was found " inflamed;" instead of saying, "the uterus was in- flamed ;" for this may not have been the case, strictly speaking. —See Chapter on Inflammation of the Uterus. And, secondly, we may conclude, that Dr. Clarke has failed to establish any other difference between "peritoneal inflammation," and the cause of the " low fever of child-bed," than that which is PUERPERAL FEVER. 369 frequently observed to exist between "sporadic and epidemic puerperal fever." We have already said enough respecting epi- demic influence, to convince any one of the extent of its agency upon this, and many other diseases. Of the Period of Attack and Symptoms. In comparing the histories of the symptoms of this disease, as detailed by a number of authors, with what we ourselves have seen, we think, taking the whole of the description together, that drawn up by Dr. Denman appears to be the most faithful. It seems to be the result of very extensive observation, and com- bines, within a very moderate space, all that is essential to dis- criminate the disease in its commencement; and to recognize it easily in its advancement and terminations. For this reason, we will detail the symptoms and characters of the disease in his own words. We are the more disposed to do this, because our expe- rience, though sufficient to convince us of the fidelity of his ac- count of the disease, has not been so ample, as to enable us to make any important divisions. • " The time when women are chiefly subject to this fever, is uncertain. There are not wanting instances, in which it has been evidently forming before delivery, or during labour, or at any intermediate period for several weeks afterwards ; and the sooner from the time after delivery the patient is attacked, if in an equal degree, far greater is the attendant danger. But the most fre- quent time of its appearing is on the third or fourth day after delivery,* when the patient is seized with a shivering fit, from the violence and duration of which, we may generally estimate the danger of the succeeding disease.f In some cases, however, there has been no cold or shivering fit, or none which was ob- servable ; and in others, the shivering fit in the state of child-bed, has not been followed by those symptoms which were to be ap- prehended.:}: * Authors differ a little as to the period at which the disease may attack after delivery. Hey says about forty-eight hours ; .Armstrong from twenty.four to thirty hours; Clarke on the second, third, and even the eighth day ; Leake on the even- ing of the second day, rr the morning of the third, &c. f This disease is not always announced by rigour or chill. Hull, Hay, Arm- strong, Leake, &c, agree it is generally preceded by shiverings; but that they are by no means essential to its formation. Clarke says it rarely happened. Mr. Hey says, that "some of the worst cases were unattended by rigour; and in others, equally severe, there was no more than a slight chilliness," p. 28. And Dr. Mar- shall Hall says, that in puerperal diseases, "pure inflammation is less marked by rigour, heat, and other obvious symptoms, than the effects of intestinal irritation." t Dr. Denman ha¬ discriminated with his usual accuracy in this instance; a mere shivering, or raiher trembling after delivery, is no very common occurrence; but this agitation is not accompanied by the sensation of cold, though it goes under 370 PUERPERAL FEVER. "Before the shivering fit, the patients have been much debili- tated,* and have complained of wandering pains in the abdo- men, which very soon became fixed in the hypogastric region, where a swelling or fulness, with exquisite tenderness soon en- sued.f As the disease advances, the whole abdomen becomes affected and tumefied, sometimes nearly to its size before delivery, the woman herself being sensible of, and describing its progress. She also feels great pain in the back, hips, and sometimes in one or both legs, and other parts affected in uterine complaints. " She scarcely can lie in any other position than on her back, or on one side with her body incurvated ; and if the disease be confined to the uterus, the seat of the pain seems to be changed when she alters her position 4 " There is either a vomiting of a green or yellow bitter mat- ter, or a nausea or loathing of the stomach, with an offensive taste in the mouth.§ An instantaneous change both in the quan- tity and appearance of the lochia takes place ; and sometimes, though rarely, they are wholly suppressed. || The milk, if se- the name of a chill or shivering by those who are unacquainted with the phenomena of fever. It is, therefore, represented to the physician as such; but he does not find it to be. followed by reaction; hence it is said, the chill was hot followed by fever. * We presume Dr. Denman means, by their being much debilitated, a sudden loss of strength, which is by no means uncommon, previously lo the attack of se- vere and dangerous fevers : this is remarkably the case in those seized by yellow fever. It cannot mean, they " were much debilitated" by the fatigue of labour ; for he and many others declare, that the contingencies of labour do not appear to have any agency in the production of the disease. t We would wish to direct the attention of the reader to this circumstance : it is one in which all appear to agree ; and which seems to settle the point, agitated by Dr. Clarke and others, namely, whether the fever was the consequence of a local inflammation of the peritoneum; or whether the inflammation was the con- sequence of the fever ; for it is here declared, pain, &c, existed before the rigour. t Dr. Denman unquestionably means by the " uterus," the peritoneal covering of this organ arid its appendages. But this mode of expressing the condition of this part must unavoidably create confusion,as we have taken occasion to remark in another place, as this viscus is liable to become inflamed, independently of, its peritoneal coat, and which is a very different, and much less dangerous disease. Mr. Hey is also faulty in this respect, for he says, " but all the varieties, so far as I can judge from my experience and reading, may be reduced to two denomina- tions, the sporadic and the epidemic puerperal fevers; in which I include inflamma- tion of the uterus and peritoneum. Dr. Armstrong runs into the same error. § Dr. Clarke supposes that many of the local symptoms, arise from an inflamma- tion of that portion of the peritoneum which may invest the particular organ or part; " such as constant sickness and vomiting of bilious matter, when the stomach is attacked," p. 84. This we believe to be a sound explanation of the vomiting, when it occurs in puerperal fever, unless it be of such instances, in which this action proceeds from offensive matters in the stomach. But vomiting is by no means a constant symptom in the early stage of peritonitis; indeed, we would say that it is rare, if our limited experience will authorize such a declaration : and when it does occur, it is almost always, in the second ; it is then obstinate, and may be regarded as a most unfavourable symptom ; and this, for the reason as- signed by Dr. Clarke. II All the writers on the subject of puerperal fever, agree in the uniformity of PUERPERAL FEVER. 371 creted, recedes, or is diminished, and the taste, with the appear- ance, is much altered.* " The urine is voided often, with pain, and in small quantities, and is remarkably turbid. A tenesmus or frequent stools come on, and, from the general disturbance, it is often manifest, that all the contents of the pelvis are at once affected by the disease. " The tongue becomes dry, though sometimes it remains moist, and is covered with a thick brown fur; but, as the disease ad- vances, its appearance varies, and in some dangerous cases, it has been little changed.f The patient immediately entertains the strongest apprehensions of her danger, and usually labours under vast anxiety, her countenance bearing indubitable marks of great suffering both in body and mind. " The progress of this disease is sometimes extremely rapid, and especiallly in unfavourable seasons, and in hot climates. In- stances have occurred in which women have died within twenty- four hours of the first attack; and I have seen a few, who never grew warm after the rigour, which then resembled a convulsion. In some, death has followed quite unexpectedly, either from inat- tention, or from the scarcely perceptible but insidious progress of the disease, the indications not having been at all proportionate to the danger. these symptoms. All declare the change which takes place in the lochia, imme- diately after the disease is formed; if we except Leake, who says it was not affected either in quality or quantity; a presumption, he says, that the uterus was not affected; and all agree, that it constitutes one of ihe most decided symptoms in this complaint. By what agency is this change effected? Does it prove that the uterus, both in its substance and covering, is always implicated in this disease ? or does it show there is a prevailing sympathy between the infl imed peritoneum and the surface which yields the lochia? Is the first rendered probable, by the lochia being deranged when the substance of the uterus is known to be affected, in the same manner as when the peritoneum is inflamed ? Mr. Hey, however, says it is, sometimes, not affected, p. 23. Are we to pronounce in such cases that the uterus is uninjured? or, if not uninjured, what part has escaped. * The want of secretion of the milk, if the disease occur before the breasts are prepared for it; and its cessation, if it has been secreted immediately after the' formation of puerperal fever, is one of the most uniform, as well as one of the most remarkable symptoms, attending this disease; and it would seem to prove one of two things: first, that the inflamed peritoneum has a control over this secretion, a sympathy only manifest at this particular time; or secondly, that that condition of the uterus by which the mamma? are influenced to the secretion of milk, is changed, by the presence of inflammation, either in its covering, or substance, or both: but most probably from its peritoneal covering being affected, as in simple hysteritis, the breasts are never so much affected, and sometimes not at all. t Mr. Hey, in speaking of the Leeds puerperal fever, says. " the tongue was never incrusted with the brown, dry fur of typhus, except the disease was of long continuance, or had been improperly treated. It was generally moist and soft, and though it was not unfrequently covered with a thick white or brownish fur, yet it was often but little altered from its natural appearance, to the last, even in bad cases, p. 32. Dr. Armstrong says, " the tongue was much paler than usual, aud appeared as if it had been recently rubbed or dusted with a very fine whitish powder; in some instances the tongue was tolerably clean and moist about the edges," p. 2. 372 PUERPERAL FEVER. " In other cases, the shivering fit is succeeded by heat, thirst, and other symptoms, according to the course observed in other fevers ; but the pain which originated in the abdomen, joined with these, is to be esteemed the pathognomonic or chief sign of the dis- ease. It seems necessary to enumerate all the symptoms, which commonly, though not exclusively, attend this fever, and not in any individual patient; yet cases will occur in practice, in which there will be much variation, depending on the degree of disease, the parts affected, the constitution of the patient, and the period after delivery when the fever makes its appearance. " The pulse has almost invariably, in this disease, an unusual quickness from the beginning.* It has often that strength and vibration observed in the disorders of the most inflammatory kind, in robust constitutions; and yet is sometimes exceedingly- feeble and quick, beyond what might be expected from the con- curring circumstances. The latter is to be reckoned among the most dangerous signs, proving, perhaps, increased irritability, with great violence of disease, and that the powers of the system are unable to struggle with it, or scarcely to bear the operation of the medicines which might be necessary for its relief. " There is much variation in the subsequent stages, but there is scarcely a worse omen than a very weak and accelerated pulse, even though the other symptoms may seem to be abated. But the mere quickness of the pulse, if not attended with other perilous signs of inflammation or fever, is not to be considered * " The frequency of the pulse in peritoneal inflammation has been so invariable, agreeably to our observation, that we regard it as pathognomonic. We were, therefore, not a liule surprised to find this condition of the artery denied by Dr. Marshall Hall, in his Essays on some of the more important Diseases of Females, p. 177. He says "'Frequency of pulse is not a less uncertain indication of inflam- mation (peritoneal.) I am enabled to say, from careful observation, that the pulse is but little accelerated in many cases of puerperal inflammation within the abdo- men, whilst it is excessively, and even alarmingly, frequent in some cases in which inflammation does not exist." We cannot bui suspect that the doctor labours un- der a great error in this statement; at least, in the first part of it—we think he has probably confounded pure hysteritis with peritoneal inflammation. See page 361. The latter declaration we fully agree to ; but it adds no support to the former part of his observations. We are the more inclined to susi ect a want of accuracy irt Dr. Hall's observation, from the loose manner in which he has conveyed his notions of the seats of the inflammation constituting the disease in question. For he says, "Considering the important and sudden changes which take place in the condition of the uterus, in parturition, we cannot be surprised that its appendage", the adja- cent vi-cera, and the peritoneum at large, should, not unfrequently, participate in this morbid condition," p. 156. Now, f om this quotati n, it would appear evident, that the appendages of the uterus, and the abdominal viscera, may be inflamed in puerperal women, independently of the peritoneum, a circumstance that has not, we believe, been verified by late pathological research. The uterus itself may, beyond all doubt; but the abdominal viscera do not appear to follow this rule. Dr. H. seems to forget that Bichat has taught us that investing membranes may be inflamed without implicating the other tissues of the organs over which they spread; and, consequently, that an inflammation of the peritoneum covering the liver, is not an inflammation of this organ, &c. PUERPERAL FEVER. 373 as indicating danger ; experience having shown that very irritable patients have sometimes an unusually quick pulse, unaccompanied with any other alarming symptom. "The signs of inflammation joined with those of extreme irri- tability, continue for a few days, when those of putridity appear; sooner, perhaps in this, than in most other diseases, which are originally of the truly inflammatory kind.* The teeth very early collect a brown adhesive sordes, and all kinds of food and drink are nauseated, except such as are agreeable from their coldness or sharpness. " A singultus attends; every return of which affects the ab- domen in the most painful manner. Petechias or vibices are often found in the unwholesome situations, and in some constitutions of the air, at a very early period of the disease, and there are fre- quently miliary eruptions; but the latter seem to be rather a con- sequence of the method of treatment than of the disease, for they do not afford that relief which sometimes follows their appearance in true eruptive fevers. " The bowels are in general very much disturbed, and in some cases a looseness takes place immediately upon the accession; in others, in three or four days after, or not till the last stage of the disease ; but it very seldom fails to attend, nor can it be removed without the greatest difficulty, as well as danger, before the dis- ease is terminated. The stools, before the close, often come away involuntarily, being always preceded by an increase of pain ; and every evacuation gives a momentary relief. They are uncom- monly fetid, of a green or dark brown colour, and working like yest. It is also remarkable that, after the long continuation of the looseness, when the patient has taken little or no solid nou- * This circumstance is familiar to all who have witnessed the most inflammatory of all fevers, namely, the yellow fever. This disease runs its course sometimes with such rapidity that the stages from the highest inflammation, to that of gan- grene, can scarcely be observed ; bidding defiance, very often to remedies of every kind. Indeed, we may remark it to be the common course with all the diseases of very high excitement, when not under the control of medical applications, to terminate in the manner just noticed of puerperal fever. It was this rapid course, with puerperal fever especially, which gave rise to the conflicting accounts we have of iis nature ; (its termination in gangrene, or in " putridity," as it is called,) and which regulated, with too many, the mode of treatment in the commencement of the disease. The apprehensions suggested by its peculiar termination, made physicians spare, or rather dread the employment of the only remedies capable of preventing such an issue. Thus, both Dr. Gordon and Mr. Hey, (indeed, we might enumerate others,) after they used, with liberal hand, blood-letting and pur- ging, rarely lost a patient. Dr. Gordon did not lose a patient out of thirty that were treated by ample blood-letting and liberal purging; and Mr. Hey seems to have been successful in equal proportion. The great secret in treating such dis- eases as yellow fever and puerperal fever, (at least, under ordinary circumstances,) consists in preventing the death of the blood vessels from over-excitement, by bleeding, &.c. Mr. Hunter explains this by saying, "debility begins very early, because the inflammation itself is interfering immediately with the actions of life." 32 374 PUERPERAL FEVER. rishment, large and hard lumps of excrement will be somelirnes discharged which one might suspect to have been confined in the bowels a long time before delivery. With regard, however, to this symptom, it is very necessary to observe, that in tklicate constitutions, great disturbances of the bowels are frequently oc- casioned by mere irritation, which are soon removed by the well- timed exhibition and repetition of some cordial opiate. " There is a peculiarity in this fever, which I believe has not been hitherto observed or mentioned. It is an erysipelatous tumour, of a dusky-red colour, on the knuckles, wrists, elbows, knees, or ankles, about the size of a shilling, and sometimes larger. This is almost universally a mortal sign, and on the in- spection of those who have died with this appearance, the dis- ease has been found to have affected the uterus principally, or its appendages. "When this fever commences soon after delivery, and con- tinues its progress with violence for a few days, our hopes of a favourable event will often be disappointed, and the impending danger may usually be foretold by the uninterrupted progress of the symptoms, or by returns of the rigour. A looseness imme- diately succeeding the attack, though in one sense it may indi- cate the degree of disease, always contributes to its abatement, and sometimes proves critical; as does likewise a spontaneous vomiting,rsometimes even towards the last change, when all hopes of recovery were abandoned. " The profuse sweat, which follows the shivering fit, has very often been completely critical. In some there has been a trans- lation of the disease to the extremities, where the part has in- flamed, and a large abscess has been formed : a similar abscess, has also in some cases been formed on one side of the abdomen, which has been healed by the most simple treatment. " Fresh eruptions of the lochia are always a favourable symp- tom, and are to be reckoned among the most certain signs of amend- ment. A substance of the abdomen after copious stools, and with a moist skin, is a fortunate alteration for the patient; but that circumstance without evacuations, and a dry skin, threaten the utmost danger." Introd. Mid. Francis's Ed. p. 568, et seq. . Dr. Clarke, p. 121, and other writers, have noticed a symptom of a remarkable kind, to which we have also borne witness, and which, so far as we have observed, has always been a fatal one; namely, the indifference of the mother to the child, and some- times even refusing to suckle it. From whence does this indif- ference proceed ? or why should it be a symptom of so mucb danger ?* * It has lately fallen to my lot to see a case of completely developed puerperal fever, in which this symptom proved fallacious. This case will be related pre- sently. PUERPERAL FEVER. 375 Dr. Clarke, p. 123, accounts for this state of the mind in an ingenious and plausible manner, by observing, " It is probable that the secretion of the milk in the gland, and the desire of suck- ling, may be in some way connected with each other, and the existence of the desire may depend upon the presence of the se- cretion, in like manner as the power of secretion in the testicles produces the passion for propagation ; and the passion in its turn affects the disposition for secretion." But to what circumstance shall we attribute this total extinction of sympathy between parts so constantly in the habit of exercising it? Is it owing to any condition of the uterus itself? or does it arise from the peritoneal inflammation simply ? or does it require the ovaria to be involved? Is this last conjecture strengthened by the fact, that the breasts become flaccid and waste away, when these organs are severely diseased, wasted, or extirpated. Of the Diagnosis. The disease we have been describing, has so many well-marked characters, that it cannot well be confounded with any other af- fection ; and we believe, that we may safely rely upon the follow- ing symptoms for its diagnosis:— 1st. Pain or tenderness in the hypogastric region, occur- ring after deliyery, from the first few hours to several days.* 2d. Swelling or tension in that portion of the abdomen where the pain or tenderness is felt. 3d. By these symptoms almost always being followed by a chill or rigour, of longer or shorter duration, or greater or less force. * Mr. Hey says that the pain experienced by the woman, soon after delivery, " was a very deceitful symptom; and when it was not preceded by rigour, occa- sioned great embarrassment by the irregular manner of its attack; and the conse- quent difficulty of distinguishing it from after-pains," p. 30. We believe that the following marks will, with much certainty, distinguish the pain of peritoneal inflammation, from that of " after-pains." 1. After-pains are always alternate, and regularly have three periods—a period of increase, acme, and decline; they always observe regular intervals, be these longer or shorter. 2. The pain when occasioned by after-pains, is never so acute; and is confined to the lower part of the hypogastric region. 3. There is always more or less discharge of the lochia, during the continuance of the after-pain, and this without a change in its appearance. 4. Tne mammce are not interrupted in their offices, if the pain proceed purely from uterine contraction. 5. If thehnndbelaid upon the abdomen, during the pain, the uterus will be found very hard at one moment, and softer the next. 6. The pulse will never be so much accelerated, as when the peritoneum is the seat of the disease; but both of these pains may be tinited; and when that is the case, the pain arising from the contractions of the uterus, offers no indication, as il is then of minor importance. 376 PUERPERAL FEVER. 4th. By the rigour being followed by reaction, terminating, for the most part, in a profuse sweat, and without this sweat moderating the fever, or other symptoms.* 5th. By this fever being accompanied by an accelerated pulse; rarely less than one hundred and twenty, and oftentimes as many as one hundred and fifty or more strokes in the minute. 6th. By the absence of milk in the breasts; either because it has not been secreted, or because the secretion has been interrupted. 7th. By a diminution, alteration, or suspension of the lo- chial discharge.! If a woman, within a short period after delivery, be attacked with the above symptoms, we may, we think, with much safety, pronounce her to be labouring under peritoneal inflammation, or puerperal fever. In this enumeration of symptoms, we have con- fined ourselves to the mention of such only as may be considered as almost exclusively pathognomonic. There are many other symptoms, besides those enumerated, that attend this disease; and, perhaps, each individual case may be attended by some one peculiar circumstance, which does not obtain in others, but which may be dependent for its existence upon some peculiarity of constitution, or accidental cause. It is, therefore, impossible to anticipate every symptom which may arise in any given instance. The symptoms, as detailed by Dr. Den- man, we believe, comprise every thing essential in the history of this fever, from its formation to its termination. And we trust, from what has just been laid down, that this disease cannot well be mistaken for any other. * Dr. Denman, as noticed above, says, this sweat has, in many instances, proved critical. + We have elsewhere remarked, that Dr. Leake says, " the lochia, from first to last, were not obstructed," p 52. Dr. Leake's account is of an epidemic puerperal fever, which attacked the pa- tients of the " Westminster Lying-in Hospital," and the disease, as it appeared there, was of a very remarkable character in several important points; and dif- fered from every other of which wc have read any account. 1. There was very little pain in the abdomen. 2. Very much less frequency of pulse. 3. The uterus, almost invariably sound. 4. Little change in the powers or functions of the mammre. 5. No change in the lochial discharges. 6. The omentum being the chief seat of disease, or found "melted down." 7. An unusual degree of headach. From Dr. Leake's account, it is evident that the epidemical constitution of the air had imposed a very mild character on this disease—its inflammation appeared to he of the phlegmonous kind, from the quantity of suppurated fluid found upon dissection, and from the common expression of the " omentum being melted down," &c; and it is farther evident, we think, that, had he carried his bleedings, &c, farther, he would have cured»all his patients. PUERPERAL FEVER. 377 Of the Prognosis. There is, perhaps, no disease, upon the issue of which the phy- sician of experience, feels greater reluctance to pronounce than puerperal fever. This unwillingness proceeds from several causes, each of which suggests the propriety of caution in making a decision. First, From its very frequent tendency to a fatal result, even under the most prompt, proper, and vigorous treatment. Secondly, From the rapidity of its march, it gives but small opportunity oftentimes for the operation of remedies, even when they are applied early. Thirdly, From the impossibility, very often, of repairing the ravages a few hours' neglect has occasioned, however faithfully and properly the remedies may be afterwards employed; and, Fourthly, From the oftentimes treacherous nature of "the dis- ease, which will sometimes suddenly terminate in death, when circumstances apparently promise recovery. These reasons should teach the young practitioner to be ex- tremely guarded in his prognosis, lest disappointment follow im- properly raised hope ; or recovery take place when he had caused it to be abandoned. We may particularly caution him against that deceitful amendment recognised by most writers on this sub- ject, which takes place sometimes as early as the first twenty hours; or as late perhaps as the third day. Here the abatement of pain, the diminution of the soreness of the belly, the subsiding of the abdominal swelling,* the less frequency of the pulse, seem but the prelude to a condition, from which no human exertion, or power of remedy, seems capable of saving the patient. Yet the symptoms now mentioned are precisely those upon which we would build our hopes of amendment, if not followed by the prostration of every power of the system : consequently, it will require much caution not to be betrayed into error. However promptly the disease may have been met, even by the most suitable remedies, the disease will, nevertheless, some- times progress with alarming rapidity. The pain and swelling will so augment, as to leave the woman no choice of position ; she finds a trifling mitigation of her sufferings while on her back, with her legs drawn up, that the abdominal muscles may be re- laxed. The pulse increases in frequency, but diminishes in force. The respiration becomes difficult; the tongue dry, and brown, or not altered, while the face, and extremities, are bedewed with a cold, clammy sweat. The face becomes pale, or partially flushed; the countenance haggard, wild, and expressive of the greatest * "When the abdomen subsides, without being preceded by copious stools, and, with a dry skin, it threatens the utmost danger."—Denman. 32* 378 PUERPERAL FEVER. distress. Delirum, vomiting,* involuntary discharges of both the feces and urine, and death. But before the scene is finally closed, the woman seems to be relieved of a part of her sufferings, by a change taking place in some of the more urgent and painful symptoms. Distention is diminished, or even sometimes entirely removed—the swelling of the abdomen subsides; and pain ceases with more or less sudden- ness. The absence of milk in the breasts, and especially if this be attended with an entire indifference to the child, must be looked upon as almost certainly fatal. If joined to these, there be little expression of suffering, a very quick pulse, and considerable swelling; and if the attack has been very early after delivery, the case must be looked upon as almost hopeless. So uniformly is danger increased by the earliness of the attack, that it is no- ticed, we believe, by every writer upon the subject; therefore, this circumstance should always be kept in view, when an opi- nion is about to be formed of the degree of danger. The extent of the abdominal swelling, seems to be of more consequence than the degree of soreness or of pain; and when it is excessive, and becomes tympanitic, it is extremely dangerous, nay, almost always fatal. Dr. Clarke says, " It has not occurred in ray sphere of observation, to see any recover, in whom the swelling of the belly has been in any very great degree," f p. 133. Also, That "those who have the disease at later periods after deli- very, are not attacked with the same violence; the depression of strength is not so great, the tumefaction of the abdomen is less extensive, and the chance of'recovery is, consequently, better," p. 133. Dr. Armstrong observes, that " an excess of sensibility is al- ways to be dreaded ; for I have had opportunities of remarking, that those patients seldom recover, who are tremblingly alive to every surrounding impression. It is well known, that unmarried women do not recover so well as married ones; the mental irri- tation, necessarily attendant upon their situation, considerably in- creasing the febrile excitement, and rendering them extremely restless," p. 26. Dr. Clarke has remarked the same thing. * We have seen more than one instance of puerperal fever terminating in "black vomit," similar to that observed in "yellow fever;" we have also seen the same appearances after rupture of the uterus. Dr. Gordon informs us, that " when these were symptoms of mortification, what ihe patient vomited was black, and had a strong resemblance to coffee grounds," p. 10. Dr. Armstrong considers it as a highly dangerous symptom," when there are frequent vomitings of a coffee- coloured fluid," p. 31. Yet gangrene, or mortification, has not been observed in any of the dissections we have read of. t I shall relate a case presently, in which there was great distention of the ab- domen, but where the woman recovered. Yet this must be looked upon but as a rare exception to the rule. PUERPERAL FEVER. 379 " Costiveness is always an unfavourable circumstance." Dr. Armstrong says, " increasing in no inconsiderable degree, the difficulty of cure. While an open state of the bowels before deli- very tends to mitigate the severity of an early attack, and a diar- rhcea'coming on afterwards, carries off the disease," p. 30. Dr. Denman says, as already noticed, that a diarrhcea may be critical, and carry off the disease, p. 568. The signs which may be looked upon as favourable, are— 1st. A diminution of frequency of the pulse, with an increase of its volume. 2d. A reduction of the swelling of the abdomen, with an abatement of pain ; provided, the first is gradual, and the latter not sudden; and accompanied by condition first. . 3d. Changing posture without suffering inconvenience ; but jactitation must not be mistaken for it. 4th. A return of milk to the breasts, attended by solicitude for the child. 5th. A restoration of the lochial discharge, after it has been suppressed; especially if it change to a healthful ap- pearance. 6th. The tongue becoming moist; losing its white appear- ance, and cleaning at the edges ; or, if it has been brown and dry, becoming whitish and moist, accompanied by condition first. 7th. If the urine become more abundant, and deposites a lateritious sediment. 8th. If the skin become cooler, and moist throughout" its whole extent; especially if attended by conditions first, second, third, fourth and fifth ; or if a natural warmth return to the extremities, after having been preternatu- rally cold, accompanied by the signs just referred to. 9th. " A subsidence of the abdomen after copious stools, and with a moist skin, is a fortunate alteration for the patient." Denman. 10th. " If the pulse can be kept under one hundred and twenty in the minute, for the first twelve days, the pa- tient will generally do well ; but if the pulse keep very quick, after the abdominal symptoms have entirely dis- appeared, affections of the chest,* and of the glandular system, or deep-seated suppurations, may be dreaded."f Armstrong, p. 32. * " If any disease hath taken its immediate origin, as it were, out of the puer- peral fever, and been combined with it, it hath been the peripneumony. I have met with several instances of this kind." Hulme, p. 15. t " Some of those who survived, recovered slowly, and were affected with wandering pains, and paralytic numbness of the limbs, like that of chronic rheu. 380 PUERPERAL FEVER. Of the Contagious Nature of Puerperal Fever.* Had not the belief, that puerperal fever was a contagious dis- ease ; and had not this belief a great effect upon the minds of fe- males who are pregnant, or who are in the puerperal state, and consequently may very much influence their happiness, we should not have touched upon this subject; believing as we do, that the opinion is altogether without foundation, at least in this country. In Europe, and especially in Great Britain, this, and a number of other diseases are believed to be contagious ; while in this country it only amounts to a fear, and not to a conviction. The disease in question, scarlatina, erysipelas, &c. &c, are in these countries looked upon as possessing the power of propagating themselves by some specific quality of their own. We shall not attempt any formal refutation of the doctrine of contagion, by exhibiting the arguments on both sides of the ques- tion ; we shall merely select the opinions of such as had ample opportunities to decide the question ; and whose conclusions are adverse to the opinion, " that puerperal fever is contagious." Dr. Huline, whose experience was ample, and who has written an excellent work upon this disease, says, that "the puerperal fever is not an infectious disease, anymore than the iliac passion, a pleurisy, a nephritis, or an inflammation in any other part of the body." Treatise on Puerperal Fever, p. 164. Dr. Hull, whose opportunities were equal perhaps to any who may have written upon this subject, says, " As far as my obser- vation goes, peritonitis puerperalis is not infectious. I have never seen a case, wherein I had reason to suppose that the effluvia, arising from the patient, produced puerperal fever, or typhus, or any other disease in another person, either directly or indirectly. The disease in question frequently arises, where there is not the least foundation for a suspicion that infection has been applied," p. 248. Mr. Hey appears strongly inclined to the opinion that puerpe- ral fever is not contagious; but seems afraid to decide absolutely upon the question. In this country, under no circumstances that puerperal fever has appeared hitherto, does it afford the slightest ground for the belief, that it is contagious. In this city, so far as we know, it has always shown itself as a sporadic disease ; and in this form, matism. Some had critical abscesses in the muscular parts of the body, which were a long time coming to suppuration, and when broke, discharged a sanious ichor." Leake, vol. ii. p. 56. * "By contagion, is understood effluvia, arising directly or indirectly from the human body under particular diseases, and capable of excitingthe same disease in other persons to whom it may be applied." Hull, p. 247. PUERPERAL FEVER. 381 it has never been looked upon as contagious, except by Dr. Arm- strong. He says, *' The peritonitic fever, when completely formed, is, in kind, though not in degree, as contagious as the epidemic :" in this sentiment he stands alone ; not even supported by those who believe in the contagious power of the epidemic. In Northumberland, in this state, (see p. 346,) where it was epi- demic, there was no evidence that it was contagious. Dr. Leake says decidedly, the sporadic puerperal fever is not infectious ; and it is only so, when epidemic, under particular circumstances, vol. ii. p. 140. Now, it would be very extraordinary to declare, for it would obtain no belief, that sporadic small-pox, measles, or hooping- cough, were not contagious; for we must ask, what is the differ- ence between the sporadic form or quality of a disease, and the epidemic form or quality of a disease ; except that the latter has its type affected by some occult influence in the air, which gives rise, at the same time, to the epidemic prevalence of the disease ? g. Treatment. We have now to consider the most important part of our sub- ject, namely, the treatment. As regards this, much discrepancy must necessarily prevail, as scarcely any two authorities can have viewed the disease under the same aspect, as the disease is so variously modified. In confirmation of this, it is only neces- sary to refer to the late researches upon this point—we say the late researches, as we believe these to be very much the most to be relied upon. We do not wish, however, to be understood as conveying any oblique censure upon former observation ; we only mean, that pathological inquiries are now conducted with much more care, and with much more success than thirty or forty years ago. For improvements in this highly interesting and important study, we are particularly indebted to the French, and especially, since the writings of Bichat has made us acquainted with the in- dependent and important role that each separate tissue performs. We do not pretend, that the same phenomena did not present themselves to former autopsic inquirers—we only declare they were not so well understood and defined. This fact can be very easily proved, by a reference to some of the most careful exa- miners of bodies dead from puerperal fever. Let us take Drs. Leake, Gordon, and above all, the accurate and faithful Clarke, as illustrative of the position now advanced, and it will be per- ceived, that no distinction is made between the parenchyma of the uterus or ovaries, and their peritoneal coverings, as seals of disease; for were this membrane inflamed, had it suppurated, or were it gangrenous, the uterus or the ovaries were said to be in 382 PUERPERAL FEVER. either of these conditions ; being altogether ignorant that the peri- toneum covering these parts may be in a pathological condition, without implicating the other structures of these organs. Again, pus has been found in various portions of the uterus, when it was cut into: this pus was supposed to be the result of the in- flamed parenchyma of this body ; for they were not aware this fluid was produced by suppuration of the internal mucous coat of the veins. Again, the uterus was often declared to be in a state of gangrene from puerperal fever: but modern research has proved, that this organ maybe " softened," (ramollissement,) and this without any particular tendency to putrefaction. And once more, that phlebitis of the uterine veins gives a typhoid character to the accompanying fever, &c, for we could easily ex- tend examples. Now, it is rendered every way probable that some occult cause may operate to produce a particular tendency in some one tissue or other, to become the seat of the disease—thus, we find in some instances, the peritoneum to be the principal seat of disease ; and this, upon certain portions of it, (see our history, &c, of this dis- ease,) in other cases, the parenchyma of the uterus is especially attached ; or its veins, or its lymphatics, and perhaps even its nerves; and each variety giving a particular character to the phenomena of the disease—hence, as we have already observed, puerperal fever is considered by Conquest and some of the French writers, as a generic term. See page 343, &c. It must, therefore, be evident, if these observations be correct, that much practical acumen is necessary to the successful treatment of this disease, that the different forms may not be confounded—it is, also equally evident, that we have much to learn in diagnosis. However, let it be understood, that though puerperal females in this country must, necessarily, like those of Europe, be obnoxious to remote causes; yet, that here, such causes, be they what they may, tend more frequently to the production of a pure inflamma- tory condition of the peritoneum, than the same causes do in other portions of the globe. We say more frequently, for this does not appear to be the case uniformly—for, in the late in- stances in the Pennsylvania Hospital, we believe that all who were attacked died, notwithstanding the most prompt and active antiphlogistic means were pursued. In these cases it must be evident, that some local, but inscrutable cause, operated, as no such condition of liability was observed in private practice. From these statements, it will be understood that no one mode of treatment can be applicable to every epidemic visitation of puerperal fever, or even every sporadic case ; and, with a view to establish this point more firmly, we shall give the experience of Professor Desormeaux, and his pupil M. Tonnelle upon this point, though we are, at the same time, persuaded, that, in this PUERPERAL FEVER. 383 country, and in private practice, the disease is almost uniformly highly inflammatory. From the views entertained by Desormeaux of this disease, he was led to adopt several different modes of treatment, the result of which he has given, together with the successes, and this at several seasons of the year; for this gentleman found, that a mode of treatment which may have been successful at one pe- riod, might not prove so at another. Among the more active remedies he used, we may reckon general bleeding, leeching, ipecacuanha, emetics, salivation: the auxiliary means were', warm hip-bath, laxatives, enemata, bark, cataplasms, and emol- lient washes for the uterus. The contradictory means, as laid down by authors, for the cure of this disease, induced M. Desormeaux to give fair trial to such as came recommended by good authority; and, not to remain satisfied by either success or failure, he tried ihe same means at different seasons of the year. General blood-letting was often found highly useful as the initial remedy, as it was found impe- riously demanded by the violent action of the system, in cases that he judged to be purely inflarfimatory; but, for the most part, this benefit was limited to the early stage of these cases, as it tailed to subdue the local inflammation, and was often of ques- tionable utility, as this first stage so quickly ran its course. On this account, local bleeding was resorted to, to overcome the local affection of the uterus and its appendages—forty or fifty leeches were applied to the abdomen, and these followed by a ' hip-bath, or poultice, and this was sometimes repeated two or three times in thirty-six or eight and forty hours. When this plan proved successful, it was speedily followed by a copious perspiration. But the good effects of this method were confined to the early stage, and previous to suppuration. He estimates the rate of success in the following manner. Of 165 cases treated by general and local blood-letting, three-fourths recovered. Ipecacuanha, as an emetic, he states* was only used in the early slage: this was sometimes successful, and at other times not, depending upon seasons, as he supposes. However, of forty cases treated by it, four-fifths recovered. This remedy was not useful after the suppurative stage had taken place; nor was it found to answer in the typhoid type of this disease. For the suppurative stage, or the typhoid variety of this disease, MM. Desormeaux and Tonnelle think they have found an important remedy in mercurial salivation; for, though by far the greater number of such cases must prove fatal, still, if salivation in- creases the number that get well, it must be looked upon as a valuable therapeutic means ; and perhaps we should have the more confidence in this plan, since the inveterate prejudices of the French against the use of mercury, would not permit them 384 PUERPERAL FEVER. to employ it, without having derived advantage from it in their trials. We have directed attention to this remedy, (see page 410, on mercurial frictions.) Mercury was only used in the advanced stage of inflammatory puerperal fever, or in typhoid cases, or where neither blood-letting, or leeching, or ipecacuanha would be useful. It was used in form of ointment—two ounces were rubbed in every twenty-four hours—the abdomen and thighs were the parts selected. The auxiliary remedies men- tioned above, were thought to be useful, especially emollient injections, once in six hours. This mode of treating any one disease, is too exclusive to be absolutely relied on; as the suc- cessful cases may not have been such from the peculiar treat- ment, but from their want of intensity; and therefore might have yielded to either plan adopted by Desormeaux and Tonnelle, while the unsuccessful instances may have proved such from their overwhelming violence, or from delay, rather than from the particular treatment being inefficient. It is necessary to the establishment of any exclusive mode, that all the patients should be as nearly as possible in the same condition, when the plan is first put in execution. Therefore, any plan may be either only more or less useful, or otherwise quo ad hoc. Most of the errors on the subject of puerperal fever have arisen from a want of the necessary discrimination between The stages of this disease, and to an ignorance that the peculiarity of the subsequent ones are entirely dependent upon, or only the neces- sary and inevitable consequences of the first stage.* Few have so far shut their eyes against the facts revealed by dissections, as not to admit that its first stage is that of high inflammation. But, as this inflammation runs its course rapidly, and is succeeded either by a gangrenous tendency, and an effusion of large quan- tities of serum in the cavity of the abdomen;, and as the body, quickly after death, manifests a strong disposition to decompo- sition, it was thought by many, that the disease, from its com- mencement, had a strong septic tendency; and remedies were employed to guard against the consequences, rather than for the removal of the cause; namely, the first or inflammatory stage.f * Dr. Armstrong, Facts and Observation?, &c., p. 60, says, *' The fir>>t stape " of Puerperal Fever, "is marked by highly inflammatory, the f-ccond, by hiehly typhoid characters; and it has always appeared lo me, that the tendency to putridity in the latter, w^is proportiomte to the degree of inflammation in the former." Dr. Denman says, " When the fever has remained for a very few days, the putrid symptoms, which are usually according to the degree of the preceding in. Jlammation, advance very rapidly." We repeat these observations, because of their unquestionable truth, and practical value. t "I cannot help suspecting," says Dr. Armstrong, "that some distinguished authors, having formed their opinion from the appearance of the disease, and the ill effects of venesection, at this period, (the gangrenous,) have thus been per- suaded that debility is the principal thing to be counteracted from the beg nning, PUERPERAL FEVER. 385 To prove this, let the treatment and the result of the plans of Denman, Gordon, Hey, Armstrong, and even Leake, be con- trasted with the mistaken practice of Clarke, and some others. In the practice of the first of these gentlemen, recoveries were common ; in that of the latter, very few escaped. Dr. Clarke in- forms us, that three out of four died, p. 132. The patients un- der his care were treated, from the beginning, with large doses of bark, and such other remedies " as have a tendency to support the strength, and diminish the irritability." It may be said, that, in the epidemic described by Dr. Clarke, there was but little evidence of inflammation, and much of "pu- tridity ;" but this should not be too hastily assumed, as we have attempted to prove at p. 356. . Nor can an inference be drawn in favour of his pathological views, from the success of his practice. The public are much indebted to Dr. Denman for the candid re- nunciation of his errors upon this subject. In the early part of his practice, he entertained great doubts of the propriety of blood- letting in puerperal fever: he thought it weakened the patient, without lessening the disease ; and for a long time, he informs us, he did not take away blood in any quantity. The influence of this highly cultivated and respectable practi- tioner, was so great, as to give tone to public opinion ; his mode of practice,-and his views were extensively adopted by the British practitioners; and they became almost the standard for the treat- ment of puerperal fever. Fortunately for the fate of hundreds, a more extended experience, and more correct notions of the nature of the disease, led him to renounce, with much magnanimity, the errors of his early life. Therefore, so soon as he was convinced of the insufficiency, or total in'efficacy of his plan, he gave it up with a candour which all must admire, though few may imitate it. He says, in the last edition of his works, as edited by Dr. Francis, p. 576— "I am now convinced by manifold experience, that my reason- ing was fallacious, and my fears groundless; and that what I had considered as proofs of insufficiency or impropriety of bleeding, in the true inflammatory puerperal fever, ought in reality to have been attributed to the neglect of performing it in an effectua manner, at the very beginning of the disease. In short, if the first stage be permitted to pass unheeded, bleeding will then cer- tainly be injurious, the opportunity having been lost; and the ■ physician called in afterwards, however great his talents may be, will too often have the mortification of being the spectator of and during the whole course of the fever. Be this as it may, the stimulant treat- inent is at once the most delusive and dangerous which can be adopted; and it is much to be lamented, that it has the weight and authority of some eminent names." —Facts and Observations, p. 63. 33 386 PUERPERAL FEVER. , mischief which he cannot then remedy, and an event which he can only deplore." We are told, that it is of the utmost consequence to the cure of this disease, that we distinguish between the true inflammatory, and the putrid puerperal fever. This would be most true and important, did such a difference really exist as is here intimated ; but the distinction attempted, has been based, we believe, upon the violence of the complaint at different times, and under different circumstances, rather than upon any essential difference in the absolute nature and seat of the diseases. See note to p. 365. Thus the sporadic puerperal fever is more easily subdued, and will bear bleeding even at a later period, than the epidemic puer- peral fever; because the former is less rapid in its course owing to the accompanying inflammation being less exalted ; and not to the latter being of a putrid character; for when this state exists, we must repeat it, it is owing to the inflammation being so tran- scendent, that the parts must die, if not speedily relieved. And though the system, under such circumstances, cannot bear, perhaps, the abstraction of blood, yet it cannot support the action of stimuli. We are persuaded, there are few errors in practice greater than that founded on the belief, that when a dis- ease will not bear depletion with profit, that it then absolutely re- quires the opposite treatment; and we are sure it has been the death of thousands. The supposed tendency to typhus in fevers of every description, when the patient has become weak, and especially if the tongue has become brown or dry, has led unhappily to the use of tonic and stimulating remedies, by far too many practitioners; for were the results of such treatment faithfully recorded, we are convinced there would be but little evidence in its favour—indeed, so con- fident are we on this subject, that we never fail to consider the cures of such a state of fever by this method, but as escapes. Let us illustrate the position we have assumed, by taking part of cases IX. p. 89, and XXVII. p. 206, as related by Mr. Hey. On the tenth day of this patient's disease, it is said, " she had had no sleep in the night, and was very restless, with some degree of delirium. We found her incessantly talking, but could procure no answer from her to any question that was proposed. She re- fused all medicine. Pulse one hundred and twenty. " In the course of the day, the abdomen became tumid, from flatus confined in the bowels: the tumefaction was unattended by pain or soreness, and entirely subsided as soon as evacuations were procured by an injection. " Ten, P. M. she was in all respects worse. Her urine came away involuntarily; she had some rattling in her breathing, and appeared to be sinking. Pulse one hundred and thirty-two. PUERPERAL FEVER. 387 Thirty drops spt. tether, sulph. were ordered to be given now and then, as a grateful cordial. " 29th, (eleventh day of illness,) we were agreeably surprised to find our patient much better. During the night she had been able to retain her urine, and had made a large quantity with proper intervals. She was quite sensible, and more composed; and had regained the power of putting out her tongue, which be- fore she h-^d lost. Pulse one hundred and six, and the tongue continued clear. Ordered to take at regular intervals, a draught ofinfus. rosx. made with decoct, cinchonce, and to have occasionally Madeira wine. "These favourable symptoms did not long continue. In the evening the pulse got up to one hundred and twenty, and the heat had increased. " From this time the patient became gradually weaker, her pulse was accelerated more and more, and her urine was again discharged involuntarily. She lived two days in a state of great anxiety and increasing restlessness, and died on Sunday night, the 1st of July," that is, on the 15th day of the disease. On this case, so for as we have related, we shall offer a few remarks: on the eleventh day of this patient's illness, she was found to be surprisingly improved ; all the favourable circum- stances, which usually announced the decline, or almost absence of the disease, were present. She was able to retain her urine, and which she made abundantly and properly, after its having passed from her involuntarily; she was sensible, after having been incoherent and stupid ; her tongue became clean, and her pulse was reduced from a hundred and thirty-two to a hundred and six. She had regained the power of putting out her tongue " which before [she had lost." The day previously to this amendment she was extremely ill, as above stated; she was then ordered the spt. aether, sulph. in small but repeated quantities. Now, is it not evident that the amendment of this patient was owing to her being only very moderately stimulated by the sether ? a stimulus at the moment, in point of' power, exactly suited to the condition of the system ; and had the physicians been contented to " let doing well alone," it is probable she would have recovered. But, over-anxious for their patient, they must prescribe several stimuli at once ; namely, bark, wine, &c, and thus undo in a moment all they have so hap- pily achieved by their previous moderation ; for Mr. Hey informs us, that " these favourable symptoms did not continue long." In this case, the system was evidently over-stimulated, and the patient succumbed ; or, had a free use of opium been made, it would, we think, have been the congenial stimulant, for this article never acts more favourably than in peritoneal inflammation after ample depletion. Indeed in many other inflammations, we have seen 388 PUERPERAL FEVER. its salutary influence when the other diffusible stimuli would have proved, most probably injurious. It may be said, that these favourable appearances now and then take place, yet disappoint the hopes they have created—this may be the case in the early stage of the disease; but when these changes take place so late as the 11th day, we should be disposed to look upon them as announcing a return to health; and had this amendment been properly cherished, it might have terminated in it; especially as the pulse was so much reduced in frequency, as to be at a hundred and six in the minute. Case XXVII., united on the 8th and 9th days, as many bad symptoms as are generally recorded upon such occasions ; that is, "the pulse become more frequent, and the patient appeared more sunk. The abdomen remained much tumefied, but manifested but little sensibility upon pressure. She still complained chiefly of the pain in her head." On the 10th day, says Mr. Hey, "I accompanied the surgeon in the evening, to visit his patient. She appeared very low and her pulse was frequent and feeble. Her tongue was dry and brown, and her teeth were incrusted with sordes. Her head was yet affected with pain, but she made but little complaint of her body. It was, however, enlarged, and though not very tender, was sensible to pressure. The symptoms of active inflammation having given place to those of a typhoid character, the purga- tives, had been omitted, and the evacuation had consequently decreased. I recommended such a repetition of the purgative as might procure an evacuation about once in four hours, and a con- tinuation of the saline mixture in a state of effervescence. The strength of the patient was supported by a light, but nutritious, diet, such as broths, jellies, chocolate, and milk. This plan was regularly pursued for four days, and the patient was then convalescent. This case is full of valuable instruction in the treatment of this disease, and indeed of every other, where there is what is termed a " tendency to typhus." It must be observed, that on the tenth day of the disease, there was what Mr. Hey himself considered a " typhoid character: the tongue was dry and brown, and there was great weakness." Yet, notwithstanding these evidences, he did not, as in the former case, goad the system to dissolution, by bark, wine, and other stimuli; on the contrary, he gave the sys- tem an opportunity of righting itself, by the abstraction of offen- sive matters from the bowels; and though he says he had omitted the purgatives, he yet' " contrived to have a stool once in four hours." Now, will any dreader of typhus permit his patient to have six stools per diem, or give the neutral mixture by way of cor- dial? Certainly he will not—he will put bark, wine, ammonia, PUERPERAL FEVER. 389 &-c. &c, in immediate requisition ; and be rewarded for his anx- iety and exertions by the loss of his patient. There is not the smallest doubt upon my mind, that Mr. Hey would have lost the atient last mentioned, as certainly as he did the other, had he ad recourse to the same remedies.* It is truly a matter of surprise, that Dr. Leake did not profit more by his experience in the fever of the " Westminster lying-in Hospital;" and by the freer use of the lancet, have saved most, probably more patients, than his account of cases now exhibits. We have thought proper to make a scale of these cases, to show that trie disease he had to encounter was comparatively a mild one, and would most probably have yielded in almost every in- stance to a more liberal plan of depletion. Dr. Leake had cer- tainly a correct notion of the nature of the disease; as his dissec- tions displayed to him in every instance the ravages of previous inflammation. Why his hand was withheld from the lancet, it is impossible to say ; for had he examined the result of his own practice he must have perceived, that the only instances of reco- very, (at least of those he has recorded,) were those in which bleeding and purging, to a greater or less extent were employed; and not a single instance of recovery when it was not employed. We have the histories of eighteen cases, the terminations of which were as follow, viz:— Cases I. II. VII. VIII.+ IX. XII. XV. XVI., were bled and purged, and recovered. IV. Bled ,^viij. on or about the seventh day . . . died. V. Bled 3yj. on the third day ..... died. XI. Bled *vij. on the third day ..... died. VI. VIII. X. XIII. XIV. XVII. XVIII4 not bled ; . died. This little schedule speaks volumes as to the comparative modes of treatment. Out of the eleven patients which were bled, eight recovered ; and of the three who died, it may be truly said the bleeding could not be expected to have been successful— for it was employed both sparingly and late. Case IV, was seen by Dr. Hunter in private practice ; and he thought, from the nature of the symptoms, it would be giving a chance to extract blood on the seventh or eighth day. This circumstance shows * We are not informed, however by Mr. Hey, of the motives which induced him not to employ the common routine of stimuli for his patient; but this is of no consequence as regards the event, as it establishes the principle insisted on ; namely, that though a patient may not bear the loss of blood, or sustain other evacuations to the extent they had previously been employed, yet that she will bear them to a certain extent; and that she will sink under the action of stimuli, when urged beyond a very moderate degree. t It may be proper to notice, that case VIII. is not case VIII. in Dr. Leake's series: it is included under the history of case VII. t This case, like case VIII. mentioned above, is also recorded in the history of case VII. See Treatise on Child-Bed Fever, Vol. II. 33* 390 PUERPERAL FEVER. the comparative mildness of the disease as it then appeared ; and Dr. Leake informs us, p. 57, that " when the disease proved mortal, the patient generally died on the tenth or eleventh day of the attack; consequently it should be looked upon as one of a mild type. In the epidemic so well described and so successfully treated at Leeds by Mr. Hey, the success was still greater, though the disease was of much greater malignity. For we are informed by Mr. Hey, that " it was by no means uncommon for the fever at Leeds, to finish its course in forty-eight hours; and in many cases, it proved fatal in a much shorter time," p. 165! Yet, the success following the plan pursued by Mr. Hey, was consi- derably greater than that which attended Dr. Leake, in a much milder form of the disease ; and this success was owing to a bolder practice, and one better adapted to the nature of the com- plaint. Mr. Hey states, that "of fourteen patients treated without bleeding, only three recovered," p. 165. And farther, that after " I had determined to use bleeding in addition to purging, of thirty-three patients whom we, (he and his father,) attended, only three died; the last twenty-six having recovered in uninterrupted succession ;" to this, he adds in a note, copious bleeding was used in all these cases except one, which was rather slight, and was cured by purging alone, p. 168. At Sunderland, where the disease was, perhaps, rather less malignant than at Leeds, Dr. Armstrong says, " those patients who were copiously bled and purged, and vomited successively, were usually convalescent on the fourth or fifth day, and from that time regained their health and strength rapidly," p. 73. He says, " Of forty-three distinctly marked cases of puerperal fever, only five cases of the whole number terminated fatally.— The thirty-eight successful cases were all treated by copious depletions of one kind or another, and in twenty-nine of them, calomel was exhibited in doses of a scruple, or half-drachm, at the beginning, and occasionally repeated in the course of the dis- temper." p. 70. Dr. Gordon, whose method of treating puerperal fever consists in large bleeding early in the disease, and plentifully purging, with the interposition of opiates, informs us that in a fair trial of his method in fifty cases, only five died. And farther, that all the five died before he had discovered by the dissection of his fourth case, the true method of treating the disease ; and that of thirty patients treated in this way, not one died. It is evident, from all that can be collected from the history of puerperal fever, and all that is revealed by numerous dissections, that this disease consists of an inflammation of some one portion of the peritoneum, and is not necessarily confined to any one PUERPERAL FEVER. 391 yiscus.* But this inflammation may be more or less extensive; it may be more or less violent; and it may run its course with greater or less rapidity as its type may chance to be. But, be it in extent unlimited or confined; be its mildness or violence what it may ; be its course rapid or slow, it nevertheless consists of inflammation of very important and influential structures of the human body ; and requires for its extinction, extensive blood- lettings; sometimes less than at others, but always liberal purging, with a most strict antiphlogistic regimen. This being premised, we shall go on to say a few words on each of the most usual re- medial agents, as employed by the best authorities, and most ex- perienced practitioners in this complaint. 1. Bleeding, This remedy was first extensively employed by Dr. Gordon for the cure of the epidemic puerperal fever, which appeared at Aberdeen in the year 1789, and continued in that place, with more or less violence, until 1792. Soon after the appearance of this disease, he discovered that early and large bleeding, with very liberal purging, was almost sure to cure this complaint; but, that the first remedy could not be advantageously used after a certain period had elapsed ; consequently, its efficacy was con- fined to that stage of the disease which consists in an active in- flammation. If bleeding were performed after this active stage had passed, it was either ineffectual or injurious ; and on this ac- count it is proper, in a pathological, as well as in a therapeutical view, that we should ascertain the causes which render a diffe- rent plan of treatment necessary, as the disease progresses; for this purpose, we shall divide its progress into three stages, each of which requires a certain modification of treatment. a. Stage First. Dr. Armstrong makes but two stages of puerperal fever: but we are of opinion that a third is essential to the well-understand- ing of the disease. We are certain that an intermediate state, or stage, takes place in puerperal fever, between the cessation of the inflammatory stage and the period of effusion ; and may be termed the " gangrenous stage,"f since it is at a time in which * Spe pages 343-4. t We are by no means satisfied with the term employed to designate the state of the parts at this period of the disease: we use it, then, with a full conviction that it does not express the idea which we would wish to convey. It is a state of a part which approaches death, but it is not death; because parts sometimes recover from it. If properly managed, that is, if not over-stimulated, the powers of the system 392 PUERPERAL FEVER. the vessels have not absolutely lost their life, though they are on the very verge of it. It is at this period that blood-letting can do no good, and stimulants will destroy. We shall have occa- sion to describe the stage more fully hereafter. The third stage is that at which effusion takes place, and at which all remedies are, as a general rule, unavailing. Dr. Armstrong describes the first in the following manner: — The first stage is variable as to its duration,* sometimes ter- minating in a little more than twenty, and sometimes continuing as long as seventy hours, but always being shorter in the epi- demical, than in the peritonitic fever."f It will be seen, at once, from the histories already given of this disease, that the duration of this stage must vary, not only as the disease may be sporadic ; but also when it is epidemic, owing to the type which occult causes may impose upon it. In a practi- cal point of view, therefore, the limit of this stage must not be rigidly fixed by any certain number of hours. This stage, strictly speaking, consists in the duration of the active state of»inflamma- tion ; and this will vary, as just observed, from the contingencies of season, constitution, age, epidemical influence, &c. In the epidemic described by Dr. Leake, this stage continued, in a num- ber of instances, much longer than the greatest limit proposed by Dr. Armstrong; for, in a case in which Dr. Hunter was consult- ed, (case IV.) he advised bleeding on the eighth day.| It would be of great importance in the treatment of this dis- ease, were there certain, or infallible signs, which would charac- terize this stage. But, unfortunately, none such exist, with which may be such, as to recover the part from the condition in which over action had placed it. * It must he borne in mind that Dr. Armstrong is deducing his stages from a particular epidemic; and, consequently, that Ihe duration of them will only apply with strictness to that especial puerperal fever; or, rather, as the puerperal fever exhibited itself at that time and place. + By the " peritonitic fever," we presume Dr. A. means the sporadic puerperal fever ; as every body seems to agree that the latter is less violent in its symptoms, and less rapid in its course, than when this disease prevails as an epidemic. If this be not his meaning, we are certainly at a loss for it; since he has declared, in the initial paragraph of his preface, that " undtr the common term puerperal fever, are comprehended bith the ordinary peritoneal inflammation, and 'the low malignant fever of lying-in women,' as these are considered as modifications of the same disease." Preface, p. 1. t We may also refer with advantage, as regards the treatment of this disease, to Mr. Hey's twenty-seventh case. In this case, he bled with much advantage, for the first time, ou the fifth day ; repeated it on the evening of that day, and on the day following ; yet Dr. Armstrong says, " he never dared to recommend blood- letting, when the disease had continued longer than thirty hours," p. 7G. This declaration of Dr. Armstrong is an additional proof of how much importance it would be to have other marks, than the number of hours which miy elapse, to judge of the continuance, or cessation, of the first stage of puerperal fever; for it must be recollected, as before observed, that the fever at Leeds was rather more malignant than that of Aberdeen. PUERPERAL FEVER. 393 we are acquainted; at least, none with so much certainty as to remove all doubt. Under such circumstances, we are obliged to rely upon symptoms, though pretty strongly marked, yet must not be looked upon as unerring. The pulse, which, in most other inflammations, so faithfully directs us, here deserts us; at least, we cannot judge of it in puerperal fever, as in pleurisy, or common fevers; as this disease imposes a character upon it, which, with our present notions, would greatly mislead us. Mr. Hey says, " the state of the pulse affords little information, either as to the propriety of bleeding, or the quantity of blood proper to be taken away ; and if we are deterred either by the apparent weakness of the patient, by the feebleness and frequency of the pulse, or by any other symptom, from bleeding copiously, we shall generally fail to cure the disease," p. 161. This statement clearly shows, that neither Mr. Hey, nor those who have preceded him, were in possession of any sign by which they could, with absolute certainty, determine the existence or termination of the first stage of this disease. The pulse, the common, and, generally, the certain guide in other febrile affec- tions, we are warned not to rely upon, for it will deceive us; on what, then, are we to rely ? Mr. Hey says, " if the disease is clearly ascertained, no other consideration is of much import- ance," p. 161. This assertion is not made with Mr. Hey's usual caution and discrimination ; for puerperal fever is still puerperal fever throughout its stages; yet Mr. Hey is particular in other places, that the treatment of one stage should not be pursued in another. We are willing to admit, that " the state of the pulse affords little information," in our present state of knowledge of that function; but we cannot be persuaded, but that every active morbid condition of the system, has a modifying influence upon the heart and arteries; and which could be detected, were our powers of discrimination equal to the necessity and usefulness of such a knowledge. In the disease in question, a disease of such deadly tendency, and rapid termination, the importance of the structure which is its seat, the decided control it has over some of the powers or actions of the heart and arteries, would lead us almost necessarily to conclude, that the mode of action of these important viscera is peculiar, and every way highly characteristic in puerperal fever, did we but possess the tact to detect it. We would, therefore, earnestly caution the practitioner against being betrayed into an indifference about the state and character of the pulse, that the assertion of Mr. Hey would almost certainly lead to; and, on the contrary, would decide'dly recommend to him the study of the pulse, and other signs in puerperal fever, with a hope, that the secret characters of peritoneal inflammation. 394 PUERPERAL FEVER. in its various grades, may be detected; and thus confer upon society a never-ending benefit. For, that there are characters of pulse in puerperal fever, (we must repeat,) we are persuaded; and, that they are susceptible of development, we as confidently believe; but to detect them with a certainty that may be useful, will perhaps require much experience and patient application, together with a most nice and discriminating touch. This faculty, (the touch,) like all our other faculties, may be much improved by well-directed disci- pline; its powers should, therefore, be carefully cultivated by the physician who is desirous of extending the benefits of his pro- fession to his fellow creatures. For, it is but by repeated trials and careful observation, that the faculty of discrimination can exist in an accurate or an exalted degree; and when it does not exist in such a degree, it cannot serve the purposes so much de- sired. Farther, the touch, like the other faculties, exists in various degrees of perfection, as an original condition; consequently, it is not, in every instance, susceptible of the same cultivation: but in all it is capable of much improvement; or at least with very few exceptions. We would, therefore, earnestly recommend the attempt. As illustrative of this point, and some others connected with the pulse, we think we cannot do better than to employ the language of Mr. Hunter upon this subject. " The pulse is often as strong a sign of the state of the con- stitution as any other action that takes place in it, though it is not so always; but, as the pulse has but one circumstance attending it that we can really measure, all the others being referrible to the sensation or feeling of the person who is the judge of it, the true state of the pulse is not easily ascertained. The knowledge of the soft, the hard, and the thrill, are such as can only be acquired with accuracy by the habit of feeling pulses in these different states. and, by many, is not to be attained ; for simple sensation in the minds of any two men is seldom alike. "The late Dr. Hunter was a striking instance of this, for, though he was extremely accurate in most things, he could never feel that nice distinction in the pulse that many others did, and was ready to suspect more nicety of discrimination than can real- ly be found. Frequency of pulsation in a given time is measura- ble by instrument; smartness or" quickness in the stroke, with a pause, is measurable by the touch; but the nicer peculiarities in the pulse are only sensations in the mind. I think I have been certain of the pulse having a disagreeable jar in it, when others did not perceive it; when they were only sensible of its frequency and strength: and it is, perhaps, this jar, that is the specific dis- tinction between constitutional disease or irritation and health. Frequency of pulsation may often arise from stimulus, but the PUERPERAL FEVER. 395 stroke will then be soft; yet softness is not to be depended on as a mark of health: it is often a sign of dissolution ; but then there must be other attending symptoms." Treatise on the Blood, Am. ed. p. 265. From what has been said, it is evident that the touch is more or less perfect in its condition, as an original sense ; and that it is capable of much improvement in its powers of discrimination ; and from what follows, it will be found there is much to learn of the various conditions of the pulse, as depending upon the nature, seat, and force of disease ; and that the opinion, that the state of the heart and arteries, if duly distinguished, may lead to the knowledge of the condition, or state of morbid action, in any particular structure of the body, is not altogether chimerical. To prove this, we shall continue our quotation from that high au- thority, Mr. Hunter. "In the consideration of the peculiarities of the pulse,it is always necessary to observe, that there are two powers always acting to produce them, the heart and the arteries ; that one part of the pulse belongs to the heart alone, another to the arteries alone, and a third is a compound of both. But the action of the heart and arteries do not always correspond; the heart may be in a state of irritation, and act quickly in its systole, while the arteries may be acting slowly ; for the heart must be considered as local, while the vessels must be considered universal, or even constitutional. The stroke, which is the pulse, with the number of them that are made in a given time, whence the pulse is commonly called quick or slow, their regularity or irregularity, as to time, and the quick- ness of the stroke itself, belongs to the heart. The quickness of the heart's action often takes place, though the pulsations are not frequent, which gives a kind of rest or halt to the artery, or pulse, especially if the pulse be not frequent. The hardness, the vibra- tory thrill, the slowness of the systole, with the fulness and small- ness of the pulse, belong to the arteries. As the pulse arises from the solids, or the machine, its state will be of course according to the nature of the machine at the time ; and is, therefore, capable of being, in either of these states, natural and diseased. " In most diseases of the constitution, whether originating from it, or arising in consequence of diseases of parts, where the con- stitution becomes affected by sympathy, the pulse is altered from a natural to a diseased state, the degree of which will be regu- lated by those affections. This alterationis commonly so constant, and so regularly of the nature of the disease, that it is one of the first modes of intelligence we have recourse to, in our inquiries into its nature ; but alone it is not always a certain guide." " The varieties which the pulse admits of, are several. It is increased in its nunlber of strokes, or it is diminished. It is re- 396 PUERPERAL FEVER. gular, or it is irregular, as to time in its stroke ; it is quick in its stroke, or diastole, and slow in its systole. It is hard in its dias- tole, and it vibrates in its systole. " In most cases, probably where the constitution is in a state of irritation, the pulse will be quick and frequent in its number of strokes in a given time, and the artery will become hard, from a constant or spasmodic contraction of its muscular coats, so as to give the feel of hardness to the touch ; besides which the dias- tole of the artery is not regularly uniform and smooth, but pro- ceeds by a vast number of stops, and interruptions, which are so quick as to give the feel of vibration, or what we could express a thrill." Ib. These quotations are sufficient to prove, that the condition of the artery in disease, as regards its volume, its firmness, its softness, its frequency, or its peculiarities of action, very much depends upon the nature of the disease, which imposes the alteration ; and that the diseased action itself will be influenced by the particular structure or structures, which are the seat of it. If this be true, and we can see no reasonable doubt of it, it seems to follow, that the peritoneum, in a state of inflammation, will give to the heart and arteries a character of action which exclusively belongs to that condition of this membrane ; and that the actions of the artery will of course vary, with the varying condition of the part or parts inflamed. As regards ourselves, we profess to have much reliance upon the pulse in all acute affections of the body; and almost always make it the guide of our prescriptions ; yet we confess we have less dependence upon it in puerperal fever, than in any other dis- ease with which we are acquainted. Not perhaps, because it is unfaithful in its reports of the condition of the system, but be- cause, we fear, we do not exactly understand them. The study of the pulse, therefore, in puerperal fever is almost a new one ; and we most earnestly recommend it to those, who may almost constantly have the charge of females, with a firm conviction that they will be amply repaid for their labours.* But to return. We would ask, what is the evidence that the first stage has run its course? This is an important question; and one, from our present data, that cannot, we fear, be answered satisfactorily. Hitherto this condition of the disease has been inferred ; rather than ascertained. It has been inferred, from the little advantage in some cases, and the marked injury in others, of blood-letting • and this is probably the amount of information upon the subject • * Mr. Travers says, that the pulse of real fever does not exceed a certain limit, and that consists with a property of distinctness. When it is innumerable, and from that cause indistinct, it ceases to be fever; it is a.powerless automatic ac- tion, and has neither the characteristics of heat of surface nor obstruction of the general secretory system. PUERPERAL FEVER. 397 hence, perhaps, the rule for withholding the lancet in certain epi- demical puerperal fevers, being regulated by hours; for it would seem, that in each individual epidemic of this nature, there is a period, caeteris paribus, at which the first stage runs its course, and this period has been signified by hours, because, when the disease had continued beyond this time, and blood-letting resorted to, it either proved unavailing or mischievous; consequently, the first stage was supposed to be past. Thus, Dr. Gordon would not promise success from bleeding, if the disease had continued from twelve to twenty hours ; be- cause this was probably the average period for the first stage, in the Aberdeen epidemic ; and Dr. Armstrong says, he has "never dared to recommend it when the disease had continued longer than thirty hours," p. 76, because in the Sunderland epi- demic, this may have been the period for the change from the first to the second stage, &c. It is true', that Dr. Armstrong has attempted the character of the first stage, by detailing certain symptoms, and has perhaps succeeded better than any one else, in defining and ascertaining its bounds ; nevertheless, he must not be considered as being alto- gether successful. It is, however, a praiseworthy attempt; and he is entitled to the thanks of the profession, for the lucid manner in which he has treated the subject. "In the first stage," he says, "after the rigours have ceased, the pulse is hardly ever less than one hundred and twenty, and sometimes, though, as far as I have observed, very seldom, as high as one hundred and forty in a minute; the blood does not seem to flow in a soft, easy, and natural current, but comes against the finger with a kind of vibratory motion, and more than ordinary pressure is commonly required to stop its course along the artery, which feels rather hard and tense. The skin is dry, and hotter than natural; the patient complains of great pain and soreness of the abdomen, breathes nearly forty times in the minute, vomits mucus and bile, is generally bound in the belly, has a white dry tongue, considerable thirst, and labours under all the restlessness and irritation of fever," p. 59. This description looks as if it were every way competent to the purposes for which it is designed ; yet there is not a symp- tom well defined as it seems to be, that may not accompany the second stage, if we except, perhaps, " rigour," which must be looked upon, when it takes place, as the initial symptom of the constitutional affection, and is of short duration.* The pulse is said to be from one hundred and twenty to one . * Dr. Armstrong, however, includes chills in his second stage: to have made these characteristics, he should have added, that these chills are not followed im. mediately by-a sense of increased heat. 34 0 398 PUERPERAL FEVER. hundred and forty strokes in a minute; so it happens in sonic instances of the second stage: and Dr. Gordon says, he has bled in some cases with good effect, when the pulse has been one hun- dred and sixty; therefore, if the bleeding with advantage be the proof of the presence of the first stage, the second cannot be characterized by a pulse of one hundred and forty ; since one hundred and sixty have been witnessed during the first stage. In Mr. Hey's case, (3d,) the pulse is recorded to be at between one hundred and thirty and one hundred and forty on the fifth day; and at a time, when all hope was abandoned; and it was but one hundred and forty-four, (a number considerably within the range, at which Dr. Gordon says he has bled profitably,) a short time before death. Mr. Hey's case, (5th,) terminated fatally in thirty- five hours; and its commencement "was accompanied with a full strong pulse." In his sixth case, the pulse was one hundred and thirty in the last stage. We might furnish many more cases of similar import; but these are sufficient to prove, that the num- ber of pulsations of the artery in a given time, will neither mark the first, nor characterize the second stage of this disease. We should place much more reliance on that peculiarity of the pulse which Dr. Armstrong describes, " where the blood does not seem to flow in a soft, easy, natural current," &c; if it were found to be a constant symptom, and to be detected with cer- tainty by even close attention, as it seems to countenance the opinion hinted above, that the inflammatory stage most probably is accompanied by a distinctive arterial action, however eva- nescent it may be in duration, or however difficult of detection. The state of the skin is very much less characteristic than even the pulse ; for in the first stage it is frequently moist, nay, wet; and in the second, it is both hot and dry. The pain and soreness of the abdomen often continue through the whole dis- ease; and though never absent from the first stage, it is never- theless constantly present in the second. The breathing is not more decisive ; vomiting is less frequent in the first than in the second stage. The tongue affords no criterion; it remains some- times as described above, until death closes the scene. Thirst is sometimes insatiable in the last stage; and the restlessness and irritation from fever attend sometimes to the last moment. We should, however, place some reliance upon the character of the pain and soreness, mentioned as belonging to the first stage: it is generally of an acute, pungent kind ; more easily excited by pressure at one portion of the abdomen than another; and very frequently confined to the hypogastrium ; there may be some swelling from the very commencement, which is sure to augment as the disease gains ground, giving to the hand the sen- sation of more or less solidity ; but the distention is never exces- sive during this stage ; is obedient to the influence of remedies, PUERPERAL FEVER. 399 by diminishing in size and sensibility; provided, the remedies, exert a control over the disease, generally. The patient is some- times disposed, and sometimes does, turn upon her side; though obviously inclined to maintain her position, for the most part, upon her back; because the abdominal muscles, by being relaxed, moderate pain. It would appear, then, that the first, or inflammatory stage of puerperal fever, the stage in which bleeding has been so'emi- nently successful, has no discovered character by which it can be distinguished from the second, in which this operation is for- bidden, after the lapse of a few hours. This circumstance we must regard as unfortunate, but perhaps not without remedy: for we must still insist, that there cannot be such a departure from the usual economy of the system, as to make puerperal fever the only exception. We must be borne with, therefore, if we still persist in recommending to physicians a more exclusive devotion and study of the several stages of this disease, that their now hidden characters may be developed. The rules which are to govern the loss of blood in this com- plaint, are therefore, necessarily reduced to rather uncertain and narrow limits; and are more dependent upon contingencies, than fixed principles. These rules are comprised in the follow^ ing directions;— 1. Bleed as early in the disease as possible. But, 2. Bleed at that time, as much as the system will well bear. 3. Repeat, pro re nata. 1st. Every practitioner is aware of the difficulty which almost constantly attends the execution of the first direction : this arises from several causes; but neiiher of which is absolutely insur- mountable. First; to the initial symptoms of ihe disease being frequently mistaken for the common occurrences of child-bed— if chill attend, as is most common, or if fever ensue without it, it is commonly attributed lo the " coming of tha milk," or that ephemeral, called " the weed;" or to some slight exposure, or unforeseen negligence. Second ; to the desire on the part of the nurse to be thought competent to any little indisposition incident to this period of child-bed. Third ; to the consequence of this belief of the nurse; losing thereby much time in witnessing the effects of her own remedies, Fourth; to the fear of censure attaching to the ngrse for any indisposition by which her patient may be attacked; therefore withholding early information. Fifih; to an ignorance of the nature and fatal tendency of the disease. Sixth ; if pain commence early, to its being mistaken for after-pains. For ihe reasons just assigned, it will, in very many cases, be out of the physician's power lo treat the disease as early, or as vigorously, as its ferocity demands ; therefore he should prevent, as far as possible, the operation of the above causes, whenever 400 PUERPERAL FEVER. the necessity may exist, by following the plan adopted by Mr. Hev during the prevalence of the puerperal fever at Leeds. Ho requested to be sent for " without delay, on the accession of shivering or unusual pain." But he adds, " Notwithstanding mv urgent request, I was seldom called until some hours after the attack," p. 76. This declaration diminishes our hopes of early applications, it is true; but the plan should be tried, as it is the only one we can adopt for the end proposed. We have already mentioned the latest periods in the opinions of several of the best authorities on this subject, at which it would be useful or proper to bleed ; we, also, attempted to show, that these directions were founded upon experience, or rather experiment, upon different occasions; that, though there were discrepancies in appearance in these statements, yet there were none in reality; as the conclusions were drawn from individual experience, in each of the epidemics, of which they gave the histories, and, consequently, that neither the short periods of Armstrong and Gordon, nor the more extended ones of Denman and Hey, should be taken for absolute guides. Therefore, in every instance of puerperal fever, especially if epidemic, as well as in sporadic cases, there may be a difference of period at which it might be proper to bleed; and that this period should be discovered as early as possible, and its limits ascertained with as much precision as it is susceptible of. For, by this means, we may extend the benefils of this operation be- yond what might at first be expected, as well as be prevented from doing mischief by it, if too late employed. As regards, then, the period after ihe attack at which we are to draw blood, it is a concurrent opinion, the earlier, most de- cidedly the better: as respects the one, at which this would no longer be useful, we have but very uncertain marks; therefore, much must be left to the experience and judgment of the practi- tioner who may have the care of the case. 2. Having ascertained the propriety of blood-letting in the early period of the disease, the questions next in importance are, first, what quantity must be drawn; and secondly, must il be repeated, and when, or under what circumstances? All the writers who have treated this disease with adequate boldness, prescribe ihe loss of a given quantity of blood; thus, Gordon, Hey, and Armstrong, limit it from twenty to thirty ounces; believing that less will not answer, and more is not gene- rally required.* In this country, we are not in the habit of regu- * Dr. Armstrong says, " the quantity of blood drawn at once in puerperal fever, should seldom be les.i than twcnty-four; and, perhaps, never more ihan thirty ounces" p. 76. Dr. Gordon say?, "I have limited the quantity of b!o"d neces-ary to be taken away, and fixed the time when taking away thai quantity will cure. Thus, I lound that twenty-four ounces of blood, taken away at one becding, within six or PUERPERAL FEVER. 401 fating our bleedings by ounces; in severe illness we almost alto- gether regulate the quantity by its effects; and we are disposed to believe this to be the safer, and the more efficient plan. For it is not to be supposed that every constitution will be affected precisely alike ; nor that the disease, in every constitution, will yield to exactly the same force of remedies. In one instance, perhaps a less quantity than twenty or thirty ounces might be sufficient, while another might require a much larger quantity ; therefore, in the one more blood may be drawn than is absolutely necessary, (though we confess it to be erring on the safer side,) and in the other, which is much more material, an inadequate quantity is too confidently relied upon. As regards our own practice, in such cases, we have always abstracted as much as the system would well bear ; that is, until the pulse was changed, pain abated, fever diminished, and there was a disposition to syncope. These alterations would take place sometimes from the loss of a smaller, and sometimes a larger quantity of blood : butr April, 1,829, t Dr. Francis's Memoir, p, 9, 36* 426 PHLEGMASIA DOLENS. lower extremities, followed by aching pain either about the up- per and inner part of the thigh, or in the ham, around the knee or calf of the leg ; and as rheumatism is by no means an unfre- quent accidental accompaniment of fever at certain seasons, the uneasiness and pain in the limb are, at first, very apt to be ascribed to this cause. " In the course of twelve to eighteen hours the pain and stiff- ness increase, and, on the limb being examined, it is found some- what swollen and perceptibly hotter than the opposite ; but there is no redness of the skin, which, on the contrary, has a smooth, white, shining appearance, and the cutaneous veins are distended with blood, and occasionally tortuous. As the disease advances, the swelling extends uniformly over the limb from the upper part of the thigh to the toes, and feels tense and elastic, but not at all diminished by the semiflexed position of the limb, which the patient generally prefers. " I also remarked the total inability to move the limb not so much on account of pain, as from want of command over the voluntary muscles. This peculiarity has been noticed by Mr. Burns in the puerperal phlegmasia dolens. " When active treatment has been adopted, the pain abates ; the swelling loses its elasticity and tension, so as to retain par- tially the impression of tbe fingers about the foot and aakle, and the heat of the limb diminishes, but the power of moving it con- tinues for a long time considerably impaired." Dr. Moore, of Ipswich,* makes a singular remark upon the opinions of Mr. White, the force of which we cannot perceive, though it purports to overthrow at once his doctrine. He says, " In refutation of Mr. White's opinion, I will state, that in no instance that has come to my knowledge, has the disease pre- ceded parturition." Now, how this refutes Mr. W's. opinion we cannot understand ; for, in no instance does Mr. W. require that parturition- should always happen before this disease can be pro- duced ; and in our humble opinion, had Dr. Moore known an instance of phlegmasia dolens preceding parturition,f it would have told very much more against Mr. W's. hypothesis, as the great agent in producing this disease, in Mr. White's opinion, would have been wanting; namely, pressure from the child's head during labour. But Dr. M. should not have attempted to pass his want of knowledge of such cases for more than it is worth; since many cases of the kind alluded to may have taken place, without his being apprized of them ; for, certainly * New-England Medical Journal, Vol. II. p. 229. t Puzos rela'es two iustanets of this kind ; one took place at the fourth, and the other at the seventh moot) \ 0f utero-gestation. And we have seen two in* stances in which it followed pi emature deliverj. PHLEGMASIA DOLENS. 427 it has happened, as stated above, that this disease has occurred to unimpregnated females. Now, if this be so, we do not see by what law of pregnancy, the woman is secured against an attack. By the by, we may remark, that Dr. M. dismisses the hypo- theses of Dr. Trye and Dr. Ferriar still more cavalierly, and with still greater brevity. Of the first he says, it "is mere supposi- tion ;" of the second, " in reply to Dr. Ferriar, I will adduce the fact, that phlegmasia dolens as frequently follows natural and easy labour, as difficult and laborious." These assertions of Dr. Moore, purporting to be refutations, were to pave the way for an explanation which he immediately after offers, in the following terms :— " After an attentive observation of cases, and a careful exami- nation of the subject, I will humbly offer the following explanation as the most satisfactory to me. " During gestation, the abdominal muscles, their vessels, and integuments, are in a state of great preternatural distention; im- mediately after parturition, when the distending cause is removed, these parts powerfully contract in order to regain their natural dimensions. If this effort be unequally exerted, if it be suddenly excited by the application of cold, if the lymphatic vessels be over-distended at the time, if plethora, or great debility subsists in the vessels themselves, an interruption and accumulation of the fluid ensues ; the great and long accumulation of which, acting as an extraneous and offending cause, will occasion inflammation. In persons of a plethoric and irritable habit, inflammation may quickly supervene; while, on the other hand, in a person of a contrary habit, it may be more tardy in its progress," p. 230. We would now ask, if ever hypothesis was more heavily laden with conjecture and supposition than this—it has not even the merit of ingenuity, much less an imposing probability, to. recon- cile its meager pretensions. The initial postulate is not founded in fact; for we cannot look upon the distention imposed upon "the abdominal muscles, their vessels, and integuments," as "preternatural," since, in being put upon the stretch by preg- nancy, they are but performing one of the offices for which they were designed. His second is no better grounded; for, after parturition has removed the distention, " the abdominal muscles, their vessels, and integuments," do not "powerfully contract in order to regain their natural dimensions;" for this is performed silently, and gradually,* and requires, for its completion, many days. We have just shown how reluctant, Dr. M. is to permit either Mr. Trye or Dr. Ferriar, to conjecture or to suppose; yet, he says himself, in the attempt to make out his explanation, "-if this effort," &c. " if it be suddenly," &c; "if the lymphatic vessels," &c; siich and such things will happen. That is, we shall have inflammation from an accumulation of lymph in the 428 PHLEGMASIA DOLENS. lymphatic vessels; and in what essential point does this " expla- nation" differ from that of Mr. White, or Mr. Trye? In none, that we can see, if we except the agent by which the interruption to the circulation of the lymph is affected—in one instance it is the head of the child; in the other it is cold and debility. We should not have thought it necessary to notice this " ex- planation " in an especial manner, had not the doctrine it incul- cates Ted to a mischievous and reprehensible plan of treatment; for the Doctor observes, " in the ordinary mode of treatment, much time is lost in inefficacious use of diuretics ; and much mis- chief and pain produced by the application of blisters, and other stimulating remedies." " From the view here taken of the sub- ject, I am fully disposed to regard it as a local disease, and decidedly recommend the early application of a large emollient poultice, which, by its relaxing and resolving power," (recollect the Doctor's opinion of the cause of the disease, its debility and over-distention,) " will, in a great majority of cases,") has he ever seen a sufficient number to determine this important point ? the Doctor only mentions two cases, and neither of which was the disease in question,) " prevent the formation of a distressing and tedious disease. And when it does not produce this most desirable effect, I should recommend its continuance, with an in- tention of producing early suppuration, which I think, next to reso- lution, the most speedy and safe termination of the disease," p. 231. Was ever a disease less understood ; or a more preposterous remedy ever proposed! The continued application of an emol- lient poultice is every thing that is necessary for the relief of a milk leg. We have good grounds for believing Dr. Moore had never seen a case of phlegmasia dolens, if we take the two cases he details as specimens. In the first case, the patient complained of a pain in the right hip and back; rigours and watchfulness; a rigidity and soreness of the abdominal muscles; pain in moving the limb; the pulse a little increased, slight thirst, and perfectly clean tongue. For this state of things, antimonials, cathartics, and fomentations were prescribed. These proved ineffectual; bark, guaiacum, and a continued blister to the thigh were em- ployed. " This course evidently increased the local affection. The upper part of the thigh, the inguinal glands, and right iliac region became more tumefied, which gradually extended to the hypo- gastrium and labium pudendi. "In the early stages of the swelling it appeared in ridges and bunches, occasionally assuming a livid, and at other times a pur- ple hue." , It became more uniformly diffused, tender, hotter than natu- PHLEGMASIA DOLENS. 429 ral; shining, but not much discoloured. The fever kept pace with the local affection ; the pulse was small and very frequent. The swelling increased. " With an intention of rousing the ac- tion of the absorbents, a volatile stimulating liniment was applied, and in turn hot vinegar; but these had no better effect than the blistering! ! "Digitalis was now administered; this increased the debility ; the inflammatory appearances became more evident; the pain, heat, soreness, and redness increased, until a discharge took place from a ruptured lymphatic in her side, about an inch from the inferior spinous process of the ilium," p. 228. The second case is still farther removed than the first, in our opinion, from a case of phlegmasia dolens. This occurred in a person of robust constitution: it supervened on natural labour. On the second day after the delivery, the patient experienced a great rigidity of the abdominal muscles, which increased in ten- derness, and presented an appearance of " ridges and bunches ;" the constitutional symptoms high; these increased until suppura- tion took place from an " opening a little below the navel." We have italicized such parts of these histories, as show at once, that they were not instances of phlegmasia dolens ; and also such, as have excited our wonder, in regard to the treatment. If the case just related, and others that we shall have occasion to mention presently, be received as instances of genuine phlegmasia dolens, the pathology of this disease will remain unsettled to the end of time. We have already cursorily mentioned the opinion of Mr. Trye, of the proximate cause of phlegmasia dolens; we shall now ex- pose it more in detail. He says, p. 70, " I have considered the proximate cause of the swelling to be seated in the lymphatic glands. I will not contend that it must be so universally, be- cause there is a probability that the original seat of obstruction and inflammation may, in some instances, be in the principal trunks of the absorbents within the pelvis, independent of, and abstracted from, the iliac glands ; in which case the inflammation may be continued along the absorbent vessels downwards ; that is, towards the labia pudendi, leg, &c, as well as upwards, or towards the thoracic duct." Dr. Ferriar is also mentioned as an inventor of a theory for phlegmasia dolens; but he does not appear to be entitled to this claim, since he has only adopted the opinion of Mr. Trye upon this subject. And were we even to admit he had not seen Mr. T's. work, he must at least have been familiar with the opinions of Drs. Denman and Latham. The lectures of the former he most probably attended. We shall make no observations upon the opinions of Mr. Trye and Dr. Ferriar, until we have noticed the hypothesis of Dr. Hull 430 PHLEGMASIA DOLENS. which we shall now give in his own words. He states, that " from an attentive consideration of the whole of the phenomena observable in this disease, and of its remote causes and cure, no doubt remains in my mind, that the proximate cause consist in an inflammatory affection, producing suddenly a considerable effusion of serum and coagulating lymph from the exhalents into the cellular membrane of the limb. " The seat of the inflam- mation I believe to be in the muscles, cellular membrane, and inferior surface of the cutis. In some cases, perhaps the inflam- mation may be communicated from these parts to the large blood vessels, nerves, and lymphatic vessels, and glands imbedded in them." We have united the hypotheses of Mr. Trye, Dr. Ferriar, and Dr. Hull, because they are essentially one and the same ; namely, that the proximate cause is an inflammation of the lymphatics and glands of the groin ; though, as a whole, Dr. Hull assumes a much broader ground ; so much so, indeed, that Dr. Davis styles it with much point, " a capacious theory." The objections which present themselves to these explanations, are, first, their incompatibility with one especial phenomenon of the disease, namely, the shining white appearance of the limb throughout the whole course of the disease ; and this so noto- riously so, as to have it as one of its genuine characters. In all instances of inflammation of either muscles, skin, lymphatics,* or blood vessels, redness is a never-failing attendant, as is well known to all who are familiar with this disease. Yet this does not happen in phlegmasia dolens, notwithstanding the numerous tissues Dr. Hull involves in the mischief. 2d. That if all these tissues were in a state of inflammation, this inflammation would manifest itself by the ordinary phenomena of this affection: namely, heat, redness, swelling, pain ; yet we find redness always wanting- in phlegmasia dolens, when this disease is pure and uncomplicated. If muscle be inflamed, redness is sure to be present; if the skin, the same thing occurs ; if the trunks of lym- phatics, (absorbents,) be the seat, we have frequent opportunities to witness that they become red ; and when the lymphatic glands are in this condition, redness notoriously attends. And though Dr. Hull does not suppose that all these parts are simultaneously affected, but successively, yet it alters not the fact, that in phleg- * In the time of Dr. Hull, the term "lymphatics" was understood to mean the lymphatic absorbents; the researches of Bichat had not then made it necessary to distinguish this set of vessels, and those whose office it is to convey the lymph, being either the termination of arteries, or the beginnings of veins. And we beg the reader to keep in mind, that where "lymphatics" are mentioned in the quota- tions of Mr. White, Mr. Trye, Drs. Hull, Ferriar, or Moore, that the lymphatic absorbents arc lo be understood. PHLEGMASIA DOLENS. 431 masia dolens, redness is always absent during the whole course of the disease. 3d. Besides, this progressive extension of inflammation cannot well be sustained, as the rapidity of the disease is such some- times, as to involve the whole limb in the course of a very few hours; whereas, the transmission of inflammation by contact even, is sure to be much slower; yet it Would not fail to betray its pro- gress by all the common phenomena of inflammation, were it to exist in such parts. 4th. When the lymphatic glands become inflamed by the ab- sorption of some acrid substance or specific poison, the venereal poison for instance, they not only become red themselves, but the lymphatics even that convey the poison, can be distinctly traced in their course, by the vivid red that marks their inflamed coats. 5th. The ordinary inflammation of the several parts declared to be involved in phlegmasia dolens, moreover, do not thus sud- denly effuse serum : of this proofs present themselves every day in the usual progress of inflammation, as in rheumatism, wounds, contusions, the insertion of poisons, &c. 6th. When the lymphatics are inflamed, together with their glands, it is acknowledged by Dr. Ferriar himself, that " the ves- sel can be distinctly traced in its course by its hardness and en- largement, and frequently by a slight inflammation of the super- incumbent skin, forming a red or purple streak, and extending with the affection of the vessel."* 7th. We do not agree with Dr. Ferriar in the assertion, that " the violent pressure on the internal iliacs, and the accompany- ing veins and nerves, which takes place during delivery, must undoubtedly be considered as a powerful occasional cause of lym- phatic inflammation," p. 120. Now, if this were true, phlegmasia dolens would be of more frequent occurrence than it is ; since this pressure is common to many labours, yet the disease in ques- tion is one of very rare occurrence. 8th. Because, in phlegmasia dolens, one of its inseparable cha- racters is the exquisite sensibility of the whole limb ; so much so in most instances, that the patient cannot bear the slightest pres- sure, or the slightest motion, yet Dr. Ferriar informs us that " the pain in lymphatic inflammation is referred to the enlarged glands, and is not remarkably increased by motion; there is more stiffness than actual pain in the whole limb," p. 102. 9th. Because, in the twelve or fourteen cases of exquisitely formed phlegmasia dolens, that we have seen, we never were able to trace the " inflamed lymphatics," or to feel the " enlarged conglobate glands;" yet both of these circumstances are de- » Med. Hist. Vol. III. p. 95. 432 PHLEGMASIA DOLENS. clared to be constantly present, by those who espouse the patho- logy under consideration."* 10th. Because, Dr. F. furnishes a case himself, which dis- proves his own explanation, viz. " Jane Waters, aged twenty- five, was delivered by an accoucheur, of her second child, Dec. 26th, 1797, after being four days in labour. During delivery she lay upon her left side. December 27th, she was affected with pain and swelling of the left knee, which descended to the leg and foot of the same side. On the 28th of December the swelling began to rise from the left knee and to affect the thigh. It extended up to the left* groin and labia pudendi. I saw her for the first time on the 3d of January, 1798. I found the swelling tense, uniform, not discoloured ; that there was a great sensation of rigidity in the limb, and that it was extremely painful on being touched or moved. She felt exquisite pain in the ham, where I could perceive the lymphatics a little enlarged. The glands of the groin were not affected, p. 127. In this case there was an exquisitely formed phlegmasia dolens; for it was attended by all the essential characters of the disease ; the limb was exquisitely tender to the touch; the swelling was uniform and elastic ; it was not discoloured ; the glands of the groin were not affected, and the lymphatics in the ham could be perceived to be a "a little enlarged." Here then was a case of genuine milk leg, without inflamed " lymphatics " or " conglo- bate glands." We think we have said enough to prove that this pathology is not well founded; and that if inflamed lymphatics, or enlarged glands be present, that they are the consequences, and not causes of the disease called phlegmasia dolens. The next hypothesis in order, and it is the last with which we are acquainted, is one of late date ; it is by Dr. David Davis, a teacher and practitioner of considerable celebrity in London. Dr. Davis attempts to prove, that phlegmasia dolens is the con- sequence of an inflammation of one or more large veins; ending in the production of an extraneous membrane, or other obstruc- tions, within their cavities; and thus offering remorse to the re- turning blood from the extremity. This view of the subject, from its supposed truth, has gained much more notoriety than can be sustained by facts, though sup- ported by the powerful aid of Velpeau ; and we may add, that of Bouillaud and Ribes. When we say this, we would not wish to be understood as implying the slightest disbelief of the truth of * Dr. Hull declares the same inability: he says, " I have never met with either enlargement or inflammation of the lymphatics in any stage of the complaint; I am, therefore, couvinced that this is a rare occurrence, and by no means essential to the disease."—Essay on Phlegmasia Dolens, p. 116. It will, therefore, be per- ceived, that our observations apply to Dr. Hull only, as far as he admits the lym- phatics to be involved. PHLEGMASIA DOLENS. 433 Dr. Davis's statement: on the contrary, we are fully persuaded that neither he, nor the gentlemen'who, both directly and indi- rectly, support his doctrine, have set down nothing that they did not see—the only question then is, were the dissections of these gentlemen cases of phlegmasia dolens? this is the point at issue— whether phlebitis and phlegmasia dolens are identical; or, in other words are the cases related as cases of the latter, any other than instances of the former? Before we proceed farther in the examination of this question, it will be proper to determine the absolute character of phlegma- sia dolens, from the best accredited practitioners; for to them alone should the appeal be made. And, perhaps, one of the older writers of this kind will be the safest guide upon this occasion. Callisen has summed up the characters of this disease most hap- pily in a very few words, making allowance for the introduction of one of its supposed causes in his time, namely, a metastasis of milk. "CEdemapuerperarum, aliis lacteum est tumeur elasticus, albescens, renitens, calidus, dolens, foveam impressi digiti haud retinens, puerperis haud infrequenter, gravidis rarissime infestus." He has, however, omitted a very material feature of the disease, namely, fever; for as far as we have seen, this condition of the system has always been present, and sometimes to an alarming degree. The essential characters then of phlegmasia dolens may briefly be stated to consist of the following strongly marked characters. 1st. Fever always to a greater or less degree. 2d. Pain gene- rally commencing in the hip groin, and sometimes the back. 3d. Swelling commencing at the seat of pain, and proceeding with more or less rapidity down the whole limb. 4th. The swell- ing elastic, not retaining the impression of the finger. 5th. The whole swollen part white, even more so than natural, in some in- stances, but never red when uncomplicated. 6th. The whole limb exquisitely sensible to the touch. 7th. Total inability to move, the limb, and action always creating great suffering. 8th. The temperature of the whole affected part much above the na- tural temperature. 9th. The labium pudendi of the diseased side almost always participates in the swelling, but never extending to the other labium, unless the other limb be also affected. 10th. After the first leg begins to improve, or is, perhaps, nearly well, the opposite leg runs through a similar course, and sometimes with an aggravation of symptoms. 11th. That the limb thus af- fected, rarely suppurates. 12th. That this disease is rarely at- tended by danger. 13th. That after the more violent stage of in- flammation is abated, which generally happens, under proper treatment, about the sixth or eighth day, that the swelling abates its elastic character, and takes on that of a common oedema. 14th. The milk usually diminishes, and sometimes disappears. 37 434 PHLEGMASIA DOLENS. We have been thus particular, yet we trust, strictly faithful, in enumerating the essential characters of phlegmasia dolens, that the coincidences and discrepancies between it and phlebitis, may be more readily subjected to comparison. Symptoms and General Character of Phlebitis. In giving an analysis of the symptoms of phlebitis, we have chosen the one condensed in the Medico-Chirurgical Review, Vol. IV. p. 509, from Recherches Cliniques pour servir a l'Histoire de la Phlebite; par M. J. Bouillaud, M. D. Revue Med. Avril et Juin» 1825; and from Expose succinct des Recherches faites sur la Phlebite ; pat M. F. Ribes, M. D. Revue Med. Juillet, 1825. We have chosen this in preference to other authorities, because they are the latest who have written on this subject, though we have no evidence that they consider phlebitis identical with phlegmasia dolens. We shall give the English version, as con- tained in the above named Review. First of Dr. Bouillaud. " Symptoms.— 1. The symptoms of inflammation in the trunk of a superficial or external vein are easily recognised* The mem- ber swells, becomes hot, painful, or is even the seat of phlegmo- nous erysipelas. The vessel itself feels tense, hard, knotty, or like a cord. Abscesses not unfrequently form in the course of the vein* The pain, our author thinks, is more dependent on an affection of the neighbouring nerves, than on inflammation of the vein itself. CEdema of the limbs is a very common attendant On phlebitis of one or more of the principal veins, and evidently arises from the me- chanical obstruction to the return of the blood—the veins being now acknowledged to be the principal conductors of the serous exhalations, (see note to page 430,) that takes place in the cel- lular tissue. Such are the signs of local phlebitis. 2. When the inflammation extends to the whole or to a great portion of that vast membrane which lines the internal surface of the venous system, we constantly find that a violent fever is lighted up. Among many of our patients, the fever presented all * It seems from late observations, that there is a marked difference in the pa- thological conditions of the internal coats of the arteries, and that of the veins: in the former, the adhesive form of inflammation is almost sure to recur; while in the latter, the suppurative is very certain to take place. This latter circumstance has been frequently observed in the veins of the brain, and in those of the uterus. Dr. Clarke observed this condition of the uterine veins in women who he declared had died of puerperal fever; but, most probably, it was from hysteritis; and Dr. Abercrombie and M. Gendrin saw marks of a similar kind in the venous tubes of the brain; It mast, however, be admitted, that the internal coats of the veins have yielded lymph when inflamed, and obliteration has f the cellular mem- brane. The progress of the inflammation to suppuration, though- always constant, if not interrupted, is not always equally rapid; some- times it requires many weeks before the pus will discharge itself, or permit an outlet to be made for it. But much will depend upon the seat of the gland that may be affected ; if it be deep, it will require a longer time, and so on. It may, however, be ob- served as a constant rule, that the inflamed gland is always longer before it suppurates than the cellular membrane when it is the seat of the inflammation. It is besides very much more painful; and is attended with higher sympathetic fever, though the breast never becomes so large as in the other instance. In the variety of this complaint now to be noticed, the same remote and exciting causes may have operated ; though we can- not say why the cellular membrane should have been selected for its seat. It commences by the same general phenomena, except we believe, that it is always preceded by chill; and the first intimation the woman may have, that it has " fallen on the breast," is a swelling and tenderness of the part upon pressure. The breast is now rapidly distended, and generally in an equal manner; that is, without a circumscribed tumour within its sub- stance. The whole progress of the inflammation, &c, in this variety, is vastly more rapid than in the other, and were we to judge merely from appearances, is more alarming; the swelling is much greater; but the pain is much more moderate. Indeed, we have seen it run on to suppuration, without the slightest pain, except from pressure. This variety passes through the same stages as the other ; and pretty much after the same manner, if we except the rapidity of its march. We have seen it pass on to suppura- tion in the course of a week. The external inflammation is much less intense, and is very rarely attended by oedema. Indeed, we have seen very extensive suppuration, with scarcely any discolo- ration of the skin. It is also much less amenable to remedies; for it is very rarely made to resolve itself, however early attacked or vigorously pursued the plan may be. The two varieties may be combined, and it is not very unfre- quent that they are : when this takes place, the inflammation of the gland always appears first, and the cellular membrane after- wards becomes implicated, either from an extension of the origi- nal inflammation in the gland, or by taking on this action later; &» we have never witnessed the cellular membrane injured, un.- MILK ABSCESS. 451 hi some time after the gland; nor have we ever seen the gland injured from the inflammation of the cellular membrane. However, if the progress of the gland to suppuration be slow, or the diseased part be very deep-seated, the cellular-membrane may remain free for a long time, unless the complaint have been treated by stimulating or other improper applications; or by the early use of poultices. In this case, the part becomes enormously swelled; the epidermis separates from the true skirt; a great number of small vesications appear, and the depending part of the breast becomes cedematous, and' sometimes even discharges a considerable quantity of serum ; indeed, the whole of the skin, covering the inflamed part, appears thickened, and saturated with a fluid, which escapes upon the smallest injury done to the part. This is so conspicuous sometimes, as to disguise the inflamed appearance of the integuments; and if it be pressed by the point of the finger, the impression will remain a long time,, though it be not in- a depending part. Of the Treatment. There is no inflammation of the phlegmonous kind, that runs on to suppuration with so much certainty, and sometimes with so much rapidity, as that which attacks the mamma. On this account, not a moment is to be lost in temporizing ; for an im- pression must be made, and that quickly, or all efforts wi 11 be un- availing, and the woman often be made to suffer for a long time an acute and almost never-ceasing pain. Is this failure to procure resolution a necessary and an una- voidable consequence ? Or is it, in part, owing to the first period of the inflammation being either neglected, or improperly treated ? We have said, that the inflammation of the breast runs on to sup- puration with great certainty : by this, we would wish to be un- derstood, that, if let alone, or if ill-managed, it will rarely fail to suppurate ; therefore, if an attempt be made to counteract this constant tendency, the remedy should be of the most decidedly antiphlogistic kind, and applied early. But our want of success in resolving mammary inflammation, does not exclusively arise from the pertinacity of its course; for there are several other causes, which almost constantly operate with equal certainty. First. It is almost constantly submitted to the management of the nurse, or subjected to the " infallible cure " of some old wo- man. Second. To very inadequate means being advised, and perse- vered in, until the time for the successful application of the pro- per remedies is irretrievably lost; or,, 452 MILK ABSCESS. Third. To stimulating and heating applications being used, which quickly inflame the skin externally; which unites with the one which has already attacked the breast within ; and thus making it necessary to contend with two enemies instead of one. Fourth. To a want of perseverance and conformity to the pre- scriptions of the physician, after he has seen the breast, because immediate relief may not be experienced, or because some other plan has been advised. Fifth. To a false delicacy and fear on the part of the patient, lest the part be examined. The above causes are almost sure to operate against the early use of proper remedies ; and it is almost certain to happen, that the physician is not consulted, until so much mischief is done, that he cannot, but in part, repair it. From what we have expe- rienced, when a fair chance has been offered us to oppose this disease, we are of opinion, that it need not suppurate near so often as it does. This holds out a strong inducement to the wo- man not to temporize, lest she incur an injury that will not be repaired through life. ' It is never too soon to oppose this disease; and if a very early opportunity occur, the woman should be advised so soon as pos- sible to employ the remedies, and to follow the plan now to be advised. 1. Local Applications. We have never found any application so successful in the very . early stage of this disease, as the frequent use of warm vinegar to the part. Its efficacy appears to us so certain, when sufficiently soon employed, that we need not in many instances look for any other remedy. It is particularly prompt in that condition of the breasts, in which a want of proper drawing leaves them; or where they become greatly and painfully distended by the sud- den secretion of milk, but which cannot be extracted with ease, or in sufficient quantity to relieve the tension, either from a de- fect in the external or inferior extremities of the tubuli lactiferi, or a proper conformation of the nipples themselves. These accumulations are always painful, and easily provoked to inflammation, by either the use of improper food, or improper local applications. It is therefore every way important that this tendency should be arrested in limine. For this purpose the vi- negar is the most comforting, and, at the same time, the most certain, with which we are acquainted. This application is highly useful also in the commencement of both the first and second varieties of mammary abscesses; and should be employed most perseveringly for at least twenty-four hours. If the pain or intumescence be not abated by this time, ..-7//. *_ A->4h $m,H" •*??*?<& IP *$&£p 4 &■ •* • V^/*Jf '.' ■• ■■■■■■■-' •■' ?*&%*Lij ' /.* s/y^v N.rn: il EXPLANATION OF THE PLATES. 517 PLATE XL Ulcerated carcinoma of the uterus. This plate, when contrasted with the former, shows the uterus altogether much thickened, the cervix of the uterus especially. Two lines meet at A ; these diverging, lead to the upper and lower, or rather to the anterior and posterior parts of the cervix uteri. All traces of the os uteri are destroyed. The points particularly deserving of notice in these plates, are ulceration without thickening in the corroding ulcer, and ulcera- tion with great thickening in carcinoma. B. The Fallopian tube. 44 518 EXPLANATION OF THE PLATES. PLATE XII. Circular gilt Pessary. Fig. 1. This plate represents the middle-sized pessary. From a. a. Two inches and four-tenths. 6. A central hole, to permit any discharge to pass, three-tenths of an inch in width. c, c. An excavation for the neck of the uterus to lie in. Fig. 2. Is a central section of the pessary. a, a. Represents the internal cavity of the pessary. b, b. Represents the depth of the excavation of c* c, of Fig. 1, five and a half tenths of an inch deep. c. A section of the central hole, b, of Fig. 1. /'/„/ TK 7'/ Viz:.'J. Si'r/inti tlniitiifh the (entre. ViiM. '<$>_. %i % risw**** /'hit, / INDEX, ABORTION, liability to, increased by plethora produced by hydatids mere increase in the circulation not sufficient to duce it • Abscess, in the labium milk Acetate of lead, in uterine hemorrhage Acid, nitro-muriatic in carcinoma uteri . aulphunc in do do pyroligneous in do do , Alum, in irregular menstruation Anatomical peculiarities of the female . Aphthous efflorescence on the female organs on the male organs Asafoedita in hysteria Astringents in uterine hemorrhage their modus operandi . Leroux's objection to their use Leake's their decided utility in leucorrhcea pro- 488, Page 178 280 309 28 447 318 252 :u 251 143 14 43 47 &c. 323 ib. ib. ib. ib. 68 B. Balsam copaiva, in hemorrhoids . Bleeding, in carcinoma uteri decline of the menses hysteria . menorrhagia . milk abscess pregnancy puerperal fever . suppression of the menses uterine hemorrhage Blisters during pregnancy in menorrhagia 210 241 145 48 G 142 452 181 391 122 317 186 142 520 INDEX. Blisters in puerperal fever in hysteria .... Blood, appearance when drawn during pregnancy Bloody infiltrations in labia pudendi causes symptoms, (see cases) treatment Borax pruritus ..... Page 4 OH ■18H 188 31 11 33 33, &c. 41 Calomel in puerperal fever . . . 351 Camphor in painful menstruation .... 126 in carcinoma uteri . . . . 251 in hysteria ...... 491 Cantharides, tincture of, in leucorrhcea 68, dec. in suppression of the menses . 112 Carbonic acid gas in carcinoma uteri 2J7 Carcinoma uteri ....... 238 first stage, symptoms of 239 treatment of ... 240 by bleeding . 211 purging 243 abstemious diet 245 cleanliness 24 G rest 248 second stage, or where symptoms of ulceration have commenced .... 249 treatment, by narcotics 250 antacids 252 sweet cream . ib. diet 245 Mr. Clarke's remarks respecting the treatment . 252 Cauliflower excrescence of the uterus 271 symptoms of 271 prognosis ..... ib. treatment by bleeding .... 276 diet ...... ib. laxatives ..... ib. astringents . . . . . '.277 tonics ...... ib. ligatures ..... 278 Cellular system of the female, peculiarities of . 16 Cicuta in decline of the menses .... 111 carcinoma uteri ...... 251 Clarke, his classification of the diseases of the uterine system . 360 objections to 361 Clitoris, diseases of . 21 given rise to the opinion of hermaphrodites ib. scirrhus of . 25 Copaiva in hemorrhoids . . 211 pruritus ...... 45 INDEX. 521 Cold bath in hysteria Costiveness during pregnancy consequences of treatment Cream in carcinoma uteri . Cutaneous system of the female Paee 501 201 202 ib. 252 16 Diet in carcinoma uteri , 245 cauliflower excrescence of the uterus . 272 decline of the menses . , 138 during pregnancy .... 191 haemorrhoids .... 209 leucorrhcea ..... 69 suppression of the menses , 111 menorrhagia ..... . 155 puerperal fever .... 419 milk abscess ..... ! 454 hysteria ..... 500 Diseases of the labia ..... „ 28 external and internal organs 21 Dysmenorrhcea ..... . 121 symptoms.... ib. causes .... . ib. treatment 126 during the flow , 125 the interval . , 127 Dr. Mackintosh's view of dysmenorrhcea 129 E. Emetics during pregnancy in menorrhagia in puerperal fever in hysteria Ergot in difficult menstruation uterine hemorrhage . Extirpation of the uterus , 185 156 440 487 126 324 229 F, Female, peculiarities of the , peculiar diseases of Fever, menstrual milk, rules for preventing 44* 13 14 96 448 .>.-) INDEX. Fever, puerperal ..... definition of . history ..... period of attack .... predisposing causes delivery, as a cause opinions of Armstrong, Hey, and Clarke prophylactics . purgatives, as . Dr. Gordon's opinion respecting . Hey's..... the author's .... seat of appearances on dissection, in the thorax in the abdomen is an inflammation of the peritoneum. this inflammation terminates in effusion the belief that this inflammation is not the effect inflammation, erroneous Dr. Denman's opinion respecting symptoms of diagnosis .... prognosis contagious, nature of the author's opinion of Dr. Hulme's opinion of Dr. Hull's . Mr. Hey's Dr. Armstrong's Dr. Leake's treatment of bleeding .... stages of ... 1st stage .... bleeding in pulse as a guide for bleeding, &c rules for bleeding in 2d stage .... purging in emetics blisters in fomentations spirit of turpentine mercurial frictions . gangrenous stage symptoms of treatment of stage of effusion, treatment of general directions and rules Fluor albus, (see leucorrhcea) Forceps in uterine hemorrhage Fomentations in puerperal fever . of active Pnce 343 ib. 346 369 348 349 ib. 351 ib. 352 ib. 387 353 ib. ib. ib. ib. 354 367 ib. 375 377 380 ib. ib. ib. ib. 381 ib. ib. 382, &c. 391 ib. ib. 393 399 403 405 ib. 408 409 ib. 410 412 413 414 417 418 51 329 409 INDEX. Calls as an application to hemorrhoids Guaiacum, volatile tincture of, in suppression of the menses H. Heartburn during pregnancy .... treatment of Hemorrhage, uterine .... connexion of the ovum with the uterus causes which may destroy this mode of action of certain of the remote causes of periods of pregnancy at which it may take place . 1st period, the first four and a half months of pregnancy treatment during this period 2d period, the remaining time of utero-gesta- tion danger in this greater than in the first indications of cure . treatment at this period delivery as a mode of arresting hemorrhage vicarious, of the menses Hemorrhoids during pregnancy . cause of treatment of after labour treatment of Hiera picra in the decline of the menses Hip bath in carcinoma uteri Hoffman's anodyne liquor in carcinoma uteri Hydatids of the uterus . causes of case of diagnosis treatment . ergot recommended Hymen, opinions respecting its existence imperforate . symptoms of consequences of treatment of . Dr. Denman's case of Dr. Cleaver's case of 524 INDEX. Hysteria during pregnancy, treatment of Hysteria ...••• seat of ... sympathetic affections simulated by predisposing causes . importance of attending to the state of the vascular system, in the treatment of case illustrating this period of life at which it most usually occurs causes of, according to Whytt symptoms of those most obnoxious to it . exciting causes of ... wind and tough phlegm in the stomach and bowels case worms . case improper aliments scirrhous and other obstructions in the stomach and intestines violent affections of the mind phenomena of, . diagnosis .... treatment .... of the paroxysm bleeding sedatives and antispasmodics pediluvium stimulants to the nostrils . enemata emetics blisters purgatives opium case illustrating the utility of camphor local applications restraint cold water bath to prevent the recurrence of the paroxysm tonics antispasmodics diet .... amusements in cases illustrating the utility of . cases showing that hysteria may be subdued by moral and physical causes Hysteritis ...... first species, causes of . symptoms .... constitutional . mixed ..... treatment, bleeding .... INDEX. J^J Hysteritis, treatment, purging fomentation. blisters sudorifics . opium emetics Page 340 ib. 341 ib. 34;2 ib. Impregnation requires the united perfection of the internal uterine surface, and at least one of the ovaria . 82 periods of . . . . . 84 never takes place before the inception of the menses .... 80, &c. never occurs after the cessation of the menses 81 Inquietude and want of sleep during pregnancy . . . 200 Inflammation of the peritoneum, (see fever, puerperal) . . 343 Injections in leucorrhcea ...... 68,&c. pruritus ..... 45 carcinoma uteri . . . 254, &c. cauliflower excrescence of the uterus . 27-J Infiltrations, bloody, in labia pudendi . . . .31 Iron, preparations of, in the decline of the menses, injurious . 142 Irritable uterus ,,.,«.» 386 Labia, abscess of • symptoms of . adhesion of prophylactic measures treatment of Dr. Denman's plan erysipelatous inflammation of treatment of cedematous swellings of . those most liable sequela? of treatment of . Labour, its influence on puerperal fever Lead, acetate of, in irregular menstruation . uterine hemorrhage menorrhagia Leucorrhcea 28 ib. 25 ib. 26 27 28 ib. 29 30 ib. ib. 349 143 318 159 51 526 INDEX. Pag« Leucorrhcea, causes which predispose to , 51 those most obnoxious to . , ib. circumstances which influence the discharge 53 different varieties of 54 var. a. L. of direct irritation . 55 b. L. of indirect irritation ib. c. L. of habit . ib. Gardien's species of . ib. seat of . . 59 stages of . 65 first stage . 66 symptoms of ib. treatment of , 68 second stage . , . 71 symptoms of . ib. treatment of , ib. third stage . . 79 symptoms of ib. treatment of , ib. nitrate of silver in . 73 Ligatures in polypus of the uterus . 267 cauliflower excrescence of the uterus , 271 Lime in carcinoma uteri . , 217 Lymphatic system of the female . • 61 M. Madder in suppression of the menses Menorrhagia ..... nature of the discharge in vessels by which the discharge is furnished those most obnoxious to symptoms of ... two varieties of first variety .... those most obnoxious to treatment of second variety those most obnoxious to . symptoms of treatment of a third variety, supposed to exist by Gardien Menses, period at which they make their appearance causes which influence the premature appearance of derangement of the. the too tardy appearance of the . four conditions of the system in which this occurs cond. a where there is little or no development of th genital organs . characters of this condition management of this condition 112 , 146 ib. , ib. 150 , ib. 151 , ib. 153 , ib. 155 , 156 ib. # ih. 157 86, &c. 88 81,85 97 , ib. 199 it of the , ib. , ib. , ib. INDEX. 527 Menses, cond. b. where the development is taking place very slowly character of this condition . management of this condition cond. c. where this development is interrupted by chronic affection of some other part character of this condition management of this condition cond. d. where the most perfect development has taken place character of this condition . management of this condition . cases of quantity usually expended » causes which influence the sparing quantity of the . . treatment of . <, , immoderate flow of the . suppression of the .... cold, the most common cause of symptoms treatment of treatment of sudden cases of every deviation from regularity does not require medical interference decline of the .... symptoms attending the treatment .... derangements about the period of the . concomitant affectioh may return after they have ceased Menstrual action essential to impregnation . discharge, a genuine secretion furnished by the lining of the uterus in what it differs from pure blood . derangement of . quality of . . . .93, hemorrhages vicarious, of the fever, does not exist .... Menstruation, history of peculiar to the human female an original function Roussel's opinion Galen's not a fortuitous discharge . symptoms of period employed by precocious .... painful ..... causes of two states of membrane discharged during treatment of ... as a sign of fecundity . Menorrhagia two varieties .... Page 528 INDEX. Menorrhagia, exciting causes treatment Mercurial ointment, in erysipelatous inflammation of the labia in puerperal fever . Milk abscess .... causes of, and prevention . symptoms of progress of . treatment of Milk abscesses, local applications, vinegar leeching regimen . purging puncturing caustic seton, operation of Dr. Physick after treatment Mother and foetus, mode of communication between Schreger's opinion respecting Muscular system of the female . N. Nervous system of the female . Nitrate of silver, its use in leucorrhcea Nymphae, enlargement of inflammation of extirpation of . 0. Osseous system of the female Ovaria, when incomplete, cannot furnish perfect ova may regain their power diseases of the . classification of P. Pain in the right side during pregnancy cause of treatment of INDEX. Palpitation of the heart ..... causes of treatment of Pessary, description of the one used by the author . directions for placing it ... proper size of remedies to be administered, before applying it period it must be worn Placenta, circumstances in uterine hemorrhage, in which it ought to be removed . directions for removing it Polypus of the uterus .... definition of causes of three species made by Levret 1st species having its origin from the fundus symptoms . mechanism of expulsion signs by which it may be known 2d sp. having its origin from the neck 3d sp. having its attachment to the orifice of the uterus .... characters by which it may be known treatment of cases of applicatio/i of ligature . Pregnancy, general condition of the system during febrile do. signs generally accompanying it 1. suppression of the menses 2. nausea and vi miting 3. enlargement of mammae 4. areolae 5* formation of milk 6. enlargement of the abdomen 7. increased size of the uterus 8. pouting of the navel 9. frothy spittle . 10. salivation 11. quickening itself not a morbid state peculiarities during propriety of bleeding during . purging do. vomiting do. blistering do. liability to abortion do. diseases of vomiting heartburn salivation • pain in the right side inquietude and want of sleep costiveness hemorrhoids . Preo-nacy, diseases of pruritus 530 INDEX. Phlegmasia dolens .... phlebitis different from cases treatment blood-letting, &c. purging . topical applications . opium external applications blisters bandaging Prolapsus uteri .... causes of Gardien's three degrees of symptoms diagnosis, difficult remedy cases of . Pruritus ..... causes of ... treatment of ... a distinct affection from furor uterinus may be communicated to the male . variety of, described by Chambon in children .... treatment of . Puberty, female diseases at . Puerperal fever, (see fever,) Pyroligneous acid in carcinoma uteri Quickening, what Rathany in irregular menstruation Rest in carcinoma uteri . Retention of urine, from blisters Salivation during pregnancy symptoms attending it treatment of Sanguiferous system of the female INDEX. 531 Secale cornutum, in hydatids Sleep, inquietude and want of, during pregnancy Dr. Denman's theory of treatment of Sulphur, its use in hemorrhoids Dr. Leake's opinion of Dr. Good's . Sympathies called forth in pregnancy Sympathy between the uterus and rectum Pacfi . 282 200 ib. 201 . 210 ib. ib. • ill 185 T. Tampon, directions for forming and applying it . . . 318 objections which have been urged against its use . . 323 modus operandi of the ..... ib. Temperament, predominant one in females . . . .17 Tonics during pregnancy . ..... 181 in derangement of the menses about the period of their decline 141 Tubes, diseases of ..... . 232 Tumours and excrescences of the external parts . . .22 Turpentine, spirit of, in carcinoma uteri . . . . 251 in puerperal fever .... 109 Umbilical vein, uses of . Urine, retention of, from blisters Uterus, displacement of, ... hemorrhage from .... connexion of ovum with causes which may destroy it displacements of, action of remote causes periods at which it may take place first period, a. second period, b. delivery in hemorrhage lined by a mucous membrane linino- of, supposed by some to be deciduous prolapsus of, (see prolapsus) inflammation of, (see hysteritis) chronic inversion of irritable .... diseases of . carcinoma of particular diseases of Uterine system, influence of . . • opinion of Sydenham, Cullen, Good, &c, respectin the author's opinion Mr. Fogo's .... 189 186 214 307 ib. 308 ib. 312 314 322 324 92 ib. 214 329 227 286 232 238 236 17 ib. 18 20 532 INDEX. Uterine contraction, how far we can control it Mr. Burns' opinion . the author's . causes of, in which we should not interfere . in all other cases, should try to preserve the ovum Pace 309 310 ib. 311 ib. V. 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Knapp's Technology, or Chemistry Applied to the' A rts and to Manufactures, edited by Johnson, Vol. II., 6vo with many hundred illustrations.——Barlow on Medicine, 1 vol ^vo VVeisbach's Mochanies Applied to Machinery and Eng.neering. edited by Johnson. Vol. II., with 500 illus- trations___Bowman's I'raclical Chemistry. Graham's Klementsof Ch'-u st\ , edited by Bridses, 2d ed . 1 vol. f?vo.. with several hundred illustrations. With various other important "Works. 4 LEA & BLANCHARD'S PUBLICATIONS. PROFESSOR MEIGS' NEW WORK.—Now Ready. FEMALES AND T~H EIR DISEASES; A SERIES OF LETTERS TO HIS CLASS. BY C. D. MEIGS, M. D.f Professor of Midwifery and the Diseases of Women and Children in the Jefferson Medical College, Phila- delphia, &c. &.C. In one large and beautifully printed octavo volume of six hundred and srventy pages. We think that Dr. M. has done to his class, and to the profession generally, a service for which they will be grateful, aud for which he merits the approbation of all. He has endeavored to perform his task, he tells us. in a spirit of " freedom and abandon," very different from tbe dulness which has hitherto charncterized medical writings; and we think he has succeeded in producing a very agreeable, amusing, clever und in- structive book, which will be read with pleasure, and be likely to be impressive.—N. Y. Annalist. He has evidently seen almost every form and variety of female disease, and not only seen, but observeJ and reflected, and if we may judge by the innate evidence aflbided by the volume itself, practised success- fully. His volume contains many practical hints and suggestions which will repay perusal.— The Charleston Medical Journal and Review. The work is written in a free, animated conversational style, and is replete with sound practical instruc- tion.— The Wtftern Lancet. We warmly commend the work of Professor Meigs as a highly interesting and instructive volume.— N. Y. Journal of Medicine. The remaining affections of the womb, included in the volumes before us, are treated of very learnedly, and much valuable instruction is communicated concerning them. Dr. Meigs' views as lo the nature and causes of these affections are generally correct, while his long and extensive experience gives to his practical direc- tions no trifling weight. The work contains a very large fund of valuable mutter, and will, in all probability, become a very popular one.—American Medical Journal, Jan 1--4-?. His great reputation, the change in the book from the usual manner of writing, and the intrinsic merits with which the work abounds, will give it a wide spread circulation, and a very general perusal.— Northern and Western Medical and Surgical Journal. The style is certainly not faultless, but yet it is one which, we venture to believe, will prove acceptable to most of the readers to whom it is especially addressed. Il is fresh, buoyant, varied and sprightly, and one is carried along by it without weariness. "As lo the doctrine and the precept of these letters," we think wilh the author, that "he had a right, at his time of life, to be heard upon them." and we are quite sure that he will be heard with great advantage. Whatever difference of opinion there may be respecting the manner of the letters, there can be no diversity as lo the matter. They are full of instruction It would be difficult lo point to a volume containing more valuable information relative to females and their diseases. We take leave of these Letters with the conviction that they will be productive of great good. They will be read with attention by many who would not have patience to wade through an elaborate, systematic treatise on diseases of females, and there is something in the dashing, random style which serves lo impress their sen- timents upon the memory. We do not undertake to say that the style is the best; it would probably be hazard- ous to assert that il is even a proper one for such a subject; but we must say. that it has contributed its share towards the pleasure wilh which we have read this volume —The Western Journal 0/Medicine and Surgery. MEIGS ON CHILDREN—Nearly Ready. ON CERTAIN DISEASES OE INFANTS. BY C. D. MEIGS, M. D. In One Octavo Volume. New Edition--Revised for this Country, 1848. THEORY AND PRACTICE OF MIDWIFERY. BY FLEETWOOD CHURCHILL, M. D., Hon. Fellow of the Royal College of Physicians of Ireland, &c. &c WITH NOTES AND ADDITIONS BY ROBERT M. HUSTON, M. D., &c. Third American Edition, Revised and Improved by the Author. WITH ONE HUNDRED AND TWENTY-EIGHT ILLUSTRATIONS. In one very handsome octavo volume. Preface to the Third American Edition by the Author.—I have been requested by the American publishers to revise this edition of my book, and to make such additions as the progress of science may have rendered necessary. This I have done so far as time permitted ; and though I confess that the work is far from being as complete as I could wish, yet 1 see no reason to modify or change the principles therein incul- cated. An extended experience will of course, in all such cases, involve the insertion of new mat- ter; and, owing to the industry of my friend Dr. Huston, I feel satisfied that few facts of importance have been omitted. I owe a large debt of gratitude to my American friends,which I gladly take this opportunity of acknowledging, and also to the profession in America for the flattering reception they have given to my volumes. No reward could be more highly valued by me, nor could anything make me more anxious, by labor and study, to make my works as perfect as possible, than the knowledge that their usefulness may extend to another hemisphere.—Dublin, November, 1847. As we have formerly called the attention of our readers to the extraordinary merits of this work, we need onlyadd, that it coxt'iiues to occupy the foremost rank among publications connected wilh the obstetric art. The author has added also to its utility by posting up all the new facts and observations which have trans- piredstnce the appearance of the last edition.—TV Y. Journal of Medicine. LEA & BLANCHARD'S PUBLICATIONS. 5 Now Complete—THE GREAT SURGICAL LIBRARY. A SYSTEM OF SUEGERY. BY J. M. CHELIUS, Doctor in Medicine and Surgery, Public Professor of General and Ophthalmic Surgery, &c &c. in the University of Heidelberg. 4™ ,„™, TRANSLATED FROM THE GERMAN, A.^U ACCOMPANIED WITH ADDITIONAL NOTKS AND OBSERVATIONS, BY JOHN F. SOUTH, Surgeon to St. Thomas' Hospital. EDITED, WITH REFERENCE TO AMERICAN AUTHORITIES, BY GEORGE W. INORRiS, M.D. Now complete, in three large Svo volumes of nearly twenty-two hundred pages, or in 17 numbers, at 50 cnh. I his work has been delayed beyond the time originally promised for its completion, by the very extensive additions of the translator, and by the size ofthe very complete Index, extending to over 170 large pages in double columns. In answer to numerous inquiries, the publishers now have the pleasure to present it in a perfect state to the profession, forming three unusually large volumes, bound in the best manner, and sold at a very low price. The most learned and complete systematic treatise now extant— Edinburgh Medical Journal. No work in the English language comprises so large an amount of information relative to operative medl Cine and surgical pathology.—Medical Gazette. We have, indeed seen no work which so nearly comes up to our idea of what such a production should be, both as a practical guide and as a work of reference, as this; and the fact that it has passed through six edi- tions in Germany, and been translated into s.-ven languages is sufficiently convincing proof of in value. It is methodical and concise, clear and accurate ; omitting all minor details and fruitless speculations, il gives us all the information we want in the shortest and simplest form— The New York Journal of Medicine. ENCYCLOPiEDIA OF MATERIA MEDICA.—Amply Illustrated. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS, COMPREHENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPO- SITION, EFFECTS AM) USES OF MEDICINES. BY JONATHAN PKREIRA, M.D., F.R.S. and L. S., Member of the Society of Pharmacy of Paris; Examiner in Materia Medica and Pharmacy ofthe Univers'.ty of London; Lecturer on Materia Medica at the London Hospital, &c. &c. Second American from the last London Edition, enlarged and improved. WITH NOTES AND ADDITIONS BY JOSEPH CARSON, M.D. In two volumes octavo, containing Fifteen Hundred very large pages, illustrated by Two Hundred awl Seventy-Jive Wood cuts. Notwithstanding the large size of this work, and the immense quantity of matter contained in its closely printed pag' s, it is offered at a price so low as to place it within the reach of all. This encyclopaedia of Materia Medica for such it may justly be entitled, gives the fullest and most ample exposition of materia medica and its associate branches of any work hitherto published in the English language. It abounds in research and erudition; its statements of facts are clear and methodically arranged, while .ts therap. utical explanations are philosophical, and in accordance wilh sound clinical experience. It is equally adapted as a text-t>ook for students, or a work of reference for the advanced practitioner, and no one can con- sult its pages without profit The editor has performed his task wilh much ability and judgment. In the first American edition he adopted the Pharmacopoeia of the United States, and the formula? set forth in that stand- ard authority; in the present he has introduced an account of substances that have recently attracted attention by their therapeutic employment, together with the mode of forming the characters and uses of new pharma- ceutic preparations, and the details of more elaborate «*nd particular chemical investigations, wilh respect to the nature of previously known and already descrilied elementary principles: all ihe important indigenous medicines of the United Slates heretofore known are also described The work, however, is too well known to need any further remark. We have no doubt it will have a circulation commensurate with its extraordi- nary merits.— The New York Journal of Medicine. CONDIE ON CHILDREN—New Edition, 1847. a practicalYreatise on fIS BHSIEA^H^ ©IF ©HHILIDIEIiHo BY D. FRANCIS CONDIE, M. D., Fellow of the College of Physicians; Member of the Am-rican Philpsophical Society, 4c. Second Edition. In One large Octavo Volume. The publishers would particularly call the attention of the profession to an examination of this work which has been extensively introduced as a text-book throughout the Union. The best treatise on the diseases of children in the English language.—Medical Examiner. A far more complete exposition of its subject than any oilier treatise on the diseases of children in the Eng- ish language.—American Medical Journal. From Prcftssor PalUn. ofthe University of St. Louis. " I consider it the best treatise on the diseases of children that we possess, and as such have been in the tabit of recommending it as a textbook to my classes." 6 LEA AND BLANCHARD'S PUBLICATIONS. MANUALS FOR EXAMINATION NOW READY. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE, FOR THE USE AND EXAMINATION OF STUDENTS. BY JOHN NEILL, M. D., DEMONSTRATOR OF ANATOMY IN THE UNIVERSITY OP PENNSYLVANIA, LECTURER ON ANATOXY IN THE MEDICAL INSTITUTE OF PHILADELPHIA, ETC., AND FRANCIS GURNEY SMITH, M.D., LECTURER ON PHYSIOLOGY IN THE PHILADELPHIA ASSOCIATION FOB MEDICAL INSTRUCTION, ETC ETC. Fencing One very large and handsomely printed Volume in royal duodecimo, of over Nine Hundred large pages, with about Three Hundred and Fifty Wood Engravings, strongly bound in leather, with raised bands. The great progress of the Medical Sciences, and the increasing number and size ofthe standard text-books in the various departments of Medicine and Surgery, have created a necessity for Com- pends or Manuals, to assist the student in the prosecution of his labors, and the practitioner in refreshing his recollection of former studies. The present work has been prepared solely to meet this want. No one could pretend to com- press into a limited space all the information necessary to the student or practitioner; but the authors hope to have succeeded in embodying in its pages the elements of medical science; as much, indeed, as is compatible with its character as an analysis. While, therefore, the volume is not offered as a substitute for the ordinary text-books, or to lessen the necessity of regular attendance on lectures, or close office study, it can hardly fail to be of practical use.in facilitating the acquisition of know- ledge by the student. It is hoped, also, that the arrangement adopted will be found at once con- cise and intelligible, and that the mechanical execution of the work, its copious illustrations, and neat, cheap and compendious form will prove all that can be desired by the student and prac- titioner. To adapt it still further to the use of the student; the work is divided into seven portions, cor- responding to the leading divisions of medical and surgical science. These are paged separately, and may be had done.up in stout covers, each being perfect in itself, and forming convenient vol- umes to carry in the pocket to the lecture room, or fitting them to be sent by mail. It will thus be seen that this work affords, at a price unprecedentedly low, a series of digests of the medical and surgical sciences, clearly and conveniently arranged, and forming a complete set of HANDBOOKS FOR STUDENTS, as follows:— ANATOMY; I MATERIA MEDICA AND 180 large pages, with 157 Illustrations. Price 75 Cents. PHYSIOLOGY; 134 pages, with 40 Illustrations. Price 60 Cents. THERAPEUTICS; 116 pages, with 29 Illustrations. Price 50 Cents. CHEMISTRY; SURGERY" 94 pages, with 19 Illustrations. 122 pages, with 51 Illustrations. | Frke 40 Ce,Us- Price 60 Cents. I ------ OBSTETRICS- ' THE PRACTICB OF MEDICINE; 114 pages, wilh 37 Illustrations. j 152 PaSes> with 3 Illustrations. Price 50 Cents. \ Price 50 Cents. Any one of which may be had separate; or, the whole will be done up and mailed, with the post- age prepaid, on the remittance of §4; or, if $o is remitted, The Medical .News will be sent in addition. It should be noticed that the amount of matter on a page U unusually large, thai making these Handbooks not only low priced, but extraordinarily cheap. LEA & BLANCHARD'S PUBLICATIONS. 7 DISPENSATORY AND FORMULARY—Now Ready. A DISPENSATORY AND THERAPEUTICAL REMEMBRANCER, COMPRISING THE ENTIRE LISTS OF MATERIA MEDICA, WITH EVERY PRACTICAL FORM LA CONTAINED IN THE THREE BRITISH PHARMACOPOEIAS With Relative Tables subjoined, Illustrating by upwards of 660 Examples, THE EXTEMPORANEOUS FORMS AND COMBINATIONS SUITABLE FOR THE DIFFERENT MEDICINES. BY JOHN MAYNE, M. D., L. R. C. S., Emx., &c. &c. Edited, with the addition of the Formulae of the U. S. Pharmacopeia, BY It. EGLESFELD GRIFFITH, M. D., Author of '-.Medical Botany," &c. In One Duodecimo Volume, of over three hundred large pages. There is no work before the Profession, presenting in ihe same compass what the author and editor have attempted lo embrace in this little volume—namely an unabridged practical formulary of the three British Pharmacopoeias, and that of the United Stales ; and this in addition to a full ampunt of collective information as to the uses of the different medicines, and other important points relating to remedial means and appliances. The various advantages derivable from possession of a clear and comparative view—such as is herein submitted—of the ofTicinal preparations directed by the high authorities referred to, are self-evident, and must be appreciated by the prescriber as well as the dispenser of medicines. Another feature of originality, which it is expected will prove highly serviceable, is the introduction, wherever deemed requisite, of extemporaneous formulae into the work These are separated from ihe phar- macopoeial or continuous text of each page in ihe (brm of foot-notes; and it need scarcely be explained, are intended (o assist the practitioner's memory, by suggestions of forms and combinations most suitable for ihe medicinal substances to which they are annexed. Mr Dear Maine:—I have looked over the proofs. Your little work will be exceedingly useful. I shall be very glad to see a copy of it, and to notice my name as you propose lo place it. Believe me, &c. &c. ROBERT LIsTUN. Cliffokd St., Nov. 3, 1847. Tlie neat typography, convenient size, and low price of this volume, recommend it especially to physi- cians, apothecaries and students in want of a pocket manual. SARGENT'S MINOR SURGERY—A New "Work, 1848. DN BANDAGING, AND OTHER POINTS OF MINOR SURGERY. BY F. W. SARGENT, M. D. In one handsome volume, royal VZmo., with nearly 400 Pages, and 12S Wood-cuts. CONTEXTS. Part I-Chapter 1, Instruments used in Dressing. Chapter 2 Surgical Dressings. Chapter 3. General Rules for Dressing. Chapter 4, On the use of Water (Irrigation, Douche, Bathing, Water and Vapor Baths), Fumi- S PartTi- EanJaVe^andetheiT Application. Chapter 1, The Roller or Simple Bandage; Compound Band- ages ; M. Mayer's System of Bandaging. Chapter 11. Regional Bandaging, (head and neck, trunk, upper 6KpAKT\\\-BandTgZmand Apparatus for the Treatment of Fractures Chapter 1. General Considerations. Chapter 2, Fractures of tbe Bones of the Head and Trunk. Chapter £ Fractures of the Bones ofthe ShouU er. Chapter I. Fractures of the Humerus, Forearm, Wrist and Hand. Chapter 5, Fractures of the Bones of the L pTkt 1V-M"chanical means employed in the Treatment of Dislocations Chapter 1. Bones of the Head and Yunk Chapter I Bones of the Upper Extremity. Chapter 3, Bones of the Lower Extremity. Chapter 4, LIBRARY OP OPHTHALMIC MEDICINE AND SURGERY—Brought up to 1S17. A TREATISE ON THEDISEASES OF THE EYE. ' BY W. LAWRENCE, F.R.S., Surgeon Extraordinary lo the Queen; Surgeon to St Bartholomew's Hospital, &c. &.C. " A NEW EDITION, nr-w ,nanu Modifications and Additions, and the Introduction of nearly Two Hundred niustrations. BY ISAAC HAYS, M.D., Surgeon to Wills' Hospital; Physician to the Philadelphia Orphan Asylum, &e. &c. lnrge ortaro volume of near 5)00 pages, with 12 plates and numerous wood-cuts through the text. In one ver ^ iargest and most complete works on this interesting and difficult branch of Medical Science. This is 8 LEA & BLANCHARD'S PUBLICATIONS. ATLAS OF ANATOMY, for the Medical Student Prict only Mtve Hollar*, fit part*. AX ANATOMICAL ATLAS ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN BODY. BY HENRY H. SMITH, M.D , Fellow of the College of Physicians, tee. UNDER THE SlPEnviSlON OF WILLIAM E. HORNER, M.D., Professor of Anatomy in the University of Pennsylvania In One large Volume, Imperial Octavo. This work consists of five parts, whose contents are as follows: Part I. The Bones and Ligaments, with one hundred and ihirly engravings. Part II. The Muscular and Dermoid Systems, wilh ninety-one engravings. Part IN. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. Part IV. The Organs of Respiraiion and Circulation, with ninety-eight engravings. Pakt V. The \ervous System and the Senses, wilh one hundred and twenty-six ensravines. Fo miiig altogether a complete System of Anatomical Plates, of nearly SIX HUNDRED AND FIFTY FUTURES, executed in the best style of art. and making one large imperial octavo volume. Those who do li- i want it in pans can have the work bound in extra cloth or sheep at an extra cost. HORNER'S ANATOMY, New Edition. SPECIAL ANATOMY AND HISTOLOGY, BY WILLIAM E. HORNER, M. D., Frofessor of Anatomy in the University of Pennsylvania, &c. &c. SEVENTH EDITION. With many improvements and additions. In two octavo volumes, with illustrations on wood. The nnme of Professor Horner is a sufficient voucher for the fidelity and accuracy of any work on anatomy; bin if any further evidence could be required of the value of the present publication, il is afforded by the fact or" i's having reached a seventh edition. It is altogether unnecessary now to inquire into the particular merits of a work which has been so long before tlie profession, and is so well known ns the present one, but in an- nouncing a new edition, it is proper to state that it has undergone several modifications, and has been much ev nded. so as to place it on a level with the existing advanced state of anatomy. The histological portion H- been remodelled and rewritten since the last edition; numerous wood-cuts have been introduced, and spe- c t c referents*-* are made throughout the work to the beautiful figures in the Anatomical Alias, by Dr. H. II. bjii.lh.— The American Medical Journal for January 1647. HORNER'S DISSECTOR THE UNITED STATES DISSECTORj BEING A NEW EDITION, WITH EXTENSIVE MODIFICATIONS, AND ALMOST REWRITTEN, OF "HORNER'S PRACTICAL, ANATOMY." In One very neat Volume, royal \'2mo., with many Illustrations on Wood. Anything emanating from the pen of Professor Horner, on anatomical science, is sure to be at once clear and correct. For more than 20 years this valuable little work has been before Ihe'profession, and during that I -.-I :od. sustained the high reputation of its author as a great practical anatomist. It is at the same time con c se and simple in its arrangement, beginning with the alphabet of the science, and gradually leading the stu deni onward to the more ample part of the study. Every student who wishes to acquire a correct knowledge of Anatomy, should have a copy of this book spread before him on the dissecting table.— The New Orleans Medical and Surgical Journal. Much Enlarged Edition—Now Ready. THE HISTORY, DIAGNOSIS AND TREATMENT OF THE FEYERS OF THE UNITED STATES. BY ELISHA BARTLETT, M. D., Professor of the Theory and Practice of Physic in the Medical Department of Transylvania University, tec. In One Octavo Volume of 550 Pages, beautifully printed and strongly bound. Decidedly the most valuable treatise on Fevers wilh which we are acquainted. As its title indicates, it coma ns ihe '• MiMory, DiagnosN and Treatment of the Fevers ofthe United States." comprehending Typhoid, Typhi's. Periodical and Yellow Fevers. The work is remarkably »ysi^matic, and written in a clear, perspi- c; m- and easy style. It is eminently calculated to be useful to tne profession, and cannot fail to secure lo its h' ' • -I'lthor a European reputation, as well as to reflect credit upon the medical literature of our country.— &. :•' ■ rn Medical and Surgical Journal. LEA & BLANCHARD'S PUBLICATIONS. 9 DUNGLISON'S PRACTICE OF MEDICINE, Enlarged and Improved Edition, Brought up to 1848. THE PRAGTIG£~OF MEDICINE; A TREATISE ON SPECIAL PATHOLOGY AXD THERAPEUTICS. THIRD EDITION. By ROBLEY DUNGLISON, M. D., Professor ofthe Institutes of Medicine in the Jefferson Medical College; Lecturer on Clinical Medicine, Src In Two Large Octavo Volumes of Fifteen Hundred Pages. Professor Dunglison's work has rapidly passed to the third edition, and is now presented to the profession as probably the most complete work on the Practice of Medicine that has appeared in our country. It is especially characterized by extensive and laborious research, minute and accu- rate pathological, semeiological and therapeutical descriptions, together with that fullness of detail which is so important to the student. The present edition has been considerably enlarged ; indeed the indefatigable author seems to have explored all ofthe labyrinths of knowledge, from which important facts and opinions could be gleaned, for the instruction of his readers. We cheerfully commend the work to those who are not already familiar with its merits. It is certainly the most complete treatise of which we have any knowledge. There is scarcely a disease which the student will not rind noticed.— Western Journal of Medicine and Surgery. One ofthe most elaborate treatises of the kind we have.—Southern Medical and Surg. Journal. The work of Dr. Dunglison is too well known, to require at our hands, at the present time, an analysis of its contents, or any exposition ofthe manner in which the author has treated the several subjects embraced in it. The call for a third edition within five years from the appearance of the first, is, of itself, a sufficient evidence of the opinion formed of it by the medical profession of our country. That it is well adapted as a text-book for the use ofthe student, and at the same time as a book of reference for the practitioner, is very generally admitted ; in both points of view, for accu- racy and completeness, it will bear a very advantageous comparison with any of the numerous co- temporary publications on the practice of medicine, that have appeared in this country or in Europe. The edition before us bears the evidence of the author's untiring industry, his familiarity with the various additions which are constantly being made to our pathological and therapeutical knowledge, and his impartiality in crediting the general sources from which his materials have been derived. Several pathological affections, omitted in the former editions, are inserted in the present, while every portion of the work has undergone a very thorough revision. It may with truth be said, that nothing of importance that has been recorded since the publication of the last edition, has escaped the attention of the author; the present edition may, therefore, be regarded as an adequate exponent of the existing condition of knowledge on the important departments of medicine of which it treats.—The American Journal of the Medical Sciences, Jan. 1848. The Physician cannot get a better work of the kind than this, and when he masters iis contents, he will have mastered all that such treatises can afford him.—St. Louis Med. <$■ Surg. Journal, June 1848. DUNGLISON ON NEW REMEDIES. NEW EDITION. NEW REMEDIES. BY ROBLEY DUNGLISON. M. D., &c. &c. Fifth edition, with extensive additions. In one neat octavo volume. A work like this is obviously not suitable for either critical or analytical review. Il is, so far as it goes, a dispensatory, in which an account is given of the chemical and physical properties of all the articles recently added to the Materia Medica and their preparations, wilh a notice of the diseases for which they are pre- scribed, the doses, mode of administration, &c — The Medical Examiner. THE MEDIGAL STUDENT, OR AIDS TO THE STUDY OF MEDICINE. A REVISED AND MODIFIED EDITION. BY ROBLEY DUNGLISON, M.D. In one neat Vimo. volume. HUMAN HEALTH; Or the Influence of Atmosphere and Locality, Change of Air and Climate, Sea- sons Food, Clothing, Bathing and Mineral Springs, Exercise, Sleep, Corpo- real and Intellectual Pursuits, &c. &c. on Healthy Man: Constituting ELEMENTS OF HYGIENE. BY ROBLEY DTXGLISOX. M.D. A New Edition with many Modifications and Additions. In one Volume. Sro. 10 LEA. & BLANCHARD'S PUBLICATIONS. THE GREAT AMERICAN MEDICAL. DICTIONARY, NEW AND ENLARGED EDITION, BROUGHT UP TO SEPTEMBER, 1848. NOW READY, MEDICAL LEXICON; A DICTIONARY OF MEDICAL SCIENCE, CONTAINING A CONCISE EXPLANATION OF THE VARIOUS SUBJECTS AND TERMS, WITH THE FRENCH AND OTHER SYNONYMES; NOTICES OF CLIMATE AND OF CELEBRATED MINERAL WATERS; FORMULAE FOR VARIOUS OFFICINAL AND EMPIRICAL PREPARATIONS, ETC. BY ROBLEY DUNGLISON, M. D., PROFESSOR OF THE INSTITUTES OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, PniLADELFHIA, ETfc. ETC. SEVENTH EDITION, CAREFULLY REVISED AND GREATLY ENLARGED, In One very large and beautifully printed Octavo Volume of over Nine Hundred Pages, closely printed in double columns. Strongly bound in leather, with raised bands. Since its first publication, many years since, this work has been steadily advancing in reputation and increasing in favor with the profession, till it may now safely be pronounced THE STANDARD AMERICAN MEDICAL DICTIONARY. Never having been stereotyped, the author has been able, in the successive reprints, to embody all the novelties and improvements of science as fast as they'have appeared, to accomplish which great industry as well as great judgment has been necessary. As an exemplification of the man* ner in which this work is kept up to the day, it may be stated that this edition contains OVER SIX THOUSAND WORDS AND TERMS not embraced in the preceding, which, in its turn, had TWO THOUSAND FIVE HUNDRED more than the Fifth Edition. The profession, therefore, can understand the manner in which this work has gradually increased until it contains satisfactory definitions of OVER FORTY-FIVE THOUSAND WORDS. Thus becoming a vast reservoir of medical Science in all its branches. It will thus be seen why it is regarded as the STANDARD WORK OF REFERENCE FOR THE MEDICAL PROFESSION. E\ cry means has been employed in the preparation of the present edition, to render its me- chanical execution and typographical accuracy in every way worthy its extended reputation and universal use. The size ofthe page has been enlarged, and the work itself increased more than a hundred pages; the press has been watched with great care; a new font of type has been used, procured for the purpose; and the whole printed on fine clear white paper, manufactured expressly. Notwithstanding this marked improvement over all former editions, the price is retained at the original low rate, placing it within the reach of all who may have occasion to refer to its pages. From among numerous notices of former editions, the publishers append a few. T1 ■(■ most complete Medical Dictionary in the English language— We^frn Lancet V.". but express the general opinion when we suy iImi Dr. Dunglison's Dictionary has not its superior, if, indeed, ii.« equal, in the English language. So much for the preceding editions. The present is, of course, an improvement on its predecessors, and coma n< all the new terms employed by advancing science. We hearti- ly recommend tl.ls Dictionary to medical men, as they will lie able to find in it almost every term used in the medical and collateral sciences, and almost every topic embraced by these long aud volumuous annuls. Il is a work deemed to constitute the proudest monumeiitof its author's industry nnd learning—to perpetuate through coming centuries the memory of his name and hts services to science—to reflect honor on American medicine.—St. Louh Med. and Surg. Journal. Tin Dictionary of Professor Dunglison mght, without any great stretch of propriety, be called a Cyclopedia or Medical Science, so comprehensive is it "in its tcope. and so minute in its details In this respect it pos- sesses a gr at advantage over its contemporary publications of the kind. Whatever one may expect to meet with in a dictionary of terms, he is pretty sure to find in as ample pages besides a vast deal of matter not commonly embraced in medical lexicons, aud not readily found in other publications.—Tlit Medical Examiner. LEA & BLANCHARD'S PUBLICATIONS. 11 A NEW EDITION OF DUNGLISON'S HIMAN PHYSIOLOGY. HUMAN PHYSIOLOGY. WITH THREE HUNDRED AND SEVENTY ILLUSTRATIONS. BY ROBLEY DUNGLISON, M.D., PROFESSOR OPTIIE INSTITUTES OF MEDICINE IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA, ETC. ETC. Sixth edition, greatly improved.—In two large octavo volumes, containing nearly 1350 pages. Dre^ntinffthis^'tion *J°„nff FEei*e? throl,Sh°ut,he u»i°n as the leading lext-book on Physiology, that in FhmSifcal exec^tinnnf h r8J)?emi1 "pessary only to remark that they have endeavored to render he number, |, JJP"r°,f. ,he,wo>-k in some degree worthy its acknowledged merits by an advance in both author ssX ien ^mLm^?h UStriJl'°ni and. *» improvement in the style of printing. The name of the author is sufficient guarantee that each new edition fully keeps pace with the advance of science. DUNGLISON'S TIIERAPEUTICS-New and Much Improved edition. GENERAL THERAPEUTICITaND MATERIA MEDICA. With One Hundred and Twenty Illustrations. ADAPTED FOR A MEDICAL TEXT-BOOK. BY ROBLEY DUNGLISON, M. D., Professor of Institutes of Medicine, &c. in Jefferson Medical College; late Professor of Materia Medica, &c in the Universities of Virginia and Maryland, and in Jefferson Medical College. Third Edition, Revised and Improved, in Two Octavo Volumes, well bound. Our junior brethren in America will find in these volumes of Professor Dunglison a "Thesaurus Medica- minum" more valuable than a large purse of gold— London Medico-Chirurgical Review. GRIFFITH'S UNIVERSAL FORMULARY—Nearly Ready. THE UNIVERSAL FORMULARY: A SYNOPSIS OF THE PHARMACOPOEIAS, DISPENSATORIES AND FORMULARIES OF EUROPE AND AMERICA. WM NUMEROUS MAGISTERIAL FORMULAS FROM VARIOUS SOURCES. BY R. E. GRIFFITH, M.D., &c. &c, Author of "Medical Botany," &c &c In One Octavo Volume. This work is intended to emhrace all that is of practical importance in the numerous Pharmacopoeias, Form- ularies and Dispensatories of Europe and of this country, as well as such formulas as appeared deserving of notice in the Medical Journals. Treatises of'Medicine. &c. See., together with many others, derived from pri- vate sources, which-have never been hitherto published It will therefore include all that is really useful in Redwood's Edition of Gray's Supplement to the Pharmacopoeias, in Jourdan's Pharmacop^e, and the several works of Ellis, Fee, Paris, Thomson, Beasley, Cottereau,Cooley, Bouchardat, &c. As, in accordance with iis title of a Universal Formulary, it will not be confined solely to medical formulas, the publishers hope that tlie numerous scientific receipts embraced, will render it of much practical importance to the Chemist and Manufacturer. It will contain UPWARDS OF SIX THOUSAND FORMULAS, alphabetically arranged, with copious indexes, pointing out the diseases in which the preparations are to be used, Sec. Sec, and thus combining the advantages of all the differentmodes of arrangement and reference, NEW AND COMPLETE MEDICAL BOTANY—Lately Published. OR, A DESCRIPTION OF ALL THE MORE IMPORTANT PLANTS USED IN'MEDICINE, AND OF TIIEIR PROPERTIES, USES AND MODES OF ADMINISTRATION. BY R. EGLESFELD GRIFFITH, M. D., &c. &c. In One large Octavo Volume, handsomely printed, with nearly Three Hundred and Fifty Illustrations on Wood. The author of the volume is well known to be particularly qualified for this undertaking, by his botanical, as well as medical and pharmaceutical knowledge; and it strikes us, on cursory examination, that it has been prepared with ruuch care and faithfulness, and that it will take iis place at once as the standard woTk on the sUliiect in this country. A succinct introductory chapter is devoted to the anatomy and structure of plants their classical composition und products, and the outlines of classification. The officinal plains are introduced under their several natural orders, which, with the general systematic arrangement of De Cart- dolle. are thrown iiUo groups afier the manner of Dr. Lindley. The plants winch are really important in the Materia .Medica are described in full, as well as the officinal part or production; the others are more briefly noticed:'nnd the references, which are faithfully made, both to the botanical and medical authorities, will serve iii all cases to direct the. inquirer to the original sources of inibrmation.—Siiliman's Journal. 12 LEA & BLANCHARD'S PUBLICATIONS. A NEW DISPENSATORY, NOW READY. A DISPENSATORY, OR COMMENTARY ON THE PHARMACOPEIAS OF GREAT BRITAIN AND THE UNITED STATES: COMPRISING THE NATURAL HISTORY, DESCRIPTION, CHEMISTRY, PHARMACY, ACTIONS, USES AND DOSES OF THE ARTICLES OF THE MATERIA MEDICA. BY ROBERT CHRISTISON, M.D., V.P.R.S.E., PRESIDENT OF THE ROYAL COLLEGE OF PHYSICIANS OF F.DINBURGH, PROFESSOR OF MATERIA MEDICA IN THE UNIVERSITY OF EDINBURGH, ETC. Second Edition, Revised and Improved, WITH A SUPPLEMENT CONTAINING THE MOST IMPORTANT NEW REMEDIES. WITH COPIOUS ADDITIONS, AND TWO HUNDRED AND THIRTEEN LARGE WOOD ENGRAVINGS, BY R. EGLESFELD GRIFFITH, M.D., AUTHOR OF "A MEDICAL BOTANY," ETC. SPECIMEN OF THE ILLUSTRATIONS. Artemisia Absinthium, "Wormwood." In One very large and handsome Octavo Volume of over One Thousand closely printed Pages, unth numerous Woodcuts, beautifully printed, on fine white paper. Presenting an immense quantity of matter at an unusually low price. LEA & BL\NCHARD'S PUBLICATIONS 13 CHRISTISON AND GRIFFITH'S DISPENSATORY—Continued. ^The Dispensatory of Professors Wood & Bache has so long and so satisfactorily supplied the tl»t 1°! f l,ro^e88'on tf)at the publishers, in presenting a new work ofthe same description, feel of n rL- • po98ee8 *dd»t'<">al attractions to entitle it to notice. The value of the original work of tl ti o8tn"™ '" WC" known '" England, where it has long occupied a position similar to that oi tne u. b. Dispensatory in this country. To this it is entitled by its clearness, conciseness, and completeness, and the care with which the author has kept it on a level with the improvements of medical science, by corrections, and embodying in it all the new articles of the materia medica, • " PreP:lrinS ll for the use of the profession in this country, Dr. Griffith has made very exten- sive additions, introducing all the processes of the U. S. Pharmacopoeia, as well as a full medical, pharmaceutical and botanical history of all articles recognized by our national standard which have been omitted by the author. In addition to this, the editor has made free use of all European and American authorities on Materia Medica, among which may more particularly be mentioned Red- wood s hecond Edition of Gray's Supplement to the Pharmacopoeia, just issued, which has supplied him with much useful information, and from which he has endeavored to convey all that appeared " J ---------.*.«.. fcv lino, u.v^i \.vi kj 11UI1UICU VYUUU-CU19 lldVC UCCII lllllUUU^CU) illustrative of articles of the Materia Medica, rendering this the only Dispensatorv now before the prolession presenting illustrations of the principal articles described therein. The attention of practitioners and students, as well as of all druggists and pharmaceutists, is especially invited to this work as one embodying in the smallest practicable space and at an exceed- ingly low price, an immense amount of indispensable information, and as presenting a complete view of the present practical state of the materia medicos of the four leading pharmacopeias, clearly arranged and concisely expressed. From T. Romeyn Beck, M.D., Prof, of Mat. Med. in the Albany Medical College, and author of " Medical Jurisprudence." Albany, Sept. 8. 1S48. " I received from you this morning a copy of the Second Edition of Christison's Dispensatory, edited by Griffith. I beg you to receive my thanks for this most acceptable present. ''I have been a diligent reader of the first edition and know its value. 1 only regret that the Circular of our College has been published, or I would have placed it among my text-books. Next spring I will certainly do 10 if 1 live and hold the professorship." From W. T. Wilson, M. D., Prof, of Mat. Med. in the Washington University of Baltimore. Baltimore. Aug 31, V-4->. "Allow me to thank you most sincerely and cordially for your kind present of a copy of Cliristison and Griffith's Dispensatory, just published by you. After a cursory glance at the volume, which I shall peruse more at leisure hereafter, I most heartily join in your opinion in regard to its great merits, containing, as it does, all the most modern discoveries and improvements in the materia medica and pharmacy, and r- ndered still more acceptable to the American profession by its beautiful illustrations, the addition of Dr. Griffith, and the handsome style in which you have succeeded in bringing it out. I trust that your enterprise will be libe- rally responded to by those for.whom the woik is chiefly intended." There is not in any language a more complete and perfect Treatise.—N. Y. Annalist. Sept., 1848. Il is not needful that we should compare it with the other pharmacopoeias extant, which enjoy and merit the confidence of the profession: it is enough to say that it appears lo us as perfect as a Dispensatory, in the present state of pharmaceutical science, could be made. If it omiis any details pertaining to this branch of knowledge which the student has a right to expect in such a work, we confess the omission has escaped our scrutiny. We cordially recommend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better.—The Western Journal of Medicine and Surgery, September, 1848. In conclusion, we need scarcely say that we strongly recommend this work to all classes of our readers As a Dispensatory and commentary on the Pharmacopoeias, it is unrivalled in the English or any other lan- guage.—The Dublin Quarterly Journal, July 1848. We earnestly recommend Dr. Chrisiison's Dispensatory to all our readers, a* an indispensable companion, not in the Study only, but in the Surgery also.—British and Foreign Medical Review. Il is exactly the work we would give to the student for daily reading, or to the practitioner for regular refer- ence. Without being encumbered wilh unnecessary detail or research, it is sufficiently explicit in its litera- ture to render it an ample encyclopaedia of iis subject; and at the same time, its practical information is so condensed and summary, yet without a sacrifice of even the least important fact, that to the student it cannot but be a texl-book invaluable in its kind. Had we said less concerning this volume we should have been wanting in common duty ; but it is not ne- cessary that we should say more to convince our numerous readers that we consider Christison's Dispensa- tory to be the best English work extant upon the subject it embraces.—The Medical Times, June lir4S ll comes not within our plan to enter into minute or detailed criticism of a work like the present, lis merits as a treatise on materia medica, chemical pharmacy, and pharmacology, we on a former occasion explained. It i< sufficient to say that the reader will find the character given in that article most ably sustained by ihe present edition. The natural and chemical history of the articles is given wilh great clearness and accuracy. The importaiit'subject of adulterations and sophistications is throughout treated in detail. The pharmacolo- gical instructions show very great practical experience and knowledge, which can be obta ned by experience alone And lastly, the therapeutic directions are expounded in a judiciou* manner, avoiding the extremes of ereat confidence and unrtasonable skepticism. In short, the work may be justly recommended as an excel- lent treatise on Materia Aledicu, Chemical Pharmacy, and Pharmacology.—The Edinburgh Medical and Sur. gical Journal, July lsH. Ji.1RTL.ETT O.A* CERT.lLV/T J.V *HEDlCI.ytE~.lynw Ready. AN INQUIRY INTO THE DEGREE OF CERTAINTY IN MEDICINE^ AND INTO THE NATURE AND EXTENT OF ITS POWER OVER DISEASE. BY KLIsSHA BARTIETT, M. D., Author of " Fevers of the United States," " Philosophy of Medical Science,'1 In One small Volume, crown Svo, extra cloth. 1* LEA & BLANCHARD'S PUBLICATION'S. ~FOWNKS' CllKMLSTKY FOR STUDENTS. A NEW AND IMPROVED EDITION. ELEMENTARY CHEMISTRY! THKORFTICAL AND PRACTICAL. BY GEORGE FOWNES, Ph. D., Chemical Lecturer in the Middlesex Hospital Medical School, Sec. Sec. With Numerous Illustrations. Second American Edition. Edited, with Additions, BY ROBERT BRIDGES, M. D., Professor of General and Pharmaceutical Chemistry in the Philadelphia College of Pharmacy, Sec. Sec. In one large duodecimo volume, sheep or extra cloth. Though this work has been so recently published, it has already been adopted as a text-book by many of the Medical Institutions throughout the country. As a work for the first class student, and as un introduclioii to the larger systems of Cheinisiry. such as Graham's, there has been but one opinion expressed concerning it, and it may now be considered as THE TEXT-BOOK FOR THE CHEMICAL STUDENT. An admirable exposition of the present slate ol" chemical science, simply and clearly wriilen. and display- ing a thorough practical knowledgeof iisdetails. as well as a profound acquaintance with its principles. The illustrations, and the whole geaing-up ofthe book, merit our highest praise.— British and Foreign Med. Rev. Remarkable for its clearness, and ihe most concise and perspicuous work ofthe kind we have seen, admi- rably calculaled to prepare the student for ihe more elaborate treatises—Pharmaceutical Journal. From JAMBS REN'YVICK, Professorof Chemistry, Columbia College, Neio York. "The very best manual of Chemistry wilh which 1 am acquainted in the English language." New York, Feb. 12th, ISIS. This work of Fownes, while not enlarging on the subject as much as Graham, is far more lucid and ex- panded than the usual small introduciory works. Professors recommending it to their classes may rely upon its being kept up to the day by frequent revisions. MANUALS ON THE BLOOD AND URINE: CONSISTING OF I. A PRACTICAL MANUAL, CONTAINING A DESCRIPTION OF THE GENERAL, CHE- MICAL AND MICROSCOPICAL CHARACTERS OF THE BLOOD AND SECRETIONS OF THE HUMAN BODY, AS WELL AS OF THEIR COMPOUNDS, INCLUDING DOTH THEIR HEALTHY AND DISEASED STATES: WITH THE BEST METHODS OF SEPARATING AND ESTIMATING THEIR INGREDIENTS. ALSO, A SUCCINCT ACCOUNT OF THE VARIOUS CONCRETIONS OCCASIONALLY FOUND IN THE BODY AND FORMING CALCULI. BY JOHN WILLIAM GRIFFITH, M. D., F.L.S., &c. II. ON THE ANALYSIS OF THE BLOOD AND URINE IN HEALTH AND DISEASE, AND ON THE TREATMENT OF URINARY DISEASES. BY G. OWEN REES, M. D., F.R.S., &c. &c. III. A GUIDE TO THE EXAMINATION OF THE URINE IN HEALTH AND DISEASE, FOR THE USE OF STUDENTS. BY ALFRED MARKWICK. The whole forming One large royal 12mo. Volume, of Four Hundred and Sixty Pages, With about one hundred, figures on five plates. The three works embraced in the volume were published in London, separately, but the imme- diate connection ofthe subjects treated, and their increasing importance, have induced the Ameri- can publishers to embody them in a volume suitable for reference and preservation. Although addressed especially to studenis, it contains almost all the information upon these matters which the pracliiioner requires.—Dublin Medical Press. The chemical processes recommended are simple, yet scientific; and the work will be very useful to the medical alumni for whom it is intended.—Medical Times. The author must be admitted to have attained his object in presenting a convenient bedside companion.— Dr. Ran/ring's Abstract. CHURCHILL ON FEMALES—Edition of 1847. THE DISEASETOF FEMALES, INCLUDING THOSE OF PREGNANCY AND CHILDBED. BY FLEETWOOD CHURCHILL, M.D., Author of ''Theory and Practice of .Midwifery," &c. &e. FOURTH AMERICAN, FROM THE SECOND LONDON EDITION, WITH ILLUSTRATIONS. EDITED, WITH NOTES, BY ROBERT M. HUSTON, M.D., Sca.Stc. In One Volume, Octavo. The rapid sale of three editions of thi« valuable work stamps it so emphatically with the approbation ofthe profession of this country, that the publishers, in presenting a fourth, deem it merely necessary to observe, that every care has been taken, by the editor, to supply any deficiencies which may have cit fated in former impressions, and to bring the work fully up to the- date of publication. LEA & BLANCHARD'S PUBLICATIONS. 15 New and Enlarged Kdltlon, Brouglit wp to 1848. ■WILLIAMS' PATHOLOGY. Now Ready. PRINCIPLES~OF MEDICINE, COMPRISING GENERAL PATHOLOGY AND THERAPEUTICS, AND A BRIEF GKNKKAL VIKW OF ETIOLOGY, NOSOLOGY, SEMEIOLOGV, DIAGNOSIS, PROGNOSIS, AND HYGIENICS. BY CHARLES J. B. WILLIAMS, M.D, F.R.S., Fellow of the Royal College of Ph\-j;nnl AlvfaruoiiAnc A II t li*» nrrJ^pilinor trtl-»ir»« h*»incr lrf>m*>r1 rtt aC" >pi- :re- ide to"he'stud"nT in'bis investigations ofthe delicate' and complex structure of this beautiful and curious organ r«mi..o'^^^^Z niLo^ and important applications of modern Che- colleges does not permit the teacher to p ^ ^^ Thege lopicS)lherefore, have been at.?." altgfbV th^Jho^vhUe L has pa.scd cursorily over th,se objects which are known only as chemical or miueralogical curiosities._______________________ JONES ON THE EYE—Lately Published. THE PRINCIPLES~AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. ^ BY T WHARTON JONES. F.R.S.. &c. &c. WITH ONE HVXDRBD VXD TEX ILLUSTRATIONS. AVITH «*£Df*,E1) By ISAAU HAYS, M.D., &c. neat volume large royal Vlmo., with Four Platcs,plain or colored, and 93 well executed Woodcuts. 7H 0"^ VCrJf TIC J 22 LEA &. BLANCHARD'S PUBLICATIONS. ILLUSTRATED SERIES OF SCIENTIFIC WORKS, NOW PUBLISHING BY LEA & BLANCHARD. This series comprises works of the highest character on the various branches of practical science. In their illustration and mechanical execution they are prepared wiihoul regard lo expense, and Ihe puhhsheia present them as equal, if nol superior, lo anything us > ct execuitd. I'.acli volume is superni'i-mlctl by a competent editor, who makes such additions as the progress of science in this country may require, anil at the same time corrects such errors us may have escaped the pre^s in London. The publishers, therefore, hope that these works may attract the approbation ot the scienitfic public by their intrinsic value, the cor- rect in -> ofthe text, the beautiful sty le in which they are produced, and the extremely low rale at which they are furnished. THE FIRST VOLUME IS PRINCIPLES OF PHYSICS & METEOROLOGY. BY J. MULLER, Professor of Physics at the University of Freiburg. WITH ADDITIONS AND ALTERATIONS BY THE AMERICAN EDITOR. ILLUSTRATED WITH NEARLY FIVE HUNDRED AND FIFTY ENGRAVINGS ON WOOD, AND TWO COL'D PLATES. In One large Octavo Volume. The Physics of Muller is a work superb, complete, unique: ihe greatest want known to English Science could not have been better supplied. The work is of surpassing interest. The value of this coninbutio n lo the scientific records of this couutry may he estimated by the fact that the cost of the original drawings and engravings alone has exceeded the sum of .£2 (KM).— Lancet. The sty le in which ihe volume is published is in the highest degree creditable to the enterprise of the pub- lishers. It contains nearly six hundred engravings executed in a style of extraordinary elegance We commend the book to general favor. Itis the best of its kind we have everseen.— N. Y Courier Sr Enquirer. We can safely say, that, if the forthcoming works be of equal merit, and produced in similar style, the series will prove one of a very invaluable character, which cannot fail lo be in universal request.—North American. From Wm. H. Bartlett, Esq., Professor of Natural and Experimental Philosophy, U. S. Military Academy, West Point. I deem this work a most valuable addition to the educational facilities ofthe country, and a rich source of information to the general reader, as it is truly an elegant specimen of typo- graphy. West Point, March 15th, 1848. THE SECOND VOLUME IS PRINCIPLES OF THE MECHANICS OF MACHINERY AND ENGINEERING. BY PROF. JULIUS WEISBACH. Edited by PROFESSOR W. R. JOHNSON, OF PHILADELPHIA. Volume I., now ready, containing about 500 pages, and five hundred and fifty wood-cuts. Volume II., completing the work, will be shortly ready, of about the same size and appearance. The most valuable contribution to practical science that has yet appeared in this country. The work em- braces not only the subjects of Statics and Dynamics, but also Hydrostatics, Hydraulics and Pneumatics— each treated in sufficient detail for every practical purpose, and no demonstration calling in the aid of higher mathematics than elementary geometry and algebra. The work is beautifully got up as to letterpress and illustrations, the diagrams being the most picturesque that we have seen.—London Athenezum. From Professor Elias Loomis of the New York University. I have examined Weisbach's Mechanics and Engineering with considerable attention, and I am much pleased with it. It is a work prepared with great care and judgment. The Prin- ciples of Mechanics are stated in a form which is clear, concise, and easily understood; they are reduced to precise rules or formulae, and are abundantly illustrated with numerical examples. The diagrams are numerous, neat, and well calculated to convey clear ideas.— The portion treating ofthe dynamics of fluid bodies is particularly rich, and the results both of theory and experiment are given in a brief and perspicuous form. The entire treatise is intelligible to one who is only familiar with the lower mathematics, and it must become a 'Standard work with mechanics and engineers. New York, May 6th, 1848. From Henry Vethake, Esq., Professor of Mathematics in the University of Pennsylvania. I have examined, with some care, the first volume of " Weisbach's Principles of the Me- chanics of Machinery and Engineering," and I have been not a little gratified in doing so. It is the most comprehensive, accurate, and be.st executed work, on the subject of which it treats, with which I am acquainted in the English language; and the labors of the American editor have considerably enhanced its original value. Let me say, too, that by presenting it, as well as the other volumes ofthe series of which it is a part, to the American public, you will, in my opinion, contribute largely to raise the standard of scholarship in our country, especially in respect to the applications of science to the mechanical an chemical arts. Philadelphia, May 26th, 1848. LEA & BLANCHARD'S PUBLICATIONS. 23 Illustrated Series of Scientific Works—Continued. THE THIRD VOLUME IS TECHNOLOGY; OR, CHEMISTRY AS APPLIED TO THE ARTS AND TO MANUFACTURES. BY F. KNAPP. TRANSLATED AND EDITED BY DR. EDMUND RONALDS, AND DR. THOMAS RICHARDSON, [Lecturer on Chemistry at the Middlesex Hospital.] [Of Newcastle.] Revised, with American Additions, by PROFESSOR WALTER R. JOHNSON, OF PHILADELPHIA. WITH NUMEROUS BEAUTIFUL WOOD-CUTS. Volume I., now ready, containing about 500 pages, and 211 beautiful wood engravings. Vol. II., preparing, of a similar size and appearance. This volume contains complete monographs on the subjects of Combustion and Heating-. Illumination and Lighting. Manufactures from Sulphur, Manufacture of Common Salt, Soda, Alkalimetry, Boracic Acid Ma- nufacture, Saltpetre Manufacture, Gunpowder Manufacture, Nitric Acid Manufacture, and Manufacture of Soap, together with an appendix containing various miscellaneous improvements concerning the foregoing subjects. The object of this work is purely practical, presenting in each topic, a clear and condensed view ofthe present stale of the manufacture, with all the improvements suggested by the discoveries of science; the whole illustrated with numerous large and well executed engravings of apparatus, machinery, processes, Sec. Sec. One ofthe best works of modern times —iV. Y. Commercial. June 1848. The original treatise is one of great value; it has been carefully translated by gentlemen themselves well versed in the processes it describes, and consequenlly familiar with llieir technical language—and it has received from them numerous important additions in which are described the most receni improvements in the various chem ical arts as practised in this country.- Mtdir.o-Chhvrgical Review. ... When we saythat this volume begins another of the superb "Library of Illustrated Books, republished from the London series by Lea& Blanchard, of which Muller's Phya.cs and Me'e.0«'0,^;^^*''b"ckh ! Mechanics and Engineering, (the first volume ofthe latter) have already appeared, that >he present work is on a subject eominghome to the business and bosoms, because to the economic interests of Americansi that it" American ediio" is Prof. Walter R. Johnson, who has enriched it will, numerous Y»«frb'« ^d''10"?- ^ results of his own industrious researches in the technological sciences j ami that it is illusira ed and printed in ihe same superb style which marked the previous works ;-we have sufficiently explained to our readers the value of a work which will not need any other cominendation.-Jyorrft. American, Juneltyw. To be followed by works on PHARMACY, CHEMISTRY, ASTRONOMY, HLAr, HYDRAU- LICS, METALLURGY, PATHOLOGICAL ANATOMY, RURAL ECONOMY, &c. &c. Specimen* may be had on application to the JPublither*. BIRD'S NATURAL PHILOSOPHY. NOW READY. ELEMENTS OF NATURAL PHILOSOPHY, BEING AN EXPERIMENTAL INTRODUCTION TO THE PHYSICAL SCIENCES. ILLUSTRATED WITH NEARLY FOUR HUNDRED WOOD-CUTS. BY GOLDING BIRD, M.D., Assistant Physician to Guv's Hospital. FROM THE THIRD LONDON EDITION. IN ONE NEAT DUODECIMO VOLUME. Containing about 400 pages and 372 Wood-cuts. This work is confidently presented lo students in Natural Philosophy as a text-book, uniting advantages 1 his worn: is connueuuy f« , . smai| type, a very arge amount of matter has been scarcely possessed by «T o*"^^ ^w pricedduodecimo volume, emlracfng in a concise but intelligible compressed into he limits of a sin ™0^ee sul(jects of Suitu.s. l)y„amics. Hydrostatics. Pneumostat.es, manner the element* of all «"" « *' ^ n ^lc,rici,^ Vol.aism. Electro-dynamics. Thermo-electricity, Gal- ?^yUn^i^^ht ^uSSd Light, The Ey^uid Optical Apparatus, Thermoucs, and Photography. „m, • t i- •„„:„ omnat nlcasin^stvle, and si ves the results of abstruse researches in a foTmadapt- «Tl,,s b°°*'* ™ »fo^^ I "appear, to have been specially designed to meet the wants °? W 'r'-i'T.r, ,t wo circumstances often forbid the study of more complete treatises : and it must of medical i»^^^° ^ Xb t0Ca„ who seek acquaintance with Natural Philosophy, but have not SKI.«W?nSie.SS to devote much time to ^«-hematics^ ^ ^ ^ ^ ^ ^ y New York, May 6th, 1848. __ Now Ready—ILLUSTRATED DOW QUIXOTE. DON QUIXOTE DE LA MAKCHA. TRANSLATED BY JARV.S. WITH COPIOUS NOTES AND A MEMOIR OF TIIE AUTHOR AND HIS WORKS, ABRIDGED FROM YIARDOT BY THE EDITOR. With Numerous Illustrations after Tony Johannot. In Two handsome Crown Octavo Volumes, extra crimson cloth, half calf or morocco. 24 LEA & BLANCHARD'S PUBLICATIONS. CAMPBELL'S LORD CHANCELLORS. Now Complete in Seven Volumes. LIVES OF THE LORD CHANCELLORS KEEPERS OF TBE GREAT SEAL OF ENGLAND, FROM THE EARLIEST TIMES TO T1IE REIGN OF RING GEORGE IV. BY JOHN LORD CAMPBELL, A.M., F. R. S. E. Now complete in seven handsome crown octavo volumes, extra cloth. Of the solid merit of the work our judgment may be gathered from what has already been said. We will add, that from its infinite fund of anecdote, and happy variety of style, the book addresses itself with equal claims to the mere sreneral reader, as to the legal or historical inquirer; and while we avoid the stereotyped commonplace of affirming that no library can be complete without it, we feel constrained to afford it a higher tribute by pronouncing it entitled to a distinguished place on the slielves of every scholar who is fortunate enough to possess it.—Frazer,s Magazine, April 1;-4S. A work which will take its place in our libraries as one ofthe most brilliant and valuable contributions to the literature ofthe present day.—Athenceum, Dec. 1847. FRANCE UNDER LOUIS PHILIPPE—Now Ready. THE HISTORY OF TEN YEARS, 1830—1840: OR, FRANCE UNDER LOUIS PHILIPPE. BY LOUIS BLANC, Secretary to the Provisional Government of 1848. Translated by WALTER K. 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During ihe lone period in which it has been issuing from the press, it ha? assumed the character of a siandanl work and asoccupying ground hitherto untouched; as embodying numerous historical faels heretofore unnoticed, and as containing vivid sketches of ihe characters and manners of the time., with anecdotes, documents, Sec. Sec, it nresents numerous claims on the attention of both the student of history and the desultory reader. P Those who have been awaiting its completion can now obtain it, forming a handsome set, twelve volumes in six, in various styles of binding. CONTENTS OF THE VOLUMES. Volume I—Matilda of Flanders. Matilda of Scotland. Adelicia of Louvaine, Matilda of Boulogne, and Eleanora of Aquitaine. Volume II.—Berengaria of Navarre, Isabella of An- gouleme, Eleanor of Provence, Eleanor of Castille. Slarguerite of France, Isabella of France, Philippa of Hainaull, and Anne of Bohemia. Volume Ill-Isabella of Valois, Joanna of Navarre. Katherine of Valois. 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Each Number contains about Two Hundred and Eighty Large Octavo Pages. And is appropriately Illustrated with Engravings on Copper, Stone, Wood, &c. THE MEDICAL NEWS AND LIBRARY, Is Published Monthly, and consists of THIRTY-TWO VERY LARGE OCTAVO PAGES, Containing the Medical Information of the day, as well as a Treatise of high character on a prominent department of Medicine. WATSON'S LECTURES ON THE PRACTICE OF PHYSIC, BRODIE'S CLINICAL LECTURES ON SURGERY, AND TODD & BOWMAN'S PHYSIOLOGY Have thus appeared in it, and the work at present publishing is WEST ON THE DISEASES OF INFANCY AND CHILDHOOD. TERMS. THE SUBSCRIPTION TO THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, IS FIVE DOLLARS PER ANNUM. When this amount is forwarded by the first of February, free of postage, it is considered in ad- vance, and the subscriber thereby becomes entitled to the MEDICAL NEWS AND LIBRARY FOR ONE YEAR, Without further charge. For the small sum of FIVE DOLLARS, therefore, the subscriber can obtain a Quarterly and a Monthly Journal ofthe highest character, presenting about FIFTEEN HUNDRED LARGE OCTAVO PAGES, With appropriate Illustrations: Or, for TEX DOLLARS, the publishers will furnish TWO COPIES OF THE JOURNAL, AND THREE OP THE NEWS; Or, for TWENTY DOLLARS, FIVE COPIES OF THE JOURNAL AND FIVE OF THE NEWS. Thus presenting strong inducements to Clubs. Postmasters and others will also thus find it worth their attention to obtain subscribers and remit their subscriptions for these works, which are among THE CHEAPEST OF AMERICAN MEDICAL PERIODICALS. try When the News is ordered separately, the subscription is One Dollar per annum, invariably * * A few copies ofthe Journal and News for IS4S being on hand, the publishers will still sup- ply both periodicals for Five Dollars, if remitted immediately. 30 THE AMERICAN JOURNAL OF TIIK MEDICAL SCIENCES. In calling the attention ofthe profession to the high character of the American Medical Journal, the publishers append an extract from the report of "The Committee on American Medical Literature," to the National Medical Association at their meeting in Baltimore, May, 184S. After adverting to other matters, they say:— "The ' Philadelphia Jottrnal,' which has been Pepper, Hall, Dexter, Jarvis, Beck, Wharton, already mentioned, was succeeded by the 'A me- Lovett, Nott, Mon-ton Stille\ Poling, Tabb, rican Journal of the Medical Sciences,1 esta- Taylor, Porter, Tuck, J. B. S. Jackson, Tee- blished in 1^27,andstillcontinued, having reach- bles, Kneeland, Gardner, Buckler,, Mendcnhall, ed its forty first volume. The longstanding of Lane, and R. S. Holmes. On Midwifery, and this publication, the support which it has received the Diseases of Women and Children, among from many of the best writers in different parts \ the principal, contributors of original papers of the country, and the elevated literary charac- \ have been Drs. Dewees, Horner, Bjgelow, ter and spirit which have distinguished it, have, Hodge, Gerhard, Geddings, Lindsay, E. War- rendered it a favourite organ of the profession. f ren, Roberts, Lee, Kane, Shanks, Taylor, So much of what is valuable in our periodical Bowen, Buel, Barwell, Bond, Sargent, Sims, literature, during the long protracted period of I and Baldwin. Many other names mi^lit be is existence, has found a place in its pages, that added to these lists, which, however, are sufli- it would be going beyond the limits of this re- <: cient evidence that the journal has been wil- port to attempt an analysis of its contents. Here > lingly and heartily upheld by the profession." have been recorded many of those daring opera- > After enumerating the other Medical Journals tions which are dwelt upon with so much pride j published in the United States, the report con- by tbe American surgeon. Numberless cases; tinues:— of unusual interest have been here related by ; " The committee will now proceed to a brief their observers, often accompanied by illustra-( enumeration of the more important articles, tions, for the most part creditable to the art: which have, within the past year, or at least which has furnished them. Many of the re- recently, been presented to the profession in the views which it contains are conceived and exe-, medical journals of this country, taking them cuted in a higher spirit than the mere mechanical; up in the order in which they have been enu- analv-^esand Taliacotian abstracts which so fre- tnerated. quenily usurp this department of scientific as, " American Journal ofthe Medical Sciences. well as literary journals. This periodical is so ':•—The number for January, 1817, contains one well known through the country, and a com- of Dr. Norris's admirable resumes, a ' Table plete series of it so generally contained in public; showing the mortality following the operation libraries, that a general index to it from the < of tying the iliac arteries.' It is founded upon commencement would be one of the mo3t ac-; a hundred and eighteen cases gathered from ceptable offerings which could be made to the various sources, which are presented in a con- medical reader. I densed form and subjected to a careful analysis. " The committee had prepared an account of j The committee have already fully expressed the most prominent articles under their several their sense of the importance of Dr. Norris's heads, but it proves to be too voluminous for a , labours. The paper which follows, by Dr. report like the present. The names of some of < Trask of Brooklyn, N. Y., is worthy of suc- its contributors will be enough to show howiceeding that just mentioned. Four very full extensively it has been supported by the ablest tables containing the history of fifty-three cases writers and practitioners of the country. In of phlegmasia dolens are given in this essay, Anatomy and Physiology, original papers have the final object of which is to establish the pa- been furnished by Drs. Horner, Moultrie, Coxe, ] thology of the affection. Articles like the two Mussey, Warren, Earle, Smith, Alison, Harri- < just cited, are necessarily of permanent value. son, Gardner, Leidy and others. In Surgery, They cannot be superseded, because they have Drs. Godman, Mussey, Randolph, H. & J. M. a solid basis of fact, and even if some of their Warren, Coates, Mott, N orris, Kirkbride, Ged- < conclusions were erroneous, the materials would dings, Nott, Shipman, Markoe, Parrish, Met- remain as the basis of future results. The in- tauer, Mutter, Horner, Pancoast, Watson, creased number of these laborious analytical Atlee, Hayward, are among those who have surveys is one of the most encouraging features lent their assistance, some of the best known; of our medical literature. In the midst of in- among them in many elaborate articles. In the , terminable discussions upon the value of the department of Practical Medicine, a great num- numerical system, the simple fact that tabula- ber of original Reports and Essays have been tion affords a final result respecting a given supplied by Drs. Chapman, S. Jackson, Emer- -number of facts, which mere perusal fails to do, son, Coxe, Horner, Hayward, Ware, Wright, very justly, that u i «i indirect benefit may re- in its minor departments, suit even from the experiments of the hy'dro- " I he first article in the number for April 1S47, ; pathist and homoeopathist, notwithstanding the is one of great practical interest. It is the ' His- f illusions and impositions that surround the foun- dry of seven cases of Pseudo-membranous Lanpi- \ tain of the Silesian boor and the laboratory of gilts or True Croup,' by Dr. J. F. Meigs. The \ the Saxon necromancer. The interest of Dr. fact that recovery took place, in four cases where \ Brown's account of his visit to the Cretins, in there was fibrinous exudation on the fauces, en-1 the institution on the Abendberg, is owing not titles the history of these cases to the most care- * merely to the novelty of the subject, which is ful examination, and affords a strong presumption ) just beginning to attract the attention of philan- in favour ofthegeneral plan of treatment adopted, j thropists, but to the agreeable style of thenar- It is well known that long series of similar; rative. In a country which has done as much cases have been observed, every one of which \ as our own for the insane, the blind and the has proved fatal, and that the whole question of! deaf and dumb, it cannot be long before the treatment is considered as involved in perplexity! improvement ofthe condition of the unfortunate by many able observers. The paper which ful- j idiot will be felt to be a public duty. Dr. Met- lows, by Dr. Baldwin, Observations on the Poi-< tauer, whose name is familiar to the records of sonous Properties of the Sulphite of Quinine, j operating surgery, reports two cases of vesico- has been most extensively quoted, and has called ' vaginal fistula, with the operations for their out various other communications confirming i relief, one of which was perfectly successful, the results at which he has arrived. In the ma- : and the other, though repeated again and again, larious regions of our country, where the "mon- was but partially so. But this, as Dr. Mettauer ster doses" of this heroic remedy are so com- \ thinks, was owing to the patient's amiable in- monly given, it is of vital importance that all the : discretions, and he is decidedly of opinion that risks they involve should be generally known, every case of vesico-vaginal fistula can be cured. Then follow various reports of medical and sur- Dr. Harris relates a case of doubtful sex, in gical diseases, among which Dr. Earle's eleven ; connection with which the editor quotes that cases of general paralysis of the insane cannot ; described by Dr. Barry, in the New York fail to be noticed for their psychological and; Journal of Medicine for January, la47- Dr. pathological bearings, as well as the happy way; Boling's new sign of pneumonia of the apex of in whioh they are related. A practical essay by < the lungs, needs confirmation by other observers. Dr. Flildreth, on letting blood from the jugular'The Committee can affirm, at least, that it is in diseases of children concludes the list of not constant. It was extraordinary if, as Dr. original communications. \ Boling asserts, the chest remained still resonant "The July number opens with another sta- > on percussion over the apex of the lung in a tistical article from Dr. Norris, on the operation - state of hepatization. This number contains a of tying the carotids, of the same high character'long notice of Dr. Wood's Practice of Medicine, with those which he has furnished in previous J by one ofthe most searching and skilful review- numbers. The next paper is one by Dr. Hal-sers our periodicals have ever enlisted in their lowell, on cholera infantum, which he calls by (service. It may be hinted, that one epithet, the singular name of gastro-follicular enteritis; I however judicious, must not be repeated too which would seem to imply inflammation of the >often; the accomplished reviewer remembers intestines seated in the follicles of the stomach. sGyas and Cloanthus. The essay is an instructive one, based on con- \ "'The number for October, 1847, has for its siderable experience and supported by two Heading article a continuation of Dr. Metealf's reported cases with a tabular analysis of twelve \Statistics in Midwifery, containing the results posl-mortem examinations. A 'Note on tkeiof 927 cases observed in private practice. It is frequency of tlie pulse and respiration of Ike I a most creditable production to the author and aged,7 by Dr. Pennock, adds authority to theithe friends by whom he was aided, and may curious results obtained by Leuret and Mitivie, ^serve as an encouragement and a model to other who found the average frequency of the pulse ? practitioners situated at a distance from the more in voung men to be G5 per minute, while that of $ active centres of scientific industry. Dr. Michel's the aged was 73; a statement in direct opposition < history of an early ovum is not without interest, to the prevailing belief on this point. ' Hydro-tihouzh iis illustration is less exquisite than the ■pathv.or the use of cold v^aterfor the Prevention i'lcones' of Wagner, and the style is wanting and Cure of Disease,' by Dr. Kneeland, is the, in the simplicity which should belong to an title of a Boylston prize essay, here published $ anatomical description. Dr. Harden's Essay on without any allusion to its laureate honours, s Isopathia. agrees with the general belief in The key to the author's position is found in the < maintaining the similarity of scrofula and phthi- following sentence: 'Instead of leading manjsis, but will hardly be thought to have esta- back to the forsaken paths of nature, physicians \ blished the doctrine, that Bright's disease is 32 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. isopathic with these affections. Why molluscum ' all officers in the public service would discharge should come under the same head is hard to ex-! their professional debt as fuithfully. Some of plain. In the days of isomerism and isomorphism, the author's expressions would seem to imply it is natural enough for a medical observer to be j that proteine exists only in vegetables, which pleased with the thought «{ introducing some cannot surely have been what he intended to such parallelism of elements into medicine, but assert. Dr. Blake's paper appears to be founded it maybe questioned, how much is gained by on the same experiments which this ingenious the somewhat promiscuous erudition and finely > physiologist reported some years ago to the drawn propositions of this elaborate essay, be- British Association, and which have already yond a harmonious name for a well known taken their place in physiological science. The principle. Dr. Kelley of Mobile, has given an indefatigable Dr. Earle gives a brief analysis of account of yellow fever as this disease has pre- five hundred and ninety-four cases of delirium sented itself to his own notice, written in clear tremens admitted into the Bloomingdale Asylum. and simple language, and keeping more closely > Then follow several reports of interesting sur- than many writers on this subject have done to Igical cases; under the name of ' Monograph' the strict results of observation. Some remark- . we have next 'A Statistical Inquiry into the able surgical cases and operations, a case of in- \ Causes, Symptoms, Pathology, and Treatment cision of the os uteri during labour on account of Rupture of the Uterus,' by Dr. Trask, of of its partial occlusion, some researches on the Brooklyn, whose labours have been already structure and functions of the ciliary processes,' mentioned with commendation. and the case of the murderer Freeman, with a I " The first paper in the April number is an long review of some of the Boa Vista fever account, by Dr. J. M. Warren, of Operations for documents, finish the list of original articles. In Fissure of the Soft and Hard Palate, with the this number, October 1847, appears a new and result of twenty-four cases, at the close of which distinct head of medical intelligence, entitled < is an important additional note upon the early elAer inhalation as a means of annulling pain. , operation for hare-lip. Dr. Warren proposed, It is remarkable, that as so much patient de- j some years ago, and has often executed, a new liberation was shown in preparing the abstract I operation, which is fully described in this paper of what was before the public, on this subject, j and the annexed cases. Dr. Peeble's ' Result an article like that of Dr. Pickford should be J of cases of Pneumonia, treated chiefly by Tartar admitted, but more remarkable still, that any , Emetic,' may be well calculated to excite at- sensible reader should have been frightened out \ tention to the possible ill effects of that remedy, of receiving the last great gift of Mercy, by the j but is deficient in the diagnostic elements of its assertions of such a writer, as would appear to \ cases. The third patient, for instance, may have happened in at least one instance. j have suffered, for all that appears, from phthisis "In the number for January 184S, the leading j with ulceration of the bowels. It does not ap- article is Dr. Leidy's paper on the Comparative j pear from the record that the previous good Structure of the Liver. This is unquestionably j health had persisted unchanged up to the period the most exact and complete Essay in the de-1 of the acute attack. Cases of successful vaginal partment of microscopic anatomy which has j hysterotomy and delivery by the forceps; of appeared in any American Medical Journal. J traumatic trismus successfully treated; of a fatal The patient accuracy of the measurements, the • gun-shot wound of the neck; of ligature of both finish and clearness of the numerous illustrations; carotids ; of the extirpation of a tumour of the are nothing more than would have been antici- j uterus, simulating ovarian disease ; of cancer of pated by those who know the zeal and talent of; the stomach, and of melanosis, are reported in this exquisite dissector and delineator. The ] this number—certainly a very remarkable col- article which follows, by Dr. Frick, is one of '< lection of important medical and surgical histo- the first attempts at the investigation ofthe che-< ries, and implying an ample supply of materials mical changes of the blood induced by disease, i to allow of such selections. Add to this Dr. made in this country. Most of the conclusions j Parson's ' Statistics of Large Surgical Opera- arrived at by the laborious observations which \ tions,' the Midwifery Statistics from private served as its basis, coincide with those of pre-1 practice, by Dr. Pleasants, and the continuation vious observers. One peculiar and novel result of Dr. Trask's paper on Rupture of the Uterus, arrived at by Dr. Frick is, that the quantity of probably the most complete account of that ac- the chlorides and phosphates of soda and potash j cident to be found inprint, and it must be owned is dependent, not upon the particular disease,! that the patriarchal quarterly has not fallen be- but upon the season of the year in which the \ low its own high standard of merit, at the point examination is made, being much higher in, where the Committee takes leave of it for the winter and spring than in summer and fall. Dr. > present."* Foltz deserves credit for printing his valuable J * These extracts are from copies of the Report to t>„ „ ,__c . , T, u , • , , ., . \ be famished to the Chairman of that Committee, Dr. Report on Scorbutus. It could be wished that Holmes of Boston. For a more particular description of the Journal and News, with numerous notices of the press, &c, see Supplement to the Medical News and Library for Dec. 1847. * VOf S k •—,VJ :&v£i j.,',:'