UNITED STATES OF AMERICA FOUNDED 1836 WASHINGTON, D. C. GPO 16—67244-1 AN INAUGURAL DISSERTATION. PHLEGMASIA ALBA DOLENS PUERPERARUM, SUBMITTED TO THE COTJSIDEHATIOH OF THE ffOJV. ROBERT SMITH, PROVOST; THE REGENTS OF THE UNIVERSITY OF MARYLAND DEGREE OF DOCTOR OF PHYSICK. 1 i'^"\ BY CHARLES S. DAVIS, Of Baltimore County, Honorary Member of the Baltimore McdicifrSiMttrf ,*TTT"" / ~~<£. -*-. BALTIMORE : PRINTED BY J. ROBINSON. 96, MARKET-STREET, 1815. % / To JOHN B. DAVIDGE, A. M. M. D. This Essay is dedicated, as a small tribute of respect, for his superior talents, &c. and for his uniform politeness, to his friend and PUPIL. 4 0 0 0 To RICHARD W. HALL, M. D. This Essay, is dedicated, as a tribute of respect for his talents, and for his uniform politeness to the AUTHOR. ESSAY PHLEGMASIA ALBA DOLENS PUERPERARUM. A.T a period eventful as the one in which the gra- duate enters on the stage of medical action, to be the safeguard of individual health, considerations in- trude themselves which have a claim upon his feel- ings. The sudden loss of life, the consequent de- struction of the family of which the possessor was a A y£~ member; the nereditary diseases of a deformed childhood, and the lingering sufferings of an imbe- cile old age, wait upon his morning walks and on his evening meditations. It would appear then, that he who has the most practical knowledge deserves the most of mankind. They do not enquire who has the greater knowledge of mind, or whose hypothesis demands the most consideration. The quality of mind, too, is not deter- yt* ***^#y mined by crude essays upon animal life, or the man- ^ ner in which the health of the body is governed. Thus influenced, the author has offered a few practi- cal observations on Phlegmasia Alba Dolens PUERPERARUM. 6 This disease has been known for a number of years, under the names of Depot du lait. CEdemea Lactum. Mauriceau, a Frenchman, was the first who who wrote a distinct history of the disease. In the year 1718, he described it under the title of L'enflure des Jambes et des Cuiesses de la femme accouche. And was followed by a number of his countrymen, Puzos, Leveret and others. Mauriceau considers this disease as a reflux of the Lochia on the part ; Puzos attributes it to a reflux of milk. Leveret adopts the doctrine of Puzos. Mr. C. White of Manchester, published two ex- cellent treatises on this disease; the first in 1792, the second in 1801. He was the first English wri- ter who described it; and although there is much useful information to be gained from reading his ex- cellent treatise on the subject, I cannot agree with Mr. White as to the cause of the disease. Mr. White supposes this disease to be produced by the child's head passing through the pelvis, and pressing upon the lymphatic vessel or vessels, as they dip down over the pubis, so as to produce a rupture of them. This cannot be the fact, for in this case what would be the effect on the remaining soft parts which line the pelvis ? Would they not be bruised and lacerated? I presume they would, and we should not have the disease in question, but we should inevitably have inflammation and suppuration of all the pelvic viscera. If the child's head should remain in the pelvis, and in one position for a length of time, it could only stop the circulation of lymph through that branch. The remaining branches, which run up and accom- 7 pany the iliac arteries, would be sufficient to carry on the circulation of lymph through the limb, and the consequences which Mr White ibretels, I have no hesitation in saying would not be produced. Again—if Mr. W's. proposition be correct, we should have this disease occurring more frequently than we find to be the fact. Every laborious case of parturition would inevitably produce the disease. " This disorder has never been known to prove fatal."* I have heard of one case where it proved fatal; in consequence of the attending physicians not keeping a record of the case, I have not been able to get a history of it. Dr. Denman says, p. 437, " I do not mean, nor should I be justified in saying, that it was never attended with danger, having heard of se- veral and seen one which proved fatal, where no other cause could be assigned or suspected." Mr. White says [page 50] speaking of the ab- sorption of lymph from the wounded lymphatic, " It will press against the uterus and occasion forcing pains and even suppression of urine." If there is a sufficient quantity of extravasated lymph to occasion the above diseases (of which I have no doubt) we should not only have forcing pains and suppressions of urine, but Ave should likewise have inflammation, abscess, caries, and death would inevitably be the consequence of such an extensive abscess, caries, Sec, It now remains for us to say to what cause the disease may be attributed. As the uterus and vagina evolve, so does the lymphatic vessels which belong to those organs, and they become more liable to take ' Mr. White, pag;e 43. 8 up any unhealthy secretion or vitiated matter which may come in contact with their orifices, and convey it on to the glands to which that particular lymphatic leads. It may either be the internal or external in- guinal glands, they then become inflamed and swol- len, and press the two sides of the lymphatic vessel in contact, which stops the circulation of lymph, and all the succeeding mischief will be produced. We most frequently find those persons whose lochia are completely arrested or discharged in small quan- tities, and of a foetid character, are more liable to this disease than any others. Their urine and foecis are of- ten both of an unnatural appearance and smell. From those causes we are inclined to believe, that the ab- sorbents take up some unhealthy secretion, or viti- ated matter, from the uterus and vagina, and produce the disease in question. This disease happens at no precise time after deli- very. It sometimes comes on the fifth or sixth day, and as late as the third or fourth week. Mr. W. says, he has known it in one instance shewing itself as early as twenty four hours after delivery. Both those cases are uncommon; it most generally comes on about the second or third week after delivery. The production of this disease, does not appear to depend on any kind of labour the patient may have undergone. As it indiscriminately happens to those who have had an easy or a difficult labour : Nor does it depend on any peculiarity of constitution, as the corpulent and the thin, the strong and the weak, are equally liable to it; those who give suck and those who do not, the young and the middle-aged, after the first or any other labour, and whether it be natu- 9 ral or preternatural—(it never attacts after a miscar- riage)—it happens at all seasons of the year, in the country as well as in large towns. The first symptom of which the patient generally complains, is a considerable pain in the lower part of the abdomen, which is more painful when pressure is made on the part. Pain in the groin of one side, ex- tending to the labium pudendi, along the anterior and interior surface of the thigh, down the course of the sartorious muscle to the anterior part of the leg; thence extending to the foot. The pain is accom- panied with a considerable fever, the pulse is quick and frequent, the heat of the body much increased, tongue white and clammy, the countenance of a pale chloratic appearance, the thirst considerable. The nights are spent without sleep, the patient perspires profusely, the appetite is lost, the intestines are either costive and the stools clay-coloured, or, they are loose and very foetid. Dr. Denman says, " It is how- ever to be observed, that this smell and appearance do not always continue throughout the course of the disease, but on inquiry will be found to have existed at, or some days previous to its commencement. The urine is discharged in small quantities, thick and of a muddy colour. All the pelvic viscerea are very tender to the touch, the os uteri is open, but not more tender than the sides of the vagina. About twenty-four hours after the pain has conti- nued, the swelling commences about the groin and extends to the labia pudendi, thigh, leg, and whole limb. As the swelling increases the pain subsides. From the period at which the limbs is attacked, all its powers of motion are lost. If you attempt to 10 move it, excrutiating pain is the consequence, with a disposition to faint, so that you are compelled to let it remain at rest. It is also so tender that the bed clothes can not be permitted to touch it without giv- ing severe pain. When the swelling arrives'at its acme, which is in about twenty-four or forty-eight hours, the limb is nearly twice its natural size—the skin is more of a deadly than a natural colour. It is very smooth, shining, hard and elastic. The swelling is equal and general, all over the limb [except where the glands are situated, which are hard tumors] it is much harder than in an anasarca, it is not so cold in any state of the disease, nor does it pit when pressed upon by the finger. No water issues out when punctured with a lancet, nor does it diminish by an horizontal position. One, or both the lower extremities, may be attack- ed together, or separately. When the latter is the case, after the disease has remained in one leg for a length of time, and the symptoms have abated and our patient appears to be fast recovering, the other leg is attacted very suddenly, without any evident cause for it. The disease then runs the same course in the second limb, that it did in the first. The limb first diseased does not appear to be influenced by the tumefaction of the second. The disease never at- tack both limbs at the same moment, but it is often complicated in both at the same time. There is very often a coldness felt in the second limb before the disease commences. The patient bears the second attack much better than the first, though its more severe. A long time often elapses before the swelling en- 11 tirely leaves the limbs, the strength returns slowly, the debility, oppression, and swelling, sometimes re- main for many weeks, and months, and the latter fre- quently for several years : and in some instances dur- ing the patient's lifetime. The limbs never returning to its original size or recovers its wonted power of agility and firmness. We are now to speak of the cure. Our first ob- ject is to check the disease within the pulvis. For this purpose, we use blood letting either general or topical. The intestinal canal, should be kept open with gentle aperients and clysters. Opiates are to be given to allay the general irritability of the system. Blisters should be applied to the groin, they have been found of much advantage by taking off the irri- tation from the part originally affected. The fever must be allayed by antimonials, and cooling medi- cines, and a spare diet. Two or three grains of James* powders three or four times a day will be found of great benefit. Fresh ripe fruits, and cool acidulated liquors may be allowed the patient, and likewise cool air should always be enjoyed. Clothes wet with acetate of lead, or warm vinegar, will be found an excellent application. Dr. Denman recommends a liniment composed of one drachm of camphor, dissolved in an ounce of olive oil, with six or eight grains of powdered opium mixed with it. The limb to be gently anointed with it night and morning, and afterwards covered with loose flannel, the limb should be bathed in warm water. If the uterine discharges be foetid it is proper to 12 inject tepid water, or a mild infusion of chamomile flowers, into the vagina with an ivory syringe. When the pain abates and the swelling begins to lesson, and there remains a quick pulse and some degree of fever. It it is proper in this stage of the disease to give tonicks such as the peruvian bark, steel, and others. Before the patient is in a condition to receive the bark in the system, it will be proper to give myrrh, in small quantities; three or four times a day. Small quantities of steel may be added to the myrrh with advantage. The patient may be allowed a fuller diet, and wine in small quantities. When the pain and fever have entirely left the pa- tient, we should then use cold bathing. The bark with or without steel will be found of advantage. Embrocating the limb with camphorated spirits of wine will assist in giving tone to the limb. Flannel dipt in hot vinegar has been highly recommended, and used principally for the cure of this disease in one of the London hospitals. A circular bandage has been found of much service in this stage of the disease. Exercise on horse back or in a carriage will be found of great benefit. Walking should not be permitted as it never fails to do injury. Expo- sure to cold damp air during the first stage of recove- ry may cause a relapse, and therefore particularly to be guarded against. ■"A Med-Hist, WZ W r#|VrV