treatise: DISEASES OF FEMALES. BY f r I WILLIAM P. DEWEES, M.D. ADJUNCT PROFESSOR OF MIDWIFERY IK THE UNIVERSITT OF PENNSYL VAKIA ; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETT J OF THE ROYAL MEDICAL SOCIETT OF DENMARK] &C. &C. THIRD EDITION, REVISED AND CORRECTED. g6't/6S~- PHILADELPHIA: CAREY AND LEA—CHESNUT STREET 1831. WP tea. EASTERN DISTRICT OF PENNSYLVANIA, to wit: BE IT REMEMBERED, That on the twentieth day of November, (L. S.) in the fifty-lirst year of the Independence of the United States of America, A. D. 1827, William P. Dewees, M. D. of the said District, hath deposited in this office the Title of a Book, the right whereof he claims as Author, in the words following, to wit : "A Treatise on the Diseases of Females. By William P. Dewees, M. D. Adjunct Professor of Midwifery in the University of Pennsylvania, &c. &.C." In conformity to the Act of the Congress of the United States, intituled, "An Act for the encoiuagemcnt of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times there- in mentioned." And also to the Act, entitled, "An Act supplementary to an Act, entitled, 'An Act lor the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, dur- ing 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. Lvdia R. Bailey, Printci. ADVERTISEMENT The following pages are presented to the public, with- o it preface or apology. The necessity of a work on the Diseases of Females, and especially the most common of j em, seems to be pretty generally acknowledged; but p 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. In this third edition many alterations and additions will be found; and it is trusted, improvements will be per- ceived, as several new chapters are added. iDCST TO W. CHAPMAN, M.D, PT10FESS0K OP THE INSTITUTE AND PBACTICE OP 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 CONTENTS. CHAPTER I. Page. Of the Peculiarities of the Female System, - - 13 CHAPTER II. Of the Diseases of the External and Internal Organs, 22 Sect. I. Of Tumours and Excrescences of the Exter- nal Parts,......23 II. Of the Diseases of the Nymphse, - - ib. III. Of the Diseases of the Clitoris, - - - 25 IV. Of the Adhesion of the Labia Pudendi of Children, - - - -,- - 26 V. Of the Abscesses of the Labia, - - - 29 VI. (Edematous Swellings of the Labia, - - 31 VII. Of Bloody Infiltrations in the Labia during or after Delivery, ----- 32 VIII. Imperforation, and too great Density of the Hymen,.....- -41 IX. Of Pruritus, or Aphthous condition of the Vulva and Vagina, 46 CHAPTER III. Of the Diseases of the Vagina, 53 CHAPTER IV. Of Leucorrhoza*.....- 55 Method of (hire. - - 74 CHAPTER V. Of the History of Menstruation, - - - - 82 VIM CONTENTS. CHAPTER VI. Page. Of Deranged Menstruation,.....1Q5 Sect. I. 1. Of the tardy Appearance of the Menses, ib. II. 2. Of the Suppression of the Menses, - - 115 Case I. ..---- 120 Case II.......121 III. 3. Of the immoderate Flow of the Menses, 127 IV. 4. Of Dysmenorrhcea, or painful Menstrua- tion, - - - ' - - - - 129 V. 5. Of the Decline of the Menses, - - 144 CHAPTER VII. Of Menorrhagia,.......157 CHAPTER VIII. Of the Signs which usually accompany Pregnancy, 170 Sect. I. 1. Suppression of the Menses, - 171 II. 2. Nausea and Vomiting, - - - 175 III. 3. Enlargement of the Mammse, - - ib. IV. 4. Areolse, --..._ ib, V. 5. Formation of the Milk, - - - 176 VI. 6. Enlargement of the Abdomen, - - 177 VII. 7. Increased Size of the Uterus, - - 178 VIII. 8. Pouting out of the Navel, - - - 179 IX. 9. Spitting of Frothy Saliva, - - - 180 X. 10. Salivation, ------ ib. XI. 11. Of Quickening,.....181 CHAPTER IX. Of the general condition of the System, and the effects of certain remedies during Pregnancy, 187 Bleeding, - - - - - . -|195 Purging, - - - - - . - 196 Emetics, -.....- 198 Blisters, - - - - . 199 CONTENTS. I* CHAPTER X. Page. On some of the Diseases of Pregnancy, - - - 199 Sect. I. Of the Febrile Condition of the System during Pregnancy, - - - - ». -200 II. Of Vomiting,......205 III. Of Heartburn, -.....208 IV. Of Salivation,......210 V. Of Pain in the right side, - - - - 212 VI. Of Inquietude and Want of Sleep, - - 214 VII. Of Costiveness,......216 CHAPTER XI. Of Hemorrhoids, or Piles,.....219 CHAPTER XII. Of Palpitation of the Heart,.....228 CHAPTER XIII. Of the Displacements of the Uterus, - - - 230 Sect. I. Prolapsus of the Uterus, - - - 231 II. Of the Chronic Inversion of the Uterus, - 242 CHAPTER XIV. Of the Diseases of the Uterus, Ovaria, and Tubes, 247 Sect. I. Of the Disorders and Diseases of the Uterus, ib. II. Of the Diseases of the Ovaries, - 248 III. Of the Diseases of the Tubes, - - - 250 CHAPTER XV. Of the particular Diseases of the Uterus, - - -252 Sect. I. Of the Carcinoma Uteri, - 253 II. Of the Treatment of Carcinoma Uteri, - 254 1. Abstracting Blood, - - - - 256 2. Purging, .....257 3. Abstemious Diet, - 260 4. Cleanliness, - - - - -261 5. Rest, - - - - - 3«3 x contents. Pape. Sect. III. Of the Polypus of the Uterus, 273 Case I. - " " 27g Case II. - .7 Case III. - - 28q Case IV. - ' Case V. IV. Mode of applying the ligature for Polypi, - 283 V. Of the Cauliflower Excrescence, - - 287 VI. Of the Symptoms, - 2 VII. Of the Prognostics, - - - " ~ VIII. Of the treatment of Cauliflower Excrescence, 292 IX. Of Hydatids of the Uterus, - - - 296 304 CHAPTER XVI. Of the Irritable. Uterus, - - - - - CHAPTER XVII. Of Uterine Hemorrhage.......327 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, ----- 328 III. 3. Of the Mode of Action of certain of the remote Causes, - - - - - ib. IV. 4. Of the Periods of Pregnancy at which Hemorrhage may take place, - - 333 First Period, - - - - - -335 Second Period,.....343 V. Delivery considered as d mode of arresting Hemorrhage,......346 CHAPTER XVIII. Hysteritis, or Inflammation of the Uterus, - - 352 Sect. I. Species First. Causes, - 353 2. Symptoms,......354 3. Constitutional Symptoms, - - - 355 II. Species Second. On the Mixed Inflammation of the Uterus, or accidental Puerperal Fever, 360 CONTENTS. XI Page. Sect. II. Species Second. Treatment, - - - 362 a. Bleeding,......ib. b. Purging,......364 c. Fomentations,.....367 d. Blisters,......ib. e. Sudorifics,......368 f. Opium,......ib. g. Emetics,......369 CHAPTER XIX. Of Puerperal Fever,......369 History, --.....- 373 Predisposing Causes,......375 Prophylactics, -......379 Seat of the Disease, and its proximate cause, - 381 Period of Attack and Symptoms, - - - - 399 Diagnosis, - - - - - - - - 40 6 Prognosis, -------- 408 Contagious nature of Puerperal Fever, - - 412 Treatment,........414 1. Bleeding, Stage First, - - ' - - - 425 Purging,.....- -441 Emetics,.......447 Blisters, .....* - - 451 Fomentations,......ib. Spirit of Turpentine,.....452 Mercurial Frictions,.....453 2. Of the Gangrenous Stage, - 456 3. Of the Stage of Effusion, - - • - 461 General Directions and Rules, .... 462 CHAPTER XX. Phlegmasia Dolens, or Milk Leg, - - - - 465 Symptoms and General Character of Phlebitis, - 480 Case! ......481 Case II.......483 Caselll......484 Case IV. ... - - 485 Xll CONTENTS. Page. Method of Cure, " 4r be satisfactorily determined, must be left to contingency, as neither reasoning, nor experiment, can well decide the ques- tion We would however suggest, that as the opinion of Madame Boivin rests upon assumption, as well as that of Percy, a jury should be induced to incline to the side of mercy, where a ques- tion of this kind was agitated. We therefore altogether applaud the decision of Percy, who acquitted a young religieuse of incon- tinence, by declaring, that vesicular moles are merely hydatids, though she would perhaps have been condemned by Madame Boivin had the appeal have been made to her. We therefore look upon the hypothesis of this lady, if adopted in its full extent, to be highly dangerous, and must remain so, unless her opinion be unequivocally proved—but fortunately, hydatids is a rare disease, and cannot often compromit character or life. In consequence of the delicacy of the covering of the hydatid, it is easily destroyed by pressure, or any conquassatory motion of the abdominal muscles or uterus ; hence they frequently burst, and give rise to a discharge of a pale transparent fluid, without odour or tenacity. And this circumstance may be said to be the only one which characterizes this complaint; for every other attending symptom, is so common to many other affections of the uterus that they would not serve to distinguish it. The greater part of the inconveniences of this complaint, arise, as in pregnan- cy, from the pressure of the distended uterus upon the surround- ing parts ; hence, we sometimes have cramps of the lower extre- mities, oedematous swellings of them, retention of urine, &c. as in a genuine pregnancy. I cannot find, in any memoranda of the case just related, any notice taken of the condition of the mam- mae, from this diseased occupation of the uterus. This disease may be known from the cauliflower excrescence, by the occasional discharge of a watery fluid, and this in different quantities at different times; whereas, in the latter disease, the quantity of fluid discharged, is much greater, and more constant. As regards the sensible qualities of each, they perhaps resemble each other pretty strictly ; but we know of no experiments to determine their chemical resemblances, or discrepancies. No remedy has hitherto been discovered for the relief of this complaint. The patient is not to be led to expect any great benefit from art; at least in the progress, or in the interval of the disease. All it can do, is to afford a degree of relief, by aiding in a species 300 HYDATIDS OF TnE UTERUS. of labour, which will sooner or later take place, from the disten- tion of the uterus. Percy declares, that after the discharge of vesicles had com- menced, he found great advantage from injecting a solution of salt in vinegar into the uterus. He declares this was followed by a rustling noise in the pelvis, occasioned as he supposes, by the agitation into which the hydatids were thrown by this unusual stimulus. On this point Mdme. Boivin declares her fear of either its utility or its safety, as in one of her own patients threatening symptoms of inflammation after its employment ensued ; and in another, it was of no advantage. She considers gentle titilation at the os uteri with the finger, stimulating injections per anum, frictions upon the hypogastrium, and the application of cold to the lower part of the trunk, to be more efficacious, and safe. Injections into the uterus, of a stimulating kind, are useful she says, when it docs not contract, or if the haemorrhage continues after it has contracted. But we are of opinion that the "Ergot," as will be recommended presently, would supersede all these remedies. Mr. Clarke declares, " when this period arrives, at which the uterus is striving to unload itself of its contents, then all the skill and energy of the practitioner will be wanting, and all his efforts will be called forth to control the hemorrhage, and to sustain the powers of the constitution. With this view, the patient should be kept perfectly still, in a horizontal posture; she should not be allowed to take any stimulating food, or drink. Cold applica- tions to the loins, abdomen, and external organs," &c. Treating it as any other case of uterine hemorrhage, by promoting, by every possible means', the contraction of the uterus. "Should any portions of the hydatid remain, and if the hemorrhage should continue profuse, an attempt should be made to remove these, in order to produce complete contraction of the muscular fibres." Vol. I. p. 120. This is to be done by introducing the hand, well lubricated, into the cavity of the uterus, and carefully detaching the adhering portions of the hydatids, and bringing them out with the hand. It will be perceived, that this direction cannot be complied with in all instances; for, in all instances, the uterus will not be suffi- ciently distended by the hydatids, to permit the passing of the hand with ease; and violence must never be employed in this, HYDATIDS pF THE UTERUS. 301 or any other Instance, in passing the hand into the cavity of the ^We3 would propose, and we think with a fair prospect of suc- cess, the free use of the secale cornutum in this complaint, to pro- cure the expulsion of the hydatids ; especially in such cases as would not easily admit the hand ; or where the contractions of the uterus were too feeble, or insufficient to their extrusion. So far as analogy, and reasoning upon a subject, will justity the employment of a novel remedy, we have them on our side ; for it is certain, that the union of hydatids with the uterus is not more strict, than the ordinary connexion of the placenta with that body ; and we know from experience, that this connexion may be destroyed, most fortunately sometimes, by this very pe- culiar and interesting drug. As regards ourselves, we should not hesitate a moment to employ it. Since writing the above, I have been favoured with a letter from Mr. Anderson of Hagerstown, Maryland, giving an account of the « Ergot" in this complaint, which I shall have much plea- sure in detailing. The trial of this substance mas made by Dr. W. D. Macgill, of the above named place. "Early last spring, Dr. M. was called to see Mrs. W., aged 40 years, who had previously enjoyed good health, and had been the mother of several children. She was labouring under a very painful affection of the womb, accompanied with periodical he- morrhagy, occurring once in twenty-four hours, usually in the evening, attended by febrile symptoms, and much disturbance of the digestive functions, and which was evidently making rapid inroads upon her constitution. During its farther continuance, her stomach became exceedingly irritable, so much so, indeed, as scarcely to retain nourishment of any description. Dr. M. ad- dressed his remedies principally to the restraining of the hemor- rhagy, and obviating the excessive weakness of the stomach. But notwithstanding, the symptoms continued to increase in violence, so much so as to endanger the life of the patient She had become very much exhausted by the repeated loss of blood, and inability to take food, (for she had now suffered for more than three months,) when the doctor made an examination per vaginam, (after having made them frequently before without any satisfactory result,) and discovered something protruding through the os uteri, which he extracted, and found that the poor woman was labouring under hydatids of the womb. He immediately sent for the Ergot, judg- 39 302 HYDATIDS OF THE UTERUS. ing from analogy that it would prove decidedly effectual in pro- ducing an expulsion of the heterogeneous mass. The event proved* that he was not mistaken in his conjecture ; for he had given the Ergot but a very few minutes, when it began to show its specific operation upon the uterus, and succeeded in a complete evacua- tion of its contents. The mass of hydatids equalled in size the head of a large child at birth, and afforded a very good specimen of the disease, a part of which we have made a preparation of. The representation in your book on the " Diseases of Women," is admirable. The floodings immediately ceased, and did not re- turn. The woman rapidly recovered, until at length she has at- tained her former health and vigour, and I believe she is again pregnant. She says her mother died of a disease exactly similar." "P. S.—Dr. Macgill had not heard of your suggestion until after the delivery. He was led to tho employment of the Ergot solely from analogy." It seems however, that the progress of gestation is not always interrupted by the presence of hydatids, as the following case proves. "Mad. Hec.—aged 40 years, had been plunged in misery and distress, from her own bad conduct, for some years. She was subject to attacks of lipothymia after eating. For four months the menses had been wanting, and it was supposed she was preg- nant. Dr. T. examined, but could not decide on this point The woman herself, who had borne nine children,, did not consider it as pregnancy. She believed, from the vomiting after food, that she laboured under scirrhus of the stomach, of which complaint her mother had died. Low diet and diluents were prescribed. There was now developed much irritation about the uterus, and leeches were applied to the groins and vagina. The irritation was removed. The stomach complaint was now much relieved. Amonth or more after this, our author was hastily summoned to Mdme. H, who was said to be in labour. The uterus was now much larger than when last examined, and seemed to fill the pelvis. There were bearing-down pains, and in these, the uterus felt very tur- gid. The os uteri, however, was close, and no discharge from thence. The pains, persisted, without any alteration in the cer- vix or os uteri. This state continued three days more, when it was perceived that, at each bearing-down pain, there was some discharge of clear water. This was followed some days after- wards, by a large number of hydatids, of various sizes, from an HYDATIDS OF THE UTERUS. 303 inch in diameter downwards. She continued to pass these bodies for fifteen days. In the mean time the size of the uterus rapidly increased, and rose out of the pelvis. It was now ascertained that there was a foetus in utero, and yet the hydatids were dis- charged daily in considerable quantities. Three or four months after this, she was delivered of a child at the full term, the hyda- tids having never ceased one day to be discharged. There were one hundred and forty-eight of these bodies collected, and the number broken and unobserved could not be estimated. The patient recovered and did well. She has since become preg- nant." We will give another case of this rare and interesting affection; as all that we can learn of a disease so uncommon and so impor- tant, will fall short perhaps, of being sufficient to establish its diagnosis and best mode of treatment In the case following, we are disposed to believe, that had "Ergot" been duly admi- nistered, it would have been more prompt in its action, and less equivocal in its safety, than the one pursued—it however termi- nated well. "A woman, after being six times pregnant, imagined herself with child for the seventh time, in consequence of the cessation of the catamenia. Soon afterwards she was attacked with incessant vomit- ing,the abdomen increased rapidly in size, and became tender to the touch, the legs also became oedematous and the breathing short. These symptoms, however, she conceived to arise from twins, and she did not apply for medical assistance. In the fifth month of the supposed pregnancy the swelling of the belly became rapid- ly enormous, the oedema extended over the trunk, and her respi- ration became very difficult, when at length labour-pains sudden- ly set in, and considerable haemorrhage ensued, which was at first checked by cold applications, but soon afterwards returned more violently. At the same time a large mass of hydatids as big as two fists was discharged. The accoucheur, who now saw her for the first time found her pale, fainting, without pulsation at the wrist, and breathing slowly and laboriously. The fundus uteri was a hand's breadth above the navel, and the tumour form- ed by the womb was regular, not elongated or lying to one side as is usually the case in this disease. The os uteri was dilated to the size of a half dollar, and was very tender to the touch. Masses of hydatids projected from it into the vagina ; and there was constant haemorrhage. The treatment adopted in these cir- 304 HYDATIDS OF THE UTERUS. cumstances consisted in the administration of tincture of castor every fifteen minutes, spirituous frictions of the abdomen, and the injection into the uterus of a solution of salt acidulated with vinegar. In consequence the labour-pains, which had almost ceased, were speedily renewed and rapidly increased in strength, masses of hydatids were at the same time discharged, and ere long the haemorrhage abated considerably. In the course of two hours the fundus uteri had descended to within a hand's breadth above the pubis ; in the course of the day it had descended still lower; the haemorrhage ceased; a warm perspiration broke out, accom- panied with rising of the pulse, and the patient soon recovered. Milk appeared in the breasts on the third day, but receded again without any bad consequence. The hydatids weighed six pounds. They were attached to the remains of a membrana decidua. Sect. X.—Of Irritable Uterus. By the " irritable uterus," we are to understand, a peculiar and permanent sensibility of this organ, but more especially of its neck, which attacks the female about the middle period of life, or a lit- tle beyond it; rarely showing itself before the five-and-twentieth year, and perhaps still less frequently after the menstrual periods have passed. Dr. Gooch,* who has devoted an excellent chapter to this subject, and was, as far as we know, the first author who treated of it, defines this disease to be "a painful and tender state of the uterus, neither attended by, nor tending to produce change in its structure." The latter part of this definition we do not think exactly correct, as we have always found some change in this part. This morbid condition of the uterus shows itself by both gene- ral and local disturbances. Of the General Symptoms.—The general symptoms are, an in- creased frequency, and a preternatural firmness of pulse, t This frequency is commonly augmented towards evening; the skin then becomes warmer, and the cheeks are reddened, by a slight • In his work entitled "An Account of some of the most important Diseases peculiar to Women, by Robert Gooch, M. D." f Dr. Gooch says, " the pulse is soft, and not much quicker than natural, but is easily quickened by the slightest emotion." p. 313. IRRITABLE UTERUS. 305 hectic blush. But the pulse is always more frequent and corded than natural, even in the absence of the exacerbation, but least so, early in the morning. We have never observed any thing like a regular rigor attend this complaint, though we have often heard the patient complain of chilliness, before an exacerbation of pain, especially if this were about to prove violent. The tongue is paler and whiter than natural, especially early in the morning ; towards evening it reddens and becomes cleaner ; more or less thirst attends, particularly in the after part of the day. The natural perceptions of the tongue are frequently per- verted ; so much so sometimes, as to lead the patient to the belief that there is a hair upon it; some say that the mouth feels as if there was dry flour in it; while others declare the sensation resembles that of grease, &c. Head-ache almost always attends, and it is generally the back part of the head that suffers ; this for the most part increases as the day advances, or as the pulse increases in force and frequency. The skin is always dry while the disease remains in full force ; and its general temperature is increased, if we except that of the hands and feet, which is much below the natural standard, espe- cially the latter; we have rarely.known the febrile exacerbation terminate in sweat The stomach is almost sure to suffer if the disease continue for a long time obstinate, though we have occasionally known it not to be implicated in the general mischief—but the latter circum- stance may be looked upon rather as the exception to the rule, as, for the most part, the appetite is impaired or very capricious, and eventually dyspepsia becomes established. The bowels are either too much confined, or are urged to diarrhoea; and if an attempt be made to remove the former condition by purgative remedies, the latter is certain to follow, by which every local symptom is severely augmented; and thus the patient suffers almost alike, from either of these conditions. The urine for the most part is sparing, high-coloured, strong- smelling, and throws down when at rest, a large deposit—or it is pale, abundant, and free from deposition ; but when this occurs, we have reason to suspect the disease is complicated with a cer- tain form of neuralgia. The urine is generally discharged with some difficulty, and even pain is felt along the course of the ure- thra. Occasionally, the urine is suppressed or retained, for many hours together, and is then voided with considerable suffering. 306 IRRITABLE UTERUS. Local Symptoms.—Sometimes the patient represents the parts as being a little swelled, but this we believe is always transient. Walking, riding, or indeed any kind of exertion, is sure to he accompanied or followed by severe lancinating pains within the pelvic cavity, especially from near, or in the course of, the ure- thra, to about the centre of the sacrum; and when the severity of the pain has abated, it subsides into a permanent dull pain in the same direction, but more diffused. More or less leucorrhoea pretty certainly attends ; the colour of which varies almost in proportion to the degree of suffering ; when this is not very intense, it is thin and nearly transparent, pretty abundant, and without odour ; while, on the contrary, when the pain is very severe and permanent, the discharge is thick, puru- lent, and is, if strict regard be not paid to cleanliness, offensive. The uterus is almost always lower in the vagina than natural, and sometimes, indeed not unfrequently, it is found prolapsed.* There is considerable heat in the vagina, and always, so far as we have observed, a more than ordinary degree of sensibility in its parietes. In this we differ from the respectable authority of Dr. Gooch, who says this tenderness is confined to the neck of the uterus.t The neck is almost always a little shortened, enlarged, and exquisitely sensible to the touch, and the os tincse is rather more closed than natural. The pain which attends this complaint is always increased by an erect position, and it as certainly abates by a recumbent one. Pain is usually felt immediately behind the mons veneris and brim of the pelvis, especially its anterior por- tion. The sensibility of the neck of the uterus is at times so exqui- sitely great, that the woman shrieks if it be rather rudely touch- ed ; nor does this pain cease, even for a very long time after it has been excited, especially at the lower part of the sacrum. Dr. Gooch tells us, that in a patient of his, it would remain for many hour's with great severity. Indeed this tenderness is so great and so constant in many intances, that great suffering is experienced if the patient incautiously sit down too suddenly, and particu- larly if upon a hard resisting seat; and the privileges of matri- mony cannot be consummated without much suffering. • By prolapsus, we would wish to be understood, such a descent of the uterus, as causes it to rest upon the internal face of the perineum. \ Dr. Gooch says, "thefinger can be introduced into the vagina, and be press- ed against its sides, without producing uneasiness." p. 312. IRRITABLE UTERUS. 307 Besides these local inconveniences, there is a symptom which is almost constantly present, and which seems, according to our experience, in an especial manner to characterize the "irritable uterus," but which is not noticed by either Dr. Gooch,* or Dr. Addison,t or M. Genest ;J this is a pulsating, throbbing, or flut- tering sensation within the vagina or pelvic cavity. So far, we have never known this symptom wanting in this affection, though it differs very much in degree. In some few instances we have known it to interrupt sleep ; but this is not the usual state of this symptom, though it is represented to be very disagreeable always ; this sensation, however, is not constant; it often suffers abate- ment, and occasionally is absent—but when present, it marks the irritable uterus in an especial manner. Dr. Gooch and Dr. Addison, in their descriptions of the "irri- table uterus," have added many symptoms that do not belong to this affection when simple and uncomplicated. To be convinced of this, it will be only necessary to compare the symptoms we have detailed above, with those enumerated by these gentlemen. Dr. A. lays down the following marks, as belonging to, or pro- duced by, "uterine irritation." He declares, the most frequent symptoms of this condition, to be— " Irregular menstruation, the discharge being preceded or ac- companied by pain in the back, loins, thighs, or in the region of the uterus itself, attended with forcing or bearing down ; the dis- charge being in excess, either in point of mere quantity, or in continuance, or in recurrence ; tenderness of the womb itself upon pressure made either externally or per vaginam ; a tenderness so great as to interfere with the privileges of matrimony, and lastly, leucorrhoea. The most frequent symptoms, however, are unques- tionably, painful menstruation and leucorrhceal discharge. Such are the few, plain, simple indications of a state of uterus which is repeatedly overlooked, though productive of the most serious disturbance, both of the general health and of particular organs ; disturbance which, when once produced, stamps a character upon the general and local ailments of the sufferer, strongly indicative, to the experienced man, of uterine irritation ; a character which confirms in the belief that it is from such irritation that the evil • Opera Citata. t Observations upon the Diseases of Females." * llecherches sur l'Hysterialgie ou Neuralgie Uterine, et son Traitement. Ga- zette Med. de Paris, Sept. 1830. 308 IRRITABLE UTERUS. originates, and that it is to correct the condition of the uterine system that his chief attention is to be directed." p. 12. In addition to these symptoms, Dr. A. enumerates a long train of nervous symptoms as belonging to this affection—in a word, he describes a well-confirmed hysteria. Indeed, the description given by Dr. A. and that given by us, do not agree in a sufficient number of important points, to induce us to believe wc are descri- bing one and the same disease. First The greater part of the symptoms enumerated by Dr. A. arc descriptive of simple dysmenorrhcea. Second. He makes the causes of "uterine irritation" consist in " irregular menstruation ;"* whereas, we are of opinion, that the aberrations of the menstrual discharge, if there be any, is owing to the inflamed, or irritable condition of the neck of the uterus. Third. The initial symptoms of the " irritable uterus," arc not those of nervous mobility, though these symptoms are almost sure to follow, if the disease persist for a considerable time. Fourth. The symptoms laid down by Dr. A. are virtually the same as those to which the inflamed spine gives rise, and which affection, agreeably to Mr. Tate, produces the hysterical pheno- mena. These symptoms, however, do not necessarily belong to the "irritable uterus," but may be looked upon as purely ner- vous, and arise out of a morbid condition of some other part, or may be the result of an "irritable uterus." Dr. A. thus cau- tions 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 • He says, that " menstruation continues as usual, or perhaps a little more abundant, but generally they are less, and sometimes suppressed." From this we should be led to conclude, that dysmenorrhoea, or even irregularity, in his estimation, are the causes of this complaint. We are every way certain, that we have seen the "irritable uterus" unaccompanied by dysmenorrhcea , and we are equally certain, that we have seen the latter many times extremely severe, without the former—these conditions appear to be rather the consequences than the cause of the «irritable uterus" in many instances j while in many others they are unattended by them. IRRITABLE UTERUS. 309 flow of the catamenia; by too frequent or too profuse menstrua- tion ; or by leucorrhoeal discharge ; I say, when you find such an assemblage of symptoms and circumstances, your suspicions will amount to a high degree of probability that the complaint is not of an inflammatory nature." p. 31. Now these very symptoms, we must repeat, M. 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, "uterine 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 as- cending and descending colon ; pain affecting the whole abdomen ; pain in the region of the stomach ; and lastly, pain in the region of the kidneys; sometimes extending down the course of the ureters to the bladder, p. 22. Now, in our opinion, the first five of these symptoms do not belong to the pure, or idiopathic, " irri- table uterus." First, because we have known them to be absent in several instances of exquisitely formed " irritable uterus ;" 2d, because they are constantly present in hysteria, where the uterus may be in a perfectly healthy state—for we have witnessed them in women who bear healthy children ; but we have never knOwn conception to take place in women who labour under " irritable uterus." And the last enumerated sign belongs more properly to the carcinomatous, than to the "irritable uterus." Fifth. Dr. A. makes very young females liable to the disease which he describes ; now, we have seen the " irritable uterus" only in women who had arrived near, or had passed, the middle period of life.* • Since the above was written, I have been consulted by letter, in the case of a young lady, only 18, who, I have not the smallest doubt, is labouring under " irrita- ble 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 interest, as it occurs in a young person, who in other respects enjoys a fair proportion of health, 40 310 IRRITABLE UTERUS. 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 ne- cessarily,) 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 confounded 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 to be the cause of all the inconveniences experienced ; and hence, the fre- quent failures of the pessary when it has been applied for the re- lief of the prolapsus. Nay, sometimes serious and permanent injury has been done by this instrument in these cases, without the practitioner being exactly aware why mischief should be caused by a machine that had been so often successful, in cases so apparently alike. And constantly it is a matter of much moment, that the two affections should not be confounded ; we would therefore suggest but which will and must very soon be destroyed, if this terrible affection be not Bpeedily removed. There is in this young lady a strong scrofulous tendency, with some development. We have recommended absolute rest; a milk and vegetable diet; the rhubarb pill; occasionally leeching or cupping -T the iodine, and injections of the solution of the nitrate of silver, on the faith of its influence upon certain inflamed sur- faces in other parts of the body.j IRRITABLE UTERUS. 311 the observance of the following precautions, when an examination is about to be made per vaginam, for prolapsus uteri. First. Let the patient be placed upon her back with the knees drawn up. Second. Let the parts be well lubricated that no pain may be excited by the introduction of the finger, tyst 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 introduced, until this has been abated by suitable means. In this case the patient will be labouring under " irritable uterus," and not a simple pro- lapsus. Besides, in the "irritable uterus," the prolapsus is not always permanent—but sometimes only so in the erect position of the body, as in standing. The " irritable uterus" has also been confounded with carci- noma of this organ, when it has been about to throw off its in- dolent condition, and to commence the ulcerative process. But the " irritable uterus" is easily distinguished from the carcinoma, by the neck of the uterus in the latter still retaining the original marks of carcinoma; as a thickening of the whole of its substance; by its having a cartilaginous feel; by its being shorter; and the os tincae being more open than natural; by tumours still occupy- ing the neck, and pelvic portion of the body of the uterus; by a pretty abundant and sometimes constant discharge, of a serous fluid, which may be occcasionally tinged with blood, and the al- most entire filling up of the vagina, by the increased size of the uterus. The " irritable uterus" has also been confounded with dysme- norrhcea, but from this functional derangement of the uterus it is easily distinguished. First. In dysmenorrhoea pain is only felt during the menstrual action ; whereas, in the other, the suffering is more or less constant, though subject to occasional -aggravation, and this of a severe kind, at other than the catamenial periods. Secondly. The " irritable uterus" is not necessarily attended by dysmenorrhcea, nor is dysmenorrhoea usually attended by this 312 IRRITABLE UTERUS. irritable condition of the uterus; for wc have seen very many instances to the contrary. Pathology.—-We have already declared our belief that this disease consists in a chronic, or sub-acute inflammation of perhaps all the tissues, that compose the neck of the uterus. The patho- logical condition of the womb, in this complaint, has, however, never been ascertained, by a post mortem examination, as it very seldom, or perhaps never, of itself destroys the patient. It were much to be desired, that an examination be made, should oppor- tunity present—as we are of opinion, that more derangement of structure would be found in some cases, than appears to be allow- ed to exist by either Dr. Gooch or M. Genest, for we have met with several cases in which the size and form of the neck of the uterus was much altered from its natural condition. Indeed, the admission of Dr. G. and M. Genest would seem to declare the 6ame 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, than in an unmixed, or idiopathic neuralgia of the uterus, that very little, if any derangement of structure takes place ; from which circumstance, we are disposed to believe, that when this disturbed condition of the womb is met with, it betrays the neuralgic form of this disease. Dr. Gooch will not admit the uterus to be in a state of chronic inflammation. He says, that, chronic inflammation, like the acute, is always " a disorganizing process ;" but if we are not very much in error, a chronic inflammation may exist for an almost indefinite period, in some instances, without any very manifest derangement of a part; and that there is some derangement in the "irritable uterus," we are, from many observations, very certain—besides, there are present in this affection, all the com- mon characters of inflammation—as heat, swelling, and pain ; but IRRITABLE UTERUS. 313 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 opi- nion is rather by analogies, than by pathological observation. He says, " the disease which I am describing, resembles a state which other organs are subject to, and which, in them, is denominated irritation. Surgeons describe what they call an irritable tumour in the breast It is exquisitely tender; an ungentle examination 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 ne- ver terminates in disease of structure." " Mr. Brodie describes a similar state in the joints." It chiefly occurs amongst hysterical females ; it is attended by pain ; at first without any tumefaction; but the pain increases, and is attended with a puffy, diffused, but trifling swelling ; the part is exceedingly tender; this assemblage of symptoms lasting a long time, and being often little relieved by remedies, occasions great anxiety, but "there never arise any ultimate bad consequences." "The disease," says Mr. Brodie, "appears to depend on a morbid condition 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 con- stitutions which they attack ; similar in pain ; in exquisite tender- ness ; 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 des- cribed, 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 mo- dified inflammation ? Does the attempt to illustrate the condition of a part involved in disease, by adducing the inexplicable phe- nomena presented by diseases of other parts, (however strong their analogy may be,) throw any light upon its pathology ? Is not the pathology 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 condition of a part present itself to the mind, by say- ing, tha the phenomena of the diseases offered as illustrations depend "upon a morbid condition of the nerves, and may be re- 314 IRRlf ABLE UTERUS. garded as a local hysteric affection ?" or In other words, is our knowledge of the pathology of the "irritable uterus" any way advanced by declaring, it is the same as in a " local hysteric affec- tion?" 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 inflammation, (either acute or chronic,) has no agency in the production of the symptoms which characterize the several dis- eases just named? Certainly it has not 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. Addison declaring the same thing ? We think not. In fact, whilst Dr. Gooch denies the presence of inflammation, he at the same time furnishes us, in the history of his cases, with sufficient evidence, that this condition of the parts concerned, really exists. Thus, in relating the history of the disease in ques- tion, in 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 shoot- ings, or electric shocks, darting from the tumour up into the ab- domen ; they recurred every five or ten minutes, making her start with such violence as to shake the bed. I have been in the ad- joining room when she has been in this state, and have perceived the shock ; between the spasms, she felt what she called a con- vulsive 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 subsided, leaving a dull permanent uneasiness. The ute- rus was so tender, that the examination of it was torture, and left severe suffering for hours."* p. 335. • We have never met with such an exquisite degree of sensibility in the ge- nuine uncomplicated irritable uterus, as is here spoken of; where this has existed, to the extent described by Dr. Gooch, we have always had reason to suspect neuralgia was added. IRRITABLE UTERUS. 315 Need better proof be given of the inflammatory nature of the irritable uterus than the treatment of this case. Certain sensations of spasms accompanied this complaint; the sensations are described as consisting oVlocal heat, throbbing, and expansion, to a feel- ing 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 bodi- ly exertion, as it almost always shows itself, after this has taken place, where predisposition has existed. Dr. Gooch says— " In one patient it came on after an enormous walk during a menstrual period, in another, it was occasioned by the patient's going a shooting with her husband, not many days after an abor- tion : in a third, it came on after standing for several hours many successive nights at concerts and parties ; in a fourth, it originated in a journey in a rough carriage over the paved roads of France ; in a fifth it was attributed either to cold or an astringent lotion, by which a profuse lochia was suddenly stopped, followed by intense pain in the uterus ; in a sixth, it occurred soon after, and apparently in consequence of matrimony." p. 314. It is evident, that the causes here enumerated, were only exci- ting 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 sensative 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 316 IRRITABLE UTERUS. 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 obnoxious to the " irritable uterus" than those of an opposite temperament —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 between that state of the uterus which gives rise to dysmenorrhcea, and that in which consists the "irritable uterus." For dysmenorrhcea is ow- ing to a certain pathological condition of the internal or 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, agree- ably 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 of the pathological condition of the neck, while labouring under the condition we are treating of. Fourthly. In dysmenorrhoea, the pain that accompanies the secretion of the menstrual blood, is not caused by any particular condition of the secreting organ, abstractedly considered, but to the changes wrought upon this fluid itself, during its elimination, causing it to remain within the uterine, cavity, until it becomes, to all intents and purposes, a foreign body, and requiring the aid of uterine contraction to expel it—hence the pain of dysmenorrhoea, and consequently, between it, and that attendant upon the " irritable uterus," there is not the slightest resemblance in either kind or cause. Fifthly. Were there the strongest resemblance between the pathological condition of the internal surface of the uterine cavity, and that of the neck of the uterus, in the two affections under consideration, we should not profit from the analogy, as Dr. G. has not pointed out the condition of the former, that we might benefit from its resemblance to the latter. Dr. Gooch insists that the " irritable uterus" is " a disease of function, and not of structure." p. 316. We would ask of what function ? For Dr. G. admits that the menses continue to be dis- charged, though not in the most healthy manner ; but we have IRRITABLE UTERUS. 317 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 severity renders it desirable; for were we candid, we must honestly confess, that the contrary of this is nearer the truth. This difficulty, how- ever, does not arise so much from the indomitable nature of the disease, as from the length of time required to overcome it, and the privations to which the woman must submit who looks for- ward 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 uncertain; especially with patients whose circumstances and avocations will not permit them to fulfil any plan, however judiciously laid down, or how- ever important its adoption may be to their welfare. We have just declared, that relief in this disease is almost always tardy; for however judiciously remedies may be devised, or how- ever faithfully they may be applied, they are far from being uni- formly 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 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- 41 318 IRRITABLE UTERUS. 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 uniform- ly 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 experience—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 im- portance of the trespass. But notwithstanding the unyielding nature of the disease of which we are treating, much may be done towards its relief, if we cannot always promise its removal; and we are rather disposed 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 management of this disease, and suggested certain cautions, that must never be lost sight of during its treatment, we will now proceed to detail all that experience has hitherto suggested for its relief. The therapeutical means will consist, first, of rest; second, of bleeding, both general and local; third, of purging; fourth, of blistering, or of the employment of rubefacients ; fifth, of narco- tics ; sixth, of injections per vaginam; seventh, of regimen; eighth, 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 sub- stance on which she is to repose ; it may be a bed, a mattress, a couch or sofa; or she may occasionally vary either of these, pro- vided 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 IRRITABLE UTERUS. 319 her mattress, to a couch or sofa, and this daily, if she choose this change, but she must preserve the horizontal position under all circumstances. She must not sit up even in the bed, or on the mattress or sofa, even for a short time, as this slight indulgence is almost sure to be followed by an increase of pain, or other inconvenience ; a fortiori, she must not be permitted either to stand for any time upon her feet, or to walk. Nothing shows the extreme sensibility of the uterus, (or rather a portion of it,) more decidedly, than that augmentation of pain, which almost instantly takes place from an erect, or even a semi- erect position, and which obliges the woman almost instinctively to return to a horizontal one. All her unpleasant symptoms are suddenly increased ; especially the throbbing sensation, which, as we have declared above, so particularly characterizes this disease. This increase of pain most probably arises from two causes ; first, from the uterus being obliged to sustain much of the weight of the abdominal viscera; and second, 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 position, but will absolutely covet it, from the immediate and certain re- lief 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 occasional necessity of bleeding from the arm or foot. We would employ general bleeding but under two circumstances of the sys- tem—first, where the circulation is vigorous ; the pulse tense or chorded ; where there is much pain, and especially in the abdo- men, accompanied by cough, or head-ache; 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 found, that the proper abstraction of blood from the system at large in the beginning of our treatment, was sure to be followed by advan- tages 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 abstract tion gives a more decided efficacy to other remedial means, 320 IRRITABLE UTERUS. Second, should the symptoms enumerated above be attended with a sparing menstrual discharge, wc would abstract eight or ten ounces of blood from the foot, and this should be repeated five or six days before the next menstrual period, if the first has not succeeded. But the " irritable uterus" will require the abstraction of blood from parts near the seat of the affection, and this again and again —the parts hitherto selected for this purpose, have been the sa- crum, or the abdomen ; but multiplied experience has convinced me, that as much advantage, to say the least, but we really think much more, has followed, when the blood has been drawn from the inner part of the thighs, three or four inches below the vulva; it may be drawn from one, or both thighs at the same time, by either cupping or leeching, and should be repeated every four weeks, a few days before the menstrual period, until pain, &c. are much abated ; or until the patient can bear to be placed upon her feet, or even walk, without much inconvenience or discom- forture. Four or five ounces may be drawn at each time. In judging, however, of this latter circumstance, 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 position upon the affected parts—we should therefore inquire into the na- ture of the existing feelings, and compare them, both in degree, and in their nature, with those that really belong to the disease. To aid us therefore in forming a correct judgment upon this im- portant point, we should, from time to time, make a careful exa- mination per vaginam, with a view to determine the existing degree of sensibility in the neck of the uterus, and the several por- tions of the vagina. By doing this, we shall be able to determine the exact impression we are making upon the disease ; and con- sequently, thereby ascertain the extent of necessity for perseve- rance. In making this estimate, we must never fail to take into consideration the state or degree of the "throbbing sensation," we have mentioned as particularly belonging to the disease ; for by this very much may be learnt—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 abate- ment of this unpleasant feeling, is the abatement of the disease itself. Purging.—There is no one of the remedies proper in this dis- IRRITABLE UTERUS. 321 ease so difficult to manage as purging—for there is no doing with or without it, as the bowels in this complaint are always either constipated, or too easily made free, and either condition is sure to aggravate the suffering ; in this opinion I am happy to be sup- ported by the experience of Dr. Gooch. But, notwithstanding these difficulties, it is everyway important that the bowels should be moved once a day ; neither less nor more. And for this pur- pose nothing answers better than the simple rhubarb pill. Blistering and Rubefacients.—We are much at a loss to de- termine 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 had been 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 bath should be used whenever the coldness of the feet claim attention, be this daily, more seldom, or oftener. The ointment should be applied to a pretty large surface of the abdomen twice a day, until a pretty extensive vesication is produced, and repeated from time to time, as the vesicles may heal, and as the urgency of the symptoms may require.* Narcotics.—Agreeably to our experience, much caution is required 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 subdue 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 * We have frequently had cause to lament the tardy effects of this ointment, though pretty well aware of the causes. The first is, the adulteration of the tartar 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 alco- hol ; a very small quantity of the latter will suffice, he says, to precipitate the tartar emetic 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. 322 IRRITABLE UTERUS. 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 has failed in other hands, as is abundantly proved by Dr. Gooch's cases. Yet there is a period at which there is both propriety and 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. 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 ge- neral and local symptoms ; and if either be increased after its ex- hibition, or in other words, if it fail in procuring relief, the quan- tity 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 aplication 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 uterus ; of this kind, is lukewarm flaxseed 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 leucorrhoea 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 IRRITABLE UTERUS. 323 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 attended 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 adhered to, and persevered in, even some time after the apparent removal of the disease—for, as noticed before, no disease bears imprudences worse than the one of which we are treating. Of the Pessary.—It frequently happens, that the uterus will remain 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 re-applied, 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 wit- nessed 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 phosphate 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 governed by any peculiarity they exhibited, or because there was any particular departure from the ordinary mode of treat- ment; they have been chosen, with one exception, (the third,) because they were considered as fair instances of the " irritable uterus," and exhibiting the most usual train of symptoms, as well as the most uniform mode of treatment. Case 1.—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 ; 324 IRRITABLE UTERUS. and when once provoked, would continue from one to two or three hours, suffering however a gradual abatement during 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 also have the effect, though in a more moderate degree than some other causes. Coughing or sneezing were 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 tender; 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 completion. This discharge was announced always by tenderness in the mammas; a sense of ful- ness in the region of the uterus, with a feeling as if the uterus were constantly sinking lower in the pelvis—there was no dys- menorrhoea, 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 varia- ble, and the digestion not bad. The tongue very slightly furred, and paler than natural. She was ordered to observe a horizontal position; a strict anti- phlogistic regimen ; to lose ten ounces of blood from the arm ; 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 IRRITABLE UTERUS. 325 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 evident melioration of symptoms ; especially of the uterus and the sur- rounding parts—their sensibility was much diminished, and the leucorrhoea 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 substituted 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 severity and frequency than before. This lady was once blistered on the sa- crum, 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 sensibility 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 re- turned. At the end of thirteen months the patient was entirely 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 indulgence. It was, 42 326 IRRITABLE UTERUS. however, soon found, that the prolapsed condition of the uterus was offering considerable inconvenience; and as the parts had entirely recovered their natural condition, a pessary was intro- duced with very prompt and decided advantage, 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 rela- ted. 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 spasm—hence bark, steel, cold bath, sea bathing, opium, hemlock, henbane, stramonium, warm bath, blistering, salivation twice re- peated, &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 leucorrhoea, and more profuse menstruation. This lady was confined to her bed from extreme weakness when we first saw her—the febrile affec- tion was more distinctly marked, and great obstinacy of bowels. General bleeding was not employed in this case ; with this excep- tion 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 haemorrhagy 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- rhoea 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 adopt- ed, and the patient was very much relieved at the end of about live 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 'isbme reason to regret, that the plan which had so far relieved the disease, had not been persevered in three or four IRRITABLE UTERUS. 327 months longer, as there was every reasonable expectation that it would have proved still more beneficial. Notwithstanding the success that attended the cases just related, as well as many more that we could mention, it is but fair to ac- knowledge, there have been others, in which no such benefit was received, though remedies, generally speaking, were faithfully used, and every reasonable precaution taken to insure success. CHAPTER XVI. ON 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 effecting 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, at 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 ovum, we discover its external covering or chorion, shoot- ing out innumerable vascular fibres—and both, when united, serve as the bond of union between the ovum and the uterus. 328 UTERINE HEMORRHAGE. The efflorescence on the uterine surface, like that which covers the ovum, is decidedly vascular ; and it 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 ear- lier months, the quantity of blood that will issue, will be com- mensurate 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 hemor- rhage 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, passions or 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 assigned for the disease 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 UTERINE HEMORRHAGE. 329 in either case, it might be the cause of hemorrhage. He gives a case purporting to be illustrative of this assumption—but confesses 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 the ac- cidental shortness of the funis. Levret met with a similar instance. And Baudelocque also mentions a remarkable case of this kind.* It must, however, be confessed by all conversant with the prac- tice 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 emo- tions of the mind : Fourthly, plethora. Each of these causes may produce 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 an increased force of circulation ; and this is generally considered sufficient, under cer- tain circumstances, to produce the evil in question. It has been thought, that whatever gave an increase of force or velocity to the circulatory system of the mother, must almost necessarily in consequence of the large size of the hypogastric and spermatic arteries ; the short distance they have to travel before they arrive at the uterus ; and their great increase in that viscus as gestation advances, very much affect 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 pretty much after 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 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 suffer- ing the vessels to become engorged. 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 be followed by this accident; but this is contrary to all experience. * Midwifery, par. 1084. 330 UTERINE HEMORRHAGE. 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 preg- nancy—and that something I believe to be uterine contraction, as without this, I am at a loss to understand the modus agendi of the remote causes. I shall not pretend to say how the causes just enumerated, in- 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 ute- rus ; 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 increases 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 contraction, 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 UTERINE HEMORRHAGE. 331 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 universally 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 ackowledged. 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, declare that I have been rewarded, and should our attempts fail nineteen times out of twenty, we are surely not justified in withholding them. I therefore make it an invariable rule, to treat the case as if success were to follow. There is one case I acknowledge, with which I never inter- fere, 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 be- come 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 centainty; 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 his 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 Mottc (Obs. 305) gives an instance where the woman went her full time, after the orifice of the uterus was considerably 332 UTERINE HEMORRHAGE. dilated. And above all, I may cite Mr. Burns himself, for an ex- ample most strictly in point. (Princip. of Mid. cd. 2d, p. 195, in a note.) He relates, with seeming belief, that cases have oc- curred of twins, one of which has been expelled, while the other remained, 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 consider- able time: if this be so, under the circumstance of one fectus 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, 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 de- cidedly taught this doctrine. Mauriceau, La Motte, and others before his time, met with the placenta in this situation, but they all 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 tho ovum : after this time, the neck is called upon (if I may so term it) for its pro- portion, as the other parts of this organ seem to refuse any farther supply : in consequence of which, it, in its turn, becomes dis- • Indeed our periodical Journals have lately in a number of instances furnished us with cases, proving that the uterus may expel a fatus prematurely, and llieu become passive, until a twin was matured j or in a condition to be expelled with advantage to itself. UTERINE HEMORRHAGE. 333 tended ; and in this act, a portion of the placenta is necessarily 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 instant- ly jeopardised, 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 form- ed, betwixt the ovum and the uterus, by means of the chorion 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 portion 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 practition- er ; provided, a sufficiently early attention may have been paid to it. It must however be confessed, that it is very difficult to esta- ♦ For a particular account of this cause of hemorrhage, and its mode of treat- ment, see System of Midwifery by the author. 43 334 UTERINE HEMORRHAGE. blish any certain rule upon this subject; since, I have seen symptoms as alarming attend an abortion of six weeks, as I have witnessed from a premature labour of the 7th month; or indeed, at any other period. It may, however, with confidence be advanced, that alarming symptoms do not show themselves as quickly in the early, as in the later 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 judg- ment 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 treatment The nature of each remedy shall also be considered; and the pe- riod 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 utero- gestation, may take place; this will consist of four periods. 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 remain- ing period of utero-gestation. 3d. Into, the period between the birth of the child, and the expulsion of the placenta, and 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 UTERINE HEMORRHAGE. 335 our first division, it would be highly improper, under almost any circumstance, to pierce the ovum with a view to the discharge of the liquor amnii; yet, at the second period, it may become an essential 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 tineas ; it will, therefore, follow, that when this takes place, the chance of arresting a flooding, and preservingthe ovum, must be diminish- ed 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—but this is by no means a proof of an open condition of the os uteri; for the coagula are always perhaps, but certainly, much the most fre- quently formed in the vagina, when an ovum occupies the cavity 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. 336 UTERINE HEMORRHAGE. 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 tincae 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 ia 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 ute- rus just spoken of, is the effect of these contractions. There is another mark equally unequivocal; and to which it may be pro- per now to advert, namely, the cessation of morning sickness; a diminution of the abdominal tumour; but, above all, the mammse becoming painful and distended with milk, and these pretty quickly followed by flaccid breasts. In both these cases, all attempts to save the ovum will be unavailing; and our whole pare must be directed to the state of the flooding. Nor is the quantity of blood expended, in itself, however ex- cessive, positive evidence that abortion will take place; espe- cially, when unaccompanied by pain—for I have repeatedly seen a very large waste, without any other evil attending; while, on the contrary, 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 flood- ing following any violence, more certainly ends in abortion, than those which come on silently and slowly, without any apparent cause. No reliance should be placed upon the opinion, that a mode- rate discharge of blood from the vagina, during, pregnancy, is useful, by removing topical plethora.! On the contrary, we should look upon every appearance of this kind with great sus- picion, and treat it as if it were to become decidedly mis- chievous. Therefore, every sanguineous discharge from the vagina of a pregnant woman, should be treated with the utmost • Pain accompanying flooding should not make us abate our endeavours to save the ovum, but 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.) UTERINE HEMORRHAGE. 337 care—all the essential indications for hemorrhage should be in- stantly complied with; and no time should be lost by tempo- rizing. The essential indications are, 1st, to arrest the bleeding; 2d, subdue pain if present; and 3d, prevent a recurrence of the hemorrhage. 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 an hemorrhage from the uterus, the sooner it be arrested, the better; every known remedy of efficacy is to be employed in succession, should the antecedent ones fail of success; and every advantage 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 patient or attendants run counter to his instructions; and in no case perhaps, is their observance of more decided consequence, than in the complaint we are now considering. One of the first steps to be taken, is to command the most per- fect possible rest of body and of mind. The patient should be placed upon 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-water, &c.—no stimulating substance of any kind should be permitted. Care should be taken, even in the administration of food* and of drinks, that the patient does not exert herself to receive them; she should be strictly confined to a horizontal position. Her food should be of the same general cha- racter as her drinks—such as thin sago, tapioca, gruel, or panada —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 desire 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 prohibited the patient; and all company excluded. 338 UTERINE HEMORRHAGE. Much mischief is sometimes done by the talking of the bystand- ers ; for they for the most part, delight in the marvellous, and relate the histories 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 patient, and the government of the attendants, we should next determine 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 arterial system ; remembering, we do little or no good by the operation, if we do not decidedly diminish the force of its action ; let the pulse rather sink under the finger than otherwise ; its repetition must be regulated by circumstances ; recollecting, however, 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 flood- ing, which were little attended to. The usual means were now employed, and for the time, the discharge was arrested ; this was early in the morning of the 16th. She remained very well until 5 o'clock, P. M. At this time she had a return of flooding ; I was instantly sent for ; and living but a few steps from the patient, was very quickly at her bedside. 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 frequency of the pulse; and the abdomen covered with ice and snow. So soon as this took place, there was an abatement of the discharge : this condi- tion was followed by slight alternate pains in the back, shooting towardsthe pubes. Forty-five drops of laudanum 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 discharge; she continued so until about 5 o'clock, P. M. when the whole scene, as men- UTERINE HEMORRHAGE. 339 tioncd before, was renewed ; she was again bled ; subjected to the application of the ice ; and the laudanum was repeated for the same reasons as yesterday. 18th, A. M. 8 o'clock, I was called suddenly to my patient, as she again had a return of fever, with hemorrhage ; she was again bled, &c. In this manner did matters proceed for several days ; it was now found, that the arterial exacerbations observed no regular period ; but whenever they did occur, there was uniformly a re- turn of the flooding; and would continue during this state of excite- ment. With a view to interrupt this condition, or to abridge it as much as possible, I placed a young gentleman at the pa- tient's bedside, with orders to bleed her the moment he per- ceived an increase of pulse ; this was accordingly done ; and from each bleeding decided advantage was discovered. The loss of five or six ounces of blood was sure to put a stop to the uterine dis- charge, in the course of a few minutes; and sometimes, would prevent its appearance, when it could be very promptly used. By proceeding in this manner until the 23d, the patient was entirely freed from this distressing complaint. She was bled seven- teen times ; and lost, by computation, one hundred and ten oun- ces of blood in the course of seven days. She gradually gathered strqngth, 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, 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 water, to which must be added a drachm of laudanum : and this be repea'ted, pro re nata. Or we may give the extract of Rathany with great advantage, in the manner already recommended at p. 154, 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 340 UTERINE HEMORRHAGE- 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 threatening symptoms, no time should be lost in employ- ing the tampon. The best I believe, is a piece of fine sponge of sufficient size to fill the vagina. It should have pretty sharp vinegar squeezed from it several times, with a view to clean it, and to have it imbued with this acid ; it may then be introduced 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, wc may, notwithstanding the profuse- ness of the discharge, and even the presence of pain, still enter- tain 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 of these conditions is to affect our conduct, as regards the hemor- 4" rhage; for this is to be staunched, though we are certain the em- bryo will be lost Much error is sometimes committed, under an impressjon that the ovum must be expelled ; and that nothing can be done advantageously for the woman, until this be effected. I have known a hemorrhage suffered to continue, almost to the exhaus- Vl tion of the patient, because pain was considered essential to the throwing off the ovum, though on each return of it, a large coagu- lum has been expelled ; or the discharge has been augmented by * injudicious manual attempts to aid the expulsion of the ovum. Both of these mistaken methods cannot be too severely repre- hended—one for blameable supineness ; and the other, for rash interference. Whatever may be the rapidity of the discharge in such cases, it is ever under command, so far as my experience will warrant the assertion, by the use of the tampon. This should be instantly resorted to ; and its effects will be quickly perceived. * • My judicious and experienced friend, Dr. Meigs, informed me, however, of a case, that fell under his notice, in which the discharge continued in an alarming quantity, though a tampon had been employed. In such a case it might be well to make a piece of sponge occupy the os externum completely, and its escape prevented by continued pressure against it with the hand. UTERINE HEMORRHAGE. 341 I deprecate, with much earnestness, frequent, and unnecessary touching. This is not only injurious, by fatiguing the patient, but by removing coagula, that may be important to the stopping of the hemorrhage. This should, therefore, always 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 the impropriety of such a procedure ; for it is agreed by the most enlightened upon this subject, that it is mischievous to effect it, and unfortunate, when it spontaneously happens. The reason is obvious. The embryo is expelled, but its involucrum is retained ; in consequence of which, the flooding is perpetuated, and much pain, and other inconvenience, if not danger, are experienced, before it is thrown off from the uterus. It must therefore repeat it as a rule, that the ovum is never to be pierced before the commencement of the fifth month,* unless the flooding is very profuse, the pains very urgent and the os uteri pretty well opened. 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 never so frequent or powerful, or the flooding never so profuse ; for the one may be diminished by opium, and the other arrested by the tampon. And if no pain attend, it almost becomes criminal to do so ; since the ovum may, by the use of the tampon and the other remedies above suggested, be preserved. I have ever found, in such cases, that much effort is required to expel the secundines ; nor will we be much surprised at this ; when we recollect the strong disposition the mouth of the uterus * Burton, and some others advise the rupturing of the ovum, even at the second month—than this, nothing can be less conformable to either sound rea- soning, or good practice. 11 342 UTERINE HEMORRHAGE. 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 maintained 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 inexperienced,) 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 thttf * put a stop to the discharge; but it is rare that we are so for- tunate. * 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, t 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 hooked extremity of the crotchet is conducted along the finger, until it be within the uterus; it is now to be gently * From some late experience, I am induced to believe, that the Ergot, if givea 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 tlie fingers—that is, where this mass continues to occupy the uterine cavity, or but very little protruded through the os tincse. •J- The drawing I have given of this instrument, is upon a reduced scale ; the reduction is one-third. I consider this much more simple than the pince a faux germc, as proposed by Levret, and recommended by Leroux and Baudelocque? or that of Burton, for the same purpose. v :wi ft UTERINE HEMORRHAGE. 343 carried up to the fundus, and then slowly drawn downwards, which makes its curved point fix in the placenta; when thus engaged, it is gradually drawn downwards and the placenta with it. The discharge instantly ceases, in every case in which I have used it. In all the instances to which I here refer, I am per- suaded 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 frequent and severe; large doses of the acetate of lead and opium were ordered, together with cold applications externally—the mouth of the uterus was a little open; the ovum protruding; quiet, cold drinks, &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 dilated, and the ovum more tangible. At three o'clock P. M. the ovum opened spontaneously, and the embryo escaped—flooding violent; pains trifling ; syncopes frequent; pulse very small and quick ; the placenta in part engaged in the os uteri—a stimulating injection was ordered, with the 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 frequent; pulse scarcely perceptible. The placenta was now removed by the wire crotchet; the flooding ceased instantly : the subsequent symptoms were very mild. Sometimes, when the ovum has opened, and the ..embryo es- caped, but has left its involucrum behind, the hemorrhage may not be violent, but may be.of long continuance ; at least it will be as long as this mass remains. In such cases, where time is not so precious to the safety of the woman, I have, in several instances of this kind, administered the ergot in twenty grain doses, with very decided and prompt advantage. The peculiarity of this period consists in the ovum not having the transparent membranes formed ; and the practice founded upon this as a general rule, is, never to break the walls of it. Second Period. This comprises all the time, from the fourth and a half, or the fifth month, to the entire completion of utero-gestation. 344 UTERINE HEMORRHAGE. 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 placenta being detached. It will follow, that the issue of blood will be in proportion to the extent of surface so exposed ; to the advance- ment 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 discharge 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, in- deed, 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 Hie same manner. It is my practice, in cases of a threatening flooding, during pregnancy; or when, from the rapidity of the discharge, the woman's strength would be quickly exhausted ; to use, in addi- tion to the means just mentioned, the tampon. I have already said, I have found fine sponge the best; but where this cannot be'procured, fine flax, or very well picked tow, or old linen, may be substituted. When the latter substances are chosen, they should be used in portions of moderate size, and well moistened with sweet oil, or melted lard—they should be introduced one by one, until tho vagina is completely filled ; the whole may be secured by a com- press, and T bandage. This latter precaution is not necessary when a sponge is used, if the piece be of proper size. From its compressibility, it is introduced without the least inconvenience, UTERINE HEMORRHAGE. 345 if previously prepared as directed ; and 1 believe it promotes coagulation quicker than any other substance, from its numerous cells giving speedy passage to the finer parts of the blood. It almost instantly puts a stop to the hemorrhage; and, in some instances, I believe, I was entirely indebted to it for the preser- vation of the lives of my patients. Some object to the employment of the tampon ; they say there is danger of local inflammation from the use of vinegar; but experience 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 putting 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 eoagula 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 coagu- late more speedily; or immediately, upon the opened extremities of the bleeding vessels, so as to induce them to contract. Hence, the almost universal employment of that class of medicines called astringents. Leroux,t however, forbids them in uterine hemor- rhage, after delivery; but he does this upon a wrong principle. He says, " dans l'hemorrhagie uterine violente qui succede a l'ac- couchment, ils ne peuvent etre d'aucune utilite. Pour s'en con- vaincre, il suffit de se representer la route qu'ils sont obliges de suivre avant de parvenir ou lieu au leur pourrait etre utile, le • "Ces sages precautions ont suspendu souvent, et quelquefois ont fait cesser des pertes de sang accompagn^es de petits caillots ; non pas en soudant, pour ainsi dire, a l'interieur de la matrice les portiones du placenta s£pare"es, mais en donnant le temps au sang arrete" a l'embouchure des vaisseaux de s'y cailleboter, et d'y former de petis bouchons moule's sur leur diametre, capables d'arreter le sang." (Mem. de l'Acad. torn. i. p. 211.) f Observations, &c. p. 200. 346 UTERINE HEMORRHAGE. temps qu'ils mettcnt a parcourir ce trajet, ct les changemcns qu'ils eprouvent avant d'y arrive." In like manner, from their mode of action, Leake* 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 "* ' them, as the sugar of lead (especially,) produces sometimes the most decided and prompt effects, let its mode of action be what it may. ,v In many instances, it exerts a control over the bleeding ves- J sels, as sudden as the ergot docs 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- I 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 ^t 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 Tesource. i] 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; .j gad 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 • On Child-Bed Fever, vol. ii. p. 301. UTERINE HEMORRHAGE. 347 advocates 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, es- caped from the uterus, t Mesnard advised delivery, if there was a flooding sufficient to cause fainting ;t and Heister§ and Puzos|| were of the same opinion, &c. &c. ; for it would be easy to mul- tiply authorities, to considerable extent, to the same end. The advocates for delivery, as the only means of arresting hemorrhage, 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 con- traction of the uterus, and by this means put a stop to the flood- ing ; the latter may be subdivided into three : 1st. Those who did not regard the situation of the os tineas, 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 es- cape 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,IF we have the authority of Pasta,** who deprecates • Traite des Accouchemens, Obs. 216. t Des Operations, p. 249. * Pasta, p. 170. § Surgery, part ii. p. 957. H Mem. de l'Acad. vol. i. p. 224. t Among the first class, may be reckoned all the accoucheurs prior to the time of Mauriceau. To the second class, and the first division of that class, belong Mauriceau, Dionis, La Motte, Deventer, &c. &c. To the second division, we may place Puzos, Smellie, Delourie, &c. &c. And to the third, we have Leroux, and most of the late writers upon midwifery. •• Vol. i. p. 132. 348 UTERINE HEMORRHAGE. the practice as both cruel and dangerous ; of Kok,* who says he has seen it followed by inflammation of the womb ; of Lcroux,t who declares it to be dangerous to both mother and child ; of Baudelocque, f who insists that nothing can justify the accoucheur, who persists to deliver while the neck of the uterus retains its • natural thickness and firmness. And I may add my own expe- rience, as I once witnessed death, as the consequence of such a proceeding. The method pursued by those of the first division of the second class, is not free from serious inconveniences, and is, perhaps, scarcely inferior to the first, as the same violence must almost ! necessarily be committed. The plan of the second division of ' the second class, (which I shall, in conformity with custom, call k Puzos' method,) is far from being the one most conformable to ' the principles of the art; since in its performance, great violence is frequently obliged to be resorted to. t 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 I 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 ^1 the success of his method, from the excessive loss of blood, and k was fearful he should be obliged to have recource to forced deli- very. 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, j will render this method ineligible. 5th. It is sometimes impossible to make a forced delivery ; es- pecially, from the fifth to the sixth and half month ; of this La Motte|| gives one example, and Smelliell another—and I once • Pasta, p. 276. t P- 241. t Vol. ii. p. 90. § Mem. sur les Pertes, &c. p. 336. | Obs. 452. 1 Collect. 33, No. 2, Ob. 1. UTERINE HEMORRHAGE. 349 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 division 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 hemor- rhage, 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 ? Cer- tainly not. If there really were no other remedy, forced delivery, with all its disastrous consequences, might be justifiable; but as we have the power of plugging the vagina, and preventing 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 enti- tle 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 certainly and success. The importance of the tampon is, perhaps, never so clearly 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 delive- ry) 1 have seen it arrest a profuse flow in almost a moment, and where the farther loss of a few ounces, must have been followed by death. Syncope, and even convulsions, have ceased upon its application. Though it be confessed, that after the failure of the remedies, recommended for the suppression of hemorrhage, as the applica- tion of the tampon, &c. there is but one means left in our posses- sion (namely, delivery) by which the flooding can be arrested, and the life of the woman preserved—yet it may be asked, is there no condition of the patient, in which it would be improper 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? 45 350 UTERINE HEMORRHAGE. I have no hesitation in answering this, in the affirmative ;—but, previously to the operation, the condition of the patient should be candidly stated to her friends ; it must be undisguisedly de- clared to them, that no undue calculation should be made of the benefit of delivery ; but, as this operation offers the only possible chance of relief, it might be adopted. We may be encouraged to do this, as it now and then happens, that the woman recovers, under such circumstances, contrary to all expectation. Hitherto, I have said nothing of opium as a remedy in uterino hemorrhage; the reason, is simply this—it has never merited the smallest commendation in my hands; for it has never been attend- ed with the slightest success ; of course, I cannot be of opinion, that it deserves the encomiums which have been so lavishly bestowed upon it by Dr. Hamilton and others. I have read, dispassionately, 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 be- i* neficial, 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 applications, as no remedy has been more extensively employ- ed, or more constantly abused. Cold, as a means to arrest flood- ing, is in almost universal employment; is usually one of the first resorted to, and the last that is abandoned—it has acquired so much popularity among the vulgar, as to render it unsafe for the reputation of the practitioner, who has omitted it in his treat- ment of this complaint. But, though confessedly an agent of great power, it has never- theless its limits of usefulness; and beyond which, it should never be urged—for its efficacy is very much confined to its influ- ence 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 contrac- tion ; but its greatest value seems to be, in controlling arterial UTERINE HEMORRHAGE. 351 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 feet and legs be 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 render- ing 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, that, in certain cases of uterine hemorrhage, the forceps are the only means to be employed or relied upon. They are exclu- sively indicated, 1st. Where the discharge is threatening, and the labour well advanced ; but where the membranes have been long ruptured, and the uterus is firmly embracing the body of the child, or the head does not advance with sufficient rapidity to afford security. 2dly. Where the head is low in the pelvis, and has escaped from the orifice of the uterus—in this case, turning • See chap, on "Unavoidable Uterine Hemorrhage," in the author's System of Midwifery, respecting a variety proposed of means lately prepared for the relief of hemorrhage. 352 UTERINE HEMORRHAGE. 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 occu- pies the inferior strait; the orifice of the uterus sufficiently expand- ed ; 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 incompetent to the sufficiently speedy delivery of. the patient; owing either to the 7W«/-position of the head, or to such a dispar- ity between 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 puer- peral woman, than in any others whatever. This does not arise from an absolute necessity; for they are neither obscure, nor nu- merous. Those which attack the uterine system and its depend- encies, have chiefly created the confusion; and this has mainly arisen from an overweening desire for great accuracy of distinc- tion, without a corresponding power to give the signs, by which each should be ascertained. Or, in some instances, from a blamea- ble generalization, making every febrile affection puerperal fever. Thus, the disease now under consideration, has almost always been confounded with puerperal fever ; and the latter, as frequent- ly blended with the former ; this has arisen almost entirely from not allowing that puerperal fever is an inflammation of some one portion, or the whole of the peritonaeum ; and in not think- ing or believing, that the proper substance of the uterus can be inflamed without necessarily involving this membrane ; though • 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. INFLAMMATION OP THE UTERUS. 353 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 peritonaeum, or, superadded puerperal fever. The first we shall define to be, an inflammation of all or any portion of the proper substance of the uterus, except its perito- naeal covering. The second, where the latter is implicated with the former. It has been rendered highly probable from the late observations of Mr. Dance, and M. Tonnelle that in hysteritis, it is the veins of the uterus that are inflamed, and constituting a genuine phlebitis. Dr. Conquest says, "the substance of the ute- rus is sometimes infilterated with pus, and becomes livid and spongy, or it may contain small abscesses ; and the uterine veins, particularly those containing blood from the spermatic arteries, may be inflamed, and contain coagula or pus." Obs. on Purp. 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 only are 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 exposed in the exercise of its functional powers, during the expulsion of the child ; from those to which extrinsic aid may give rise, when its powers have been insufficient for the purposes of delivery ; from those which may arise from the artificial delivery of the placenta ; or those which may act independently of either, but not readily cognizable. Under the first head we reckon, 1st, the long and reiterated efforts the uterus is occasionally forced to make, to overcome the resistance which opposes the expulsion of the child; whether this arise from the rigidity of the neck of the uterus ; or of the 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- 354 INFLAMMATION OP THE UTERUS. den, rude, and unnecessary interference in the separation of the placenta ; or to the injuries it may sustain from a placenta that has been too adherent. 4th. To those which may arise from exposure to cold; checked perspiration ; some secret influence of the air; improper regi- men, &c. 2. Symptoms. Which ever 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 occasionally lancinating ; but it is always greatest when the uterus contracts, and produces after pains. From the after pains, with which it is sometimes confounded, it may be distinguished by the latter being always alternate ; and when the contractions subside which produce them, the woman is altogether free from pain, until they are again renewed. There is no swelling of the abdomen, in the commencement of this disease, unless it arise from the augmented size of the uterus itself; but which is never so great at the onset of the complaint, as to make it conspicuous. The abdomen does not participate, in the slightest degree, with the uterus, in simple hysteritis; hence, there is none of that tenderness, which is wit- nessed in peritonaeal inflammation, or puerperal fever. Sometimes there is a frequent desire to make water, attended with more or less pain ; or there may be a retention of urine ; especially, if mechanical aid has been required to effect the deli- very ; and the passing of water is accompanied by a sense of heat or burning, in the urethra and vulva. INFLAMMATION OF THE UTERUS. 355 The urine is almost always high coloured ; generally scanty, and will deposit a lateritious sediment. In judging of the urine however, wc 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. 3. Constitutional Symptoms. The symptoms which we have just enumerated, may be looked upon as strictly local, and such as would necessarily arise from an inflamed condition of the uterus; but these symptoms exist but a short time independently of constitutional disturbance. Soon after pain, &c, as above described, is felt, we find the heat of the body very much increased, without, for the most part, the interposition of "chill." The head becomes painful, the face flushed, and very frequently there is delirium,* if the febrile irritation be not soon relieved. The tongue is white, much loaded, and Dr. Clarke says, dry; but this we have never witnessed at the beginning of 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 an hundred.t 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 ked 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. • It may be looked upon as almost a character of hysteritis, that delirium almost always attends it; while in the unmixed puerperal fever, of peritoneal inflamma- tion, it rarely occurs. \ This is another peculiarity in hysteritis, as distinguished from peritonitis, and serves to show how much inflammation of particular structures influence the circulating system. There is no instance of pure hysteritis, so far as we have seen, in which the pulse is as quick, as it is in puerperal fever. 356 INFLAMMATION OF THE UTERUS. As the lochia arc interrupted to a greater or less extent in inflam- mation 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 vessels or rather on the degree of contraction of the uterus. Consequently, their being more or less abundant, must depend upon the state of the' vessels which furnish them ; and the state of these vessels must necessarily be influenced like 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 accu- mulation of blood in the uterine vessels, which stretches them anew ; and second, an aggravation of the inflammation 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 ute- rus 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 conse- quence of this condition of the uterus, and not the cause of it. It would be as rational to say, because there is a sparing secre- tion of urine in nephitis, that this scarcity is the cause of the in- flammation of the kidneys ; or that a diminished quantity of bile, is the cause of the inflammation of the liver in hepatitis. It is true, that the lochial discharge is highly important at this time to the uterus itself; since it unloads its vessels, and thus prevents the consequences that would most probably 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 cavi- ty, 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. INFLAMMATION OF THE UTERUS. 357 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 resistance is owing to the abatement of the swelling which had interrupted its flow; and the reduction of the swelling, is but a consequence 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 diminution, or stoppage; as there would now be an accumulation in the substance of the uterus, not only of all the blood sent there to supply the lochial discharge, but also that, which always at- tends upon inflamed vessels. And on the other hand, when the cause which arrested or diminished the lochia (namely, inflam- mation) 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 peritonaeal inflammation, or puerperal fever ; for we must be permitted to use them synonymously. (See Chap- ter on puerperal fever.) On this account, we never have an en- tire suppression of this secretion, as in puerperal fever, unless the disease runs an unusually long course, or has peritonaeal in- flammation added, or combined with it. Indeed, in a number of cases we have seen the offices of the breasts remain undisturbed during the whole continuance of the disease. This circumstance is worthy of notice; since it not only serves as a distinguishing mark between the two species of hysteritis, but also proves to us, that the influence of the peritonaeum, 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 peritonaeal coat of the uterus ? or is it only when the ovaria become involved, that this secretion is so decidedly interrupted, or suspended ? We believe it to be the latter. Does not this fact serve to account for certain discrepancies in 46 359 INFLAMMATION OP THE UTERUS. the accounts we have of the inflammation of tho 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 peritonaeal 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 mammary secre- tion was but partially disturbed, though a true peritonaeal inflam- mation existed. Thus we find, that the epidemic fever described by Dr. Leake, as it appeared in the " Westminster lying-in hospital," was re- markable for the following peculiarities; first, the omentum being the most common seat of the inflammation; 2d, the almost total ex- emption of the uterus, and its appendages, from disease; 3d, the little disturbance of the lactiferous secretion, as will appear from the following statements. In case V., " the uterus as well as the bladder, was perfectly sound, and without mark of inflammation, or other morbid affec- tion;" state of milk not mentioned. In this case, " the omentum was melted down." In Case VIII., " the omentum was much inflamed; but the greater part of it was destroyed by suppuration." " She had milk in her breasts, until a day or two before her death." "The fundus uteri seemed to partake of the general inflammation which had attacked the omentum." " The lochia was not defect- ive, neither was there a want of milk till after the febrile attack." Case XL, "the omentum was suppurated, 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 natural appearance, and was per- fectly 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 INFLAMMATION OP THE UTERUS. 359 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 circumstances, we have known the uterus 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 becomes stimulated to contraction after being thus painfully distended; 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 in peritonitis, they are generally disposed to constipation; or this complaint may be ushered in by diarrhoea; but this is rare, though no unusual attendant in the progress, or last stage of the disease; or 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 the disease is about to yield, there is an alleviation of all the more distressing symptoms ; there is a softening, or reduction of the uterine tumour, with an abatement of its tenderness ; the pulse loses its febrile and inflammatory character; it is less frequent; 360 INFLAMMATION OP THE UTERUS. softer, and more yielding ; the skin becomes relaxed, and dispo- sed 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 change to a more florid colour. The urine becomes more abundant, and less high coloured ; the milk is more freely secreted, &c. But should the disease not have abated, either owing to its intensity or the feebleness of the means employed, the inflam- mation may terminate in suppurations in various parts of the pro- per substance of the uterus, and which are almost sure to be followed by death. Sometimes, however, there is reason to 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 escap- ing in a larger quantity, but very foetid ; in a word, the woman now sinks from irritative fever. Or, the inflammation may commu- nicate itself to the peritonaeal coat of the uterus, by passing along the Fallopian tubes, or otherwise; and thus adding puerperal fever to the inflammation of the uterus, and thus making the second species. Species IL The Mixed Inflammation of the Uterus, or Accidental Puer- peral Fever. When the peritoneum, covering either the uterus, or its appen- dages, becomes the seat of inflammation, the disease is called by Dr. Clarke, a mixed case ; and is one of almost certain fatality. 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 INFLAMMATION OP THE UTERUS. 361 run on to its second stage. This extension of inflammation to the peritonaeum 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 ; hiccouch; tenderness, and swelling of the abdomen ; vomiting; an inability to lie, other than on the back; a total stop- page of the lochia ; a cessation of the mammary secretion ; cold sweats; muttering delirium ; a dry, husky, blackish, tongue; diarrhoea, &c. When the disease, by its extension, becomes the second spe- cies of hysteritis, it may be considered as almost necessarily fatal: at least, we recollect no instance of recovery. Nor is this surpris- ing ; 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, therefore, almost necessarily dies. Dr. Clarke has furnished us with the appearances of the parts after death, in both species of inflammation of the uterus. He says, "upon examining the bodies of women, who have died under this disease, we have found little or no extravasated or secre- ted fluids in the cavity of the abdomen, when the disease has existed simply. The peritonaeal surfaces have been also discov- ered free from disease in some cases; in others, however, the peritonaeum, which covers the uterus, has been partially inflamed, and that covering the posterior part of the bladder. Inflammation 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 cutting 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 Fallopian tubes, and also in the substance of the ovaria, which are distend- ed by inflammation and matter, so as to equal in bulk, in some cases, a pigeon's egg." " I have never had occasion to meet with any case in which * In these cases, it is more than probable that the disease was a genuine phle- bitis of the uterine veins. 362 INFLAMMATION OF THE UTERUS. 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-let- ting, and other depletions, can prevent the fatal termination of this disease; or, at least, prevent its ending in suppuration, from which, the escape with life, must necessarily be rare. And though this disease is declared by Dr. Clarke, to be, "of all the serious complaints, which attack the woman in the puerperal state, the least fatal," he is not to be understood to mean, that this is the case when this complaint is not boldly 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 INFLAMMATION OP THE UTERUS. 363 it, abstracted blood, both from the system at large by bleeding, and also by large lcechings 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 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 repeat- ed again and again; nor do we know any reason for stopping, but the reduction of the disease. But our bleeedings 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 bleed- ing, by the application of moist warmth. Should these abstrac- tions of blood not prove effective, and pain, fever, and other un- pleasant 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 answered or until we are convinced our efforts will be unavailing, by the approach of the second stage, or by the addition of peritonaeal in- flammation. Perhaps there is scarcely a disease which demands such exten- sive bleeding as the simple hysteritis; several reasons concur to render this necessary, nay, indispensable. First, from delivery having lately taken place, the uterus is much engorged with blood, at the period at which it is attacked by inflammation; its vessels, therefore, are still distended, and its whole substance in a highly irritable state; consequently, a new quantity of blood is invited to its parietes. Second, owing to the insulated position, and independent eco- nomy of this organ, it becomes very readily filled with blood, but parts with it, unless under particular circumstances, as in hemor- rhagies from this part, with great difficulty, or at least very slow- ly, as is proved by its bulk several days after delivery; conse- quently, large quantities may be taken from the general system, 364 INFLAMMATION OF THE UTERUS. without greatly influencing the qauntity contained in the sub- stance of the uterus. Third, owing to the lax and distensible condition of the ute- rine vessels, they are readily re-streched 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 Fourth, 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 state relieved, is now suspended, namely, (the tonic contraction of this organ;) hence, the enlargement of this viscus in this dis- ease ; and hence, it is a favourable symptom, when it diminishes in size, as it shows a return of the tonic contraction, and conse- quently an abatement of inflammation. All these circumstances show the necessity of blood-letting; and at the same time, prove, that it will require much to be sbstract- ed, before this particular condition of the uterus can be relieved. 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 the bleeding, purging must be instituted simultaneously. Dr. Clarke entertains apprehensions of the pro- priety of this mode of depletion. He says, " neither can I recom- mend a course of purging, as serviceable in the inflammation of the uterus, which follows delivery. It is always, I believe, right, in the first instance, to procure two or three stools ; but afterwards, it will be enough to preserve the regular motions of the bowels, by giving, from time to time, small quantities of cas- tor oil, or a little rhubarb, mixed with other medicines, which may be proper. The objection which I have found to long con- tinued purging is, it has always the effect of preventing that gentle perspiration, which, if it can be produced and kept up, will do more towards curing the disease than any remedy which I know." P. 75. We are always sorry to differ, in practical points, with this INFLAMMATION OP THE UTERUS. 365 respectable author; but we cannot, in justice to ourselves, or to those who may feel disposed to consult our opinions, avoid say- ing, that these opinions are contrary to our experience altogether. We have always found it absolutely necessary, as well as highly Useful, to purge from the beginning to the end of the disease; and, as in puerperal fever, we continue it, with more or less activity, throughout. And, if we are to be governed by the pathology of this disease, there cannot be a moment's hesitation upon the sub- ject. The patient is labouring under an inflammation of a most ac* tive kind, which, if not speedily removed, will terminate either in disorganization, or in dissolution. We have already noticed the peculiar situation of the uterus at this period; the difficulty of divesting it of its blood, by bleeding; and the great quantity which is required to be drawn, to have an influence upon the im- mediate seat of the disease. This being the case, it is every way evident, that, whatever will co-operate with blood-letting, in di- minishing the general quantity of this fluid, without its absolute abstraction, or divert it from its tendency to the uterus, as well as emptying the vessels in the nieghbourhood, will much con- tribute to the reduction of the disease. On this account, we would as earnestly recommend purging in this disease, as in puerperal fever, where its value is not disputed, and for nearly the same reasons. Besides, our experience is decidedly in favour of this treatment We cannot look upon the objection urged by Dr. Clarke, as having the least force; for we have never found it practically correct, that, in the inflammation of the uterus, "perspiration will do more towards curing the disease, than any other remedy." Dr. Clarke admits the absolute necessity of bleeding, and the propriety of repeating it again and again; yet, he would have us believe, that "a gentle perspiration, if it can be produced, and kept up," will compensate for the further loss of blood; than which there can be no greater error; and were we to rely upon this state of the skin for the cure of an inflammation of the uterus, we should, we are persuaded, but add to the already too frequent opportunities, by post mortem examinations, of determining, that " upon cutting into the substance of the uterus, pus is often found." P. 69. It appears to us, that Dr. Clarke has mistaken the gentle perspiration which takes place at the decline of the disease, and which, as a consequence of the solution of the fever, was procured 47 366 INFLAMMATION OF THE UTERUS. by free blood-letting, and other depletions, for the cause of the abatement of the uterine inflammation ; if this be so, and he has relied upon the production of perspiration for the cure of this complaint, we need be at no loss to account for the condition of the uterus just described. Besides, Dr. Clarke is no way confident that a perspiration can be procured at will; for he says, "if it can be produced;" and how much important time may be lost, for a benefit, so contingent! Can any further evidence be required of the necessity of blood- letting, than the formation of pus within the substance of the uterus? Or can there be stronger reasons to believe, that in the cases which presented these appearances after death, this remedy, and perhaps others of a similar kind, had been too sparingly employed ? From these facts, wc never have had the smallest hesitation to give purging medicines with a liberal hand; nor have we ever had reason to condemn ourselves for the practice. We have said that purging should be commenced with prompt- ness after bleeding; for this purpose, calomel should be given in a pretty liberal dose, say ten grains, and followed, unless it operate freely in two hours, which it very rarely does, by equal parts of the sulphate of magnesia and magnesia itself, in the manner fol- lowing. R. Sulph. Magnes. ?--_••-»- «• • -. Magnee. alb. ust. Iaa 3»J- M. div. in nj. One of these to be taken every hour in sweetened water or lemonade, until they operate freely. The discharges from the bowels should be kept up, by small doses of calomel, Seidlitz powders, or the Epsom salts, so as to procure eight or ten evacuations in the twenty-four hours; but so contrived, as not to break in upon the rest at night This is readily managed, by choosing proper times for the exhibition of the me- dicines. Our general plan is, after the first day, (for during that, we may not have a choice, owing to the time at which we may be called,) to give six or eight grains of calomel at bed time, and purging it off the next morning by any of the milder cathartics just mentioned, provided, we see the patient early in the disease. Should there be bilious discharges, a circumstance very com- mon, the continuation of the calomel should be insisted on as just directed, in preference to any other purge; for none other will answer with so much certainty or advantage. Purging is then kept up with a vigour proportionate to the INFLAMMATION OF THE UTERUS. 367 violence or abatement of the disease; but it is not to be aban- doned, because the disease pertinaciously runs on to the second stage, and though it may be proper to withhold the further drawing of blood, we have never known it proper to prevent the free action of the bowels. For should the disease terminate in suppu- ration, and the woman not succumb immediately, there is nothing so likely to promote absorption, as purging. c. Of Fomentations. Dr. Clarke recommends fomentations to the abdomen; we never advise them, for we have never seen them of the slightest use in hysteritis, and we have known them do mischief. They do 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 appli- cation of dry, or merely moist substances, very useful; by pro- moting the contractions of the uterus so as to expel these foreign bodies. The one we have most commonly used is the "tansy pancake." This is made by mixing flour and water together to the consistence of a batter, and adding to it a quantity of tansy; and then to be fried like a pancake; but made much thicker; (say half an inch,) when done, it is to be placed between two cloths, it is applied to the abdomen. Under the circumstances, for which we recommend this application, it will, we think, be found highly useful; at least it has proved repeatedly so with us. It certainly combines all the good properties of the fomentation, without its disadvantages; but let it be clearly understood, its employment is confined to the cases above stated; namely, where the uterus, distended with coagula, produces much pain, and the ordinary efforts of this organ are found insufficient to expel them. 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 368 INFLAMMATION OF THE UTERUS. have seen, how to decide; their efficacy, if they possess any, is unquestionably very limited. Dr. Clarke and others are decided- ly 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 be treat- ed by brisk purging. It is many years since we last used them j and we cannot venture to recommend them. e. Of Sudorifics. Our opinion of this class of remedies, may be collected from what we have already said on the subject of « perspiration:" we shall only add, that, in the early stage of the complaint, their powers are altogether inadequate to the state of the disease; and, when it is on the decline, they are generally unnecessary. We have thought them occasionally useful, where the force of the pulse had been abated by the treatment, and nothing but a little fever- ishness came on in the evening, accompanied by watchfulness 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. But our rule is, never to rely upon them, to the exclusion of evacuants, f. Of Opium. In the commencement of the disease, the pain which some- times attends hysteritis, has led to the free use of opium ; but it is always unfortunate for the patient; for it never subdues the pain, and it is sure to augment the existing evils by its stimulus, and by its constipating effects upon the bowels. It is, therefore, clear, it is not proper in the beginning of the disease; nor is it much more eligible in its decline, as it may interrupt the dis- charges from the bowels, at a time they may be much needed. In combination, as in Dover's powder, it may be now and then useful; but we think no decided advantage is gained by its use, unless it be to relieve some sudden symptom, as severe and unex- pected pain in the bowels, from flatulency, or other causes, when the fever is pretty well under command; to moderate unneces- sarily severe purging, or hypercatharis, or to give temporary INFLAMMATION OP THE UTERUS. 369 comfort to an exhausted, or irrecoverable patient. Indeed, if de- pletion has been ample, there is very little use in the opium.* g. Of Emetics. Emetics have been thought highly useful, in almost every complaint of the puerperal woman. From their reputed efficacy in peritonaeal inflammation, as recommended by Mr. Doulcet, they have been thought useful in inflammation of the uterus, and accordingly have been recommended in such cases. Our experi- ence exactly coincides with that of Dr. Clarke on this point, that they "constantly add to the pain, by the agitation they occasion, 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 dependence is chiefly upon bleeding and purging. The treatment for the second species, or the mixed inflammation of the uterus, will be learnt under the head of Puerperal Fever. CHAPTER XVIII. OF PUERPERAL FEVER. This term by some is now looked upon as generic, and should therefore be employed with more severe restrictions. Dr. Con- quest says, that " in reality it designates only a prominent symp- tom 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 * 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 bled, and may require, for temporary purposes, the aid of laudanum. Us indiscriminate use, however, cannot be too severely condemned, in diseases of high action. 370 PUERPERAL FEVER. 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 peritonaeal investments of the uterus, and abdominal viscera; inflammation 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 doubts but it is, from the respectability of the authority, the term puerperal fever, is used in Great Britain much more vaguely than in this country. And though our notions respecting this disease are not logically accurate, they are nevertheless more definite than they appear to be in England, agreeably to Dr. Conquest For we do not 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 inflamed womb, that much confusion existed, as both hysteritis and peritonitis were expressed by the same term, though very different tissues were implicated in the two diseases; yet with this admission, we are by no means prepared to say at this moment, that much practical mischief has arisen from this wrong location of the inflammation, as both, caeteris paribus, require very much the same treatment, though we profess to be warm sticklers for correct pathology. And we will at once declare, that by puerperal fever we understand, inflammation of some one portion or other of the peritoneum, which attacks women almost immediately, or within a few days after their delivery; and is distinguished from every other affection of the febrile kind, by being always attended by a more highly accelerated pulse; by a painful soreness of the abdomen; and with more or less distention, (after a short time,) of this cavity. This disease is frequently but not always ushered in by a chill. However authors may disagree about the nature of this disease; its remote and proximate causes; its' mode of treatment; and its • For these reasons M. Tonnell6 prefers the term, puerperal fever, to more specific names, as we shall have occasion to say presently. Strictly speaking, puerperal fever means, a fever that may attack a woman in child-bed—and as the term has no pathological meaning, it is preferred by this writer, as it will embrace all the febrile affections to which the woman may be liable after\lelivery, however varied their seat or nature. TUERPERAL FEVER. 371 specific nature; they nevertheless, 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 secretion of the milk, if it has not taken place previously to the attack of the disease; its immediate arrest if it has commenced to be formed; the diminution, or suppression of the lochia; the constipated condition of the bowels; the peculiar character of the alvine discharges; the exemption, for the most part, from delirium; the loss of maternal feeling, &c. The fatal character of this fever is almost proverbial; Dr. Den- man declares, "it occasions the death of much the greater part of those who die in childbed;" and many others bear a like tes- timony of its dangerous tendency. Dr. Clarke declares, that three out of four die. " Perhaps there is scarcely a disease which we arc acquainted with, 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 befel 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. Tonnelle prefers the term to peritonitis, or metro-peritonitis, as being more comprehensive; and as it expresses nothing of itself—that is, 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 child- bed fever, the peritoneum was found affected in 193; the uterus and its appendages in 197. In 165 cases, the changes in the perito- neum and uterus were differently combined; those of peritoneum simply were 28, those of the uterus were 29. In 79 cases, the alterations of the uterus were produced by simple metritis; super- ficial ramolissement 29; profound ramollissement 20; inflam- mation of the ovaries 58; with ulcers 14;—total 190. 372 PUERPERAL PEVER. 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 inflamma- tion and suppuration of the inguinal and lumbar glands, in 9 instances, making 134;—total changes effected in the uterus, 324. Suppuration of the veins of the uterus, 32 ; with ramollisse- ment or putrescency, II; with metritis and ramotlissement, 5; with peritonitis without any other alteration, 34; entirely insu- lated, 8;—total 90. Suppuration of the lymphatics with the veins, 20; with those of the uterus, 13; with ramotlissement of the uterus with sup- puration, 6 ; with simple peritonitis, 3; without any other altera- tion, 2 ;—in all 44. Inflammation of the ovaries with simple peritonitis, 29 ; with' alterations of the uterus, 27; with simple metritis, 8; without any other alteration, 2;—in all, 62.* It appears from these tables, that the alterations of the uterus, exceed by a little, those of the peritoneum, if taken collectively; but if taken alone, they very much exceed them. And that in 134 cases there was pus in the veins and lymphatics. It is difficult to assign the cause of the results observed by M. Tonnelle'T 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 alterations 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 its character is known to be modified by local causes, however inscrutable these causes may be. We are therefore much inclined to the belief, that peritonaeal inflammation is very much more common in this country, than metritis, properly so called; * It is proper to remark, lest this table should appear to contradict itself, that the reason of the whole amount of the two classes of affections, exceeds in number all the cases dissected, is, that in many cases peritonitis was complicated with, metritis. PUERPERAL FEVER. 373 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 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 epidemic; and when this happens, its ravages are sometimes truly awful, as its malignity is thought to be increased, by tho peculiar constitution of the air, which renders it epidemical. In this, almost all the wri- ters upon this subject agree. Dr. Leake says, " it will always be found most fatal, when most epidemical, that is, during the distemperature 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. Eelectic 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- • In the year 1746, this disease raged in Paris to a terrible extent, espe- cially in the Hotel Dieu. It attacked only the poor women ; yet it was neither so violent nor so common when they were delivered at their own houses, as when placed in the hospital. It 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, und of this country. Quoted by Clarke, in Essays, p. 104. 48 374 PUERPERAL FEVER- 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. Denman, that " it destroys the greater part of the women who die in child- bed :" for when deaths occur in the puerperal state, this disease has its full share of them. But deaths in childbed are compara- tively 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 u 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 pretend 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 apparent 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 1S12." P. 16. These facts incontestibly 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 PUERPERAL FEVER. 375 Britian. See Dr. Gordon,* Dr. Joseph Clarke,t 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 the first few days of confinement will be committed, and the patient be subjected, in consequence, to the fevers just mentioned.§ Be- sides, 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 peritonaeum 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 inflammation 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 * See Dr. Gordon's account of the puerperal fever, when it appeared as an epidemic in Aberdeen, in Scotland. f See Dr. Joseph Clarke's account, as it appeared in Dublin in 1760. Dun- can's Medical Comment, for 1790. It again appeared in Dublin in 1767. 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. § We consider the milk fever certainly, and the " weed" most probably, of artificial origin ? for we believe we are correct in saying, where the nursing has been properly conducted, they never appear; or if they do, it is very rarely. 376 PUERPERAL FEVER. assigned; but it seems that nothing satisfactory has yet been ascertained upon these points. For M. Tonnelle* has pretty satis- factorily ascertained, that neither cold nor moisture can be looked upon as causes. For when this disease raged in "la Maternitic," the hospital to which he was attached, as the pupil of the late M. Desorneaux, neither of these powers could have operated. As regards cold, it was observed, that though the disease was very common in January, which was very cold and dry, yet in Decem- ber 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 drought was very unusual in degree and in duration. In a word, the disease prevailed in its greatest extent during cold dry weather; in temperate weather, as well as during moist temperate weather —while at other periods of the year, when similar weather pre- vailed, the disease was neither more frequent nor more severe. Neither could the frequency or severity of the disease be traced to a vitiation of the atmosphere of the hospital. Indeed the disease prevailed in the most whimsical manner—now existing exten- sively and severely, and then disappearing; and as suddenly re- appearing. 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, t Besides, the male is unquestionably * Des Fievres Puerperales Observers a. la la Maternitie de Paris. \ A case of this kind occurred lately. A lady was delivered at 6 o'clock P. M., of six month's 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 tho 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 PUERPERAL FEVER- 377 liable to peritoneal inflammation as well as the female ; and when it occurs in them, the same general phenomena present themselves. Thus Dr. Armstrong, p. 2, assures us, " it does not seem to depend upon the difficulty of labour, for in most of the women in whom it occurred, parturition was remarkably easy, and the placenta was cast off after a proper interval, and without more than usual pain. - Nor was the lochial discharge, before the attack, in any way apparently affected." Mr. Hey says, p. 21, "it is somewhat remarkable, that I have scarcely known an instance, in my own practice, of this disease coming on lifter 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 peritonaeum 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 directed, in their operation, to this part, during the time of child- bed. Hence this disease (the inflammation of the peritonaeum,) is very frequent, and has been also called puerperal fever." " It has been conceived, that this predisposition might depend upon some change in the state of these parts, or of the cavity of the abdomen succeeding to the act of labour, or the contraction of the uterus. Yet it seems not to be conformable to the wisdom of nature, to construct parts so that the circumstances to which they must necessarily be exposed in a state of health, should either prove a predisponent, or an immediate cause of disease. Moreover, the alteration of the state of the cavity of the abdomen, is so frequent an occurrence, and this complaint is comparatively frequent. Her labour was sufficiently easy for a premature delivery; but the patient sank rapidly until the moment of death. When I saw her, (9 o'clock A. M., fifteen hours after the birth of the child) she was nearly without pulse, though she retained her senses; the abdomen was much swollen, and extremely distended—she died six hours after. I am of opinion that this was an instance of inflammation of Uie peritoneum preceding delivery. 378 PUERPERAL FEVER, 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 peritonaeum, 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 peritonaeum as certainly and as pow- erfully, as in England, or other portions of Europe. We might readily multiply authorities to prove this curious fact; and from its importance, it should challenge the attention of the physician to an investigation of the cause of it; for we are not altogether satisfied with the explanation that Dr. Denman gives of this singular exemption ; namely, " because of the parti- cular care with which they are then managed." Were this the cause alone, it would be easy to arrest the progress, or at least to mitigate the violence of this malady, by bestowing the same attentions ; especially upon those who have easy labours, while the disease was ravaging as an epidemic. Indeed, it would seem, that the public had some right to expect a practical illustration * Dr. Clarke has committed a little mistake is his anatomy ; the cervix uteri is not covered by the peritoneum; it is only the body and fundus, that derive a coat from this membrane. PUERPERAL FEVER. 379 of the suggestion from the author of it; and we truly regret, that he had not turned his attention to it. c. Of Prophylactics. It is true, there appears from the practice of some, a foundation for the opinion just named above ; so far at least, as certain medi- cal treatment comprises that peculiar care bestowed upon women, who have had laborious labours, alluded to by Dr. Denman ; for 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- self, and from Mr. Hey, who followed his practice, it does not • 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." 380 PUERPERAL FEVER- appear, that the plan under consideration, deserves tho sweeping encomium bestowed upon it by its inventor ; that it was highly proper and very useful, we have every disposition to believe ; but that it ever prevented the disease, wc 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 negative ; that some of the women who took it, escaped the dis- ease ; but this is no proof, that the calomel and jalap prevented it; for it is not fair to presume, that every newly delivered 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 inquiry; and we would earnestly recommend it to those whose practice will furnish them with opportunities, to inquire into the fact, and endeavour to discover the cause, why a tedious and pro- tracted labour, should be any way instrumental in diminishing the liability to puerperal fever. For we may well ask, how it is, that long suffering and very certainly lesion of some kind, and to various extents, should diminish the predisposition of this dis- ease, or abate the force of the exciting causes! Will a slight inflammation of the proper substance of the ute- rus, and of the vagina, which follow almost'necessarily as a con- sequence, of a long protracted or preternatural labour, interrupt the tendency to peritonaeal 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 * 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 sec this illustrated in the practice of Mr. Hey, just alluded to; 1or the powerful operation of a cathartic may be, and doubtless is, sometimes, the exciting cause ui the disease. PUERPERAL FEVER. 381 labour, had such an affection of the bladder, as to occasion a sup- pression of urine?"* Denman. Introd. Francis's Ed. p. 574. 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 peritonaeal inflammation. This inflammation does not confine itself to any one portion of this membrane. The mesentery, omentum, the liver, the mesicolon; in a word, every portion of the abdominal contents may be the seat of this inflamma- tion; nay even the pleura and lungs have been found inflamed; 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 peritonaeal inflammation had • We do not mean, that these facts should be taken for more than they are worth? for we are aware, that different explanations may be given of them; for of the first it may be said, that the woman who lives free from the disease long enough to have milk secreted, and an abscess to form, most probably had no predisposition to the disease, and would have escaped the fever, without the abscess; and, that the abscess was only an evidence of this want of disposition, and not of its being prophylactic. Of the other, it may be said, that the free- dom from this fever, should be referred to the tedious and painful labour, of which the suppression of urine was a consequence; and therefore, that this symptom should not be considered as having any agency in procuring the ex- emption. 49 382 PUERPERAL FEVER- 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 quan- tity, inasmuch as I have often absorbed, by means of a sponge, several pints of it." Essays, p. 135. When effusion is extensive, the existence of a previous inflam- mation is less evident; this has led some to conclude, that this effusion was not the effect of active inflammation ; but rather the result of a certain disposition of the vessels of the parts affected, essentially different from an inflammatory action. It is easy to refine too much, and nowise difficult for a sturdy polemic, to deny the force of the most obvious facts. What but the resolution of inflammation yields such a quantity of fluid as is found after puerperal fever ? what but inflammation giving out coagulable lymph will account for the interstices of the intestines being filled up; their surfaces covered; and their various convo- lutions connected in masses ? what but an inflammation, and that of the most active kind, will give rise to such an acceleration of pulse; such immoderate heat; such intense pain; such exquisite soreness, as almost constantly combine in the puerperal fever ? In a word, we must repeat, what other condition of the blood- vessels, than inflammation, induces them to give out so suddenly, and so excessively, their fluids ? Besides, inflammation of the peritonaeum from other causes, is known to terminate in large effusions within the abdominal cavity; 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, he would scarcely have consented to have agitated the following questions. I. "Does the fever in a puerperal woman, dispose the peri to- PUERPERAL FEVER. 383 naeum 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 peritonaeum to throw out the coagulating fluid?" III. " Does the inflammation precede or follow the effusion ? If the latter, is the inflammation excited by a stimulating quality of the matter itself ? or lastly, are the fever, the inflammation, and the effusion of fluid, entirely independent of each other, as to cause and effect, and are they only parts of one whole, which is a disease sui generis?" p. 157. If the first question mean, as we presume it does, that the fever in question may so act upon the peritonaeum as to force it to effu- sion without any intermediate condition, as inflammation, we would answer it in the negative, and for the following reasons: 1st. Because, we know of no instance of an effused fluid re- sembling the one found in the cavity of the abdomen, without the intervention of some altered condition of the parts concerned; nor of any other fluid, to the same extent, in the same space of time. In cases of large collections of water in cavities, as in as- cites, &c., it is always very gradual; and seems to be rather ow- ing to the defect of absorption, than to an increase of deposition; though in some instances there is strong reason to believe it to be the result of a previous inflammatory action. 2d. Beriause, 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. 3d. Because, in all instances of the resolution of inflammation by effusion, a serous fluid is thrown out; and when thrown out, the inflamed surface which yielded it, is always relieved from the excitement; either in part, or altogether. II. The second question we would answer also in the negative ; and for reasons that might be in part collected from the answers to the first; for, 1st, if the inflammation of a portion of the peri- tonaeum, 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. 2d. Were 384 PUERPERAL FEVER. this admitted, it would be supposing, that an inflamed surface, and one which is not inflamed, would yield the same fluid, which is contrary to all experience. III. To the third query and consequences, we would say, that inflammation always precedes effusion ; and that the fever is but the result of the local inflammation. 1. Because, a sense of soreness and tenderness, is always expe- rienced in some one portion of the abdominal cavity, before the fever is well formed ; and in the accounts we have of this fever, as it appeared in the Hotel Dieu, we are told, that "afler 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 peritonaeum. 3. Because, fevers from other causes have no tendency to pro- duce peritonaeal inflammation ; as milk fever, the weed, or even erysipelas ; consequently, that there must be a disposition in the peritonaeum, to take on inflammation after delivery.* 4. Because, whatever excites inflammation in the peritonaeum, by local irritation, as tapping, sometimes ; rupture of the uterus ; inflammation of the proper substance of the uterus, when it involves this membrane, &c, but not until then ; extraneous substances passing from the stomach and bowels into the cavity of the abdo- men ; punctures or wounds in this cavity, give the same pheno- mena ; proving beyond doubt, that when this membrane is indis- putably the seat of inflammation, the system at large sympathizes in the same manner as in puerperal fever. From these facts, and others developed by dissection, we have no hesitation to declare, that puerperal fever is an inflammation of the peritonaeum. This inflammation always terminates in effusion or suppuration before death; and never, or but very rarely, in gangrene, so far as dissections have yet discovered, t Dr. Clarke says, p. 135, that • We may include, with much propriety, under the head of delivery, those instances of abortion, which have been followed by puerperal fever. Dr. Hull says, " it sometimes attacks women who have suffered an abortion, or who have been prematurely delivered, as well as those who have gone their full time of utero-gestation." Treatise on Phlegm. Dolens, p. 228. Mr. Hey also informs us, that he met with two cases of puerperal fever after abortion, p. 27. See note to page 347. f Dr. Fordyce intimates, from the character of the symptoms, and the ana- logy of the circumstances, that we might suspect gangrene sometimes; but there PUERPERAL FEVER. 385 " the inside of the uterus, or of the intestines, has not been found inflamed in any of those whom I have had an opportunity of ex- amining after death; much less have I found any signs of gan- grene, or mortification." These are curious facts as regards this disease; and they are particularly valuable as coming from so ve- racious and candid a man as Dr. Clarke; and completely estab- lishes Bichat's doctrine of the tissues; the disease which killed the patients he examined was " the low fever of child-bed," and had agreeably to him a strong tendency to "putridity," as his practice declares, and as on one occasion he avows. P. 115. For he expressly says, that " all the medicines which have been employed with a view to the diminution of an inflammation, have, in the course of my experience, failed in curing the disease. It became therefore next an object, to try whether such as have a tendency to support the strength and diminish the irritability, would be attended by better success." " 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, 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 inflammations: for the pain goes off suddenly, and even the soreness some- times, 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 por- tion was destroyed by suppuration. Case IX. The greater part of the omentum was suppurated; the remaining portion much inflamed, &c. Case XIII. Great part of the omentum was destroyed, and converted into matter; what remained had become gangrenous;" this is the only mention made of gangrene by Dr. Leake, and the part being in this condition, must have been the result of previous inflammation, but which had not relieved itself by effusion, and thus died. For he makes no mention of a fluid in the abdomen, but declares, that that portion of the omentum which is inserted round the great curvature of the stomach, was considerably inflamed. 386 PUERPERAL FEVER. 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 peritonaeum 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 compa- ring 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 dis- ease. * In both of the diseases which he describes, (Essays, sect. III. p. 81, and Sect. VI. p. 102,) the peritonaetic inflammation, and the puerperal fever, attack at the same period after delivery ; they are both preceded, sometimes by rigor, 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 secre- ted; 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 stomach, the appearance of the tongue, the condition of the brain, the feel of the skin, &c. the same ; or at least, they are without a marked difference in any respect In • Dr. Clarke says, " it is very well known, that during the Btrong exertions of labour, every woman suffers a kind of temporary fever; or, in other words, the action of the heart and arteries is very considerably accelerated. Now if this should happen to a woman under the influence of the causes adverted to above, (namely, the epidemic constitution of the air, &c.) and if under these circum- stances, any occasional cause of fever should occur, such as exposure to cold, or infection, the disease thence arising will be most susceptible of that type, to which the system has the greatest aptitude." P. 152. And to show his entire belief in the power of the air, he says, the epidemic disposition of the season must likewise always be taken into the account; otherwise, under these circum- stances, of (predisposition) " the same disease would always arise, if the same occasional causes were applied, which is not the case." P. 151. He further adds p. 151, "now the nature of the epidemic constitution, which had prevailed at the time when this disease was prevalent at Paris in 1746, and in London in 1787 and 1788; was a disposition to diseases of debility; with such a predisposition, if any diseased state, especially fever, should appear in a parturient woman, it would almost certainly put on that character which the preceding history of this disease fullv iustifies." Now it is evident, that in such cases the nature of the disease is not changed, it is only the character of the type that is affected. * PUERPERAL FEVER. 3S7 both, does the pulse increase in rapidity, as the soreness and distention of the abdomen increase ; and both have the same attending symptoms, and the same period for their fatal termina- tions. Both have the same kind of effusions. The differences observed in post mortem examinations are in- deed very trifling; in the inflammation of the peritonaeum, "the appearances, upon examining the bodies of women who have died of the disease, have been those of inflammation of this membrane, 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, uterus, the internal peritonasal lining of the muscles of the abdomen, will in their turns, or altogether, be found to partake of the disease ; and as far as my experience leads me to judge, no part more than another."* " A very large quantity of a fluid is generally collected in the cavity of the abdomen, resembling serum mixed with pus ; but it differs from both of them in this respect, that it is not homoge- neous in its texture, but intermixed with portions of a solid matter, resembling pieces of the same solid matter as is found on the surfaces of the peritonaeum, the nature of which will be more particularly taken notice of hereafter." P. 88. Of the examinations he made of those who died of " the low fever of child-bed," he says, "the first thing which presents itself, is a collection oi fluid in the general cavity of the abdomen, sometimes very large in quantity ; insomuch, that I have often absorbed with a sponge several quarts of it. It is of the same nature with that which I have described in a former section, (namely the above,) as far as can be ascertained by its sensible qualities. There is something very remarkable in the smell of this fluid, which is peculiar to itself, and distinguishes it from any other fluid which I have ever met with in the human body, • Walter is said to have dissected more than five hundred(a) women who had died in child-bed. He constantly found in those who died of puerperal fever, the peritonaeum, 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. (a) We have at a venture changed the number to 500 from 5000, believing there must have been an error in the text from which we quoted. 3S8 TUERPERAL FEVER. either in health, or in disease.* Where it is in large quantity, all the .surfaces of all the viscera, and of the peritonaeum generally, will be found covered with a crust formed of a solid part of this matter, resembling coagulating lymph. Its particles cohere but slightly ; so that by a little agitation, it will mix with the fluid matter. The parts lying under this coat or crust, are not always inflamed A If there be any insterstices between the intestines, or the other viscera of the cavity of the abdomen, they are fre- quently 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 incrustcd, 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 propor- tion 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 inflammation in some part of the cavity of the abdomen ; but it has not been confined invariably to any particular part." " Sometimes the peritonaeal 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."\ P. 135. Now, the only difference we can discover from the histories of * Is not this circumstance absolutely conclusive of the identity of the two diseases ? does not this peculiar smell of the extravasated fluids, prove the same- ness of the inflammation which yields them ? and do not the various seats of the inflammation establish their kindred nature ? For Dr. Clarke informs us, it was not confined, in either case, to any one particular part. f 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 relieved, and the redness disappears. i "We have, indeed, been told, that, in the dissections of some who are said to have died of this disease, (puerperal fever) no appearances of inflammation have been discovered; but I should suspect, that, in such cases, some important appearances had been overlooked, or that error had been committed as to the nature of the disease, and probably in its treatment." Denman, lntrod. 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, viz. abdominal inflammation." Gordon, p. 117. PUERPERAL FEVER. 389 the dissection of the two diseases, is, that the neck of the uterus and bladder are generally more inflamed than other portions of the peritonaeal 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 differ- ences ; but we cannot view them in this light; since the apparent discrepancies can easily be accounted for, without the necessity of supposing them unrelated to each other. We have marked by italics the points of resemblance. We will first notice, however, the coincidences of appearances; and then attempt to account for the seeming differences. 1st. In both cases, the extravasated fluid, agreeably to Dr. Clarke's own statement, are the same; as he says, "it is of the same nature" in both instances. Now, let us ask, is it probable that dissimilar diseases of the peritonaeal 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 peritonaeum called puerperal fever, yields a fluid of particular qualities or properties within the abdominal cavity; and if a fluid of pre- cisely the same kind is found in the abdomens of those who die of "the low fever of child-bed," that the same action must have yielded both, and that they must be one and the same disease? We think, the force of this conclusion is irresistible. 2d. In the inflammation of the peritonaeum, Dr. Clarke says, the surfaces of all the viscera in their turn, ot altogether, may be in- flamed ; he says, that precisely the same thing happens, but not to the same extent, in "the low child-bed fever:" it is then the degree of inflammation, agreeably to this, and not the absence of it, in 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. 1. 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, 50 390 PUERPERAL FEVER. are not always inflamed; whereas, in the fever from peritonaeal inflammation, this condition is obvious, especially about the neck of the uterus and bladder; and no crust is noticed. This, at first sight, might lead some to suppose, that a very material difference existed between the two diseases; and espe- cially if they be not aware, that a number of causes may make a difference in the intensity of any given disease; but especially in one so liable to become epidemic, as puerperal fever. For the sporadic cases, of all such diseases as may become epidemic, are milder; and, consequently, more manageable, than when they become epidemic. * If this be so, it can only happen from the sporadic cases acquiring the intensity which the epidemic con- stitution 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 distempera- ture 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 commonly 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 peritonaeal inflammation, and the epidemical puerpe- ral 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 peritonaeal 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 • 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 anticipating 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. 391 the reigning disease may differ very essentially in type, at the different periods of its visitations. Thus, no two yellow fevers, as epidemics, were precisely alike in this city. The fever of 1793, was very different from that of 1798; and that of 1797 different from both, as regarded the conditions of the system; and this consequently, made it necessary to change our therapeutical 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 in- fluence upon more than one disease at the same time; and this fact gives the strongest evidence^of a distemperature of the air. Thus Dr. Gordon informs us, that erysipelas, and the puerperal fever, "began in Aberdeen at the same time; and afterwards kept pace together; they both arrived at their acme" together, and they both ceased at the same time." Treatise on Puerperal Fever, p. 50. Dr. Clarke says, "inflammatory diseases.had been extremely infrequent; or, if they occurred at all, they were principally of the erysipelatous kind. Eruptive diseases, particularly those which are attended with great depression of strength, had attack- ed great numbers of patients. The ulcerous sore throat, with or without the searlatina, had been very general, both in London, and also in the country at a distance from the capital. Most of the fevers had been of the low, nervous, and malignant kind, ap- proaching to that type which has been by some called putrid." P. 115. " About the same period also, in some situations in the coun- try especially in low and marshy places, the generality of patients under inoculation had recovered with great difficulty. Abscesses formed in the axillae; large ulcers and sloughs took place, both there and at the place of insertion of the matter."* P. 116. Again, " the stimulus of her labour, (the woman whose case he is relating) brought on a degree of fever, which degenerated in consequence of the nature of the then prevailing epidemic constitution, into a low type." P. 150. Yet, with all this evidence before him, Dr. Clarke insisted on * Much more difference will be perceived between the small-pox under ordi- nary circumstances, and the form it assumed in the cases just stated by Dr. Clarke, than between "peritonei inflammation," and "the low fever of child-bed," yet Dr. C. did not hesitate to call both " small-pox." 392 PUERPERAL FEVER. the slight difference which he observed between the sporadic puerperal fever, (for such were the cases of peritonaeal inflamma- tion which he describes,) and " the low fever of child-bed," which was a puerperal fever, or an inflammation of the peritonaeum, in an epidemic form, to be different diseases; and seriously admon- ishes the young practitioner not to mistake the one for the other. Every body familiar with the diversifying influence of an epi- demical constitution of the air, knows the variety of type it will force the same disease to assume, at the different periods of its visitations, or even in different situations. Some, who have not been attentive to the influence of the cause just mentioned, and who neither recognise its existence, nor acknowledge its power, have been led into serious, and we had nearly said, absurd er- rors, on the subject of puerperal fever. Thus Dr. Kirkland sup- poses 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 ad- ventitious 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 sur- prised, that 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 constant- ly operate in such a manner as to give a peculiar type to a dis- ease similar to that which an epidemic constitution of the air might effect, we have no hesitation to believe; since, in such situations, the disease is not only more common, but is some- times exclusively confined to them. But in granting this, it does not do away the possibility of its prevailing as an epidemic else- where. Indeed, the history of this disease as an epidemic, abundantly proves, that the situations remote from hospitals, or even from cities, have been visited by this fatal malady.* On this head Mr. Hey says, that "it must be allowed, that the puerperal fever has occurred as an epidemic, most frequently in hospitals; but if any • 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 si2;e. PUERPERAL FEVER. 393 proof were wanting that it may be epidemical, independently of any cause peculiar to hospitals, that proof is abundantly supplied bv 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 peritonaeum 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 peritonaeum be in- volved in inflammation, there is no propriety in the title ; and if it be, it cannot be other than genuine. But to return; Dr. Clarke says, that " the parts under the crust or coat," (of coagulable lymph) " are not always inflamed;" this must certainly be understood to declare, that they generally are; and if they generally are, the appearance of inflammation must produce a stronger resemblance to the peritonaeal inflammation, than he appears to have been willing to admit. Not that we con- sider this circumstance essential to the establishment of our posi- tion, that the peritonaeal inflammation of child-bed women, and "the low fever of child-bed," are one and the same disease. For, had Dr. Clarke told us he had never found " the parts under the crust or coat inflamed," it would not have permitted us to doubt for a moment the identity of the affections, for the reasons stated above. For this, and every other species of inflam- mation, may throw out even large quantities of fluid under cer- tain stages of its continuance; but when it does, the inflammation which gave rise to the effusion, becomes relieved, either alto- gether, or in part, as this effusion may be more or less extensive, or as the inflammation may have been more or less exalted. These effects are familiar to every body; for they present themselves to us almost daily, in the consequences of burns, scalds and blis- ters. 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 394 PUERPERAL FEVER. 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 abdomens of those who died from peritonaeal 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 pecu- liarity was the result of an epidemic influence ; and the reduction of this inflammation kept pace with the profuseness of the effu- sion. 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 were pursued. Now, it cannot be supposed, that all these opinions were right; yet each attempted to support the propriety of his practice, by detailing such phenomena and 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 a while, it was discovered, that the first plan was entirely without success ; that the second had some, but it was very limited; while the third, was attended by a fair proportion of recoveries. Just so has it been with puerperal fever ; for, the rapidity of its march, and the strong tendency of the body after death to putrefaction, led to the belief, that it could be no other than a putrid, or typhoid fever; and the want of success in curing it, by PUERPERAL FEVER. 395 the remedies 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 deci- dedly 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 obscurities 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 derangements of the uterine system,t and the peritonaeum, into the following classes : 1st Into the inflammation of the uterus and ovaria. 2d. The inflammation of the peritonaeum. 3d. Cases of inflammation of the uterus, ovaria, and fallo- pian tubes, or of the peritonaeum, connected with an inflammatory state of the system. 4th. The low fever of child-bed, &c. The Doctor was solicitous, that these several affections should not be confounded ; to prevent which, he admonishes the inex- perienced practitioner in the following words : "Before 1 close this part of my subject, 1 must beg leave to caution those of my • 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 Maternity," this condition was comparatively rare; hence they have divided, into the inflamma- tory, typhoid, and the ataxic varieties. The typhoid was by far the most frequent, and the ataxic the most rare, while the purely inflammatory, occurred but 39 times in 222 of the fatal cases examined by them. This however must only be received, as the reports of the type of the disease as it appeared in that hospital; and though no modifying circumstance could be discovered in that institution, yet it is every way certain there must have been one, and that thjs account will not serve as an infallible guide, for the treatment of this disease in this countiy. This peculiarity in the influence of an hospital atmosphere, has been lately proved in the Pennsylvania Hospital of this city ; for the cases of puerperal fever which presented themselves, were fatal in an unprecedented degree, yet this disease was confined to this place, as it did not occur in private practice, at least we dkl not meet with a single case. Yet even in the most frequent form of this disease (the typhoid) in the Paris Hospital, it was acknowledged, that the typhoid symp- toms were preceded by an inflammatory stage, and this is all that we absolutely contend for. \ By the uterine system, we would wish to be understood only such portion of it, as is within the abdominal cavity, or such parts as have a peritonaeal covering. 396 PUERPERAL FEVER. readers, whose experience may havo 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, 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 lon»;,) to distinguish, with any profitable accuracy, the different condi- tions he has described. Nor is this to be wondered at; as he has, in the very threshold of his inquiry, created confusion by neglecting a most important part of his subject; namely, not informing us, in what, or from what, condition of the system, this fever proceeds. 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 peritonaeal 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 por- tion of the uterus) of their peritonaeal covering, consequently this first division must mean "puerperal fever," if this fever consists of an inflammation of the peritonaeum, as we have already insist- ed on. His seeond division, a fortiori, must be considered as puerperal fever; since its distinctive mark consists in an "inflammation of the peritonaeum." We have already noticed, p. 358, Dr. Clarke's attempt to institute a distinction between this condition of the ab- domen, 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 in- sinuates, that an inflammation of that portion of the peritonaeum which covers the uterus, ovaria, and fallopian tubes, is different from an inflammation of other portions of this membrane ; and he considers it necessary, that an inflammation of these parts should be distinguished from inflammation of other portions of the peri- tonaeum, which we hold to be impossible. And were it possible, no kind of practical good could result from the discrimination. His fourth, appears to be in opposition to his own facts, oi PUERPEUAL FEVER. 397 even reasonings. In this, he attempts to prove that " the low fever of child-bed," is not a peritonaeal inflammation.—We have already noticed this effort, p. 358. From what we have said, we think wc 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 strictly to any one portion of the peritonaeum; and from Dr. Clarke's own acknowledgment, "the surface of the stomach, liver, spleen, omentum, great and small intestines, uterus, the internal lining of the muscles of the abdomen, will in their turn, or altogether, be found to partake of the disease; and, as far as my experience leads me to judge, no part more than another." See page 359. We must look upon the peritonaeum as a unit; and that, when inflamed in any one part, the same general symptoms will arise; and that the whole of it is now liable, from this cause, to be in- volved in the same condition as that part; hence, if the inflamma- tion commence at any given point, it may travel over the whole, or a great portion of its surface, or it may be confined to the ori- ginal focus. A want of attention to this circumstance, has led all the wri- ters,* so far as we recollect, into the error of considering the in- flammation of the peritonaeal covering of the uterus, as a distinct disease from puerperal fever, by calling it an inflammation of the uterus. In this, there is a great want of precision ; for the inflam- mation of the uterus, properly so called, is a very distinct disease from peritonaeal 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 wc most willingly assent But he adds immediately after,"but, * Dr. Armstrong might have been looked upon as an exception, as he men- tions " simple hysteritis," did he not immediately after appear to lose sight of the distinction, by following Dr. Denman and Dr. Baillie; especially the latter, who speaks of " the inflammation of the uterus and its appendages," under the head of inflammation of the uterus. Morbid Anatomy, P. 362. Sec also text below. 51 398 PUERPERAL FEVER. however symptoms may vary from affections of particular parts, or in particular constitutions, there is but one essential nature of the disease; and if we have a true notion of this, we have less reason to be solicitous about the cause, or the determination of the part originally or principally affected. For a similar treat- ment may be enjoined, with equal propriety, for an inflammation of the uterus, omentum, peritonaeum, or intestines, or perhaps any of the contents of the abdomen; whether the disease remain local, or a fever be produced by its influence being extended to the constitution in general." Introd. to Mid. Francis's ed. p. 565. Yet is Dr. Denman himself betrayed into a want of precision in the very next sentence; for he says, that "the inflammation of the uterus is far less dangerous than an equal degree of inflam- mation of any of the viscera of the abdomen, especially in the state of child-bed; because the uterus readily admits of a return of the lochial discharge, which always affords relief, and some- times cures the disease." Here we are at a loss to understand, whether, by an inflamma- tion of the uterus, it is intended to include its coverings, or to strictly confine the inflammation to the substance of the uterus, without its covering being involved. Wc arc, however, inclined to believe he meant the whole mass of this organ, from what im- mediately follows; "because the uterus readily admits of a return of the lochial discharge, which always affords relief, and some- times cures the disease." Ib. We shall merely remark upon this last passage, en passant, that Dr. Denman has evidently mistaken an effect for a cause. For in inflammations of the uterus, the lochia do not return until this condition is relieved; and if the inflammation be relieved by any cause, so as to permit the lochial discharges to return, it is evident that the reduction of the inflam- mation is the cause of the return of the lochia, and that the disease 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 inflamma- tion, though it may ultimately contribute to this end by its con- tinuance. Dr. Armstrong, however, quotes the above passages differently; 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 PUERPERAL FEVER. 399 complain of. Nor does Dr. Baillie discriminate any better; for, in speaking of the inflammation of the uterus, he says, "the in- flammation 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 indisput- able; for he ae"ds, "but the peritonaeum 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 peritonaeum 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 peritonaeal covering of the uterus was found " inflamed;" instead of saying, "the uterus was inflamed:" for this may not have been the case, strictly speaking. See chap- ter on Inflammation of the Uterus. And, secondly, we may conclude, that Dr. Clarke has failed to establish any other difference between "peritonaeal inflammation," and the cause of the "low fever of child-bed," than that which is frequently observed to exist between "sporadic and epidemic puerperal fever." We have already said enough 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 combines, within a very moderate space, all that is essential to discriminate 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 this disease in his own words. We are the more disposed to do this, because our experience, though sufficient to convince us of the fidelity of his account of the disease, has not been so ample, as to enable us to make any important additions. "The time when women are chiefly subject to this fever, is 400 PUERPERAL FEVER. uncertain. There arc not wanting instances, in which it has been evidently forming before delivery, or during labour, or at any intermediate period for several weeks afterward; and the sooner from the time after delivery the patient is attacked, if in an equal degree, far greater is the attendant danger. But the most frequent time of its appearing, is on the third or fourth day after delivery,* when the patient is seized with a shivering fit, from the violence and duration of which, we may generally estimate the danger of the succeeding disease.t In some cases, however, there has been no cold or shivering fit, or none which was observable; and in others, the shivering fit in the state of child-bed, has not been followed with those symptoms which were to be apprehended."^ " Before the shivering fit, the patients have been much debili- tated^ and have complained of wandering pains in the abdomen, which very soon became fixed in the hypogastric region, where a swelling or fulness, with exquisite tenderness, soon ensued. || • 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 day5 Leake on the evening of the second day, or the morning of the third, &c. f This disease is not always announced by rigor or chill. Hull, Hey, Armstrong, Leake, &c, agree it is generally preceded by shivering; but that they are by no means essential to its formation. Clarke says it rarely happened, Mr. Hey says, that " some of the worst cases were unattended by rigor; and in others, equally severe, there was no more than a slight chilliness." P. 28. And Dr. Marshall Hall says, that in puerperal diseases, "pure inflammation is less marked by rigor, heat, and other obvious symptoms, than the effects of intestinal irritation." + Dr. Denman has not discriminated with his usual accuracy in this instance; a mere shivering, or rather trembling after delivery, is no very uncommon oc- currence ; but this agitation is not accompanied by the sensation of cold, though it goes under the name of a chill or shivering by those who are unacquainted with the phenomena of fever. It is, therefore, represented to the physician as such; but he does not find it to be followed by reaction: hence it is said, the chill was not followed by fever. § We presume Dr. Denman means, by their being much debilitated, a sudden loss of strength, which is by no means uncommon, previously to the attack of severe and dangerous fevers; this is remarkably the case in those seized by yellow fever. It cannot mean, they were " much debilitated" by the fatigue of labour, for he and many others declare, that the contingencies of labour do not appear to have any agency in the production of the disease. 1 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 peritonaeum ; or whether the inflammation was the consequence of the fever; for it is here declared, pain, &c. existed before the rigor. PUERPERAL FEVER. 401 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 scat of the pain seems to be changed when she alters her position."* "There is either a vomiting of a green or yellow bitter matter, or a nausea or loathing of the stomach, with an offensive taste in the mouth.t An instantaneous change both in the quantity and appearance of the lochia takes place; and sometimes, though rarely, they are wholly suppressed.^ The milk, if secreted, * Dr. Denman unquestionably means by the "uterus," the peritoneal covering of this organ and its appendages. But this mode of expressing the condition of this part, must unavoidably create confusion, as we have taken occasion to remark in another place, as this viscus is liable to become inflamed, independently of its peritoneal coat, and which is a very different, and a much less dangerous disease. Mr. Hey is also faulty in this respect; for he says, " but all the varieties, so far as I can judge from my experience and reading, may be reduced to two denominations, the sporadic and the epidemic puerperal fever; in which I include inflammation of the uterus and peritonaeum. Dr. Armstrong runs into the same error. f Dr. Clarke supposes that many of the local symptoms arise from an inflam- mation of that portion of the peritoneum which may invest the particular organ or part; "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 declara- tion ; and when it does occur, it is in the second almost always; it is then obsti- nate, and may be regarded as a most unfavourable symptom; and this, for the reason assigned by Dr. Clarke. t All the writers on the subject of puerperal fever, agree in the uniformity of 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 in quantity, a presumption, he says, that the uterus was not affected; and all agree, that it constitutes one of the most decided symptoms in this complaint. By what agency is this change effected ? Does it prove that the uterus, both in its substance and covering, is always implicated in this dis- ease ? or does it show there is a prevailing sympathy between the inflamed peri- toneum and the surface which yields the lochia ? Is the first rendered probable, by the lochia being deranged when the substance of the uterus is known to be affected, in the same manner as when the peritoneum is inflamed ? .Mr. Hey 402 PUERPERAL FEVER. recedes or is diminished, and the taste, with the appearance, 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 arc 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.t The patient immediately entertains the strongest apprehensions of her danger, and usually labours under vast anxiety, her countenance bearing indubitable marks of great suffering both in body and mind." "The progress of this disease is sometimes extremely rapid, and especially in unfavourable seasons, and in hot climates. In- stances have occurred, in which women have died within twen- ty-four hours of the first attack; and I have seen a few, who never grew warm after the rigor, 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 proportion- ate to the danger." 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 second, that that condition of the uterus by which the mamme 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 affect- ed, as in simple hysteritis, the breasts are never so much affected, and sometimes, not at all. f Mr. Hey, in speaking of the Leeds puerperal fever, says, " the tongue was never incrusted with the brown dry fur of typlius, except the disease was of long continuance, or had been improperly treated. It was generally moist and soft; and though it was not unfrequently covered with a thick white or brownish fur, yet it was often but little altered from its natural appearance, to the last, even in bad cases. P. 32. Dr. Armstrong says,' "the tongue was much paler than usual, and appeared as if it had been recently rubbed or dusted with a very fine whitish powder; in some instances the tongue was tolerably clean and moist about the edges." P. 2. PUERPERAL FEVER. 403 " In other cases, the shivering fit is succeeded by heat, thirst, and other symptoms, according to the course observed in other fevers; but the pain which originated in the abdomen, joined with these, is to be esteemed the pathognomonic or chief sign of the disease. It seems necessary to enumerate all the symptoms, which commonly, though not exclusively, attend this fever, and not in any individual patient; yet cases will occur in practice, in which there will be much variation, depending on the degree of disease, the parts affected, the constitution of the patient, and the period after delivery when the fever makes its appearance." " 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, • The frequency of the pulse in peritoneal inflammation has been so invaria- ble, agreeably to our observations, that we regard it as pathognomonic. We were therefore not a little suprised to find this condition of the artery, denied by Dr. Marshall Hall in his Essays on some of the more important Diseases of Fe- males, p. 177. He says, "frequency of pulse is not a less uncertain indication of inflammation (peritoneal). I am enabled to say, from careful observation, that the pulse is but little accelerated in many cases of puerperal inflammation within the abdomen, whilst it is excessively and even alarmingly frequent in some cases in which inflammation does not exist." We cannot but suspect, that the Doctor labours under a great error in this statement; at least in the first part of it—we think he has probably confounded pure hysteritis with peritoneal inflam- mation. See page 328. The latter declaration we fully agree to; but it adds no support to the former part of his observations. We are the more inclined to suspect a want of accuracy in Dr. Hall's observation, from the loose manner in which he has conveyed his notions of the seats of the inflammation constituting the disease in question. For he says, " considering the important and sudden changes which take place in the condition of the uterus, in parturition, we cannot be surprised, that its appendages, the adjacent viscera and the peritoneum at large, should, not unfrequently, participate in this morbid condition." p. 156. Now from this quotation it would appear evident, that the appendages of the uterus, and the abdominal viscera, may be inflamed in puerperal women, inde- pendently of the peritoneum, a circumstance that has not, we believe, been veri- fied 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 conse- quently, that an inflammation of the peritoneum covering the liver, is not an inflammation of this organ, Sic. 401 PUERPERAL FEVER. with great violence of disease, and that tho 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 r to be abated. But the mere quickness of the pulse, if not attended with other pe- rilous signs of inflammation or fever, is not to be considered as indicating danger; experience having shown thot very irritable patients have sometimes an unusually quick pulse, unaccompa- nied 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. Petechia? 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- • This circumstance is familiar to all who have witnessed the most inflamma- tory of all fevers, namely, the yellow fever. This disease runs its course some- times with such rapidity, that the stages, from the highest inflammation, to that of gangrene, can scarcely be observed; bidding defiance very often, to remedies of every kind. Indeed, we may remark it to be the common course with all the diseases of very high excitement when not under the control of medical applica- tions, to terminate in the manner just noticed of puerperal fever. It was this rapid course, with puerperal fever especially, which gave rise to the conflicting accounts we have of its nature; (its termination in gangrene, or in " putridity," as it is 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 purging, 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 diseases as yellow fever and puerperal fever, (at least under ordi- nary 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 ihc action., of lilc." PUERPERAL FEVEft. 405 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 appear- ance in true eruptive fevers." " The bowels are in general very much disturbed, and in some cases a looseness takesjpplace 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 foetid, of a green or dark brown colour, and working like yeast. It is also remarkable, that after the long continuation of the looseness, when the patient has taken little or no solid nour- ishment, large and hard lumps of excrement will be sometimes discharged, which one might suspect to have been confined in the bowels a long time before delivery. With regard, however, to this symptom, it is very necessary to observe, that in delicate constitutions, great disturbances of the bowels are frequently oc- casioned by mere irritation, which are soon removed by the well- timed exhibition and repetition of some cordial opiate." "• There is a peculiarity in this fever, which I believe has not been hitherto observed or mentioned. It is an erysipelatous tu- mour, of a dusky red colour, on the knuckles, wrists, elbows, knees, or ankles, about the size of a shilling, and sometimes larger. This is almost universally a mortal sign, and on the inspection of those who have died with this appearance, the disease 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 rigor. A looseness imme- diately succeeding the attack, though in one sense it may indicate the degree of disease, always contributes to its abatement, and sometimes proves critical; as does likewise a spontaneous vomit- ing, sometimes even towards the last change, when all hopes of recovery were abandoned." ' • The profuse sweat, which follows the shivering fit, has very often been completely critical. In some there has been a trans- 52 PUERPERAL rr.VKU lation of the disease to the extremities, where the part has inflam- ed, and a large abscess h,;.-; been foiiucd ; a similar abscess has also in some cases been formed on one >idc of the abdomen, which has been healed by the most simple treatment." "Fresh eruptions of the lochia arc always a favourable symp- tom, and are to be reckoned among the most certain signs of amendment. A subsidence of the abdomen after copious stools, and with a moist skin, is a fortunate alteration for the patient ; but that circumstance without evacuations, and a dry skin, threat- en the utmost danger." laired. Mid. Francis's Ed. p. 5GS, etscq. Dr. Clarke, p. 121, and other writers, have noticed a symptom of a remarkable kind, to which we have also borne witness, and which, so far as we have observed, has always been a fatal one ; namely, the indifference of the mother to the child, and some- times even refusing to suckle it From whence does this indif- ference proceed ? or why should it be a symptom of so much danger ?* Dr. Clarke, p. 123, accounts for this state of the mind, in an ingenious and plausible manner, by observing, "it is probable that tlie 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 secretion, in like manner as the power of secretion in the testicles produce the passion for propagation; and the passion in its turn affects the disposition for secretion." But to what circumstance shall we attribute this total extinction of sympathy between parts so constantly in the habit of exercising it? Is it owing to any condition of the uterus itself? or does it arise from peritomcal inflammation simply ? or docs 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 mark- ed characters, that it cannot be well confounded with any other * It has lately Mich to my lot to see a cuse of completely developed puerpe- ral fever, in which this symptom proved fallacious. This case will be related presently. PTTERPERAL FEVER. 407 affection ; and we believe, thnt wc may safely rely upon the fol- lowing symptoms for its diagnosis: 1st. Pain or tenderness in the hypogastric re