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PRACTICAL OBSERVATIONS IN MEDICINE.
238 treatment is only so far available as it has reference to the her attendants, induced them to believe that everything state of the bowels, and the development of the teeth. Be- which was swallowed passed directly onwards through the inyond simple emollient ablutions, local remedies are uncalled testines without any delay whatever in the stomach. Hence, for; we must be satisfied with seeing the disease remain sta- they inferred that these organs must have sustained serious tionary until the period of the first dentition is completed, injury by the means used to accomplish delivery, and were rather than by local applications drying up a discharge which rendered incapable of retaining either food, drink, or is evidently vicarious. anything else taken into them. Such discouraging notions In the abovecase the only local application employed was preying upon the patient’s mind, and alarming her exceedan alkaline lotion, and this only with a view to allay the iningly, produced, therefore, great despondency, which, as is tense pruritus. The irritation of teething was evidently the always the case, proved highly injurious, and no doubt very cause of all the other symptoms both in the head and bowels. much retarded recovery. She felt feverish and restless, with complete inability to lie Hence, the gums were freed several times in the course of the treatment, and each time with marked benefit. quiet in any position. Twenty drops of laudanum were given her in camphor julep, and repeated in two hours; but it had no effect whatever in restraining the action of the bowels, and produced a little drowsiness. A powder, composed of PRACTICAL OBSERVATIONS IN MEDICINE. only six grains of calomel, and the same of Dover’s powder, was afterwards administered, and followed in three hours by half BY GEORGE SMYTH, M.D. an ounce of castor-oil ; but these medicines, it was stated, LECTURER ON MATERIA MEDICA AND THERAPEUTICS AT THE CHARcaused great sickness, and enfeebled the patient so much LOTTE-STREET SCHOOL OF MEDICINE, BLOOMSBURY. during their operation, that she swooned once or twice, when it was found necessary to give her a little brandy in order to PUERPERAL INFLAMMATION. restore her. Uterine phlebitis and peritonitis, accompanied from the onset with My attendance was requested on the following morning, diarrlacea of a peculiar and obstinate character; the two former thirty hours after the birth of the child, at which affections treated without venesection.: the latter, after opium, nearly she the following condition:-In the counteperiod catechu, and c7aalk hadfailed, arrested by acetate of lead ; reco- nance therepresented is an expression of great anxiety and despondency virtues on the and observations physiological therapeutic very ; strongly depicted; face and cheeks pale and sunk; lips almost of some of the remedies employed. bloodless, thin, and girt tightly round the gums; skin hot and MRS. H-, aged thirty-three, after a difficult and protracted parched; tongue hard, dry on the point, and covered with a labour, was delivered of her third child, by instruments, dirty brownish fur over the posterior two-thirds. She complains at five o’clock on the morning of the 17th of August, 1844; of great and incessant thirst; pulse about 132, feeble, with a child born alive. She is a woman of fair complexion, and peculiar thrilling sensation, and slightly intermittent. Abdoweakly, rheumatic constitution, and has for a length of time had men very painful on pressure, much swollen, soft, and tympavery bad health, being almost always more or less ailing; she is nitic ; uterus large, easily felt above the brim of the pelvis, consequently much emaciated, and delicate looking in appear- and exquisitely painful when pressed; acute and constant ance. She has suffered greatly from rheumatism, which, she pain complained of in the right iliac region, which occasionally states, has visited nearly joint in her body, but princi- shoots across towards the left, and up towards the umbilicus. pally confining itself to those of the inferior extremities, Lochial discharge has ceased to flow; alvine discharges very where it has sometimes fixed so severely as not only to entirely offensive, very frequent, and passed involuntarily. There is preclude the possibility of her getting about without assist- much complaint of distressing headach, but for which she ance, but often obliged her to remain in bed, even for several thinks she would go to sleep; it is chiefly confined to the days together, though not bodily ill at the time. This state of temples and forehead, which feel very hot. Let a dozen and health and appearance, and condition of physical powers, com- a half of leeches be applied directly on the right iliac region,, menced, according to her own statement, nearly three years over the seat of greatest pain; these to be followed by fomenago, having supervened upon an attack of inflammation of the tation for fifteen or twenty minutes, with cloths wrung out of womb, with which she was then afflicted, after confinement of warm water as hot as the patient can bear, and afterwards her second child. During that illness she lost a large quantity the lower part of the abdomen to be covered with a large of blood, both by the lancet and leeches, and was reduced, linseed-meal cataplasm of an equal temperature; the forehead whether by the disease or loss of blood, to such an extreme state and temples to be kept cool by the constant application of of prostration and debility, that she never afterwards was able cloths wetted with vinegar; and if the pain should not abateto regain her previous and usual standard of health and strength, before evening, three leeches then to be put upon each temple. although every means were tried; she continued, to a certain Powder of opium, four grains; chloride of mercury, eighteen extent, a helpless invalid. Previous to marriage, and even up grains; conserve of roses sufficient to make six pills: take to the above period, she says, she had always enjoyed excellent one every four hours. Camphor mixture and mucilage, of health, was stout and plump, and completely free from pains of each three ounces; solution of acetate of ammonia, two ounces: every kind, either in the joints of the limbs or other parts; is make a mixture; two table spoonfuls to be taken with each not aware that either of her parents was subject to rheum- pill. To have an enema of warm water administered as seen as convenient. atism, as she never heard them complain of it. About five or six hours after the birth of the present child, 19th.-Eleven A.M.: Had some sleep last night for the up to which time everything had gone on comfortably, she first time since her confinement, but is restless, and much diswas seized with a shivering, or obscure rigor, which turbed by frightful dreams. Skin still hot and parched; pulse lasted only eight or ten minutes. This was immediately suc- above 132, smaller, and even more feeble than yesterday; ceeded by a severe lancinating and deeply-seated pain in the tongue more coated, dry, and hard, with much complaint of right iliac fossa, accompanied with much pain and tenderness thirst; abdomen appears more swollen, but there is evidently in the hypogastrium, which latter obliged her to have the not much, if any, increase of pain or tenderness on pressure; abdominal bandage loosened, on account of the annoyance occa- no improvement in the state of the bowels; motions watery. sioned by its pressure. In the course of an hour subsequent The leeches to the temples were not applied, as the pain and to the commencement of the rigor, she suddenly experienced heat abated under the use of the vinegar, and have not rean urgent desire to evacuate the bowels, when a copious fluid turned. The leeches to the abdomen bled well, and drew motion was passed without inconvenience or pain, but on the away a considerable quantity of blood, which caused a sensacontrary, with much satisfaction and feeling of relief to the tion of faintness, followed by much weakness, that continued system; soon after, however, the desire returned, equally ur- for some length of time after. Let the linseed-meal catagent, and when responded to, was in like manner followed by i plasm be kept steadily applied to the abdomen, and continue another and another in quick succession, until, at length, from’, the mixture and pills, with an addition of two grains of their frequency, and urgent nature, all power of either con- opium to the latter, making one grain in each pill; barleytrolling or restraining them became totally lost. The de- water, with a little nutmeg grated into it, for drink; and to jections consequently passed involuntarily, and even some- have an enema of decoction of starch administered as soon as times without the patient’s being conscious of their occurrence, prepared.—Eight P.M : No improvement in any of the symptoms ; the abdomen continues distended, painful, and tympathough the latter circumstance happened rarely. When any drink or other fluid was taken, it only appeared nitic. Let the starch enema be repeated to-night, with a to increase the evil, as an evacuation accompanied with much drachm and a half of tincture of opium added to it. tormina was the immediate and invariable result; and this 20th.-Ten A.M.: Skin cooler to-day, and somewhat softer; very remarkable phenomenon not failing to impress itself and pulse undulatory; tongue dry and raved prominently on the notice of the patient, and likewise upon hard, with still much thirst. Had slept at
thereby
every
slight
continues frequent, feeble, and
intervals,
239 taltic action which commenced in the intestines the moment the wine-and-water had entered the stomach, and did not cease until an evacuation had taken place. Let the astringent mixture and pills be discontinued. Acetate of lead, twelve grains; powder of opium, three grains; confection of roses, sufficient to make six pills: one to be taken every four hours. To have twenty-five drops of Battley’s sedative liquor of opium in camphor julep, for a night draught. The wine, beef-tea, jelly, &c., to be continued as usual. 24th.-Eleven A.M.: Spent a very comfortable night, and feels better altogether; bowels somewhat restrained since she commenced the last pills; the vaginal discharge is now very considerable, and very offensive. Let a weak solution of chloride of lime be used as an injection, two or three times a day; in other respects, go on as before. 25th.-General improvement in all the symptoms, and there is some appearance of return of lacteal secretion. The same medicine and diet to be continued. 26th.-The general amendment progresses steadily; only five dejections during the last twenty-four hours, and these were partly passed voluntarily; discharges from vagina greatly six hours. diminished; pulse now under 98, of tolerable strength, and 21st.-Ten A.M.: Slept not at all in the beginning of the night, regular. She begins to wish for food. Let the pills henceforand was very restless; but towards morning went off to sleep, ward be taken every six or eight hours only, as it may be conduring which there was much muttering delirium. She never- sidered necessary. To have the lean part of a mutton-chop theless reports herself better and more refreshed to-day. for dinner, and the wine and other nourishment to be contiPulse under 130; tongue rather softer and moister, with less nued as usual. 28th.-Sat up in bed a little while yesterday; alvine evacuacomplaint of thirst. Abdomen appears smaller, and is evidently less tender; but no change observable in the state of tions are now reduced to only three in the twenty-four hours, the bowels, either as regards the frequency or mode of occur- are consistent, and passed voluntarily; no tenderness anyrence of the dejections ; urine increased in quantity, and where over the abdomen, excepting in the right iliac region, voided more freely. I thought, when leaning over the patient where there is still some, though not complained of, unless to-day, I could discern mercurial foetor, though very indis- considerable pressure be made on the part. The vaginal distinctly. Let the calomel and opium pill be suspended for the charge has almost entirely disappeared. Omit the pills, but present, and take instead a pill composed of three grains of continue the night-draught as usual, and in other respects go camphor and one grain of opium, every six hours. The as- on as before. Liquor of cinchona, two drachms; tincture of tringent mixture and nourishment already prescribed to be cinnamon, half an ounce; syrup of orange-peel, six drachms; continued, and the starch enema repeated again to-night. distilled water, six ounces and a half. Make a mixture. Two The patient having expressed a wish that the cataplasm to table-spoonfuls to be taken three times a-day. the abdomen, if possible, might be dispensed with, it was ac30th.-Had some retching during the last two mornings, cordingly laid aside, and a cloth, soaked in warm turpentine, after taking the medicine, which the patient dislikes, and was applied over the hypogastrium in its stead. takes reluctantly. In other respects, she feels comfortable, 22nd.-Eleven A.M.: Passed a more comfortable night, hav- and has no complaint to make. Let the mixture be omitted, ing lain quiet but slept little; the bowels still running on un- and take the following pills instead:-Disulphate of quinine, restrained, notwithstanding that all the other symptoms twenty-four grains; confection of roses, sufficient to make appear to be steadily improving. The pulse is less frequent, twelve pills. One three times a day. and has acquired better strength; the tongue looks better, Sept. 2nd.-Has gone on steadily improving since last visit... and the abdomen is slowly decreasing in bulk, and is much and is recovering strength rapidly; appetite is very good, and less tender, the pain being now principally confined to the she sleeps well without the assistance of the night draught, right iliac fossa, where it first originated. Mercurial foster which has been dispensed with for the last two nights; alvine to-day is more distinct, and there is sponginess of the gums, evacuations passed regularly twice in the twenty-four hours, but scarcely any salivation. During the last twelve hours, a and present the normal appearance. She is now able to large quantity of urine has been discharged, double the amount, suckle her infant, lactation having become almost fully estain fact, passed in the same time at any other period since blished. It is unnecessary to pursue the history of the case further she became ill. I had no opportunity of examining it, as it in detail, as the patient went on gradually improving to perwas not preserved; but it was reported to be high-coloured, rather thick, and voided freely and without pain. Let the fect recovery. There is, however, one circumstance connected medicine and other remedies already prescribed be continued. with its subsequent progress, which I must not omit noticing, 23rd.-Half-past eleven A.M.: Had rather a restless night in and that is, the continued accelerated state of the pulse up the beginning, but afterwards slept soundly for four hours un- to a certain period. all the other symptoms were,. either disappearing entirely orinterruptedly, when she was awaked by the nurse for the pur- one after another, pose of taking food. She again went off to sleep; but this improving, and the patient to all appearance was becoming time it was short, and disturbed by unpleasant dreams. Thinks quickly convalescent, still the pulse did not seem to partake herself much better and stronger; pulse not above 122, and of in the general amendment going on in the system, at least better strength; tongue beginning to clean on the edges, and not to that extent which might have been expected. Having moist. Abdomen goes on diminishing in size, but the only per- fallen to between 88 and 98, it there remained fluctuating ceptible improvement in the condition of the bowels is, that between these two numbers, but generally keeping within a she now feels to consent to the occurrence of the dejections, few beats of the latter. This circumstance puzzled me not a, though still without the slightest power of preventing or re- little, and at first I was at a loss how to account for it; but straining them. The motions have also become less offensive the difficulty was soon explained in the following manner :during the last two days. The same phenomenon still existsIt appeared that on the 3rd, 4th, and 5th, the patient was which existed at first-namely, the intestinal action which each day troubled with occasional slight chills, followed by immediately takes place on the introduction of either food orflushes of heat, when, at the same time, the pain in the right drink into the stomach. The patient states, that as yet iliac region, to which I have already directed attention, and nothing appears to her to remain in the stomach, even for’ which still continued to exist more or less, became suddenly a minute after it is swallowed; that the moment anything isincreased, though not to such a degree as to demand instant taken, particularly if it be fluid, "a sort of working" (to use, attention, and active means of relief to be used. The patient, her own expression) commences at the pit of the stomach., in short, did not make any complaint about it, or even mendownwards through the intestines, end.tion the circumstance on the day when it first occurred, lest, and thence,incontinuing an involuntary evacuation. With this latter, as she said, leeches should be applied; nothing, therefore, invariably the intestinal disturbance ceases, but only for the time, as a6was done, and the same medicine and diet were continued. similar cause again and again produces a similar effect. - On the 9th, however, she was greatly alarmed by a sudden gave her some wine-and-water, and was soon fully convincec1 gush of purulent matter from the vagina, amounting to three of the presence of tliis very curious and remarkable circum- or four ounces at least. It was not preceded or attended stance, from the distinct borborygma accompanying the peris with any unusual pain, and took place when she was raising
occasionally during the night; motions continue to be passed frequently and involuntarily on taking food or drink; abdomen not more tympanitic, nor pain greater on pressure; external parts greatly tumefied, and there is much complaint of pain during micturition, to accomplish which there is also some difficulty. Let the pudendum be fomented, and then covered with a linseed-meal cataplasm. Continue the pills, but omit the mixture. For nourishment, to have arrow-root, beef-tea, and jelly. Chalk mixture, four ounces; compound infusion of catechu, three ounces; tincture of the same, half an ounce; aromatic confection, two drachms. Make a mixture, twoo table spoonfuls to be taken every three or four hours, according to circumstances.-Eight P.M.: No impression as yet made on the alvine evacuations by the astringent mixture. There is now a rather foetid discharge from the vagina, but she feels more comfortable in those parts since the application of the cataplasm; in other respects no change, only that she complains of being low and weak. The mixture and pills to be continued, and the starch enema to be repeated again tonight. In addition to her other nourishment, to havehalf an ounce of port wine, with warm water-and-sugar, every four or
,
Although gradually
,
-
240
sitting posture in bed. At my visit the next subjected; and by it alone, independent of any local disease, only surprised, but much gratified, to find that I have reason to suppose that the same train of consequences the pulse had fallen considerably below 80, and the pain in might be induced. the right iliac region had also nearly ceased to exist. She Nor is this merely an opinion of conjecture, but one founded progressed in strength daily afterwards, and having continued in experience and fact, as it has occurred to me to witness in the tonic pills up to the 18th, they were then left off, her another female, with a state of constitution and health almost health being fully re-established. identical, to follow a case of uterine hfcmorrhage, in which Remarks.—Before proceeding to offer any observation on there was no organic disease whatever. The relation of this the case now given at much length, I think it necessary, in case must, however, be postponed to a future number of the first place, to direct attention to the state of ill-health THE LANCET. and ill-diathesis, already briefly alluded to in the history of it, which appeared to have existed in this lady’s system for a ON RETROVERSION OF THE UTERUS, AND considerable period previous to the attack for which I was
herself to the
day,
I
was
not
___________________
called upon to treat her. At the time her accouchement ITS TREATMENT BY INFLATION. took place, she was reduced to a state of much general emaBY CHARLES HALPIN, M.D., Cavan. ciation and great weakness, which plainly showed that the THE Number of THE LANCET for July 25th contains a confunctions of assimilation and nutrition had been long and tinuation of the valuable series of " Illustrations of Inflamseriously interfered with, and obstructed in the performance mation and Ulceration of the Uterine Neck," by Dr. J. H. of their normal and healthy actions. The cause which operated in producing this condition was supposed to have origi- Bennet. The case described in the following statement is one interest in a practical point of view. nated in a former attack of puerperal inflammation with of exceedingly great " uteri a cause of which she had been affiicted nearly three years before the The case is headed, Ulceration of the cervix and further, it is described as " Ulceration existing abortion ;" The to her second child. after birth having given present, previous to impregnation; retroversion of the uterus occurring cure of that attack, it appeared, was entrusted entirely to during treatment, without any appreciable cause; flooding both to but bloodletting, principally depleting measures, simulating menstruation; abortion." had been carried to a it was and local, which, st.ated, general I shall not enter into the question of impregnation taking fearful extent, blood having been drawn to syncope several times from the arm, and leeches several times applied to place during the existence of an ulcer on the cervix uteri, further than to observe, that we have no evidence before us the abdomen as well. It is not my intention to enter here upon a lengthened in this case to show that the cervix uteri was in a state of ulcerawith the period at which impregnation took inquiry, as to whether this process of bloodletting was abso- tion coincident for it from the dates, that this patient had conappears, place; in at the to counteract the time, order lutely necessary or not I two months prior to her first application to Dr. Bennet, disease; or whether the latter might not have been subdued ceived he discovered the ulcerated state of the part; and again, by other milder and less injurious means. That the first when I do not think we are warranted in giving our assent to the of a there is no effect of the bloodletting was salutary nature, laid down by Dr. Bennet, that in this case the reason to doubt. By it solelv, perhaps, the inflammatory. proposition action was arrested, and thereby the life of the patient saved, "ulceration was a cause of the abortion," for we find that it which being the grand object sought to be attained, conse- was complicated with retroversion of the uterus, unreduced, or, to Dr. Bennet, "irreducible ;" and we know that quently, so far as the therapeutic effects of the remedy were according is the almost inevitable consequence of this malabortion it be said to have succeeded. might required, completely But what were its subsequent effects on the constitution of position of the womb. Having made these few remarks, I the individual? and were there no disadvantages attending shall proceed to consider the case as one of retroversion of the this plan of treatment which probably would not have been uterus, simply; and my chief object in doing so is to point out incurred had the lancet been more sparingly used? Had it to the attention of Dr. Bennet and the profession a method of not the effect, slowly and insidiously manifested, of damaging correcting this malposition of the uterus, which suggested itself the constitution by reducing the system to a state of inanition to me some years ago, and which has since been found comand great prostration of vital power, and thereby incapacitat- petent by others in the profession to effect this object, after every other known means of reduction had been tried, and ing its several organs, especially the reparatory,* for the found unavailing-I mean, inflation of the pelvis. of those functions which alone the loss proper performance by In December, 1839,I was called into consultation in a case could be supplied, and health and strength recovered. Such, at all events, is to be inferred, because it was from of retroverted uterus, which for a period of seven daysresisted this period, correctly speaking, perhaps the period of conva- our best directed endeavours to rectify. Inflation of the pelvis itself to me; we acted on the suggestion, and the lescence, that the derangement in the functions of assimila- suggested tion and nutrition, and the alteration in the physical appear- uterus was restored almost instantaneously to its normal position. Nor had we the slightest trouble with it afterwards. ance already alluded to, began to manifest themselves. I communicated this case to the Obstetrical Society of IreInstead of the patient’s former state of health and strength, Mtherto always good, becoming re-established, as might have land on the 2nd of January, 1840, in a paper which I read been expected, after the disappearance of the primitive and before them, and which was subsequently published in The radical disease, a state of the opposite kind ensued. She con Dublin Journal of Medical Science for March, 1840, (vol. xvii. tinued weak and languid, looked pale and sickly, and wasting in page 68.) This method of treating retroversion of the uterus has been flesh, soon became thin and emaciated; then followed attacks found equally successful in other hands. The accompanying of rheumatism and spasms, with many other ailments, to note I received from Dr. Brunker on 20th October, 1844: which she had previously been a total stranger. Dundalk, 18th Oct. 1844. Now it would, perhaps, be a difficult matter to explain satis" SiR,-As I am sure you will be gratified to hear of the factorily the nature of the change which must have taken place in the constitution, in order to produce such a manifest success of the mode of treatment proposed by you, to remedy deterioration in the general health of the individual, and that, a retroverted uterus, I beg to inform you, that I tried inflation too, after all trace of the original disease had ceased to exist; of the vagina in a patient in the County of Louth Infirmary a and it would also be an equally difficult matter, no doubt, to few daysago, whose case was a very urgent one, and I am determine positively whether that change was communicated, happy to say, with almost immediate success, and relief of all in this instance, by the nature and severity of the disease, or the urgent symptoms-though all the usual manoeuvres to followed as a con; ;quence of the extent to which the remedial rectify the uterus were diligently made use of previously, but measures, the bloodlettings, were carried in the treatment of with no avail. I certainly should not hesitate, at once, to init. Both may have acted simultaneously, as it is probable flate the vagina in a similar case, without having recourse to they did; but it is my firm conviction that the latter was the any other expedient.-Your obedient servant, "E. G. BRUNKER, M.D., principal, nay, I believe it to have been the sole agent of all To Dr. Halpin, Cavan." ’° Surgeon to Louth Infinnary. the ills and afflictions to which this person was afterwards I believe it is pretty certain that Dr. William Hunter first * When from a sudden loss of blood, or a deficiency of it in the system, aroused the attention of the profession to this affection, in a or any other cause, the stomach is deprived of a proper and suftlcient snpon the subject, published in the fifth volume of "Meply ot that fluid, its innervation becomes diminished, and a state of atony, paper This may be only temporary, the organ soon dical Observations and Inquiries:" he termed it retroversion or loss of power, results. recovering itself; or, continuing, it may lapse into that intractable and of the uterus. Yet, undoubtedly, it was well known previous xlebilitating form of indigestion known and described under various syno- to the date of the case on which his observations were nymes, but most appropriately, perhaps, under that of chronic atonic gasfounded. This will be seen by the perusal of two cases which tric dyspepsia; and which, I apprehend, was the morbid condition that Inow quote, from " Smellie’s Treatise of the Theory and Pmcwas insidiously induced, and so long existed, in our patient. "
thereby
every
slight
continues frequent, feeble, and
intervals,
239 taltic action which commenced in the intestines the moment the wine-and-water had entered the stomach, and did not cease until an evacuation had taken place. Let the astringent mixture and pills be discontinued. Acetate of lead, twelve grains; powder of opium, three grains; confection of roses, sufficient to make six pills: one to be taken every four hours. To have twenty-five drops of Battley’s sedative liquor of opium in camphor julep, for a night draught. The wine, beef-tea, jelly, &c., to be continued as usual. 24th.-Eleven A.M.: Spent a very comfortable night, and feels better altogether; bowels somewhat restrained since she commenced the last pills; the vaginal discharge is now very considerable, and very offensive. Let a weak solution of chloride of lime be used as an injection, two or three times a day; in other respects, go on as before. 25th.-General improvement in all the symptoms, and there is some appearance of return of lacteal secretion. The same medicine and diet to be continued. 26th.-The general amendment progresses steadily; only five dejections during the last twenty-four hours, and these were partly passed voluntarily; discharges from vagina greatly six hours. diminished; pulse now under 98, of tolerable strength, and 21st.-Ten A.M.: Slept not at all in the beginning of the night, regular. She begins to wish for food. Let the pills henceforand was very restless; but towards morning went off to sleep, ward be taken every six or eight hours only, as it may be conduring which there was much muttering delirium. She never- sidered necessary. To have the lean part of a mutton-chop theless reports herself better and more refreshed to-day. for dinner, and the wine and other nourishment to be contiPulse under 130; tongue rather softer and moister, with less nued as usual. 28th.-Sat up in bed a little while yesterday; alvine evacuacomplaint of thirst. Abdomen appears smaller, and is evidently less tender; but no change observable in the state of tions are now reduced to only three in the twenty-four hours, the bowels, either as regards the frequency or mode of occur- are consistent, and passed voluntarily; no tenderness anyrence of the dejections ; urine increased in quantity, and where over the abdomen, excepting in the right iliac region, voided more freely. I thought, when leaning over the patient where there is still some, though not complained of, unless to-day, I could discern mercurial foetor, though very indis- considerable pressure be made on the part. The vaginal distinctly. Let the calomel and opium pill be suspended for the charge has almost entirely disappeared. Omit the pills, but present, and take instead a pill composed of three grains of continue the night-draught as usual, and in other respects go camphor and one grain of opium, every six hours. The as- on as before. Liquor of cinchona, two drachms; tincture of tringent mixture and nourishment already prescribed to be cinnamon, half an ounce; syrup of orange-peel, six drachms; continued, and the starch enema repeated again to-night. distilled water, six ounces and a half. Make a mixture. Two The patient having expressed a wish that the cataplasm to table-spoonfuls to be taken three times a-day. the abdomen, if possible, might be dispensed with, it was ac30th.-Had some retching during the last two mornings, cordingly laid aside, and a cloth, soaked in warm turpentine, after taking the medicine, which the patient dislikes, and was applied over the hypogastrium in its stead. takes reluctantly. In other respects, she feels comfortable, 22nd.-Eleven A.M.: Passed a more comfortable night, hav- and has no complaint to make. Let the mixture be omitted, ing lain quiet but slept little; the bowels still running on un- and take the following pills instead:-Disulphate of quinine, restrained, notwithstanding that all the other symptoms twenty-four grains; confection of roses, sufficient to make appear to be steadily improving. The pulse is less frequent, twelve pills. One three times a day. and has acquired better strength; the tongue looks better, Sept. 2nd.-Has gone on steadily improving since last visit... and the abdomen is slowly decreasing in bulk, and is much and is recovering strength rapidly; appetite is very good, and less tender, the pain being now principally confined to the she sleeps well without the assistance of the night draught, right iliac fossa, where it first originated. Mercurial foster which has been dispensed with for the last two nights; alvine to-day is more distinct, and there is sponginess of the gums, evacuations passed regularly twice in the twenty-four hours, but scarcely any salivation. During the last twelve hours, a and present the normal appearance. She is now able to large quantity of urine has been discharged, double the amount, suckle her infant, lactation having become almost fully estain fact, passed in the same time at any other period since blished. It is unnecessary to pursue the history of the case further she became ill. I had no opportunity of examining it, as it in detail, as the patient went on gradually improving to perwas not preserved; but it was reported to be high-coloured, rather thick, and voided freely and without pain. Let the fect recovery. There is, however, one circumstance connected medicine and other remedies already prescribed be continued. with its subsequent progress, which I must not omit noticing, 23rd.-Half-past eleven A.M.: Had rather a restless night in and that is, the continued accelerated state of the pulse up the beginning, but afterwards slept soundly for four hours un- to a certain period. all the other symptoms were,. either disappearing entirely orinterruptedly, when she was awaked by the nurse for the pur- one after another, pose of taking food. She again went off to sleep; but this improving, and the patient to all appearance was becoming time it was short, and disturbed by unpleasant dreams. Thinks quickly convalescent, still the pulse did not seem to partake herself much better and stronger; pulse not above 122, and of in the general amendment going on in the system, at least better strength; tongue beginning to clean on the edges, and not to that extent which might have been expected. Having moist. Abdomen goes on diminishing in size, but the only per- fallen to between 88 and 98, it there remained fluctuating ceptible improvement in the condition of the bowels is, that between these two numbers, but generally keeping within a she now feels to consent to the occurrence of the dejections, few beats of the latter. This circumstance puzzled me not a, though still without the slightest power of preventing or re- little, and at first I was at a loss how to account for it; but straining them. The motions have also become less offensive the difficulty was soon explained in the following manner :during the last two days. The same phenomenon still existsIt appeared that on the 3rd, 4th, and 5th, the patient was which existed at first-namely, the intestinal action which each day troubled with occasional slight chills, followed by immediately takes place on the introduction of either food orflushes of heat, when, at the same time, the pain in the right drink into the stomach. The patient states, that as yet iliac region, to which I have already directed attention, and nothing appears to her to remain in the stomach, even for’ which still continued to exist more or less, became suddenly a minute after it is swallowed; that the moment anything isincreased, though not to such a degree as to demand instant taken, particularly if it be fluid, "a sort of working" (to use, attention, and active means of relief to be used. The patient, her own expression) commences at the pit of the stomach., in short, did not make any complaint about it, or even mendownwards through the intestines, end.tion the circumstance on the day when it first occurred, lest, and thence,incontinuing an involuntary evacuation. With this latter, as she said, leeches should be applied; nothing, therefore, invariably the intestinal disturbance ceases, but only for the time, as a6was done, and the same medicine and diet were continued. similar cause again and again produces a similar effect. - On the 9th, however, she was greatly alarmed by a sudden gave her some wine-and-water, and was soon fully convincec1 gush of purulent matter from the vagina, amounting to three of the presence of tliis very curious and remarkable circum- or four ounces at least. It was not preceded or attended stance, from the distinct borborygma accompanying the peris with any unusual pain, and took place when she was raising
occasionally during the night; motions continue to be passed frequently and involuntarily on taking food or drink; abdomen not more tympanitic, nor pain greater on pressure; external parts greatly tumefied, and there is much complaint of pain during micturition, to accomplish which there is also some difficulty. Let the pudendum be fomented, and then covered with a linseed-meal cataplasm. Continue the pills, but omit the mixture. For nourishment, to have arrow-root, beef-tea, and jelly. Chalk mixture, four ounces; compound infusion of catechu, three ounces; tincture of the same, half an ounce; aromatic confection, two drachms. Make a mixture, twoo table spoonfuls to be taken every three or four hours, according to circumstances.-Eight P.M.: No impression as yet made on the alvine evacuations by the astringent mixture. There is now a rather foetid discharge from the vagina, but she feels more comfortable in those parts since the application of the cataplasm; in other respects no change, only that she complains of being low and weak. The mixture and pills to be continued, and the starch enema to be repeated again tonight. In addition to her other nourishment, to havehalf an ounce of port wine, with warm water-and-sugar, every four or
,
Although gradually
,
-
240
sitting posture in bed. At my visit the next subjected; and by it alone, independent of any local disease, only surprised, but much gratified, to find that I have reason to suppose that the same train of consequences the pulse had fallen considerably below 80, and the pain in might be induced. the right iliac region had also nearly ceased to exist. She Nor is this merely an opinion of conjecture, but one founded progressed in strength daily afterwards, and having continued in experience and fact, as it has occurred to me to witness in the tonic pills up to the 18th, they were then left off, her another female, with a state of constitution and health almost health being fully re-established. identical, to follow a case of uterine hfcmorrhage, in which Remarks.—Before proceeding to offer any observation on there was no organic disease whatever. The relation of this the case now given at much length, I think it necessary, in case must, however, be postponed to a future number of the first place, to direct attention to the state of ill-health THE LANCET. and ill-diathesis, already briefly alluded to in the history of it, which appeared to have existed in this lady’s system for a ON RETROVERSION OF THE UTERUS, AND considerable period previous to the attack for which I was
herself to the
day,
I
was
not
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called upon to treat her. At the time her accouchement ITS TREATMENT BY INFLATION. took place, she was reduced to a state of much general emaBY CHARLES HALPIN, M.D., Cavan. ciation and great weakness, which plainly showed that the THE Number of THE LANCET for July 25th contains a confunctions of assimilation and nutrition had been long and tinuation of the valuable series of " Illustrations of Inflamseriously interfered with, and obstructed in the performance mation and Ulceration of the Uterine Neck," by Dr. J. H. of their normal and healthy actions. The cause which operated in producing this condition was supposed to have origi- Bennet. The case described in the following statement is one interest in a practical point of view. nated in a former attack of puerperal inflammation with of exceedingly great " uteri a cause of which she had been affiicted nearly three years before the The case is headed, Ulceration of the cervix and further, it is described as " Ulceration existing abortion ;" The to her second child. after birth having given present, previous to impregnation; retroversion of the uterus occurring cure of that attack, it appeared, was entrusted entirely to during treatment, without any appreciable cause; flooding both to but bloodletting, principally depleting measures, simulating menstruation; abortion." had been carried to a it was and local, which, st.ated, general I shall not enter into the question of impregnation taking fearful extent, blood having been drawn to syncope several times from the arm, and leeches several times applied to place during the existence of an ulcer on the cervix uteri, further than to observe, that we have no evidence before us the abdomen as well. It is not my intention to enter here upon a lengthened in this case to show that the cervix uteri was in a state of ulcerawith the period at which impregnation took inquiry, as to whether this process of bloodletting was abso- tion coincident for it from the dates, that this patient had conappears, place; in at the to counteract the time, order lutely necessary or not I two months prior to her first application to Dr. Bennet, disease; or whether the latter might not have been subdued ceived he discovered the ulcerated state of the part; and again, by other milder and less injurious means. That the first when I do not think we are warranted in giving our assent to the of a there is no effect of the bloodletting was salutary nature, laid down by Dr. Bennet, that in this case the reason to doubt. By it solelv, perhaps, the inflammatory. proposition action was arrested, and thereby the life of the patient saved, "ulceration was a cause of the abortion," for we find that it which being the grand object sought to be attained, conse- was complicated with retroversion of the uterus, unreduced, or, to Dr. Bennet, "irreducible ;" and we know that quently, so far as the therapeutic effects of the remedy were according is the almost inevitable consequence of this malabortion it be said to have succeeded. might required, completely But what were its subsequent effects on the constitution of position of the womb. Having made these few remarks, I the individual? and were there no disadvantages attending shall proceed to consider the case as one of retroversion of the this plan of treatment which probably would not have been uterus, simply; and my chief object in doing so is to point out incurred had the lancet been more sparingly used? Had it to the attention of Dr. Bennet and the profession a method of not the effect, slowly and insidiously manifested, of damaging correcting this malposition of the uterus, which suggested itself the constitution by reducing the system to a state of inanition to me some years ago, and which has since been found comand great prostration of vital power, and thereby incapacitat- petent by others in the profession to effect this object, after every other known means of reduction had been tried, and ing its several organs, especially the reparatory,* for the found unavailing-I mean, inflation of the pelvis. of those functions which alone the loss proper performance by In December, 1839,I was called into consultation in a case could be supplied, and health and strength recovered. Such, at all events, is to be inferred, because it was from of retroverted uterus, which for a period of seven daysresisted this period, correctly speaking, perhaps the period of conva- our best directed endeavours to rectify. Inflation of the pelvis itself to me; we acted on the suggestion, and the lescence, that the derangement in the functions of assimila- suggested tion and nutrition, and the alteration in the physical appear- uterus was restored almost instantaneously to its normal position. Nor had we the slightest trouble with it afterwards. ance already alluded to, began to manifest themselves. I communicated this case to the Obstetrical Society of IreInstead of the patient’s former state of health and strength, Mtherto always good, becoming re-established, as might have land on the 2nd of January, 1840, in a paper which I read been expected, after the disappearance of the primitive and before them, and which was subsequently published in The radical disease, a state of the opposite kind ensued. She con Dublin Journal of Medical Science for March, 1840, (vol. xvii. tinued weak and languid, looked pale and sickly, and wasting in page 68.) This method of treating retroversion of the uterus has been flesh, soon became thin and emaciated; then followed attacks found equally successful in other hands. The accompanying of rheumatism and spasms, with many other ailments, to note I received from Dr. Brunker on 20th October, 1844: which she had previously been a total stranger. Dundalk, 18th Oct. 1844. Now it would, perhaps, be a difficult matter to explain satis" SiR,-As I am sure you will be gratified to hear of the factorily the nature of the change which must have taken place in the constitution, in order to produce such a manifest success of the mode of treatment proposed by you, to remedy deterioration in the general health of the individual, and that, a retroverted uterus, I beg to inform you, that I tried inflation too, after all trace of the original disease had ceased to exist; of the vagina in a patient in the County of Louth Infirmary a and it would also be an equally difficult matter, no doubt, to few daysago, whose case was a very urgent one, and I am determine positively whether that change was communicated, happy to say, with almost immediate success, and relief of all in this instance, by the nature and severity of the disease, or the urgent symptoms-though all the usual manoeuvres to followed as a con; ;quence of the extent to which the remedial rectify the uterus were diligently made use of previously, but measures, the bloodlettings, were carried in the treatment of with no avail. I certainly should not hesitate, at once, to init. Both may have acted simultaneously, as it is probable flate the vagina in a similar case, without having recourse to they did; but it is my firm conviction that the latter was the any other expedient.-Your obedient servant, "E. G. BRUNKER, M.D., principal, nay, I believe it to have been the sole agent of all To Dr. Halpin, Cavan." ’° Surgeon to Louth Infinnary. the ills and afflictions to which this person was afterwards I believe it is pretty certain that Dr. William Hunter first * When from a sudden loss of blood, or a deficiency of it in the system, aroused the attention of the profession to this affection, in a or any other cause, the stomach is deprived of a proper and suftlcient snpon the subject, published in the fifth volume of "Meply ot that fluid, its innervation becomes diminished, and a state of atony, paper This may be only temporary, the organ soon dical Observations and Inquiries:" he termed it retroversion or loss of power, results. recovering itself; or, continuing, it may lapse into that intractable and of the uterus. Yet, undoubtedly, it was well known previous xlebilitating form of indigestion known and described under various syno- to the date of the case on which his observations were nymes, but most appropriately, perhaps, under that of chronic atonic gasfounded. This will be seen by the perusal of two cases which tric dyspepsia; and which, I apprehend, was the morbid condition that Inow quote, from " Smellie’s Treatise of the Theory and Pmcwas insidiously induced, and so long existed, in our patient. "