An Account of some of the most important diseases peculiar to women

Front matter

THE

ABNER WELLBORN CALHOUN

MEDICAL LIBRARY

Preface

I was formerly Physician in the two Lying-in- Hospitals of Westminster and London, and Lecturer ' on Midwifery at St. Bartholomew's Hospital, and I have for many years been extensively employed in the practice of Obstetric Medicine ; thus I have had the best opportunities of acquiring a practical knowledge of this branch of our profession, and the strongest motives for collecting and arranging it into a shape suitable for communication. I do not say this in a tone of exultation, for I have little reason ; on the contrary, the thought of the opportunities I have enjoyed is always accompanied with the painful reflection, how imperfectly I have used them : this has depended partly on not knowing their full value when I first came into possession of them, but chiefly on a long course of ill health ; and I write this preface principally to persuade those who come after me, to turn their great

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opportunities to a good account. If I knew a young man placed in such a station, in whose eminence, founded on his professional utility, I felt interest, I would say to him, remember that your station is one which can be enjoyed only by a very few ; do not consider it as one of lucrative conspicuousness, but as a, trust which Providence has confided to you, and which you will neglect unless you do your utmost to improve your branch of medicine. He who has the care of a Lying-in- Hospital, is a Lecturer on Midwifery, and is resorted to by the public as" an obstetrical Physician, has opportunities of acquiring knowledge in, and extending the bounds of, obstetric medicine, which no other physician, surgeon, or general practitioner can possess, whatever may be his talents. Your task will go on prosperously, the sooner you have ceased to read, and begun to observe and think : do not, however, attempt to dispense with reading, but despatch it as speedily as is consistent with accuracy. Keep a note-book, read the most esteemed original writers on the most important subjects of your art, and while reading them note down briefly those points which you wish to remember, so as to have no occasion ever to look into the book again ; provided you get the points of the work, the more briefly you do it the better ; if you are skilful at this, you will find that a page will hold a pamphlet ; and that twenty pages will often hold a bulky volume ; if you read German, read Richter's Bibliothek Chi-

PREFACE. IX

rurgische, for he is the greatest master of the art of condensed analysis. Thus your manuscript volume will become a Bibliotheca of your branch of medicine, and you will never afterwards have occasion to consult the books themselves. There are some writers whom it would be wrong to abandon thus ; master-minds, whom we return to again and again, not merely for the knowledge which ! they contain, but to observe how their minds worked, and the older we grow the fonder we become of them ; such in England, are Harvey on Physiology, and Sydenham on Medicine; but few such minds appear in any branch of knowledge; and with most of them, when you have squeezed out the juice, you may safely throw away the rind. Having thus made yourself acquainted with what was known by the most experienced writers on the most important subjects of your art, you are prepared to undertake the more difficult task of observing and reflecting for yourself: watch cases attentively, and take notes of their important particulars; not of every case, but only of the most important; and not lengjhy notes, containing a diffuse description of unimportant trifles, which from the time which they occupy will soon cease to be written, and if written, are sure never to be read ; but a short description of the leading circumstances, with an equally short mention of the reflections, which they-suggest. Make yourselves perfect in the art of examining dead bodies : accustom your hand to open them, and your eye to

PREFACE.

detect with accuracy morbid appearances. In putting down this important part of a case, come at once to the essential morbid appearances; have a head for parts examined which were found healthy: thus you will despatch these in one line, unlike some who take up three-fourths of their report with the description of parts in which no morbid appearances were found. Five years industriously spent in the way which I have advised, provided you have a mind adapted to investigation, will make you more competent to advise and act in the difficulties and diseases of your branch of the profession than most persons you come in contact with, and than many a man far older than yourself; and after ten years so employed you will find yourself in possession of materials in a state fit to be produced, of various degrees of value; some of them, "little articles of intellectual traffic with your neighbours, and some things worthy to be deposited among the general stores of human knowledge."* As you grow older, you will gradually fabricate with greater facility materials of greater value, and thus you will go on improving till you arrive at that age when the mind, satiated by action, longs for repose. But from this "idea of the good Physitian and his rewarde," I must drop several fathoms down to speak of my own humble volume.

When I came to see diseases on a large scale I

* Mr. Abernethy's first Lecture at the College of Surgeons.

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was naturally led to compare what I saw of them in nature with the way in which they are represented in books; to contrast the country which I was myself exploring with the best maps of it. In so doing it appeared to me that these maps were very defective in their representation, even of the most important places ; some being laid down imperfectly, others inaccurately, some both the one and the other, and other important districts not laid down at all. Of many of the most important subjects, there is no account whatever, excepting what is to be found in compendiums and systems, and here they are delineated so briefly, and often so obscurely and inaccurately, that it is utterly impossible for the young practitioner to acquire a clear and competent knowledge of them ; such a one as instruction might supply him with antecedent to experience. Take any one of the great questions in obstetrical medicine and surgery, and turn to the account given of it in these sources of information; and I defy the student, however attentively and thoughtfully he may read, to carry away with him any but partial and confused notions. At least the most important subjects deserve to be represented on a larger scale, with , copiousness, precision, and that selection of materials — that separation of the wheat from the chaff, which none but an experienced writer is equal to, and which no compiler can effect. Accounts of every difficulty in labour, and every disease of women, in the unimpregnated, the pregnant, and the puerperal states,

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and every disease of infancy and childhood ; accounts of all these subjects on such a scale, would be more than any man could write, and I might almost add, read ; but the great questions at any rate ought to be thus delineated. Dr. C. M. Clarke has supplied the deficiency, in one class of the diseases of the unimpregnated state ; hence I have not touched on any of these excepting only polypus of the uterus; and I should not even on that, if I had not some additions to make of practical importance, especially the account of polypus of the neck or lip of the uterus, in which the usual diagnostic sign, the stalk being encircled by the orifice of the uterus, is no guide, and when trusted to, leads the practitioner into error, as I have repeatedly witnessed; when this polypus grows with a very thick neck it sometimes puzzles the most experienced practitioners. But what Dr. C. M. Clarke has done for one class of diseases, requires to be done for others ; or what would be better, for the select or most important subjects throughout obstetric medecine. Such accounts I have attempted to give of the peritoneal fevers of lying-in women, of the disorders of the mind in lying-in women, of the mode of distinguishing pregnancy from the diseases which resemble it, of polypus of the uterus ; the account of the irritable uterus, I consider as a new map of a district which had not been laid down before, and like all new maps, an imperfect one. The other papers have a more partial object. When an author at-

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tempts to execute his own view of a subject, he is the last person in the world to judge whether he has succeeded or failed ; when he has finished his task it is impossible for him to see it from the same point of view, and in the same light, as the public will; and as he himself would if he could forget its thoughts and phrases, and read it with a fresh and impartial mind. He may show it to a judicious and well-informed friend ; but this is a poor thermometer of public opinion: the only one is publication, and to this I must trust the fate of my volume.

As my plan was in most cases to give a full account of each subject, and to include in it everything which I thought interesting or important about it, I have necessarily had to include many particulars already well known : but even these I have not related from books, but from my own personal experience ; even in the most common-place fparts I claim to be more than a compiler. The chapter on the art of distinguishing pregnancy from the diseases which resemble it, does not contain any point which was not already known, yet I know no books from which I could have compiled it unless I had had ample experience in cases of doubtful pregnancy : the materials are drawn from my own observation arranged and cemented by my own reflection : this is a very different process to compilation. If the object of the student is to learn only what has been said on a subject, the pursuit of knowledge

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is an easy task; but if his object is to learn what is true on a subject, the pursuit of knowledge is the task of a life.

If the profession should approve of this volume, and Providence should prolong my life, I may probably (as I possess materials) attempted similar accounts of other Diseases of Women and Children.

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Part I

The most fatal disease to which lying-in women are subject is known under the names of Puerperal or Child-bed Fever, Puerperal Peritonitis. Its essential symtoms are pain and tenderness over the abdomen, with a rapid pulse*. It begins a few days after delivery, with pain of the abdomen, shivering succeeded by heat, and a quick pulse. As the disease advances, the milk becomes suppressed, the belly tumid, and the breathing short; when it terminates fatally, it does so commonly about the fifth day, but often in less than half that time. On opening the abdomen, morbid appearances are not uniform, but the most common and remarkable are a copious effussion of lymph and serum on

* f Dr. Lowder adopted a very good method to form an accurate definition of the disease. He read all the different authors of character who had written on the subject, and noted down all those pathognomonic symtoms which they agreed were .necessary to constitute the disease, and on com. paring these with his own experience, he found them to be very few — fever, intense pain of the head, and in tense pain of the abdomen.'— ( Lowder, MS. Lectures.) 3 the surface and in the cavity of the peritoneum. Thus it is a fever essentially complicated, with an affection of the peritoneum. A better name than Puerperal Fever, or Puerperal Peritonitis, would be that which I have plached at the head of this paper— ' Peritoneal Fever' — for it would express the fact, that an affection of the peritoneum is an essential accompaniment of the diseases, without defining what that affection is, because it is not uniform.

A remarkable circumstance about this disease is, that it is much more prevalent in some seasons than in others. In populous towns and cities it occasionally appears at any time^ but the cases are few in number, mild in degree, and, if detected early, and treated properly, generally recover. Sometimes, however it becomes extraordinarily prevalent. In a lying-in hospital, in which there is commonly so little illness that the office of physican is almost a sinecure, cases of this disease sometimes become so numerous, that the physican finds it impossible to do his duty without visiting the hospital at least twice a day. In populous places so many cases occur, and so many of them are fatal, that the practitioner of midwifery goes obout his task with unusual anxiety; and even in a thinly peopled country, where the death of a lying-in woman is almost an unheard-of event, fatal cases have occurred in rapid succession, spreading terror among the pregnant woman of the neighbourhood.

Another remarkable circumstance about this disease, is, that when it is most prevalent, it is most dangerous. Each case is much more difficult of cure than when it occures seldomer. The practitioner finds that, although the group of symtoms resembles what he was formerly accustomed to, he has now to deal with a diseas far more obstinate and successful, and his usual remedies are not so destructive as formerly; he loses case after case in spite of his best efforts. When it has been thus raging for a considerable time, it at lengh subsides ; the cases become less frequent and less severe ; the practitioner finds his treatment becoming more successful, partly because experience has taught him to detect it earlier and so treat it better, but probably also because the disease has itself become milder.

There is still another remarkable circumstance in the prevalent or epidemic form of this disease. It is not uncommon for the greater number of cases to occur in the practice of one man, whilst the other practitioners of the neighbourhood, who are not more skilful or more busy, meet with few or none. A practitioner opened the body of a woman who had died of puerperal fever, and continued to wear the same clothes. A lady whom he delivered a few days afterwards, was attacked with and died of a similar disease ; two more of his lying-in patients, in rapid succession, met with the same fate; struck by the thought that he might have carried the contagion in his clothes, he instantly changed them, and met with no more cases of the kind. A woman in the country, who was employed as washerwoman and nurse, washed the linen of one who had deid of puerperal fever; the next lying-in patient she nursed died of the same disease : a third nursed by her met with the same fate, till the neighbourhood, getting afraid of her, ceased to employ her. The disease has occurred in some wards of a hospital, the others being free from it ; but after ventilating, cleansing, and painting these wards, they became as healthy as the others. Facts such as these have long led to the suspicion that the disease might be communicated from one lying-in woman to another in the clothes of the practitioner or nurse, or the furniture of a tained chamber.

From the little I have already said about the symptoms of this disease, and the morbid appeaances discovered after death, it is clear that it essentialy consists in fever, with an inflamed state of the peritonum ; but fever may vary, not only in degree, but in kind, or (as it is commonly called) type , and inflammation may vary, not only in degree, but also in kind or type. Hence, in investigating the nature of this degree, one of the first questions is, whether it is strictly uniform, differing only in degree in different cases, and requiring only different degrees of the same treatment ; or whether it differs to such a kind or type, that the mode of treatment which is necessary in some cases, is distructive in other;. The latter is the conclusion to which we must inevitably come, at first sight, in tracing the history of this disease in the works of those who have written about it. This

I propose to do through the last half century, not for the useless purpose of raking up old and obsosolate opinions, but because it is unsafe to draw inferences, except from a wider survey of facts than the experience of a single individual, or of a single epidemic, affords.

Puerperal fever was prevalent in Derbyshire, and the adjacent countries, between 1765 and 1775, and was described by Dr. Butter of Derby. His opinion was, that bleeding ought never to be used in this disease, unless when complicated with inflammation, and even in these cases bleeding of three ounces were sufficient ; that the best remedy was ten grains of rhubarb, and ten grains of cordial confection every day, till the stools became natural ; and that this mode of treatment never failed. He gives several cases, all of which recovered.

In 1787, that is about ten years after Dr. Butter wrote, a puerperal fever was prevalent and fatal in London, and was described by the late Dr. John Clarke. It generally began on the second or third day after delivery, and terminated fatally in a week — sometimes as early as thirty-six hours.* Its essential symptoms were pain and tenderness of the belly, with a rapid pulse. As the disease advanced, the milk became suppressed, the belly large, the breathing short, the pulse quick and weak. The appearances on dissection were those of inflammation in some parts of the viscera of the abdomen, but this was never extensive, and sometimes there was none. The effusions of inflammation, however, were very abundant ; they often amounted to several pints, and appeared to be pus and lymph mixed with serum. The surfaces of the viscera were coated with lymph, but the peritoneum underneath was nofred. The interstices between the viscera were filled with masses of lymph, which formed a cast of their shape. Of the patients attacked with this disease, more than two-thirds died : bleeding was injurious ; leeches to the abdomen were useless ; emetics were hurtful ; bark and cordials, though indicated by debility, were inefficacious. Dr. Clarke suspected that the disease might be occasioned by the purge which is always given to lying-in women on the second day after delivery ; but glisters were not more successful.

Now compare the accounts which Dr. Butter and Dr. Clarke have given of the results of their practice. The former seems to have lost none of his patients, and found a daily dose of rhubarb and cordial confection a never failing remedy ; the other lost more than two-thirds of his patients, and nothing seems to have done any good. What can explain this contrariety of statement ? A perusal of their prfBgip'hlets at once solves the mystery; they are talking about two different diseases. That described by Dr. Clarke was a genuine puerperal fever, accompanied by an affection of peritoneum, which occasioned the effusion of lymph and serum ; that described by Dr. Butter is quite different. Its ordinary duration was from ten days to five or six weeks. Whoever is familiar the tremendous disease which I am considering, and knows that the patient is either dead or safe at the end of a week at longest, will instantly percetive that a disease so protracted cannot be the same ; and a perusal of Dr. Butter's cases leaves no doubt oNn the subject. It was a slow remitting fever, not attended by any affection of the peritoneum. Its chief symptoms were sleepless nights, great depression of spirits, a quick pulse, one or two exacerbations of fever every day, and a very disorderly state of the alimentary canal. I have repeatedly seen it, but never as an epidemic, and though it lasts a long time, I believe it never kills. Dr. Butter imagined that this fever, which he never failed to cure, was the same disease which he describes as so fatal in London.

But the contrary statements of physicians do not always admit of so easy a solution. Dr. William Hunter, and Richter, the professor of medicine and surgery in Gottingen, were two of the most useful minds that ever appeared in our profession. They were men of great talents and knowledge, singularly adapted for natural investigations, and remarkable for clearness of intellect, and correctness of judgment. If any men could, such men might be trusted for giving accurate reports of a disease. Yet compare the accounts which these distinguished men have left of their experience in puerperal fever. Dr. William Hunter used to say in his lectures — " Of those attacked by this disease, treat them in what manner you will, at least three out of four will die. Upon examining the bodies, "the uterus, the viscera, and every other part of the abdomen, are found to be inflamed. There is a quantity of purulent matter in the cavity of the abdomen, and the intestines are all glued together. We tried various methods, (bleeding, refrigerants, stimulants, mithridate,) but every thing failed." Richter, speaking of the child-bed fever, says, " I have often seen the child-bed fever, and always treated it successfully. I have also seen cases, both near and at a distance, in which the fever was treated differently from what I am accustomed to treat it, and the patients died. I therefore think that I have a right to offer my opinion about the nature and treatment of this fever y

One would at first sight suppose that Richter had committed some error like that of Dr. Butter; but the following remarks must remove this suspicion. " It is plain," says he, '• that it is not every fever which attacks a lying-in woman which is to be called child-bed fever. Its principal symptoms are debility ; swelling of the abdomen, colic-like pains; pains in the abdomen, on external pressure; pain of the head, especially in the forehead. The disease is commonly fatal in a few days. On dissection, the viscera of the abdomen are found inflamed, suppurating, gangrenous. The means for preventing the disease, or, if it has already begun, for curing it, are timely evacuations by purgatives.*

* Medicinishe und Chirurgische Bemerkungen von D. A. G. Richter, b. ii. s. 60.

There can be no doubt that Hunter and Richter both meant, thus far at least, the same disease — that it was the child-bed fever which is attended by inflammation of the peritoneum, and which, if not cured, kills in a few days. But what shall we say to their very opposite experience? the one, whatever he did, lost three patients out of four, the other, by the gentlest aperients, never failed to cure the disease. Richter, at the time he wrote this statement, must have been sixty years of age. The inexperience of youth, therefore, will not explain it, and it is explicable only on the supposition, either that, old as he was, he had never seen the epidemic puerperal fever, or that, if he had, tha epidemics which he had seen were singularly mild.

The reader will feel curious to know the mode of treatment which in Richter's hands was so successful. On the first symptoms of child-bed fever, he gave a purge two days successively, each * enough to operate three times. On the following days smaller doses were given, enough to operate once, or at most twice, and this plan was continued till all symptoms had ceased.

Dr. Lowder, who, about thirty years ago, lectured on midwifery, at the medical school of Guy's and St. Thomas's Hospitals, and who was esteemed by the best judges of those times as an excellent practical physician, gave the following account of this disease : That the pathognomonic symptoms were pain .of the abdomen, pain of the head and fever ; that it terminated fatally in a space of 4 time between forty-eight hours and one week ; that the appearances on dissection were redness of the peritoneum, adhesion of the intestines, effusion of serum, mingled with pus and lymph. He thought that the inflammation was erysipelatous and the fever typhoid. When the inflammatory symptoms were distinct, he permitted a few ounces of blood to be drawn, but if the symptoms were typhoid, bleeding was positively injurious — he mentioned it as the assertion of many medical men, that all the patients who were bled, died. Whenever the fever was typhoid, he recommended bark, and mentioned two cases, apparently hopeless, which recovered by taking daily a gallon of the decoction. •

Among the London physicians, Dr. Denman was the chief believer in the inflammatory nature of puerperal fever, and in the safety and absolute necessity of bleeding, provided it was used early and actively. There can be no doubt he meant that puerperal fever of which peritoneal inflammation is an essential part ; and if I understand him rightly, he believed, that whenever the peritoneum was affected in that way which terminates in the effusion of serum and lymph, it was always with that form of inflammation, which bears, and requires bleeding. His mode of treating the disease seems to have been this : First, at the commencement of the disease, by a full bleeding from the arm, and if the effect of it was beneficial, by another bleeding after a few hours ; if the constitution of the patient was feeble, he preferred cupping, or leeches to the abdomen. Next, by an emetic of ipecacuanha or tartarized antimony, so as to procure full vomiting, and after this had subsided, if the disease was not extinguished, the emetic was to be repeated. These emetics generally, produced not only vomiting, but sweating and purging ; if not, sulphate of magnesia dissolved in thin gruel was given every few hours, till it procured several stools. Having succeeded in procuring these evacuations, he gave a full opiate. The rest of the treatment consisted in a saline aperient every morning and an opiate every night.

Puerperal fever was epidemic in Aberdeen more than two years, between 1789 and 1792, and was described by Dr. Gordon, a physician of that place. He states that the essential remedy was blood-letting, employed early and freely ; thafr when he took ten or twelve ounces away, the patient generally died, but when lie took twenty-four ounces away at once, and during the first six hours of the disease, the patint commonly recovered. " If practitioners," said he, ** allow themselves to be guided by the pulse, they will run info a fatal error, because the pulse is more frequently weak and feeble, than strong and full, even at the beginning of the disease, yet I bled notwithstanding with great success. The pluse, instead of being thereby weakened, became more full and strong than before," " This disease seized such women only as were visited or delivered by a practitioner, or taken care of by a nurse

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who had previously attended patients affected with the disease." His treatment consisted in a very early and very large bleeding, a bolus of three grains of calomel and two scruples of jalap, followed by a daily purgative, and a nightly opiate. Of the patients whom he attended, twenty-eight died out of seventy-seven ; and although his practice, when it had fair play, was much more successful, he yet confesses the loss of some.*

From the foregoing account of the experience and opinions of different physicians, who had opportunities of observing puerperal fever, what inferences are we to draw? Supposing, that each observed accurately the disease which he witnessed, and that no mistake was made in the formation of his opinion, the inevitable conclusion is this : — that puerperal fever, by which I always mean that fever which is accompanied by an inflammatory state of

* Sprengel, in his history of Medicine, gives the following account of this work. " The history which Alexander Gordon has given of an epidemic puerperal fever, which he considered as inflammatory, and which nevertheless he treated with drastic purgatives, such as jalap and sweet mercury, without resorting to bleeding." — Histoire de la Medicine, par Kurt Sprengel, torn, vi. p. 343. If this is a specimen of the accuradjl of this history, it will diminish the confidence with which we should consult this very learned and' otherwise useful publication. The more, however, I 'look into compilations, and trace them to their sources, the more I suspect compilers find that, if they were very scrupulous about accuracy, they would never get on in their work. It is but fair to state, that I have used the French copy translated by A. J. L. Jourdan, who is very alert at exposing the "erreurs grossieres" of his rival translatior, M. Geiger. "I hope that this is an " erreur grossiere" of Sprengel.

the peritoneum, is not one uniform disease, but may occur under different forms, — that sometimes it is so mild as to be curable by the gentlest aperients, and at other times it is very obstinate and fatal. That in this latter form it sometimes consists of acute inflammation of the peritoneum with inflammatory fever which bears, and is curable only by early and active depletion, sometimes of inflammation and fever of a low type, in which depletion is useless, and even pernicious.