THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 LOS ANGELES 
 
 GIFT OF 
 
 SAN FRANCISCO 
 COUNTY MEDICAL SOCIETY
 
 THE NEW SYDENHA 
 
 SOCIETY. 
 
 INSTITUTED MDCCCLVIII. 
 
 VOLUME II.
 
 G C H 
 
 ON SOME OF THE 
 
 MOST IMPORTANT DISEASES 
 
 PECULIAR TO 
 
 WOMEN; 
 
 WITH OTHER PAPERS. 
 
 |rcMorn feaiy 
 
 ROBERT FERGUSON, M.D., 
 
 PHYSICIAN EXTRAORDINARY TO THE Q.UEEN ; 
 
 CONSULTING PHYSICIAN TO KING'S COLLEGE HOSPITAL ; 
 
 FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS. 
 
 THE NEW SYDENHAM SOCIETY, 
 LONDON. 
 
 MDCCCLIX.
 
 589
 
 Mismertir.il 
 tikray 
 
 WP 
 II/-D 
 
 &51lf 
 
 1151 
 PREFATORY ESSAY. 
 
 The present volume was published thirty years ago, at 
 a time when there was no English work on this branch of 
 medicine, which could satisfy the craving of those who 
 hungered and thirsted after knowledge of some of the 
 most appalling diseases incident to human nature. 
 
 Except where the highest principles are concerned, a 
 decade makes the mass of scientific discoveries and opinions 
 old. What is enunciated as, and proved to be, a truth, is 
 rapidly absorbed into the sum of truths already secured; 
 the labour of a life is crushed into a formula which, in pro- 
 portion as it becomes current and useful, ceases to be 
 instructive : all those fine processes by means of which 
 the ore was extracted and minted are laid aside and for- 
 gotten. Thus it has been with the opinions of Gooch, 
 which, by clearing away the obscurities of the subjects he 
 has discussed, have imparted so much certainty to thought 
 and action, that we have almost ceased to be conscious of 
 the daylight he shed on them, by reason of the very large- 
 ness and commonness of its diffusion. I conceive, there- 
 fore, that this Society has clone well in putting into the 
 hands of the student this volume, which will enable him to 
 mark, and if possible appropriate, the methods by which a 
 mind like Gooch' s worked; thus affording him the occasion 
 by which he in his own day may learn to co-ordinate and 
 transmit his own experience for the benefit of others.
 
 vi PREFATORY ESSAl'. 
 
 The general features of the work are its pre-eminently 
 practical character, its manly tone, devoid of trash and 
 frippery, an ardent love of truth, a dislike of all con- 
 fident assertions, an abhorrence of all means which prosti- 
 tute knowledge to notoriety or to gain. 
 
 Gooch's mind was singularly intolerant of error ; he was 
 rarely deceived by appearances or misled by the innume- 
 rable frauds by which self-love warps our judgment. It 
 was necessary for him to see clearly, otherwise he could 
 not see at all. His ardent temperament, which even a life 
 of suffering could not subdue, made him feel a deep inte- 
 rest in all things with which he came in contact. Hence 
 his powers of attention to, and his firm grasp of a subject 
 — its constant presence to his mind — were the conse- 
 quences of his mental constitution ; always striving to 
 arrive at clear and true results. Besides these character- 
 istics, he had the great gift of knowing, not only his 
 knowledge, but also his ignorance ; so that the reader 
 will find that what is left out in the treatment of any of 
 the subjects discussed in this volume was omitted purposely, 
 as unripe and insufficient. The lacunas were indicated for 
 time and other labourers to fill up. 
 
 These various traits, which T have noticed as observable 
 in his written works, were tenfold more apparent in 
 his conversation, which was singularly forcible, both as to 
 expression and illustration ; and so totally devoid of all 
 assumption of superiority, that one soon felt assured of an 
 excellent and sympathising listener on any subject one 
 had at heart, the sum of one's knowledge of w T hich was 
 speedily laid bare under his rare talent of questioning and 
 suggestive comment. 
 
 A physician, thrown as he is amid scenes of mental 
 and corporeal suffering, often becomes involved in advising
 
 GOOCH AS AN AUTHOR. Vll 
 
 the living as well as in caring for the dying. In such a 
 capacity Gooch was pre-eminent ; for no one possessed in 
 greater force than himself the two qualities which are 
 essential to form a good adviser, viz., the interest to get 
 up his subject, and the ' esprit juste ' to decide on it. 
 
 Gooch was no mere chronicler of so-called facts, but an 
 historian who could see in the very germ the laws by 
 which the subject was evolved : a very few cases set his 
 penetrating intellect on the true track. He worked by 
 insight rather than sight, intensively rather than exten- 
 sively. " The period of my life," he says, " when I im- 
 proved most rapidly, was when I gained clear and orderly 
 notions of the objects of examination. The faculty of 
 observation requires rather to be guided than to be sharp- 
 ened : the finger soon gains the power of feeling when 
 the mind has acquired the knowledge of what to feel for." 
 The converse of the proposition is no less true ; for at no 
 time of his life is the physician's mind more stagnant than 
 when it is overwhelmed by the 'multa' rather than 
 concentrated on the 'multum' — when his prerogative of 
 seeing much is levelled to that of a routinist or of a nurse 
 — whose mental vision is blinded by seeing many things. 
 
 It is this love of truth, this necessity for clear concep- 
 tions, which make the methods adopted by Gooch in the 
 treatment of any subject so instructive. The whole is 
 presented to us in so lucid a form, its parts so well pro- 
 portioned, that the laws by which it was developed in the 
 master's mind run the hazard of escaping the attention 
 of the student. 
 
 Up to Gooch's time, nothing which could satisfy was 
 known as to puerperal fever. At the bed-side it was a 
 toss-up what would be the issue of opinions and treat- 
 ment, when there was no solid base to rest upon ; and yet
 
 Vlll PREFATORY ESSAY. 
 
 the necessity of action was instant — the disease the most 
 appalling — the occasion, with all its accompaniments, in- 
 dividual and social, the most absorbing in all its interests 
 which the physician could contemplate. Such a state of 
 things was intolerable to a mind so constituted as was that 
 of Gooch, which could not bear to be lurching here and 
 there amid a storm of conflicting opinions. Was the 
 disease really one, varying merely in degree ; or were 
 there many, each one differing in kind? Such was the 
 problem to be solved, and the student will do well to mark 
 the process by which Gooch is guided to its solution, for 
 the method is of general application. "To determine (he 
 says,) whether any two similar maladies are the same, four 
 things are essential to be known : — 1, A knowledge of 
 causes — 2, Symptoms — 3, Effects of remedies — 4, Morbid 
 appearances." 
 
 Before applying to his own experience, Gooch appeals 
 to the experience of others, and the rapid historical survey 
 he takes is a model of critical investigation. Not only is 
 there an outline of the opinions of his predecessors, but 
 the right of each to hold such opinions, as estimated by his 
 mental aspects and his opportunities, is brought to bear 
 on the solution of this intricate problem. With regard to 
 causes, nothing satisfactory to Gooch was found; hence 
 this element is set aside. The investigation of the influ- 
 ence of the other three criteria, however, establishes the 
 following canon: — Symptoms and morbid appearances 
 afford only probable grounds for the identity of diseases 
 — Effects of remedies, conclusive grounds. " The effects 
 of remedies (he says,) on a disease, if accurately observed, 
 form the most important part of its history. They are 
 like chemical tests, frequently detecting important dif- 
 ferences in objects which previously appeared exactly
 
 prERPRRAL FEVER. IX 
 
 similar.'' I have elsewhere stated my belief that the neglect 
 of this canon, that is, the neglect of therapeutics, and 
 the almost exclusive attention to dead instead of to living 
 pathology, both on the Continent and with us, has led to 
 the existence of Homoeopathy. 
 
 Under this test, Gooch discovered that puerperal fevers 
 were many, requiring varying modes of treatment. The 
 merit of this dogma will be appreciated, if the student 
 will endeavour to realise the state of professional opinion 
 and practice at the time it was enunciated. We have now 
 to deal so rarely with fevers of an inflammatory type, that 
 Gooch's practice, and indeed that of his contemporaries, 
 appears heroic even to exaggeration. You are directed to 
 bleed to faintness from a large orifice — to encourage the 
 collapse by the upright posture — to resort to a second 
 bleeding — then to relays of leeches, and to twenty grains 
 of calomel, followed by half an ounce of salts every other 
 hour until purging was superinduced. All this was to 
 be done at the instant of attack, if possible ; life hinged on 
 the vigour of a timely practice. 
 
 If ever there were a temptation to be one-sided, here it 
 existed. The profession and the public believed in these 
 gigantic measures, and believed in nothing short of them ; 
 immunity was certain, even on failure, in a course judged 
 by Gooch's contemporaries as the only possible one. It 
 required a singular combination of qualities to enable a 
 man thus associated, and thus acting, to perceive truth, 
 in spite of the authority of his age, and in the teeth of 
 his own habits and successes. But I must not, by epito- 
 mising, defraud the reader of the profit and pleasure of 
 witnessing, in the essays on puerperal fever, the modes by 
 which Gooch established its varieties. The largeness of 
 his views — the subtleness of his comments — his earnest 
 reverence for the trust reposed in the physician for the
 
 X PREFATORY ESSAY. 
 
 safeguard of human life — his ceaseless activity in alleviating 
 human suffering — his strong appeal against indifference 
 and apathy — cannot fail to awaken, and I believe to 
 strengthen, the best resolves. 
 
 I have stated that Gooch did not touch on the causes of 
 puerperal fever. The subject was unripe. A rational 
 humoral pathology which solves this question was unknown 
 in our schools. In Germany the doctrine of the vitality of 
 the blood, though always maintained by these, the greatest 
 of European physiologists, yet had little influence on the 
 dogmas of practical medicine. In France the experiments 
 which proved irrefragably the changes in the life of the 
 blood, were barely commenced in Gooch' s time, and were 
 not seen in all their import, either in France or here, till 
 later. The labours of Gaspard, Dance, Tonelle, Majendie, 
 and Cruveilhier were entirely unknown to Gooch, and 
 although they pointed very distinctly to the cause of 
 puerperal fever, yet the scattered and diffused light de- 
 manded concentration in order to afford a distinct view. 
 In our own country, his indefatigable industry, zeal, and 
 vast accumulation of facts, had led Dr. Robert Lee to place 
 the cause of puerperal fever in inflammation of the veins ; 
 that is, in the solids. 
 
 Twenty years ago my position as physician to the 
 General Lying-in Hospital forced on me the reconsidera- 
 tion of the malady which was ravaging that Institution 
 from year to year, and led to the publication of an Essay 
 embodying the following conclusions : — 
 
 1. The phenomena of puerperal fever originate in a 
 vitiation of the fluids. 2. The causes which are capable 
 of vitiating the fluids are particularly rife after childbirth. 
 3. The various forms of puerperal fever depend on this 
 one cause, and may readily be deduced from it. 
 
 Under the first head I showed how all the accidents
 
 PUERPERAL FEVER. XI 
 
 of puerperal fever may be artificially produced by vitiating 
 the blood. By a comparison of a variety of series of facts, 
 I found that in puerperal fever there were two sources at 
 least of blood vitiation : 1, The direct insertion of noxious 
 matter into a vein ; 2, Mechanical injury to the solid 
 walls of the blood-vessels, inducing the products of inflam- 
 mation, which products being conveyed into the torrent 
 of the circulation, act, as in the first case, as blood-infec- 
 tants. I indicated, moreover, a third source of blood- 
 poisoning by inhalation, adducing in corroboration facts 
 from my own experience, since fully confirmed by others, 
 of fatal disease in the children and attendants of those 
 who had died of puerperal fever. 
 
 Under the second head, — that the causes capable of viti- 
 ating the blood are very rife in childbed, — I showed that 
 both the above sources of vitiating, viz., noxious matters 
 and mechanical injury, existed in the condition of the 
 puerperium. 
 
 I examined Cruveilhier's doctrines of the analogy between 
 an amputated stump and the uterine placental surface as 
 accounting for the similarity of diseases ensuing respec- 
 tively on amputation and child-birth, and the general 
 result to which I was led was, that the phenomena of 
 puerperal fever arc not peculiar to lying-in women — that 
 the malady is not a fever sui generis. 
 
 Plow a variety of fevers, requiring each a differing 
 treatment, might be produced by one cause — for the laws 
 governing these varieties — for the action of accessorial 
 causes in epidemics, and for other subjects connected with 
 or arising out of the main topic : for these points I must 
 refer the reader to the original work, the notice of which 
 I have obtruded on him here, merely as a link in the 
 history of puerperal fever. 
 
 b
 
 XU PREFATORY ESSAY. 
 
 When, after a long lapse of years, I look back on these 
 my earlier efforts, I see no cause to modify opinions which 
 have now, I believe, merged into the current doctrines of 
 the day. A discussion on the nature and treatment of 
 puerperal fever, which has just taken place in France — 
 (" De la Fievre Puerperale de sa Nature et de son Traite- 
 ment." 1858. Paris 8vo.) — under the sanction of the 
 Imperial Academy of Medicine, has attracted my atten- 
 tion, not only by the vigorous display of polemic talent, 
 but by the enunciation of doctrines and results at the 
 present moment which I had advocated a quarter of a 
 century ago. 
 
 Content to remain within the pale of their own genial 
 activities and rich literature, the French, unlike the Ger- 
 mans, rarely glance at the labours of foreigners ; hence I 
 cannot but accept the coincidences of opinion common to 
 them and me as confirmations of results arrived at by 
 independent workers in a common field. 
 
 There is, however, a series of facts detailed which 
 deserve every attention ; those in which the lesions of 
 puerperal fever appear in the foetus in utero communicated 
 through the maternal system. These facts of reciprocal 
 action of mother and child, as evinced in syphilis and other 
 contaminating diseases, should be stored up as likely to 
 explain, at no distant day, the latent processes of hereditary 
 malady. 
 
 Gooch, during the latter years of his life, devoted much 
 time to the study of mental disease. — Such was the close- 
 ness of his watch over ' public' cases, and such the felicity 
 of his analysis, that the Chancellor of the day referred the 
 most intricate and important of these to his practised 
 judgment. Not only was he employed by the highest 
 kgal functionary in thus aiding him in clearing away the
 
 PUERPERAL MANIA. X1H 
 
 obscurities which darkened these questions ; but he did 
 not hesitate to bring into public view cases in which he 
 conceived individuals to have been falsely charged with 
 madness. Had he lived to have watched over public in- 
 terests, the vigour of his lash would have prevented the 
 intrusion of much, which has since rendered the subject 
 of mental disorder a study full of contradictions and con- 
 fusion. 
 
 The cause assigned for puerperal mania is traced by 
 Gooch to those laws of metamorphic change which have 
 since been known as laws of organic evolution and invo- 
 lution. The growth of the uterus and its appendages 
 during gestation, and their relapse to their pristine con- 
 dition after it, are accompanied, as are all organic changes, 
 by great development of nerve-force. Hence the extreme 
 impressionability of women during childbearing. The 
 demand on the blood for the supply to the foetus, and, 
 subsequent to birth, to the infant ; the lochial discharges 
 — in a word, the general conditions of gestation, may 
 readily induce debility. It is on this stage of ' excitement 
 without power,' that Gooch bases his theory of puerperal 
 mania, and thence deduces his indications of treatment, 
 so opposed as that treatment was to the depletory system 
 of his contemporaries. 
 
 Since the publication of this essay, other causes of a 
 toxic nature, as albuminuria and purulent infection, have 
 been recognised as incitants of mania. 
 
 From the chapter on insanity, considered as an object 
 of moral science, the student may replenish his armoury 
 with weapons necessary to meet the attacks of those, who, 
 even at the present moment, contend that the knowledge
 
 xiv PREFATORY ESSAY. 
 
 of the physician is unnecessary and non-essential to the 
 treatment of mental malady. If it be possible ever to 
 rescue this most difficult of subjects from the audacity of 
 diletanteism or from ignorant philanthropy, Gooch's argu- 
 ments should do so. 
 
 At first sight Gooch may seem to rely, too exclusively, 
 on corporeal treatment, banishing the moral ; but a colla- 
 tion of his views will show this idea to be erroneous, as 
 his tenth case proves. So long as we acknowledge the 
 1 commercium,' or fellowship of mind with body, so long 
 must we not dare to neglect their reciprocal influence in 
 the treatment of mania. The battle between Somatist 
 and Spiritualist is an idle strife. The whole theory of 
 morals is based on the postulate, that the mind is suscep- 
 tible of change by spiritual agencies. The foundations of 
 education l'epose on the fact of mental nourishment for 
 mental development. A course of ethics is more likely 
 to enlighten our morals than any alterative virtues of 
 sarsaparilla ; and the discipline of old Euclid will scarcely 
 be displaced in elucidation of geometric truth by the 
 quintessence of any pharmacopoeia. Look on the brain, 
 as the organ of thought, and we adopt a theory with all 
 its consequences — and the Iliad, the Paradise Lost, the 
 dclicise of Shakespeare and Dante, become mere cerebral 
 secretions. Say that the brain is the medium by which we 
 think, and we express a simple fact devoid of all theory, 
 consonant with what we know of every other force in nature, 
 namely, that not one is manifested to us except through a 
 medium ; its own essence is behind the generated phe- 
 nomena, in a world divined, but not seen nor felt. 
 
 Beside these general arguments on the side of the 
 Spiritualist, the sudden return to sanity of the insane, so 
 frequently witnessed, is in accordance with the laws of
 
 THEORIES OF INSANITY. w 
 
 mental change, and admits of no better explanation than 
 that which accounts for our sudden conviction. 
 
 Organic chemistry is too tardy in its exhibition of mole- 
 cular action to afford the faintest aid in explaining the 
 advent of that inner ray, which, in the twinkling of an eye, 
 dispels the gloom of the disordered mind ; still less will it 
 account for those flashes from genius which lighten and 
 guide mankind from age to age in its conflict with the 
 moral and the material world. 
 
 Gooch has barely opened the great question as to the 
 nature of insanity, when he demurs to the legal definition 
 of it, as consisting in " insane belief." The belief may 
 be rational and well-founded, but it may still exercise an 
 undue action on feeling and conduct, breaking up those 
 finer judgments and processes of thought by which the 
 sound mind is regulated. 
 
 I myself have never been able to approach nearer to the 
 doctrine of moral insanity than by means of the slender 
 clue here afforded. 
 
 Since Gooch's time, his theory, together with that of 
 monomania, have either been created or have assumed a 
 prominence which has startled, if it has not convinced, the 
 public mind. Both theories are derivatives of that larger 
 one which considers the various modes of mind, under the 
 abstract term of 'faculty,' each faculty (imagination, 
 judgment, attention, perception, &c.) being a separate 
 entity, having a definite portion of the brain for its seat or 
 organ. Willis, Pinel, Gall, and Spurzheim are the origi- 
 nators of this view of mental organization, but, though they 
 have largely influenced the opinions of specialists, they 
 have not induced any metaphysician of note to adopt the 
 metaphysical portion, nor any anatomist of name to adopt 
 the anatomical portion of their system. Moreover, no two 
 of the originators of this e schema' arc agreed either as to
 
 XVI PREFATORY ESSAY. 
 
 the number of our faculties or of their supposed seats in 
 the brain. Indeed, if we take any or all of these organs, 
 as mapped by their authors, the mechanism of the mental 
 machine will on trial speedily come to a dead-lock. It will 
 be impossible to account for a page of human thought, or 
 to track through its wheelwork the sequence of actions 
 which any single hour of human existence may score. 
 
 This is not the place to enter fully into the discussion 
 of so large a subject as the nature and aspects of insanity ; 
 nevertheless, a few comments may direct attention to 
 doctrines which, though current, are too paradoxical to be 
 received by the legist with favour. 
 
 If the mind is to be considered as the composite of facul- 
 ties or organs, each a power in itself, and having each a 
 material seat for the manifestation of that power, it follows 
 that any one or more of these organs may become the 
 seat, or seats, of disease, leaving the others intact and 
 sane. Here we flounder at once against an insufficient 
 nomenclature. That division of insanity, of Heinroth's, 
 which Prichard considers and adopts as the best, acknow- 
 ledges only mania and monomania — the madness of all the 
 organs, or of one ; but Marc and others give instances of 
 two and more 'monomanias, co-existing with a mass of 
 sound organs ; proving at least this — that the subject which 
 has so insufficient a nomenclature is ill-defined and illogical. 
 As long as the single organ affected with insanity was of 
 a subordinate rank in the intellectual hierarchy, the doc- 
 trine of monomania did not attract much notice. But 
 when it is asserted that there is an " organ of volition," 
 and that the ' will' can go mad, and thus present us with 
 the theory of moral insanity, the case is very different. 
 This theory asserts that a man may be of sound under- 
 standing, and yet, in spite of his reason, against his con- 
 science, and with a struggling will, is compelled, for exam-
 
 THEORIES OF INSANITY. XV11 
 
 pic, to commit homicide. It is clear that under such a 
 theory no distinction between bad and mad is possible. 
 If the theory be just, a counsel may lay claim to im- 
 punity for his client, by asserting that, though his reason 
 rebelled against the deed, though his conscience abhorred 
 it, yet under a mad organ of volition the unfortunate 
 gentleman shot down his neighbour, for whom at the 
 instant of homicide he entertained the highest respect. 
 
 Is the theory tenable ? No doubt that all morals are 
 based on the doctrine of ' free-will.' Nothing can be 
 imputed to man, as good or bad, in which his will is com- 
 pelled, or does not participate. In so far, then, as the 
 theory of moral insanity implies a compulsion, however 
 enforced, it is sound. But what is an organ of volition, 
 which, like an organ of sense, may become in itself and 
 separately the seat of disease, and manifest disorder of 
 function ? The will is the person, it is ourselves in action 
 or effort. We do not make our sensations ; we cannot forge 
 our convictions ; we are compelled to see the object before 
 the open eye, as we are compelled to acknowledge the 
 truth of a geometrical problem. The powers of sensation 
 and of reason are great and beneficent endowments, 
 which we use, but do not create ; but we are accountable 
 for every act of the will, inasmuch as it is we ourselves, 
 and no other, who create and produce them. To say, then, 
 that there is an organ of volition separated from the Ego, 
 the ' self,' the ' person,' as the organ of vision, which 
 conveys the matter of vision, is separated from the mind 
 percipient of it, is to assert that there are impersonal 
 volitions, acts of the will which belong to nobody — which 
 rise spontaneously by some inexplicable irritation of the 
 supposed organ. Such an organ so acting independently 
 of the person is a pure nonentity, and an involuntary 
 volition, an absurdity.
 
 XVlil PREFATORY ESSAY. 
 
 The passions and appetites, in their disordered actions, 
 have been brought under this same theory of moral in- 
 sanity, I think equally objectionably. It is asserted that 
 they may act isolatedly, and become mad and rampant 
 amid the serenity of a calm intellect, and in spite of right 
 judgments. A sudden impulse to motiveless murder, for 
 example, may at any moment turn the hand of a father 
 against the child, or compel the husband to slaughter the 
 wife, at the very instant that he warns her to escape. The 
 analysis requisite to show the largeness of assumption in 
 this theory, to point out the looseness of narrative of the 
 facts adduced in favour of it, would be out of place here. 
 
 I may state that there is no ' passion' without arousing 
 mental phenomena. Lust has its images of dalliance ; hate 
 its malevolent emotions ; avarice its crooked, grasping 
 thoughts and mean persistencies ; ambition and honour 
 their issues, the nobility and worth of which are measured 
 by motives. Whether these active "affections" are accom- 
 panied by bodily sensations or not, is not the question. 
 The point is, whether the appetites and passions ever exist 
 without that mental armature which in the sane state 
 we are certain forms their very essence, and is necessary 
 to their fruition. The suddenness of an impulse may be 
 granted. We know, however, only two conditions of 
 mind in which this suddenness appears ; viz., in the im- 
 pulses of the madman, and in those of the criminal.* The 
 moment the insane entertain ' suspicion,' that moment 
 the sequences of passion follow : first fear, then hatred of 
 the objects of that fear, and, on the earliest occasion, des- 
 truction of that which, in his insane belief, the maniac 
 thinks will relieve him of the burden of terror ; there is 
 
 * This not being an exhaustive analysis, I have selected ' suspicion' as the 
 commonest of those mcnsal states through which the harmless maniac passes 
 before he becomes dangerous.
 
 THEORIES OF INSANITY. xix 
 
 no lack of motive, therefore, in accounting for the impulses 
 of madness. 
 
 When we see one who outwardly had hitherto stood 
 well in the world's opinion, suddenly leap into the gulf of 
 crime, our first desire is to examine the inner life of the 
 man, and the investigation results in our finding either the 
 evidences of madness, or the manifestations of depravity, 
 in a long dalliance with criminal thoughts which have re- 
 curred again and again, entertained and repelled, with 
 lessening horror, till the understanding becomes bewil- 
 dered, the conscience silenced, and the will overpowered 
 by the vehement temptation of the hour. Mentally the 
 man had long been a criminal. 
 
 Such are the two conditions under which the impulsive 
 passions of anger, fear, lust, &c, have hitherto been known 
 to operately suddenly and dangerously. But now we are 
 asked to acknowledge the existence of a third, under 
 which there shall be exhibited the effects of passion with- 
 out any of its motives, and the effects of madness in the 
 presence of a perfectly sound intellect. As a Commissioner 
 of Pentonville Prison, 1 had abundant opportunities of 
 learning the natural history, so to speak, of crime, and its 
 relation to mental disorder ; and, without ransacking the 
 labours of divine or moralist, or turning to the workings 
 of our own hearts, I am convinced that the law of conti- 
 nuity is no more broken in the moral than it is in the 
 physical world ; and that a man in the plenitude of his 
 intellect, entire in his moral judgment as to right and 
 wrong, suddenly filled with unwonted and motiveless lust 
 of murder, is a monstrosity, the existence of which must 
 not be received without the most searching inquest. 
 
 Some of the difficulties which embarrass us in the study 
 of mental disorder are, I think, to be traced, first, to an 
 ambiguous nomenclature; and, secondly, to a premature
 
 XX PREFATORY ESSAY. 
 
 search after the cause of mental phenomena. Thus, the 
 term monomania, substituted by Esquirol for the older one 
 of melancholia, becomes in Prichard's hands, ' partial de- 
 rangement of the understanding :' hence, instead of the 
 understanding being crazed on one subject, we have it 
 crazed in one part — and by implication therefore sound 
 in others. The searching after causes of mental pheno- 
 mena, instead of adhering to the Baconian injunction of 
 observing their laws, is hazardous. At this instant almost 
 all our knowledge of the nervous system is transitionary 
 and incomplete. The import of the nerve-tube and its 
 contents is still a desideratum ; no one has traced a fibril 
 from periphery to centre. The value and co-ordination of 
 electricity in its relation to nerve-force, is, even in the 
 hands of Bois-Reymond, a mere sketch. Under Brown 
 Sequard the posterior spinal columns have been dispos- 
 sessed of their supposed power of transmitting sensation. 
 Surely, where the very rudimentary knowledge is so scanty 
 and so uncertain, it is a large demand on our faith to ask 
 us to believe that a finger may be laid on the very patcli 
 of cerebral pulp which generated the immortalities of 
 the ' Principia ;' and that on the right hand and on the 
 left we can assign limits by rule and compass to other 
 portions of brain, as the officinae or workshops of the poet 
 and mechanician. 
 
 Besides, to expect that the perception of the mani- 
 festations of the moral world shall be modelled on a plan 
 similar to that of the material, as seen in the sensory 
 ganglia, is scarcely permissible : for what analogy is there 
 between the two orders of phenomena — between the odour 
 of a rose and our notions of futurity — between bitterness 
 of taste and bitterness of heart — between the oscillations 
 on the tympanum and the thoughts which are conveyed 
 from soul to soul, and which the waves of air but typify.
 
 THEORIES OF INSANITY. XXI 
 
 Even in the material world many cosmic powers influence 
 the mind through organic tissues not fashioned after those 
 of the senses : thus gravitation, though always present, is 
 chiefly cognizable by muscular effort. 
 
 However I will not dwell more on a subject which, I 
 trust, may find a more competent exponent than myself. 
 
 The few remarks I have hazarded are offered with all 
 respect for the talents of the founder of the theory of 
 moral insanity, and for those of his followers. I have 
 often made it a subject of anxious thought — often sat 
 down, pen in hand, to master its (I must say) loose defi- 
 nitions and looser narratives* — and as often have risen 
 impressed with the feeling that there must be grave errors 
 where the premises merge into such a mass of paradoxes. 
 I have been astonished to find how many of the cases ad- 
 duced rest on mere assertions of et ipse vidi — and how 
 often the facts narrated show that the conduct of the 
 maniac, supposed to be urged by a mad will only, is really 
 the result of a mad understanding, filled with delusive 
 ideas and insane judgments. I have never seen a single 
 example, in my public or private practice, of a case 
 answering to the definition of moral insanity ; nor have I 
 been more fortunate in my appeal to the experience of 
 others ; for of my colleagues and friends none have been 
 able to point to a moral maniac. In our courts of law 
 where he is paraded, there is always the spectacle of a 
 
 * As an instance I beg the reader to turn to page 42 of Prichard's work, 
 for details of a model case (No. 4) of " moral insanity and high excitement, 
 which never displayed any sign of intellectual madness." Within a dozen 
 lines after such a heading he will find the pathie described as "wild, 
 exciteable, thoughtless, full of schemes and absurd projects." A little 
 further on, this moral maniac with unscathed intellect insists on examining a 
 farm, which he is about to take, at night, by the help of a lantern.
 
 XXU PREFATORY ESSAY. 
 
 jury acquitting, in the teeth of the judicial conviction and 
 summary, by a verdict resting on a hopelessly confused 
 array of medical opinions strongly opposed to each other. 
 
 These acquittals are known to result from the unwilling- 
 ness to entertain the question of capital punishment where 
 there is the shadow of a doubt ; although that doubt may 
 be based on nothing bearing on the facts. The general 
 result to society is very disastrous. A life is lost, and, if 
 taken under a paroxysm of ferocity and cruelty, that 
 very ferocity is the plea urged for acquittal — ' No man in 
 his sound mind could so act ;' this man, therefore, is 
 morally insane. Freed from the gallows as irresponsible, 
 he is consigned to a madhouse, whence he could be let 
 loose on society by virtue of a medical certificate of re- 
 turning sanity, did not that community which proclaims his 
 irresponsibility tacitly agree to regard him as a criminal, 
 and enforce an imprisonment, under the fiction of the 
 Royal pleasure, for the ' natural period of the life of the 
 homicide. 5 That this last judgment, to which society in- 
 variably reverts, is the right one, is proved, if we compare 
 results. The genuine madman who is homicidal, may 
 be as dangerous in, as he was out of confinement ; for, as 
 the impulse arises anywhere, so it is always to be expected, 
 watched, and guarded against. The case is very different 
 with the moral maniac, in which class there is not an 
 example, that I can find recorded, of a return of this fit of 
 'instinctive' homicide, after trial and incarceration. His 
 conduct is very like that of any sane man, who, having 
 had a narrow escape from the gallows, and entertaining a 
 wholesome dread of its effects, eschews everything which 
 may again bring it in view. The whole subject of insanity, 
 in its medico-legal aspects, is at this instant involved in 
 contradictions, issuing, I believe, from the assumption of a
 
 [RRITABLE UTERUS. XX1U 
 
 wrong theory of mental phenomena, the result of a vain 
 attempt to determine their causes, instead of noting 
 their laws. 
 
 Another, and a very original chapter, on the subject of 
 disease of the nervous system, is given by Gooch, under 
 the title " Of the Irritable Uterus." I believe he was the 
 first to call attention to a malady of greater import than 
 he himself suspected, and which, even yet, is regarded as 
 almost an isolated disease, having little connexion with 
 those uterine affections, now so rife, and so well known. 
 This comparative neglect on the part of the profession is 
 attributable, mainly, to the belief that Gooch had not all 
 the elements of a just diagnosis, which have existed since 
 his time, as afforded by the ' speculum.' 
 
 Gooch describes a malady, of which the essential symp- 
 tom is pelvic pain, subsisting even for years, thoroughly 
 incapacitating the patient for the performance of many 
 of the duties of life, and yet unaccompanied by any ap- 
 preciable structural change. The disease thus described 
 is an undoubted reality : many of those from whom Gooch 
 took his views I have seen, and some few are yet alive to 
 prove how long this obscure malady adhered to all the 
 modifications of structure and function incident to ad- 
 vancing age. I have repeatedly examined with the specu- 
 lum the seat of pain, and as often been satisfied that it 
 is independent of any vascular complication. In those 
 who are most obnoxious to this form of the disease, there 
 is frequently an hereditary taint of gout or rheumatism, 
 or they are the offspring of very nervous parents, them- 
 selves exhibiting the nervous temperament in excess. One
 
 XXIV PREFATORY ESSAY. 
 
 of the seats of this neuralgic malady is the vagina itself, 
 which is so exquisitely tender as to render intercourse in- 
 tolerable ; indeed, in several instances, this condition has 
 led to separation, and the unbalanced nervous power has 
 been the index to greater evils, merging in insanity. It 
 is this form which Gooch has described so ably; separating 
 it from all inflammatory disease, whether chronic or acute, 
 and, by analogy afforded by similar affections in other 
 parts of the body, classifying it with disorder of the nervous 
 function. There is, however, another form, or rather 
 another degree of it, which he has not described, but 
 which, in our time, all have had opportunities of witnessing 
 who have noted those instances, which have of late been 
 so largely multiplied, and which are the despair of the 
 practitioner and the bane of many a domestic circle. In 
 this series, the purely nervous aspect of the malady is 
 marked by some obvious change in the uterus or its 
 appendages ; but this change is by no means a constant 
 one, either in its seat, extent, or nature. Sometimes there 
 is a congested condition of the uterus, altering its shape 
 into that of a retort; the enlarged and curved fundus 
 being exquisitely sensitive of pressure. At other times 
 the cervix, or some portion of the uterine walls, is the seat 
 of congestion, of varying consistency, and of pain. In other 
 instances, the uterus may be entirely healthy, but the pain 
 is referred to either ovary, or to some obscure spot of the 
 pelvis itself. I have known the same general train of 
 symptoms co-exist with every form of uterine ulceration, 
 and without any of them; with every degree of uterine 
 infiltration, and without any one of them. In a word, the 
 local changes have been the fluctuating, the nervous affec- 
 tion the constant element : in it, therefore, and in no 
 doctrine of a phlogistic origin, can I place the essence of
 
 IRRITABLE UTERUS. XXV 
 
 this strange disease. Under a notion of its local origin, I 
 have now had abundant opportunities of seeing the effects 
 of local treatment, ranging between the use of the actual 
 cautery, through various modes of caustication, to that of 
 a simple astringent, or even watery injection : all have 
 failed to cure, and often even to alleviate the pain. Those 
 who are thus affected go from specialist to specialist, and 
 generally, after years of trial and endless expense, subside 
 into invalid habits, unrelieved; or they gradually wear 
 out the disease. The majority recover sooner or later; 
 but there are others who perish from some form of innu- 
 trition and defective sanguification, the commonest being 
 phthisis and that kind of chronic rheumatism which attacks 
 the small joints, gradually crippling the hands and feet 
 first, before it extends to the larger joints, or disorganizes 
 the heart. 
 
 The two commonest local lesions incident to this ma- 
 lady are ovarian cyst and a large hypertrophied uterus; 
 with the advent of these the painful symptoms cease. 
 
 This malady, I believe, is deeply rooted in the very 
 essence of that complex organic function termed the 
 generative, which, in its most comprehensive sense, in- 
 cludes no inconsiderable portion of the moral as well as 
 the physical development of the female organization. By 
 whatever name that controlling power may be called — 
 whether nisus formativus, or any other expression indicative 
 of nerve-force — whatever may be the seat of this power, 
 whether cerebrum, cerebellum, or medulla oblongata, which 
 co-ordinates the phenomena of the procreative function 
 during the thirty years of woman's life in which it is in 
 activity; it is this co-ordinating power which seems to be in 
 fault in the malady in question, judging from a comparison 
 of its symptoms with the phenomena of the function. In
 
 XXVI PREFATORY ESSAY. 
 
 attempting to establish this comparison, I must premise 
 that the whole tendency of modern phys ology is to track 
 every complex function of the body to a central nerve- 
 power ; as is well known as to the functions of sensation 
 and motion ; more obscurely as to the co-ordination of the 
 heart's action; still more wonderfully in the power of 
 modifying capillary and molecular action, as shown in 
 Bernard's experiments on the sugar-secreting power of 
 the liver. 
 
 These centres of power, it is also well known, are 
 reached and called into action by a variety of causes, both 
 internal and external, by malady and by medicament. In 
 the disease before us, though the train of symptoms may 
 be, and often is, evoked by some trivial and varying 
 structural lesion, still after the removal of the supposed 
 cause these symptoms persist — a fact tending to prove 
 that the connecting link between them is rather one of 
 occasion than of necessity. Premising, then, these remarks, 
 I will attempt to show that the range of the malady is 
 co-extensive with the range of the procreative function in 
 its widest sense, as involving both mind and body. The 
 forces which inhere in this complex function assume a 
 sovereignty and control over all others so despotic as to 
 bring into emphatic relief the great law of nature, that the 
 individual life but subserves to that of the continuation of 
 the species — a law by virtue of which every drop of blood 
 necessary to the safety of a sickly mother is used, at her 
 risk, to secure the vigorous nourishment of the unborn 
 offspring. The process of sanguification is deeply involved 
 during half the life of woman in furtherance of the func- 
 tion of generation, which has the power of determining 
 capillary action towards certain organs at definite periods, 
 for a definite time. In some disorders of the generative
 
 IRRITABLE UTERUS. XXV11 
 
 system this function exhibits a misplacement of this power 
 in the form of vicarious discharge. In the special one 
 under consideration, the uterus or its appendages assume 
 almost the characters of an erectile tissue. A very slight 
 cause will determine their injection, which becomes per- 
 sistent ; thus I have known the fundus uteri to enlarge in 
 eight hours to double its natural size, immediately after 
 the easy and painless introduction of the uterine sound, 
 and continue thus enlarged, and exquisitely painful for 
 upwards of a year, without any other change in its struc- 
 ture. In other cases the consequences of mechanical and 
 chemical means applied to the cervix have been grave — a 
 pelvic abscess has resulted, with its fearful consequences 
 of purulent infection ; hence I have invariably inculcated 
 the greatest reserve in the topical treatment of the 
 irritable uterus. The power of being affected by excited 
 capillary action is not limited to the uterus, from which 
 organ it mostly shifts to either ovary. It is on these two 
 organs — uterus and ovary — that the constant excitation 
 determines disease : in the former, the walls enlarge as in 
 false pregnancy without any internal tumour ; in the latter, 
 a cyst forms in a hypertrophied stroma : in both, the 
 climacteric age, if attained, is fraught with danger from 
 haemorrhage. In many instances there is a marked me- 
 tastasis of action between the uterus and lungs, as in 
 vicarious menstruation ; and when that is perceived, phthisis 
 is one of the terminations of the irritable uterus. Not 
 only is the determination of misplaced capillary action a 
 feature of this malady, but there is a profound alteration 
 in the blood itself; the anaemia is certainly less manageable 
 than that of chlorosis, but the nature of the change in this 
 fluid is unknown to me. Besides this control over the blood, 
 both as to its circulation and its composition, the process
 
 XXV1H PREFATORY ESSAY. 
 
 of nutrition is in many interfered with by a depravity of 
 appetite, which is much more persistent than that so 
 common in the caprices of pregnancy. In one instance, 
 my patient ate nothing but grapes and bread for 
 twelve months, and presented a degree of emaciation 
 apparently incompatible with life. The weakness termi- 
 nated in coma, or rather in a trance-like state which 
 lasted two days, from which she awoke free from unna- 
 tural appetites, and in six weeks was well ; she is now a 
 wife and a mother. In another instance, coffee was the 
 chief staple of food, nearly everything else being vomited 
 up. The former patient had been recumbent two years, 
 the latter eight, when 1 saw them. 
 
 The modifications of the moral nature of woman are as 
 profound, though not so apparent, as that of her physical, 
 during the procreative period. The heightened sensi- 
 bilities, the awakened fancy, the necessity of attracting 
 sympathy, the abnegation of self in the entireness of 
 devotion to the offspring, the development of the passion 
 of fear, in its various aspects, which maternal solicitude 
 engenders and keeps up, sharpening the perceptive facul- 
 ties, and investing the forebodings of the mother with 
 all but the keenness of prophetic vision, these finer 
 developments of the moral force, which are essential to 
 functions delegated to woman, in order to secure the pro- 
 tection of man and the safety of the offspring — these, I 
 say, become strangely distorted in the malady before us. 
 The desire of sympathy assumes the most inordinate pro- 
 portions, and the patient clings to any one who, from what- 
 ever motive, will afford it. They who do not respond, 
 whether parent, or brethren, or husband, become objects 
 of suspicion, or of dislike. The family circle is divided or 
 broken up, and there is a desire to seek away from home
 
 IRRITABLE UTERUS. XXIX 
 
 that comfort which the " femmc incomprise " imagines is 
 banished from it. Not a few instances were known by 
 me of persons, who, though morally and physically totally 
 incapable of the task, were desirous of leaving their conch 
 to nurse our soldiers in the Crimea. The passion of fear 
 makes these sufferers dwell incessantly on the pain they 
 feel, and the love of sympathy renders a communication of 
 their sufferings a necessity. Like all maladies in which 
 the moral force is attacked, there is the danger of its 
 spreading by imitation. In most cases these patients 
 remain incumbent for months or years. Her room is the 
 family gathering-place, in which everything is discussed 
 and determined: the choice of a habitation — the tether of 
 travel — the cultivation of society — in a word, all freedom 
 of thought and action in the family, becomes pivoted on 
 the conditions of this distressing and formidable disease. 
 
 The malady is not confined to the rich or the single ; 
 when it attacks the wife and the mother, all the social 
 evils which accrue are multiplied a hundred-fold. The 
 erotic element is in most cases entirely extinguished. All 
 intercourse is dreaded or loathed, at the very instant when 
 the victim, under the passion for sympathetic commisera- 
 tion, is ready to give up her whole soul to the first acquaint- 
 ance, nurse, or practitioner, who will listen and pity. They 
 who have been able to watch this real and most formidable 
 malady through years, have many a tale to tell — of hus- 
 bands estranged, children neglected, and home stripped of 
 all its holiest influences, authority delegated to strangers 
 and abused, ill-assorted marriages, expenditure stretched 
 for health's sake to its extreme limits, harassing from the 
 uncertainty of the demand which throws the responsibility 
 of life on him who refuses to honour it. 
 
 Even they who recover from the disease retain many
 
 XXX PREFATORY ESSAY. 
 
 of those habits formed during its acute stages, which in 
 themselves become substantive, though secondary evils. 
 Thus there is risk from the use and abuse of stimulants 
 and sedatives formerly essential. Then the long habit 
 of recumbency diminishes the power of muscular exer- 
 tion ; while the dreamy condition of mind arising out of 
 it, gives a false direction to all moral activities. Very few 
 are the same beings after, that they were before the in- 
 gress of this disease. As to the treatment of this malady, 
 I adopt the general views and indications given us by 
 Gooch. The theory I have promulgated to account for 
 its complex phenomena, I regard merely as an expression 
 by which the disease is affirmed to be of nervous origin, 
 affecting body and mind, and requiring other than mere 
 topical measures. Whenever the local complications are 
 clear and urgent, local means cannot be dispensed with. 
 Unfortunately the passion of fear and the desire of sym- 
 pathy render these patients, as a class, dissatisfied with any 
 but such means of cure as they think are commensurate 
 with the magnitude of their malady, and worthy of the 
 spirit of martyrdom within them, which makes the most 
 heroic measures the most welcomed. They suffer and, 
 strange to say, they love to dwell on and promulgate their 
 sufferings ; hence, he that does most locally is most 
 prized and retained, till another promises to do more, when 
 the former idol is cast down, and another set up in its 
 place. There is no disease in which moral influence exer- 
 cises a greater power on the high-wrought sensibilities 
 which are its essence : a kind or a harsh word, a casual 
 phrase, will strengthen or cut short the usefulness of the 
 best practitioner. 
 
 The exaggerated fear of "ulceration," "tumour/' &c, 
 induced by the nomenclature of uterine disorders, weighs
 
 UTERINE POLYPUS. XXXI 
 
 heavily on the mind, which will not be appeased until 
 every mode of investigation has been resorted to which 
 can satisfy the alarmed fancy. On the part of the medical 
 attendant, therefore, the greatest reserve is requisite; for 
 generally, not only the patient, but the whole family, are 
 at his feet. Formerly the use of the speculum was all 
 but insisted on, in the case of the young and the unmar- 
 ried. Now that the scope and means of treatment are 
 better understood by society, this measure as to this class 
 of patients is dispensed with, or resorted to under a tacit 
 understanding of its well-considered necessity. Local 
 measures, I repeat, are not to be set aside. The speculum, 
 therefore, cannot be dispensed with in genuine structural 
 disease demanding topical treatment ; but its use crushes 
 so much of all that is feminine, that I know no measure 
 which so imperatively compels an honest answer to the 
 question, " Would you, under existing circumstances, resort 
 to this expedient were - the patient your daughter, sister, 
 or wife?" That answer must be left to each man to make 
 before his own conscience, and justify to society by his 
 scientific attainments. 
 
 In this malady of the irritable uterus, I believe, the 
 greatest amount of benefit is attained from general, and 
 the greatest risk of mischief incurred from topical treat- 
 ment. 
 
 The essay on uterine polypi must still be considered one 
 of the best in our medical literature, for clinical purposes. 
 Whoever can so master, as to use its contents, will scarcely 
 meet in practice with much that will be new to him. 
 The seat of these growths, their variety, the symptoms
 
 XXX11 PREFATORY ESSAY. 
 
 engendered, the remedy, are so clearly laid down, that 
 nothing remains for the practitioner but action. 
 
 The chief recent additions to our knowledge of uterine 
 polypi are as to their intimate structure and classification — 
 in a word, their natural history — which resolves itself into 
 that of fibroids. Any of the received manuals of histology* 
 will afford the student ample information as to the micro- 
 scopic anatomy of fibrous tumours, together with the usual 
 amount of discussion and dispute as to almost every 
 theoretic deduction in this world " de minimis." 
 
 He may safely neglect, therefore, all research after causes 
 of accidental tissues, which will be revealed only when 
 we know what are the causes of life. He need not throw 
 away much time in seeking for the reasons of the peculiar 
 form of polypi, or for their supposed origin from the vital 
 impetus given to uterine structure by a stray ovule en- 
 tangled in its meshes diverting the processes of local 
 nutrition, as the cynips diverts those of the oak -leaf in the 
 formation of the gall-nut. He may entertain, as an incen- 
 tive to further inquiry, Velpeau's dictum, that all morbid 
 products tend to take on the characteristic structure of 
 the organ in which they are found. These, and a hundred 
 other questions of the natural history of disease, may 
 afford good mental discipline, and possess much interest, 
 as propounded by the great masters of transcendental 
 anatomy ; but the logic of philosophic medicine is so dif- 
 ferent from that of clinical — the working faculties, by 
 means of which truth is attained in each, are so differently 
 grouped — that the risk of becoming disqualified for prac- 
 tical decision is by no means slight, in him who is absorbed 
 
 * The monograph of Dr. A. Farre, on the Anatomy, &c, of the Uterus, 
 published in " Todd's Encyclopaedia of Physiology," is most worthy of attention, 
 from its copiousness and accuracy, and for its original research.
 
 UTERINE POLYPUS. xxxiii 
 
 in these leisurely contemplations of the closet. The 
 serviceable points brought out by the anatomist, however, 
 are all-important to the practitioner. 
 
 1. These growths are devoid of all arterial, and possess 
 merely a venous circulation (Cruveilhier). This, however, 
 is too confidently asserted, inasmuch as occasionally even 
 a large artery is found in the stalk of these polypi. The 
 denser fibroids, according to Dr. A. Farre, cannot be in- 
 jected. 
 
 2. Injury to their structure is rapidly followed by a 
 form of decay, like that which is seen in vegetable matter. 
 Nevertheless inflammation ending in suppuration has been 
 known to take place in the very heart of these growths. 
 Their centres are also the occasional seats of softening, of 
 effusion of blood, and of cysts. 
 
 3. If they persist throughout a life, they partake more 
 or less of the atrophy of age, common to all tissues, or 
 they become calcareous. 
 
 4. Spontaneous cure is rare, and takes place by these 
 tumours detaching themselves from the cellular membrane 
 in which they are imbedded, and either escaping into the 
 cavity of the abdomen, where they are reported (Becquerel) 
 to cause no inconvenience and undergo no change, or 
 dropping through the vagina more or less altered and 
 broken up. 
 
 5. The division of fibroid growths according to their 
 scat, into sub-peritoneal, interstitial, and sub-mucous, is 
 eminently practical. From all these three points they 
 disturb the circulation ; least so from the first ; more so, 
 and even dangerously, from the two last. 
 
 6. Their presence generally is the occasion of partial or 
 general uterine hypertrophy, increased vascularity, aug- 
 mented sensibility in the pelvic organs, and displacement. 
 
 7. Medical treatment is for the most part only palliative.
 
 XXXIV PREFATORY ESSAY. 
 
 The cases of interstitial fibroid which I have sent to the 
 absorbent thermal springs have been benefited by the 
 reduction of the size and vascularity of the uterus, but 
 not in the diminution of that of the tumours themselves. 
 
 As haemorrhage is the chief source of danger, so the 
 chief indication is to prevent it. One of the greatest of 
 surgical authorities of modern times, a man who united in 
 greatest power, thought, manual dexterity, well-weighed 
 audacity, unfailing resource, and immense experience, — 
 Dupuytren, — declares interstitial fibroids to be " inoper- 
 able." They may be multiple, or too large, or too near the 
 peritoneal cavity ; or they may require the uterine walls 
 to be largely cleft ; in a word, the operation of enucle- 
 ation, from our ignorance, in most cases, of all the sources 
 of clanger, or from our knowledge of some, is too hazardous 
 to be warranted. When it has been successful, the tumour 
 has been near or in the neck of the uterus ; and even here 
 the risks of operation are very great, and can only be 
 incurred in the presence of the certainty of death from 
 haemorrhage. Where no operation is possible, it is a great 
 object to carry on the patient to and through the critical 
 age. 
 
 The flooding in interstitial fibroid is uterine, and the 
 result of irritation, and certainly ceases for the most part 
 after the climacteric period, leaving the fibroids compa- 
 ratively innocuous in their action on the constitution. It 
 is difficult to account for it ; but the tampon will arrest 
 the haemorrhage, as was proved in a case which I saw in 
 consultation with Dr. Farre, where the patient was draining 
 to death. 
 
 For the submucous fibroids, or true uterine polypi, 
 there can be no hesitation as to their removal as soon as 
 practicable. In this kind of fibroid haemorrhage is a 
 constant symptom, and independent of size or age. I
 
 UTERINE POLYPUS. XXXV 
 
 have within a few weeks seen, in consultation with Dr. 
 Elliot of Camberwell, an example of polypus of the cervix, 
 with abundant bleeding, at the age of sixty-five. The best 
 modes of removing the polypi resolve themselves into two, 
 — excision and ligature. Some unite the two. The former, 
 however, is, I believe, almost the only one now resorted to 
 by those most conversant with the operation. It was sup- 
 posed that it entailed the risks of haemorrhage, which were 
 avoided by the use of the ligature. I have stated Cruveilhier's 
 opinion, that the circulation in the fibroid is venous only : 
 but Dupuytren distinctly says that arteries of good size are 
 found coursing through the centre of the peduncle ; but, 
 curiously enough, he adds that they never bleed after ex- 
 cision, which fact he attributes to his mode of ablation by 
 means of a strong pair of scissors which contuse as well as 
 cut. In his two hundred operations, bleeding ensued but 
 twice, and then was readily controlled by the tampon. I 
 have now for many years always excised polypi, and have 
 not seen a single case of haemorrhage result. This is, I 
 believe, the experience of the profession at large. 
 
 The objections against the operation by ligature arise 
 in the great danger of blood-infection from absorption 
 of putrilage, inducing the terrible consequences incident 
 to this mode of poisoning. 
 
 Even when the operation is successful, the long delays 
 before the canula can be removed, the necessity of retain- 
 ing it in the vagina for days, and of restricting the patient 
 to certain positions of the body to prevent the metallic 
 tubes from injuring, or even perforating, the peritoneal 
 cavity, are circumstances which greatly depress and worry 
 her. Then the stench from the decaying polypus is most 
 offensive and intolerable. If therefore, the ligature be 
 used, excision below it should be performed before these 
 changes in the polypus take place.
 
 XXXVI PREFATORY ESSAY. 
 
 There are other modes of destroying the polyp, but 
 not of such general use as those mentioned. The best 
 instrument for crushing these growths, when they are not 
 too large, is the dentated spoon-shaped forceps used in 
 removing the bones of the fcetal head after craniotomy; 
 but the same objections apply, though in a minor degree 
 to this, as to the operation by ligature. 
 
 I have no experience of the " ecraseur ;" but, judging 
 from the mechanism of the instrument, it must be appli- 
 cable only in the cases where the stalk is easily reached. 
 All these modes of looping the polyp are, as Dupuytren 
 has observed, anything but easy in practice, as is proved 
 by the fact of such a variety of inventions for its accom- 
 plishment. 
 
 At the time Gooch published his work, the coma and 
 convulsions of infancy were invariably attributed to inflam- 
 mation of some portion of the brain ; a theory which led to 
 the heroic practice of bleeding from the jugular, to copious 
 leeching and rapid mercurialization. The doctrine of the 
 reflex function of the nerves, and the pathology of tubercular 
 meningitis were, as yet, entirely unknown. 
 
 Unless we believe that a remedy can be persisted in 
 when it invariably fails, we must admit that this depletory 
 system, which at that day was generally resorted to 
 throughout Europe, was not as injurious as it is in our own 
 time. I have shown in my essay on puerperal fever, that 
 the type of febrile disease varies at various periods, and 
 that the same group of symptoms will require at different 
 epochs a different treatment. With regard to hydro- 
 cephalus, I remember well how rapidly the head symptoms 
 were removed under the vigorous handling of the best
 
 SIMULATED HYDROCEPHALUS. XXXVll 
 
 practitioners of a former day, and I recollect also how 
 quickly the black and dry tongue of typhus was cleansed 
 by the lancet. I witnessed in Edinburgh the treatment of 
 scarlatina by enormous bleedings, which seemed to be the 
 only means of arresting suffocation from the rapid swelling 
 of the fauces. The routinist and grosser observers of that 
 day, having but the one maxim, that what is right now is 
 right always, continued a method of treatment long after 
 the conditions of its success had passed away. It was not 
 so with Gooch, whose fine powers of observation and 
 penetration led him to rank the influence of differences 
 quite as highly as that of analogies. He had no faith in 
 easy and universal formulae — " Bleed and save " — " Brandy 
 or death." These sovereign remedies and facile principles 
 he was content to postpone to the more laborious process 
 of observation, and his paper on the Cerebral Affections of 
 Infancy, though confessedly behind our present state of 
 knowledge, is a remarkable instance of what an honest and 
 sagacious mind can effect when it is unwarped by precon- 
 ceived notions. Gooch was satisfied, from his own expe- 
 rience, that there were cases of hydrocephalus and coma 
 which did not bear depletion — nay, sank under it. He 
 immediately ransacked the medical literature of his day, to 
 discover how far the experience of others bore out his own 
 view T s, and found in the experiments of Kelly, and in the 
 doctrines and instances of Marshall Hall and Abercrombie, 
 that effusion into the ventricles might take place under 
 two opposite conditions of the circulation ; nay, even his 
 own sensations and wretched health are utilised to eke out 
 his proposition : — " Any one, who from long defect in the 
 organs of nutrition, is reduced so that he has neither flesh 
 on his body nor blood in his veins, well know^s what it is 
 to lay down his head and doze away half the day without
 
 XXXVlll PREFATORY ESSAY. 
 
 any congestion or inflammation of the brain." The sketch 
 is from nature, and easily recognised by those who, having 
 the privilege of his intimacy, were often near his couch 
 in his freer hours, and partook of the charm of a con- 
 verse filled with feeling and intellect, where every kind of 
 subject was touched with the lightness and strength of a 
 master hand. 
 
 Gooch arrived at the following classification of the 
 various forms of cerebral affection of infancy : — 
 
 1. A form depending on nervous exhaustion, curable by 
 means which support the system. 
 
 2. A form marked by the sudden effusion of serum, 
 depending on a state of circulation the opposite to conges- 
 tion and inflammation. 
 
 3. A form of coma, the result of inflammation or 
 congestion, requiring active measures of depletion at its 
 very onset. 
 
 The mode in which Gooch has defined the second form 
 is highly characteristic of his sagacious mind. He made 
 out that this was a substantive form of malady ; but in 
 what essentials it differed from the other two forms he 
 declines giving an opinion. He points out, however, certain 
 differences as to the state of the circulation, and then adds 
 a fact of morbid anatomy, the import of which was not 
 understood till lately. " How far," he says, " our opinion of 
 the nature of the case may be modified by the loltite cheesy 
 substance in the arachnoid membrane — whether the mode 
 of treatment was wrong, or, on the contrary, right, but not 
 prompt and active enough — on these points I shall not offer 
 a conjecture. '' 
 
 We are now aware that of all the sources of hydro- 
 cephalus, the presence of tubercle deposited either in 
 the pulp of the brain or on its membranes, is by far
 
 SIMULATED HYDROCEPHALUS. XXXIX 
 
 the most common. Simple inflammation with effusion; 
 toxic apoplexy, the result of the poison of scarlatina 
 and measles ; the coma and convulsion of albumenuria, 
 and infantile diabetes, are more or less apparent, and not 
 difficult of diagnosis. But the onset of tubercular meningitis 
 is rarely suspected until the case is about to terminate 
 in death. The previous steps of this disease are recognised 
 rather by our regrets than our fears. It is remembered 
 when the issue is at hand, that the temper had long been 
 changing ; the head often troubled ; the faculties preco- 
 ciously ripened ; the disposition uncertain and wayward ; 
 the careless activities of childhood curbed and rendered 
 sedate, by causes not indeed unnoticed, but unknown or 
 falsely interpreted, by those whose very affections would 
 tend to warp the judgment which should determine how 
 much to hope for, and what to fear. A few hours at last 
 reveal the insidious nature of a malady which speedily 
 ends in fatal coma, produced by the irritative action of 
 tuberculous matter. 
 
 This malady is but an instalment of that greater one 
 known as tuberculosis, which enters so largely into the 
 diseases of infancy, because at no other age are the condi- 
 tions of its production so rife. During the first ten years 
 of life the vital activities are in their fullest play ; there is 
 not only nourishment, but growth. Everywhere there is 
 an incessant demand for plastic matter, and every organ 
 is in a constant state of change and of excitement. The 
 brain especially, according to the laborious researches of the 
 brothers Wenzel, does not increase much after the eighth 
 year. Hence the powerful influence of errors in regimen 
 in determining disease in childhood. Hence the readiness 
 with which exudations take place from the poison of fevers, 
 — the membranous coryza — the false membranes of croup
 
 xl PREFATORY ESSAY. 
 
 and diphtheria — the tubular exudations of infantile dysen- 
 tery. Hence the rapid deposit of " cheesy " matter in 
 acute meseraiacis, the result of the so-called infantile re- 
 mittent fever, a malady which in its severer forms rarely 
 fails to leave a similar deposit on the brain and peritoneum. 
 Hence also the astounding rapidity with which those pre- 
 disposed to scrofula develope phthisis. I have known 
 tuberculous infiltration of the lung to occur so suddenly 
 and extensively as to be mistaken by a competent stetho- 
 scopist for latent pleurisy. 
 
 In our workhouses and our factories the various causes 
 which induce exudation are rife, and the effect therefore 
 common. 
 
 In the affluent classes, wherever the hygiene of child- 
 hood is neglected, or is ordered by the sovereign crotchets 
 of some energetic parent, this malady of tubercular menin- 
 gitis will creep in ; and here I would raise my voice against 
 that pernicious system of brainwork miscalled infantile 
 education. It ignores, or is ignorant of, the laws both of 
 the physical and functional development of this most im- 
 portant organ. It neglects the sequences under which its 
 various faculties appear. It has little regard to the laws 
 under which the senses educe the powers of the brain. It 
 either crushes the imagination, so active in childhood, by a 
 premature development of the reflective faculties ; or it 
 overwhelms a faculty which requires no stimulus, by a host 
 of artificial expedients. Hence the greater development 
 of early madness ; hence the instances of disproportioned 
 faculties — the wayward will — the unbalanced conduct — 
 the physical exhaustion and cramped development of the 
 body, the result of the contention of inharmonious and 
 disordered powers and passions. The chapter on the 
 early training of childhood is yet to be written; and even
 
 UTERINE HEMORRHAGE. xli 
 
 were it at hand, I believe that the errors of the present 
 system are so methodised and enrooted, so many prizes 
 are offered for treading its paths, that few would listen to, 
 and fewer practice its precepts. One of the most thought- 
 ful minds of our time (Sir B. Brodie) in pointing out some 
 of its vices, has all but preferred leaving the brain fallow, 
 to storing it as it now is stored, in infancy and ehildhood. 
 
 The remaining essays of Gooch require little comment, 
 as they are all but complete in themselves, and not much 
 has been added by later investigators to his contributions. 
 
 To many, haemorrhage with a contracted uterus has 
 appeared an anomaly, and undoubtedly the phenomenon 
 is rare. Nevertheless, it is truly and exactly observed. 
 The classes of cases in which it may occur are, — 
 
 1st. After certain blood diseases, as purpura, and its 
 congener, scurvy. I have remarked also that chronic nettle- 
 rash, and some other skin diseases, impair the coagulability 
 of the blood, and so induce this kind of haemorrhage. I 
 am unable to say to what extent albumenuria produces a 
 similar result, although I have remarked that it is a 
 common source of profuse menstruation. 
 
 2ndly. It may occur after, and appears to be caused by, 
 cardiac disease in all its forms. 
 
 3rdly. It may accompany chronic hepatic disease, 
 induced by a long residence in the tropics. 
 
 4thly. I have met with two instances of that form of 
 congenital blood disease, designated by the Germans as 
 '* bleeders," and in both the haemorrhage after labour was 
 frightful, although the uterus was at first firmly con- 
 tracted. One of these patients imagined herself to be the 
 subject of cerebral congestion, to relieve which she used
 
 xlii PREFATORY ESSAY. 
 
 to resort to depletion after her own fashion, namely, by 
 running a fine needle into her under lip, from which small 
 wound she collected in a tumbler, in rapid-flowing drops, 
 as much blood as she liked. It required some time and 
 firm pressure to stop the flux. In both these instances 
 there was great toleration of bleeding, and faintness was a 
 distant contingency. 
 
 5thly. It may occur in highly nervous and irritable con- 
 stitutions. Dr. Arthur Farre reminds me that a former 
 patient of mine, who has passed over to his care, always 
 exhibits this form of haemorrhage under a firmly contracted 
 uterus. He imagines that the very condition of extreme 
 contraction induced by an irritable nervous system is un- 
 favourable to the formation and retention of those natural 
 plugs afforded by coagula in the uterine sinuses. In a 
 word, the uterus dislodges and squeezes out these plugs, so 
 that when the tension of the uterine fibre is relaxed, there 
 is nothing to stop the egress of the blood which such 
 relaxation attracts into the uterine vessels. Remembering 
 the circumstances alluded to in this particular case, I am 
 disposed to accept Dr. A. Farre's solution of the problem. 
 
 There are certainly two conditions which enter into the 
 consideration of causes arresting uterine haemorrhage ; 
 1, the contraction of the uterine fibre; 2, the plugging 
 of the veins by coagula. 
 
 The latter appears to be the sole mean of safety in 
 those cases of intense flooding in which the uterus flaps 
 about the hand like a wet towel. Incapable of contraction 
 for hours, yet ceasing to ooze out a drop of blood, there is 
 nothing apparently between life and death but a few soft 
 coagula plugging up the sinuses.
 
 SIGNS OF PREGNANCY. xliii 
 
 Gooch's chapter on the signs of pregnancy is as com- 
 pact, clear, and practical as possible. The additions made 
 to this subject, since it was written, are — 1, Signs derived 
 from auscultation ; 2, Signs indicated by certain chemical 
 changes in the fluids. The latter are not of much value, 
 and the reader will find that value discussed in Dr. 
 Montgomery's able work on the history of Pregnancy 
 with the sobriety and fulness which seem characteris- 
 tics of the Dublin school ; the works emanating from 
 which have most deservedly placed it second to none in 
 Europe for largeness of view and practical instruction. 
 
 The stethoscope applied to the abdomen of a pregnant 
 woman is said to detect the following sounds : — 
 
 1. A shock, with a rubbing sound, depending on the 
 movements of the foetus. 
 
 2. A souffle, or blast, synchronous with the maternal 
 pulse — its seat and cause disputed. 
 
 3. The double beat of the foetal heart. 
 
 4. The " funic souffle," discovered by Kennedy of Dublin. 
 
 5. A supposed murmur, which Stoltz of Strasburg says 
 accompanies the decomposition of the liquor amnii. 
 
 6. A crackling sound (such as is imitated by drawing 
 the nail over a rush-seated chair), caused by the separation 
 of the placenta, discovered by M. Caillaut. 
 
 The sounds Nos. 2 and 3 are the most important. I may 
 premise, however, that uterine auscultation requires much 
 practice, and is full of uncertainties. The sounds are often 
 not detectable, often intermit or become feeble, without 
 any assignable reason. With regard to time, it may be 
 asserted, as a general rule, that these sounds are not heard 
 till between the twelfth and the twentieth week. When 
 heard, they afford the strongest presumptions of pregnancy. 
 
 With respect to No. 2, or the uterine souffle, it certainly 
 
 d
 
 xliv PREFATORY ESSAY. 
 
 exists in cases of tumour of the womb and pelvis, without 
 any pregnancy. It has been found in cases of putrid 
 foetus and diseased placenta; hence it affords no dia- 
 gnostic mark as to the foetal or placentary development. 
 Bouillaud, I think, has established that it may be caused 
 by the pressure of any tumour on the pelvic vessels ; for 
 he and others have displaced the souffle by shifting the 
 position of the woman. Granting, however, that this 
 souffle may arise from various causes, I am not disposed 
 to exclude the uterine circulation as one of them; for I 
 have now for several years detected abnormal sounds in 
 the pregnant uterus, where it has been the seat of that 
 pain Wigand describes as rheumatic. These sounds are 
 opposite the painful spot, and begin and cease with the 
 advent and departure of that pain. 
 
 The double beat not synchronous with the maternal pulse 
 is the most precious sign as to the certainty of pregnancy, 
 and the life and position of the foetus. But it is often not 
 heard, and often requires more time to detect it than is 
 accorded, for obvious reasons, by most mothers. The ear 
 is best educated for this kind of examination, by accus- 
 toming it to ausculting the infant immediately after birth. 
 When the intensity, the tone, and the place of these 
 cardiac sounds in the foetus are well fixed in the memory, 
 they are readily distinguished through the pregnant uterus 
 in subsequent examples. 
 
 These sounds should always be compared with the beat 
 of the maternal pulse, otherwise a false diagnosis may 
 ensue. A girl in the humbler classes was violated and left 
 by her lover, a sailor. The menstruation ceased, the 
 belly enlarged. The uterus was not developed; yet the 
 'tic-tac' of the foetal heart was heard 140 times per 
 minute close under the stethoscope.
 
 LAW OF CONTAGION. xlv 
 
 The case was deemed one of extra-uterine fcetation, 
 until Drs. Challice and Druitt, in consultation with myself, 
 found that these supposed foetal sounds were synchronous 
 with the maternal pulse — heard through a mass of ascitic 
 fluid — which being evacuated by tapping, cleared up every- 
 thing, except the poor girl's reputation. 
 
 The literature of auscultation applied to questions of 
 pregnancy is very diffuse and cumbrous, requiring a critical 
 hand to compress and sift its available truths. On the 
 whole, the absence of the uterine souffle and cardiac 
 sounds do not prove the absence of pregnancy, while the 
 presence of either or of both affords the strongest pre- 
 sumption of its existence. By the cardiac sounds, the 
 kind of presentation, the number of children, and the 
 question as to whether they are alive or dead, are all 
 fairly determinable. 
 
 Gooch has preserved only one of the several ' articles ' 
 he wrote for the non-medical public — that on the plague, 
 published in the ' Quarterly Review.' The reader will 
 judge for himself how far the logic of the doctrine of 
 contagion is brought out in the discussion, and he cannot 
 fail to mark the breadth of argument and the polish and 
 keenness of the style by which an important question was 
 settled. But commerce and the commercial mind brook 
 no hindrance ; therefore all questions as to quarantine are 
 virtually laid aside in this country, or only acquiesced in 
 because the other States visit a relaxation of the quaran- 
 tine laws on the part of England by a prohibition of the 
 entrance of her vessels into their ports. Whenever other
 
 Xlvi PREFATORY ESSAY. 
 
 nations shall have adopted the doctrines of free trade, the 
 enforcement of exclusion of infected vessels and goods will 
 be found impracticable. The increased communication, 
 the rapidity of transit, the immense movement of man 
 from place to place, must entail evil as well as good in a 
 social point of view. Already diseases hitherto indigenous 
 to a section of humanity are slowly but surely creeping 
 up to commercial centres, from whence they will be rapidly 
 propagated. One form of Asiatic leprosy is approach- 
 ing the Levant from Arabia. The yellow fever has lately 
 ravaged Lisbon under a temperature perfectly similar 
 to that of London or Paris. The history of every disease 
 which is communicated from man to man, establishes this 
 melancholy truth, that ultimately such maladies overleap 
 all obstacles of climate, and demonstrate a solidarity in 
 evil as well as in good among the brotherhood of nations. 
 Such has been the case with small-pox, measles, scar- 
 latina, and the plague. In 1817, a little active charity 
 towards a section of Hindoos perishing of famine might 
 have crushed in the germ that fatal cholera which reeked 
 from the putrid masses of the dead and the dying. That 
 neglect had been visited by the death of fifty millions of 
 people of all nations and kindreds, by the time this scourge 
 appeared in 1832 in England. The investigation of the 
 laws of propagation of this malady was intrusted by the 
 College of Physicians to me, and the reader may perhaps 
 not grudge -the waste of an idle hour in turning to the 
 46th volume of the ' Quarterly Review' for 1832, for the 
 discussion of the facts which establish the doctrine of 
 contagion in general. The exaggerated fears of society at 
 that time are fairly reflected in the article, which proves 
 at least this, — that of all the terrors the imaginary are the 
 most terrible.
 
 CONCLUSION. XlVU 
 
 This essay was the first to bring out these conclusions 
 and comparisons which have since been treated in so 
 masterly a way by Dr. Graves of Dublin, and subsequently 
 by Dr. Baly in his elaborate volume of reports on the 
 cholera. 
 
 I fear I have done little justice to the mental life of 
 Gooch, styled as he is in a letter now before me by Southey 
 the poet, as one of the most remarkable men of his time. 
 Such was also the opinion formed of him by Walter Scott 
 and by Lockhart. A short and interesting biography in a 
 volume of the ' Family Library,' written by one of his dearest 
 friends, Dr. Herbert Southey, will give the reader a view 
 of Gooch's external accidents and fortunes — how he strug- 
 gled, and how often success was marred by illness. Of his 
 inner life, the play of fancy, the power of thought, the 
 depth of feeling, the weight and force of illustration, the 
 lucidity of expression : these qualities can only be judged 
 by that circle of intimates which is now narrowing daily. 
 They have all, without a single exception, passed through 
 the ordeals of life in a way worthy of their own reputation 
 and of his friendship. To them I offer this imperfect 
 sketch. Their memories and affections will complete the 
 picture, and their indulgence will, I trust, overlook my 
 shortcomings. 
 
 ROBERT FERGUSON. 
 
 L25, Park Street, Gkdsyenor Square; 
 March, IS 59.
 
 [AUTHOR'S DEDICATION.] 
 
 TillS VOLUME 
 
 IS AFFECTIONATELY INSCRIBED BY ITS AUTHOR 
 TO 
 
 WILLIAM BABINGTON, M.D., F.B.S., 
 
 AND FELLOW OF THE COLLEGE OF PHYSICIANS; 
 
 FOR SIXTEEN YEARS HIS CONSTANT FRIEND. 
 AND ON TOO MANY OCCASIONS 
 
 HIS M U C H-V A L U E D PHYSICIAN; 
 
 A MAN WHO, TO THE CULTIVATION OF MODERN SCIENCES, ADDS 
 
 THE SIMPLICITY OF ANCIENT MANNERS; 
 
 WHOSE EMINENT REPUTATION AM) RARE 1SENEVOLENCE OF HEART 
 
 HAVE LONG SUED A GRATEFUL LUSTRE OVER A PROFESSION 
 
 WHICH LOOKS UP TO HIM WITH 
 
 A MINGLED FEELING OF 
 
 RESPECT, CONFIDENCE, AND REGARD.
 
 P E E E A C E. 
 
 I was formerly Physician to the two Lying-in Hospitals of West- 
 minster 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 ar- 
 ranging it into a shape suitable for communication. I do not say 
 this in a tone of exultation, for I have little reason; on the con- 
 trary, 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 opportunities 
 to a good account. If I knew a young man placed in such a 
 station, in whose eminence, founded on Iris 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 uides's 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
 
 lii PREFACE. 
 
 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 dispatch 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 tins, 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 Bichter's Bibliothek Clururgische, for he is the 
 greatest master of the art of condensed analysis. Thus your manu- 
 script 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 winch they contain, but to observe 
 how their minds worked — and the older we grow the fonder we be- 
 come 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 j and 
 not lengthy notes, containing a diffuse description of unimportant 
 trifles, which from the time 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 yourself 
 perfect in the art of examining dead bodies : accustom your hand to 
 open them, and your eye to detect with accuracy morbid appearances. 
 En putting down this important part of a case, come at once to the
 
 PREFACE. Hii 
 
 essential morbid appearances j have a bead for parts examined which 
 were found healthy : thus you will dispatch 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 in which I have advised, provided you 
 have a mind adapted to investigation, will make you more com- 
 petent to advise and act in the difficulties and diseases t>f 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 Iris 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 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 imper. 
 fectly, 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 cmestions in obstetrical medicine and surgery, and turn to the 
 
 * .Mr. Abernetliy's first Lecture at the College of Surgeons.
 
 Hv PREFACE. 
 
 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 expe- 
 rienced' 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, and 
 every disease of infancy and childhood; accounts of all these sub- 
 jects 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 dia- 
 gnostic 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 medicine. 
 Such accounts I have attempted to give to the peritoneal fevers 
 of lying-in women, of the disorders of the mind of 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 
 attempts 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 lie
 
 PREFACE. lv 
 
 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 
 (ate of my volume. 
 
 As my plan was in most cases to give a Ml account of each sub- 
 ject^ and to include in it everything which I thought interesting or 
 important about it, I have necessarily had to include many particu- 
 lars already well known ; but even these I have not related from 
 books, but from my own personal experience ; even in the most 
 common-place parts I claim to be more than a compiler. The 
 chapter on the art of distinguislung 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, 
 uidess 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 ; tins 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 is an easy task ; 
 but if liis 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) 
 attempt similar accounts of other Diseases of Women and Children.
 
 CONTENTS. 
 
 CHAPTER I. 
 
 PAGE 
 
 The Peritoneal Fevers of Lying-in Women. Part I . .1 
 
 Ditto ...... Part II .20 
 
 CHAPTER II. 
 
 The Disorders of the Mind in Lying-in Women . . .54 
 
 Thoughts on Insanity as an object of Moral Science . . S7 
 
 CHAPTER III. 
 
 The Mode of Distinguishing Pregnancy from the Diseases which 
 resemble it ....... 98 
 
 CHAPTER IV. 
 Polypus of the Uterus . . . . . .124 
 
 Of Polypus of the Uterus, attended by unusual circumstances . 144 
 Of Excrescences from the Uterus which are liable to be mis- 
 taken for Polypus ...... 149 
 
 CHAPTER V. 
 Of the Irritable Uterus ...... 15G 
 
 CHAPTER VI. 
 
 Of some Symptoms in Children erroneously attributed to Con- 
 gestion of the Brain ...... 179 
 
 Is the Plague a Contagious Disease ? .... 189
 
 CHAPTER I. 
 
 THE PERITONEAL FEVERS OF LYING-IN WOMEN. 
 
 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 symptoms are pain and tenderness over 
 the abdomen, with a rapid pulse.* It begins a few days after de- 
 livery, 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, the morbid appearances are 
 not uniform, but the most common and remarkable are a copious 
 effusion of lymph and serum on 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 placed at the 
 head of this paper — 'Peritoneal Fever' — for it would express the 
 fact, that an affection of the peritoneum is an essential accompani- 
 ment of the disease, 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 ex- 
 
 * ' Dr. Lowder adopted a very good method to form an accurate definition of this 
 'disease. He read all the different authors of character who had written on the 
 ' subject, and noted down all those pathognomonic symptoms which they agreed 
 ' were necessary to constitute the disease, and, on comparing these with his own 
 ' experience, he found them to be very few— fever, intense pain of the head, and 
 'intense pain of the abdomen.' — (Lowder, MS. Lectures.) 
 
 B
 
 <* PERITONEAL FEVERS. 
 
 traordinarily prevalent. In a lying-in hospital, in which there is 
 commonly so little illness that the office of physician is almost a 
 sinecure, cases of this disease sometimes become so numerous, that 
 the physician 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 mid- 
 wifery goes about his tasks 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 women 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 occurs seldomer. The prac- 
 titioner finds that, although the group of symptoms resembles what 
 he was formerly accustomed to, he has now to deal with a disease 
 far more obstinate and destructive, and Ins usual remedies are not 
 so successful 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 length subsides ; the cases become less frecpient and less severe ', 
 the practitioner finds his treatment becoming more successful, partly 
 because experience has taught him to detect it earlier and to 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 after- 
 wards, Avas 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 washer- 
 woman and nurse, washed the linen of one who had died 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 neighbour- 
 hood, getting afraid of her, ceased to employ her. The disease has 
 occurred in some wards of a hospital, the others being free from it;
 
 PERITONEAL FEVERS. 3 
 
 but after ventilating, cleansing, and painting these wards, they be- 
 came 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 ihe furniture of a tainted chamber. 
 
 From the little I have already said about the symptoms of this 
 disease, and the morbid appearances discovered after death, it is 
 clear that it essentially consists in fever, with an inflamed state of 
 the peritoneum ; 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 inves- 
 tigating the nature of this disease, one of the first questions is, 
 whether it is strictly uniform, differing only iu degree in different 
 cases, and requiring only different degrees of the same treatment; 
 or whether it differs so much in kind or type, that the mode of 
 treatment which is necessary in some cases, is destructive in others. 
 The latter is the conclusion to which we must inevitably come, at 
 first sight, in tracing the history of tins 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 
 obsolete opinions, but because it is unsafe to draw inferences, except 
 from a wider survey of facts than the experience of a single indi- 
 vidual, or of a single epidemic, affords. 
 
 Puerperal fever was prevalent in Derbyshire, and the adjacent 
 counties, 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 bleedings 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 puer- 
 peral 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 — some- 
 times 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 breath- 
 ing short, the pulse quick and weak. The appearances on dissection
 
 4 PERITONEAL FEVERS. 
 
 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 not red. The inter- 
 stices 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 cor- 
 dials, 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 
 glysters 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 Ins 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 
 pamphlets 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 the 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 with the tremendous dis- 
 ease which I am considering, and knows that the patient is either 
 dead or safe at the end of a week at longest, will instantly perceive 
 that a disease so protracted cannot be the same; and a perusal of 
 Dr. Butter's cases leaves no doubt on 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. 
 
 I Siit the contrary statements of physicians do not always admit of 
 so easy a solution. Dr. William Hunter, and Eichter, the professor
 
 PERITONEAL FEVERS. ."> 
 
 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 investi- 
 gations, 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 
 1 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. 
 ' T\ e tried various methods, (bleeding, refrigerants, stimulants, 
 ' mithridate,) but everything failed/ Eichter, 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 
 1 and at a distance, in which the fever was treated differently from 
 ' what I am accustomed to treat it, and the patients died. I there- 
 ' fore think that I have a right to offer my opinion about the nature 
 ' and treatment of this fever/ 
 
 One woidd at first suppose that Eichter 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 vis- 
 ' cera 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/* 
 
 There can be no doubt that Hunter and Eichter both meant, 
 thus far at least, the same disease — that it was the child-bed fever 
 which is attended by inflammation of 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 
 
 * Medicinische and Chirurgische Bemerkangen, von D. A. G. Richter, b. ii. s. 60.
 
 fi PERITONEAL FEVERS. 
 
 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, the 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 
 Avas esteemed by the best judges of those times as an excellent prac- 
 tical 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 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 be- 
 liever 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 inflauunation is an essential part ; and if I un- 
 derstand 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
 
 PERITONEAL FEVERS. / 
 
 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 pro- 
 curing 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 ascribed by Dr. Gordon, a physi- 
 cian of that place. He states, that the essential remedy was blood- 
 letting employed early and freely; that when he took ten or twelve 
 ounces away, the patient generally died, but when he took twenty- 
 four ounces aicay at once, and during the first six hours of the 
 disease, the patient commonly recovered. ' If practitioners/ said 
 he, ' allow themselves to be guided by the pulse, they will run into 
 ' 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 pulse, 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, who had previously 
 ' attended patients affected with the disease/ His treatment con- 
 sisted 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.* 
 
 * 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 Medecine, par Kurt Sprengel, torn. vi. p. 343. If this is a specimen of 
 the accuracy 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 ahout accuracy, they would never get on in
 
 8 PERITONEAL FEVERS. 
 
 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 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 peri- 
 toneum 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. 
 
 Whilst these different opinions were formed and promulgated in 
 England, some zealous and able physicians on the continent thought 
 they had discovered a successful mode of treating tins hitherto in- 
 tractable disease. 
 
 In 1782, the Royal Medical Society of Paris, being ordered by 
 the Trench government, made a report on the mode of treating 
 puerperal fever, which had been employed with unfailing success by 
 M. Doulcet, one of the physicians to the Hotel Dieu. There can 
 be no doubt that this disease was the genuine puerperal fever ; it 
 began about three days after delivery, was attended by pain and 
 distension of the abdomen, and a quick, small, contracted pulse; 
 the milk was suppressed. After two days the pain diminished, or 
 disappeared altogether ; there came on a cold viscid sweat, a weak 
 tremulous pulse, delirium, and death took place on the third or fourth 
 day. The abdomen contained two or three pints of fluid like un- 
 clarified whey, with flakes like curd over the surface of the intes- 
 tines. After losing a vast number of patients, M. Doulcet happening 
 to be in the hospital at the moment when a woman was seized with 
 the disease attended by sickness, he ordered fifteen grains of ipecacu- 
 anha to be divided into two doses, one to be given directly, and the 
 other an hour and a half afterwards. It produced vomiting and 
 purging, and the latter was kept up by a potion made with two 
 ounces of oil of almonds, one ounce of syrup of marsh mallows, and 
 
 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 
 translator, M. Geiger. I hope that this is an ' erreur grossiere' of Sprengel.
 
 PERITONEAL FEVERS. V 
 
 two "'rains of Kermes' mineral. In what closes and M'ith what fre- 
 quency this was given, is not stated; was it a potion for one clay, or 
 one close ? The same remedies w r ere used the next, and every day 
 until the symptoms of the disease had subsided ; the woman recovered, 
 and the same treatment was employed in every subsequent case. 
 From losing every patient, he now lost none. During four months 
 nearly two hundred were cured ; five or six refused to take the 
 medicine, and all these died. The success of the remedy depended 
 on its being given at the moment of attack ; the loss of a few hours, 
 however, was not always irreparable. When this account arrived in 
 England, it produced, as may easily be supposed, a strong sensation, 
 and the practice was tried by various physicians with different 
 results. Dr. Walsh said it was infallible ; Dr. Denman that it was 
 eminently useful ; Dr. Lowder that it disappointed him ; Dr. John 
 Clarke that it was injurious ; and it soon fell into disuse. Was it 
 ever fairly tried in tins country ? that is, not after the disease had 
 established itself for several hours, but at the moment of attack, 
 and with the potion of almond oil and Kermes' mineral.* 
 
 Dr. Boer of Vienna was for a long time physician to the large 
 lying-in institution and director of the midwifery school in that 
 city, and was much distinguished for his practical acuteness. Many 
 years ago he thought he had discovered an almost infallible remedy 
 for puerperal fever. Of this discovery he gives the following 
 account. I might abridge it, but the reader will prefer his own 
 interesting narrative. 
 
 ' I once lost in one day two lying-in women from puerperal 
 ' fever ; the one I attended alone, the other in consultation with 
 ' the ordinary house physician. — At the same time I had also in 
 1 the practical school (of midwifery) two lying-in women ill with 
 ' the same disease. The next day one of them died, and in the 
 1 other death was approaching. It was the seventh or eighth day 
 
 * Kermes' mineral, or the poudre fies Chartreux, was made by boiling four pounds 
 of antimony, one pound of the solution of fixed nitre per deliquium, and three pounds 
 of rain water, for two hours, and then filtering the boiling liquor through paper. This, 
 on standing, deposited a yellow powder ; the liquor was poured off, and the powder 
 washed and dried. ' This precipitated sulphur,' says Quincy, ' is really, as I am con- 
 ' vinced from facts which have fallen within my own observation, the most certain and 
 ' powerful antimonial medicine that can be given with safety. It has been recom- 
 ' mended in fevers, but the use of medicines of this class is not yet enough authorised 
 ' by experience to render such a practice eligible. The doses given have been from 
 'one grain to four, but it is best to begin first with the smallest dose, especially with 
 ' young persons, as the force of its operation varies greatly in different constitutions.'
 
 10 PERITONEAL FEVERS. 
 
 of her disease ; the belly was very prominent, tense, and so painful, 
 that she could hardly bear the bed-clothes ; everything passed 
 away from her unconsciously. She had an excessively quick 
 pulse, starting of the tendons, and wandered in her talk ; her 
 breathing was difficult and broken, and her countenance fallen : 
 the milk of the breasts had gradually disappeared, and almost 
 from the beginning of the disease no lochia were to be seen. With 
 the death of these three lying-in women, to which I already in 
 anticipation added the fourth, I was so depressed in spirits, that 
 in the evening I sought for consolation in the society of two inti- 
 mate friends ; but I could not divest myself of the fatality of these 
 diseases. Among other thoughts it occurred to me to try a 
 hitherto unemployed preparation of antimony, which I was assured 
 in many kinds of fever had manifested an uncommon efficacy. In 
 this case, thought I, there is nothing to be lost in the attempt. I 
 went home, provided myself with a dose of it, and reached, about 
 ten o'clock in the evening, the chamber of the dying woman. I 
 found her worse than she was six or seven hours before ; but as one 
 of the students and two of the female practitioners were waiting at 
 the bed-side, I was obliged to take care not to be seen giving 
 a dying woman a remedy out of my packet. I gave it, therefore, 
 unseen to the midwife, who gave it to the patient, instead of one of 
 the common camphor powders, mixed with tea. I then wished the 
 poor creature an eternal good night. 
 
 ' When I went the next morning, my first question was, when did 
 the patient die? "Die?" answered the midwife. "Early in the 
 morning she begged half a cup of coffee. She sat up in bed, and 
 would not rest till the nurse combed out her hair. I thought her 
 delirious." She seized me by the hand, and thanked me. I knew 
 not at that moment whether what I saw was an improvement, 
 or only a delusive lighting up from the insensibility of a fatal gan- 
 grene ; but it was a real amendment. She had in the night a pro- 
 fuse sweat, and passed much urine, after which she said she felt as 
 if she had imbibed a new life. The pain and distension of the 
 belly were gone; the pulse beat more freely and slower; the 
 breathing was calm, the tongue naturally moist, the diarrhoea had 
 almost ceased, and the lochia began again to appear. In short, all 
 the symptoms seemed gone by magic. She longed for a little wine 
 and water, which was given her. After four days, during which
 
 PERITONEAL FEVERS. 11 
 
 ' she passed a great quantity of uncommonly thick and turbid urine, 
 ' with a mucous sediment, she became free from fever, and after 
 ' eight or nine days she left the hospital. 
 
 ' Although this unexpected recovery rejoiced me much, I was far 
 ' from ascribing it to the medicine. I rather looked on the whole 
 ' happy revolution as the effect of a natural crisis. It was not long 
 ' before another lying-in woman, notwithstanding all the means used, 
 1 was in the same extreme circumstances. I gave her the same 
 ' medicine with the same consequences, only the improvement was 
 ' not so sudden. The patient had a profuse sweat, and passed mine 
 ' which looked more like a dissolved bilious stool than urine. In 
 ' five or six days she was perfectly restored. * * * * 
 
 ' A tier twelve or fourteen such desperate cases, in which it always 
 ' effected a cure in one and the same way, and after I had tried the 
 ' common antimonial preparations without any good effect, and often 
 ' with distinct injury, I began against my will to place especial con- 
 ' fidence in it. After I was convinced of the efficacy of this medi- 
 ' cine in cases where the disease had reached the highest degree, 
 ' I proceeded to order it at the beginning of the disease. From that 
 ' time, in our practice, the puerperal fever was never fatal; it never 
 ' even reached a dangerous stage, for the medicine as certainly 
 ' obviated the disease as it cured it when it was already fully 
 ' formed/ 
 
 For the truth of the foregoing statement, Dr. Boer appeals to 
 those who accompanied him at the bed-sides of those patients. 
 ' "When/ he remarks, ' on the one hand I consider the preparation 
 ' and the component parts of this antimonial remedy, and on the 
 1 other the symptoms and nature of the disease in which it effected a 
 ' cure, I can no longer reconcile myself with the common idea of the 
 ' healing power of medicines. I am firmly of opinion, that either 
 ' the succession of symptoms from which we conclude the presence 
 ' of a disease are not sufficiently determined, and the true nature of 
 ' most diseases is still hidden, or that certain substances must pro- 
 f duce in our bodies an entirely different effect to what we commonly 
 ' believe/* 
 
 The sequel of this narrative is very disappointing. Dr. Boer 
 never explained what Iris antimonial preparation was. I have been 
 told he would give it to any medical man with directions how to use 
 
 * Dr. L. J. Boer's Abhandlungen und Versuche. Beobachtungen uber das Kind- 
 bettfieber, b. i. s. 116.
 
 12 PERITONEAL FEVERS. 
 
 it ; but that the mode of its preparation was a secret which he never 
 divulged. The above account was published in the year 1790 ; in 
 1806, he published a systematic account of the different forms of the 
 puerperal fever which he had seen, in which he states that his sub- 
 sequent experience had only corroborated his former estimate of the 
 efficacy of the puerperal powder ; but the only passage which throws 
 any light on the preparation of this medicine is one in which he 
 praises 'the mild calx of antimony, or other preparation of this 
 1 medicine, more powerfully sudorific/* Boer thought higlily of 
 M. Doulcet's mode of treatment, and it is not at all improbable that 
 Kermes' mineral, which formed a part of that plan, was the anti- 
 monial preparation which constituted his puerperal powder. 
 
 I have hitherto been describing the experience and opinions of 
 practitioners of the last age, all of whom, I believe, are now dead. 
 I come now to my own time — to the experience and opinions of my 
 contemporaries, who are still alive, about a disease which I, as well 
 as themselves, have had ample opportunities of seeing both in pri- 
 vate families and in lying-in hospitals. In entering on this part of 
 my subject I shall of course cease to be the mere chronicler, and 
 become almost unconsciously the critic of opinions. It is now many 
 years ago since the opinions were published which I am about to 
 examine. If an author was to examine his own writings, composed 
 fifteen years ago, on a subject on which his mind, instead of being 
 stationary, had been every year accpriring new knowledge which had 
 suggested new thoughts, he would of course find many things to 
 alter, and it is probable that what I shall have to say in the shape 
 of criticism on these works, is nothing more than what would occur 
 to the authors themselves, if they were employed in examining them 
 anew. 
 
 About the year 1813, puerperal fever was very prevalent for two 
 years in the counties of Durham and Northumberland, and for one 
 year in Sunderland and the neighbouring district ; and an account 
 of it was published by Dr. Armstrong, who was at that time prac- 
 tising at Sunderland. Out of forty-three cases in that town, forty 
 occurred in the practice of one surgeon and his assistant, and he 
 mentions several other instances of the disease occurring only among 
 the patients of particular practitioners. In the cases which he saw, 
 the pulse was seldom less than 120 in a minute, and mostly rather 
 
 * Doer's Traktat vom Puerperalfieber, s. 91.
 
 PERITONEAL FEVERS. 13 
 
 full, tense, and vibrating, or very small, sharp, or wiry. He 
 describes the disease, however, as occurring under two forms, — 
 'one accompanied with the symptoms of simple peritonitis, the other, 
 ' marked by a less evidently declared inflammation of the abdomen, 
 ' was connected with a more overpowering and oppressive fever/ 
 In this latter form he thinks that what seemed actual debility was 
 only a greater degree of oppression from more intense inflammation. 
 ' A great many women died of this disease, and I was credibly 
 ' informed/ says he, ' every patient perished who was not bled in the 
 ' beginning/ When we compare this remark with the opposite 
 remark in Dr. Lowder's time, that every woman who was blooded 
 died, what shall we think of human experience ? In some cases he 
 describes the symptoms of inflammation within the abdomen as being 
 scarcely or not at all complained of by the patient; there was 
 ' oppressive languor, diminished sensibility of the nervous system, 
 ' great frequency of the pulse, quickened respiration, flatulence of 
 1 the stomach ;' the patients made little or no complaint of pain in 
 the abdomen, but when pressure was applied to it they shrunk. In 
 some cases even this symptom was absent ; pressure on the belly 
 induced no change on the countenance, yet dissection discovered 
 traces of inflammation both in the brain and abdomen. 
 
 Dr. Armstrong divides the disease into two stages ; the first that 
 of excitement, the last that of collapse. In the first, bleeding and 
 purging are the essential remedies ; but when the stage of excite- 
 ment is over, and that of collapse has begun, these same remedies 
 are useless and pernicious. Physicians, by not being consulted till 
 the stage of collapse, have concluded that the disease would never 
 bear depletion ; that it was one of debility, and required bark and 
 cordials. Hence it is of vital importance to distinguish the stage 
 of excitement from that of collapse, that these remedies may be 
 employed only in the former. The stage of excitement lasts from 
 about twenty to seventy hours; the pulse is about 120, and vibrat- 
 ing; in some cases, however, it is much quicker, soft, and com- 
 pressible : there is great apparent debility, but it is oidy apparent, 
 and so far from being an objection to depletion, is a more urgent 
 reason for it. It is important to distinguish this state of depres- 
 sion from collapse. In the stage of collapse the pulse becomes very 
 small, weak, and quick, (from 140 to 100), the breathing quick, 
 the heat of the body diminished, the abdomen large. Dr. Armstrong 
 flunks that the elder physicians used bloodletting unsuccessfully, 
 not only because they employed it too late, but too sparingly. He
 
 14 PERITONEAL FEVERS. 
 
 thinks that its success depends on being used very early and very 
 actively. His own practice was to bleed from the arrn to syncope, 
 then to give a scruple of calomel in mucilage, and two ounces of a 
 solution of sulphate of magnesia in infusion of senna, every hour till 
 they operated. The rest of the treatment consisted in low diet, 
 purgatives, and after the inflammatory symptoms had been subdued 
 small opiates by the stomach or rectum. Sometimes one full bleed- 
 ing was sufficient, sometimes it required to be repeated after a few 
 hours; in all cases the blood was buff-coloured; sometimes a 
 scruple of calomel was insufficient to produce speedy and free purg- 
 ing, and the dose was increased to half a drachm. In a very few 
 cases the gums became sore, and these recovered with unusual cele- 
 rity. Out of forty -three cases, five oidy died. Dr. Armstrong found 
 that the combined action of bleeding and purging was necessary to 
 subdue the disease; 'copious bleeding immediately succeeded ly 
 c copious purging on the onset.' 
 
 About a year after the publication of Dr. Armstrong's account of 
 the epidemic at Sunderland, Mr. Hey, of Leeds, son of the cele- 
 brated surgeon of that name, published an account of puerperal fever 
 which had prevailed in that town and neighbourhood several years 
 before that at Sunderland. It began in 1809. I need not describe 
 the symptoms which I have so often repeated, and shall only notice 
 a few of the most important : the pulse at the beginning was some- 
 times strong and full, but more frequently it was week, or speedily 
 became so ; there soon appeared great debility and sinking ; when 
 blood was drawn from the arm, the crassamentum was covered with 
 a ' thick coat of size, and was very firm/ The elder Mr. Hey had 
 long been in the habit of treating those cases of puerperal fever 
 which occasionally occurred by first an active purgative, and occa- 
 sionally a bleeding, and during the remainder of the disease a saline 
 purgative every morning, enough to operate four or five times, and 
 an opiate every night ; but this treatment was totally inadequate 
 to the intractable form of the disease which they had now to combat ; 
 for some time every case that they met with terminated fatally. 
 Out of fourteen cases, only three recovered. This plan being so 
 unsuccessful, physicians were consulted about the subsequent cases, 
 and apparently at their suggestion bark was tried in decoction or 
 powder, and in very frequent doses; but this plan was as little or 
 even less successful. Remarking that in proportion as he receded 
 from the antiphlogistic treatment his success diminished, and that 
 the remedies which did most good were purges, he was inclined to
 
 PERITONEAL FEVERS. 
 
 15 
 
 return to the former with more activity ; and this inclination was 
 strengthened by reading the pamphlet of Dr. Gordon of Aberdeen, 
 winch plan he adopted chiefly with this difference, that he often 
 carried bleeding much further than Dr. Gordon, and omitted the 
 nightly opiates which Dr. Gordon had used. His plan, therefore, 
 now consisted in early and active bleeding and purging. The first 
 fidl bleeding was often followed a few hours afterwards by a second, 
 and sometimes even a third. A bolus of three grains of calomel, 
 and twenty-five grains of jalap, was given immediately; and this 
 was followed by a solution of salts in an infusion of senna, repeated 
 till they operated freely ; the pinging was kept up till the symptoms 
 were quite subdued : the result of this compared with the result of 
 his former practice was striking — he had formerly saved only three 
 out of fourteen ; he now lost only three out of thirty -three. 
 
 As the advocates for bleeding contend that it is quite useless, 
 unless employed early and actively, the reader will naturally ask how 
 early and how actively? As an answer to this question, I have thought 
 it useful to make a table of Mr. Key's successful cases, showing- 
 how many hours the disease has lasted before bleeding was employed, 
 how many ounces of blood were taken away, and whether the re- 
 covery was speedy or protracted. The reader will observe, and it is 
 an instructive fact, that in most of the cases remedies were used 
 within a very few hours of the attack, (sometimes only four, or even 
 two had elapsed,) and the recovery was speedy; but in that in 
 winch nearly two days had elapsed before the remedies were em- 
 ployed, the recovery was very protracted. 
 
 Number of Hours from 
 
 the Attack. 
 
 Pulse. 
 
 Ounces of Blood 
 taken. 
 
 Mode of Recovery. 
 
 4 
 
 12 
 
 2 
 
 24, but coming on slowly 1 
 
 4 
 
 4 
 
 13 
 
 6 
 
 Coming on slowly several") 
 
 17 
 
 140 
 138 
 130 
 
 120 
 
 134 
 112 
 
 20 
 30 
 30 
 
 14 
 
 36 
 37 
 70 
 48 
 36 
 39 
 52 
 
 53 
 
 24 
 
 Speedy. 
 Speedy. 
 Speedy. 
 
 Speedy. 
 
 Speedy. 
 
 Speedy. 
 
 Long weak. 
 
 Speedy. 
 
 Protracted. 
 
 Speedy. 
 
 Speedy. 
 
 Speedy. 
 
 Speedy.
 
 16 PERITONEAL FEVERS. 
 
 The treatises of Dr. Armstrong and Mr. Hey produced a strong 
 impression on the minds of medical men in this country. It con- 
 vinced them that the puerperal fever which was then, and had been 
 for several years, infesting various parts of the island was an acute 
 inflammation of the peritoneum, and that bleeding and purging, em- 
 ployed very early and very actively, was the only mode of treatment 
 which was capable of arresting it ; but the impression did not stop 
 here ; it produced a general conviction, that the present was a fair 
 representative of all former and all future puerperal fevers ; that 
 bleeding and purging were its essential remedies in all places and 
 seasons ; that they had failed only because they had been used too 
 late and too sparingly, and would succeed if they were used early 
 and actively. In short, that a light had been thrown on the nature 
 of puerperal fever, which explained the failures of physicians in 
 times past, and would ensure them success in times to come. Of 
 these conclusions, as far as they relate to the disease which the 
 writers had been witnessing and treating I have no doubt ; but as 
 far as they relate to past and future epidemics, it may be useful to 
 examine the reasoning which led to these conclusions, and how far 
 they have been corroborated by subsequent experience. 
 
 I have no doubt, from the symptoms and progress of the disease 
 which Mr. Hey witnessed at Leeds, and Dr. Armstrong at Sunder- 
 land, that it was a genuine puerperal fever ; that is, fever accom- 
 panied by an affection of the peritoneum, although the proof by dis- 
 section was wanting in both.*" I applaud the zeal and ability with 
 which they investigated its nature, and conducted its treatment; 
 but a question of great difficulty and importance still remains, 
 namely, whether the puerperal fever, accompanied by an affection of 
 the peritoneum, and often epidemic, does not assume different types 
 in different seasons, being sometimes acutely inflammatory, and 
 bearing and requiring early and active depletions ; at others, charac- 
 terized by debility, or what has been called action without power, 
 in which depletion, however early and actively employed, is useless 
 and pernicious. 
 
 There are only two sources which can afford materials for solving 
 this question. 1st, A comparison of the records of past epidemics 
 
 * ' It is to be regretted that no examination could be obtained, as morbid dissection 
 
 might perhaps liave thrown some additional light on the nature of the disease.' 
 
 drnutrong on Puerperal Fever, p. 10. Mr. Hey also makes a similar complaint.
 
 PERITONEAL FEVERS. 17 
 
 with our experience of the present, in order to see whether they are 
 sufficiently similar to warrant the conclusion that they are curable 
 by similar modes of treatment. 2dly, To apply the mode of treat- 
 ment which has been so successful in the epidemic which we have 
 witnessed to the treatment of future epidemic puerperal fevers. Of 
 these two sources of information, is it not obvious that the former 
 affords only probable or conjectural evidence, and that the latter only 
 affords conclusive proof? At the time when Dr. Armstrong and 
 Mr. Hey published their Treatises, and when they and the medical 
 profession entertained such sanguine hopes, they were in possession 
 only of the former source of information; and they appear to me to 
 have laid far too much stress upon it, and permitted it to lead them 
 to far too positive conclusions. The two circumstances which seem 
 to have contributed chiefly to this opinion were, the similarity be- 
 tween the symptoms of past epidemics and the symptoms of that 
 which they themselves had witnessed, and the vestiges of inflam- 
 mation discovered on dissection. Dr. Armstrong remarks, that 
 ' there is perhaps no disease more uniform than puerperal fever in 
 f the symptoms and morbid derangements which it induces/ and he 
 quotes Dr. Hulme in favour of the ' immutability of the puerperal 
 1 fever/ 
 
 In the leading circumstances of the disease there is certainly great 
 uniformity ; it almost always commences a few days after delivery, 
 is marked by pain and tenderness of the belly, and a rapid pulse ; if 
 not cured, terminates fatally within a week, and, after death, com- 
 monly leaves the depositions and effusions of inflammation. Thus 
 far it is very uniform, but no further. To say nothing of its causes, 
 there are at least three things requisite to form the history of a 
 disease : 1st. Its symptoms. 2d. The effects produced by remedies. 
 3d. The morbid appearances discovered after death. In the history 
 of puerperal fever there is, even in the first and third of these par- 
 ticulars, considerable difference: this is apparent even in the experi- 
 ence of Dr. Armstrong himself, who describes the local inflammatory 
 symptoms as being sometimes very distinct, sometimes very indis- 
 tinct, and sometimes absent altogether, the patients not only com- 
 plaining of no pain in the abdomen, but bearing pressure without 
 the slightest shrinking. Compare, too, the symptoms of the disease 
 as described by Dr. Gordon, of Aberdeen, and those described by 
 Dr. Clarke, of London. In the appearances discovered after death, 
 there is also this great difference in different epidemics, that some- 
 
 c
 
 18 PERITONEAL FEVERS. 
 
 times there are the effusions of inflammation, with extensive redness 
 of the peritoneum, at other times the peritoneum is quite pale ; in 
 the sequel it will appear that there is a still greater difference in the 
 appearances after death. But if from the symptoms and morbid 
 appearances we pass to the second particular in the history of the 
 disease, namely, the effects of remedies (which form not only an 
 essential, but the most important part of this history, for the two 
 others are of no value but as they throw light on this) there is 
 perhaps no disease of which the histories have been so opposite. 
 Eichter could almost always cure it. Dr. William Hunter and Dr. 
 Clarke could scarcely ever cure it. In Dr. Lowder's time it was 
 observed that every woman who was blooded died. In Dr. Arm- 
 strong's time it was observed that every woman who was not blooded 
 died. 
 
 Throughout the whole chapter on the pathology of the disease, 
 Dr. Armstrong writes as if he thought that the symptoms during 
 life, and the appearances discovered after death, were infallible 
 guides to the nature and the treatment of the disease. Thus he 
 remarks, that if a practitioner were to see a woman soon after delivery 
 suffering pain in the abdomen, a quick pulse, and the other signs of 
 fever, and after death were to find no other morbid appearance than 
 extensive traces of inflammation in the abdomen, he would at once 
 conclude that the disease was active inflammation, and would in 
 future treat it as such ; and, alluding to those writers who have 
 considered the low epidemic fever of child-bed as a different disease 
 from peritoneal inflammation, he says, ' it becomes a matter of great 
 ' practical consequence whether symptoms and dissections justify 
 ' such a distinction/ It appears to me that symptoms and dissec- 
 tions cannot settle the question, and that Dr. Armstrong lays more 
 stress on the argument than it will bear. Supposing many cases of 
 a disease, which bore in general a striking resemblance to one another 
 in the symptoms and the appearances on dissection; this would 
 naturally suggest as a strong probability that they would all be 
 affected in the same way by the same remedies: but suppose that 
 on applying these remedies to all these cases, with the same activity, 
 at the same stage of the disease, and, as far as can be made out, 
 under the same circumstances, they produced different effects on 
 different cases, some being relieved and recovering, others being 
 made worse and dying; this would be more conclusive evidence of 
 a difference between these eases, than the symptoms and morbid
 
 PERITONEAL FEVERS. 19 
 
 appearances were of their identity. The effects of remedies on a disease, 
 if accurately observed, form the most important part of its history; 
 they arc like chemical tests, frequently detecting important differences 
 in objects which previously appeared exactly similar. How many 
 diseases are there in which the symptoms are inadequate guides : in 
 cases apparently syphilitic and apparently similar, some as soon as 
 mercury affects the mouth begin to mend, and rapidly recover ; in 
 others, the ulcers begin to spread ; and so imperfect are the appear- 
 ances as guides, that I have known the first surgeons in the profes- 
 sion giving opposite opinions about the same case, and a nose lost 
 from taking the opinion of the majority. The local pains and con- 
 stitutional disturbance which occur in feeble and bloodless persons, 
 and which are aggravated by bleeding and other evacuants, strikingly 
 resemble the local pains and constitutional disturbance which occur 
 in vigorous and plethoric persons, and which the lancet and other 
 evacuants relieve and ultimately cure ; yet how many years is it 
 before the young practitioner learns that there are cases apparently 
 so similar yet really so different, and how to distinguish them 
 ■ — and how many practitioners are there who never learn it at all ! 
 Symptoms and dissections can never do more than suggest proba- 
 bilities about the nature of a disease and the effect of a remedy on 
 it. A trial of the remedies themselves is the only conclusive proof. 
 Sydenham was so aware of this, that he says, 'Epidemic diseases 
 ' may seem alike to the unwary, because in some sort they do agree 
 ' to outward appearance -' adding this confession, ' when a new 
 ' species of fever arose, I was doubtful how to proceed, and notwith- 
 ' standing the utmost caution, could scarce ever preserve one or two 
 ' of the first patients from danger/ so far from infallible were, 
 symptoms as guides. 
 
 These are the remarks which have occurred to me in examining the 
 reasoning which led to the belief that puerperal fever is always an 
 acute peritonitis : the next question is, how far this belief has been 
 corroborated by subsequent experience ? I proceed to relate my own.
 
 20 PERITONEAL FEVERS. 
 
 THE PERITONEAL FEVERS OF LYING-IN WOMEN. 
 
 PART II. 
 
 I was appointed physician to the Westminster Lying-in Hospital in 
 the year 1812, and as the elder physician, Dr. Thymic, was aged 
 and infirm, the whole task devolved upon me for several years, to 
 attend both the in- and the out-patients in their difficult labours, and 
 their illnesses. In the latter, I could resort to the experience and 
 skill of Dr. Maton, who then held, and still holds, the office of con- 
 sulting physician to the hospital. My situation gave me ample 
 opportunities of observing the diseases of lying-in women among the 
 poor of London and its neighbourhood. 
 
 I had not been physician to the hospital long before I remarked 
 how much more healthy it was at one time than at another ; some- 
 times, for many months, there was no sickness among the patients ; 
 as soon as the labour was over they were well ; they required nothing 
 but an opiate for their after-pains, and a few doses of aperient medi- 
 cine, and the medical part of my office was almost a sinecure. At 
 other times, cases of illness were perpetually occurring ; as soon as 
 one Mas over another began ; often I had several at the same time 
 under my care; this would go on for several months, and then cease, 
 leaving the hospital healthy for a long time. 
 
 The cases which were so numerous in these unhealthy seasons 
 had the common symptoms and course of puerperal fever. They 
 began a few days after delivery; the leading symptoms were diffused 
 pain and tenderness, with some swelling of the abdomen, a quick 
 pulse which was generally at first full and vibrating. Sometimes it 
 was small, but still it was hard and incompressible ; the skin was 
 hot, though not so hot as in other fevers ; the tongue was white and 
 moist, the milk was suppressed. As the disease advanced, the belly 
 became less painful, but more swelled, and the breathing short; 
 towards the end, the pulse was very frequent and tremulous, and 
 the skin covered with a clammy sweat; even in this state the 
 tongue continued moist and the mind clear, and death took place
 
 PERITONEAL FEVERS. 21 
 
 generally about the fifth Jay. On opening the abdomen, which was 
 often as large as before delivery, the intestines were found distended 
 with air, the peritoneum was red in various parts, its surface was 
 covered with a coat of lymph, the intestines adhered to one another, 
 and the omentum to the intestines; coagulable lymph was deposited 
 on various surfaces, especially in the depressions between the convo- 
 lutions of the bowels and on the omentum, on both which parts it 
 often lay in large masses; the cavity of the peritoneum contained 
 several pints of a turbid fluid, apparently serum mixed with lymph. 
 In the uterus the morbid appearances were generally confined to its 
 peritoneal covering, which was coated with lymph, on removing 
 which the membrane itself was found unnaturally red; but in some 
 cases the disease had penetrated deeper into the uterus, the substance 
 of which was sometimes infiltrated with pus, and sometimes con- 
 tained small abscesses about the size of a nut ; the inner surface of 
 the uterus, especially at the fundus, often appeared black and 
 ragged, as if gangrenous. The enlargement of the abdomen depended 
 entirely on air in the intestines ; when there was no air there was 
 no enlargement, even though the peritoneum contained several pints 
 of fluid. The first time I noticed this was in the body of a young 
 Woman who had died with all the symptoms of puerperal fever, 
 excepting the tumid belly. When the body was lifted from the bed 
 on to the board on which it was to be opened, the belly, instead of 
 being tumid, was sunk and hollow, and we began to think that her 
 case had been mistaken ; but on opening the abdomen we found 
 several pints of turbid fluid. 
 
 The disease generally began very suddenly. After being epiite 
 well, feeling no sense of illness, or at least making no complaint, 
 the patient was seized at once with chilliness, or shivering, and pain 
 in the belly, and the pulse rose to 120 or 130; but sometimes the 
 attack was more gradual. For many hours, or even for a day or 
 two, there were pain and tenderness in one part of the abdomen, 
 then in another, with long intervals, in which there was no pain 
 anywhere ; and during all tins time the pulse would remain quiet, 
 or not cpiicker than 80 or 90. In short, the disease would have an 
 incipient stage ; but this was not a common occurrence. 
 
 I soon found that I had to deal with a very fatal disease. When 
 I saw the patients after it had been going on two or three days, or 
 even longer (which was no unusual circumstance among the out- 
 patients), I seldom or never saved them; the sunk countenance,
 
 22 PERITONEAL FEVERS. 
 
 the small weak pulse of 110 or 160, the tympanitic belly, the short 
 breathing, and sometimes the clammy sweat, all indicated a fatal 
 disease, past the reach of depletion, even if it had ever been fit for 
 it; and cordials appeared to promise the only chance of recovery, 
 but they were seldom or never successful : wine mixed with gruel 
 or egg for diet, and diff usable stimulants for medicines, were almost 
 signals of a fatal termination. I was soon satisfied that the disease 
 was incurable in this stage. Within the hospital I used to see it 
 earlier, sometimes within a few hours of its commencement, although 
 even here this was not always the case ; for we had not yet learnt 
 how soon the curable stage passed over, and how vitally important 
 it was to begin the treatment at the very beginning of the disease. 
 Besides this, the patients of a lying-in hospital are slow to confess 
 themselves ill; they look upon pain of the belly as nothing but 
 after-pains, and dread the active remedies which a confession of ill- 
 ness brings upon them ; even after the confession the nurses are 
 often dilatory in communicating it, and thus many hours used often 
 to pass before I was called to the case, notwithstanding the activity, 
 intelligence, and rare humanity of Mrs. Wright, the matron. There 
 was another frequent cause of delay. In a very large proportion of 
 cases, the disease began in the night ; the patient would go to bed 
 complaining of nothing, and be waked in the night or at daybreak 
 by pain in the belly and chilliness ; but the night-nurse thought it 
 unnecessary to disturb anybody, and I lived two miles from the 
 hospital. Whenever puerperal fever is prevalent in a hospital or 
 neighbourhood, effectual means ought to be taken to obviate these 
 causes of delay. 
 
 When I saw the patient very soon after the attack, I found a 
 different group of symptoms to what I had witnessed in the latter 
 stage; the pulse was not so quick, about 120 or 130; it was gene- 
 rally full and vibrating, or if small, it was hard and incompressible ; 
 the skin was hot, the belly was slightly full and tense, and very 
 painful and tender, so that the patient could neither bear to have it 
 pressed nor to turn from one side to the other in bed. These 
 symptoms, especially the character of the pulse, looked like an in- 
 flammatory disease, for which the remedy was depletion ; the appear- 
 ances discovered on dissection corroborated this notion; remedies of 
 an opposite kind had been tried unsuccessfully. Dr. Penman's 
 and Mi. Gordon's account of the subject afforded encouragement 
 lor the trial of depletion, and I was still further encouraged by
 
 PERITONEAL FEVERS. 23 
 
 the experience of Dr. Maton. We therefore resorted to general 
 and local bleeding", and purging; the blood drawn from the arm 
 formed a crassamentum which cupped and buffed in the greatest 
 degree; the patients expressed relief from this treatment: it was 
 soon clear that bleeding and purging did more good than any 
 remedies we had tried, and our success in the treatment of this disease 
 was decidedly increased. We w ere just in this state of opinion and 
 practice, when the publication of Dr. Armstrong's treatise rendered 
 us more bold in the use of our remedies, and induced us to employ 
 depletion with more activity. 
 
 I now found that, provided I saw the patient within a few hours 
 of the attack, I could generally arrest the disease. The mode of 
 treatment was as follows : A vein was opened in the arm, with 
 a wide orifice, so that the blood flowed in a full stream, and it was 
 allowed to flow till the patient felt faint ; the arm was then tied up, 
 and her head was raised so as to encourage the faintness for many 
 minutes. As soon as the faintness had subsided, she took from ten 
 to twenty grains of calomel in a teaspoonful of arrow-root, and after- 
 wards half an ounce of sulphate of magnesia dissolved in beef-tea or 
 thin gruel, every other hour, until several copious evacuations were 
 procured from the bowels ; when the patient had thoroughly re- 
 covered from her faintness, from ten to twenty leeches were applied to 
 the painful and tender parts of the abdomen ; when the leeches had 
 fallen off, a bag long and broad enough to cover the whole abdomen 
 was stuffed with hot poultice, which was spread so as to form a 
 cushion nearly an inch thick; this was laid hot over the whole 
 abdomen, and renewed so often as to keep up heat and moisture. 
 If the patient complained of the weight of the poultice, the bag was 
 stuffed with scalded bran. We found this application of infinite 
 value, not only as a means of encouraging the bleeding of the leech- 
 bites, but also as a perpetual fomentation. 
 
 In the treatment of acute inflammation in the vital organs, the 
 customary practice is to consider local bleeding as a milder means of 
 effecting the same object as general bleeding, and to postpone it till 
 the stage for the latter is over. To me it appears that they are 
 calculated to effect two different objects, both of which are necessary 
 at the beginning of the treatment; the one to reduce the violence 
 of the general circulation, the other to empty the distended capil- 
 laries of the part. As long as the pulse is quick, full, and hard, it 
 is in vain to take blood from the affected part : if we could coin-
 
 24- PERITONEAL FEVERS. 
 
 pletely empty its gorged capillary vessels, tliey would be instantly 
 gorged again, whilst the heart and large arteries are injecting them 
 with so much violence. On the other hand, after having reduced 
 the force of the general circulation, the capillary vessels of the part 
 often remain preternaturally injected : this I conclude from the fact, 
 that the patient is often not relieved till local bloodletting has been 
 used, and then is relieved immediately. Hence, as soon as the 
 patient has recovered from the faintness occasioned by bleeding from 
 the arm, leeches ought to be applied without delay. 
 
 I waited till the purgatives had operated fully, that I might know 
 what impression the combined operation of general and local blood- 
 letting and purging had produced on the disease, before deliberating 
 about the employment of a second bloodletting. The common 
 effect of these remedies was this : as long as the faintness lasted in 
 the slightest degree, the pulse remained soft, and often slower, and 
 the pain was much less, or ceased altogether ; but an hour or two 
 after the bleeding, when the circulation had recovered, the pain 
 returned more or less, and the pulse regained much of its hardness 
 or incompressibility. This state continued till the leeches had bled 
 freely, and the purgatives had acted repeatedly and copiously. The 
 state in which the patient was found after this, determined me 
 whether or not to employ a second bleeding. 
 
 My two chief guides were the state of the abdomen and that of 
 the pulse. If the abdomen was still painful and tender, and the 
 pulse retained any of its hardness or incompressibility, or if the 
 pulse was not so small and weak as to forbid a general bleeding, 
 a vein was again opened in the arm, and the blood allowed to flow 
 till it produced faintness, which was encouraged as after the first 
 bleeding : on the contrary, if the pulse was small and weak, if the 
 pain was gone and only soreness remained, I preferred a repetition 
 of the leeches. Mere soreness without pain, and with a feeble state 
 of the general circulation, is more surely relieved by local than by 
 general bloodletting; and the best mode of employing it is by 
 relays of leeches ; as soon as the orifices of one set have done bleed- 
 ing, to apply a fresh set, till the soreness and tenderness are gone. 
 The rest of the treatment consisted in purging during the day by 
 calomel and salts, the constant application of the bag of poultice or 
 bran, and leeches to the abdomen till all the tenderness was gone. 
 
 The active treatment, that which will determine the fate of the 
 patient, should lie begun and ended during the firsl day: when
 
 PERITONEAL FEVERS. 25 
 
 employed later, it is under great disadvantages, and with very 
 diminished chances of success. When I consider the extent of the 
 membrane which is affected, and the rapidity with which the effu- 
 sions of inflammation are sometimes poured out, so far from won- 
 dering that the curable stage passes over so soon, it is to me a 
 subject of wonder that the disease should ever be cured after it has 
 lasted twelve hours. The more I have seen, read, and thought of 
 this formidable disease, the more strongly am I impressed with the 
 belief, that whatever may be the proper mode of treatment, it is not 
 fairly tried uidess employed in the early hours of the disease. 
 
 1 think it useless to trouble the reader with a number of cases, 
 which would greatly lengthen this paper, without any adequate ad- 
 vantage ; but I will relate a few instances as specimens of the disease, 
 and the way in which I used to treat it, during several seasons in 
 which it was prevalent, between the years 1812 and 1820. 
 
 A healthy young woman, an in-patient of the "Westminster 
 Lying-in Hospital, April 1815, was quite easy and well on the 
 second day after her delivery, but late in the evening of that day 
 she was seized with rigor, and pain and tenderness of the abdomen. 
 After the rigor had subsided, the pain and tenderness of the abdo- 
 men became more severe, and she had a full vibrating pulse of 120. 
 She took eight grains of calomel, a scruple of jalap, and a quarter 
 of a grain of tartar emetic ; a vein was opened in her arm, and she- 
 was bled to syncope. During this state the pain nearly ceased and 
 the pulse fell to 88. I saw her about two hours afterwards; she 
 Mas dozing, continued easier, and the pulse was feeble; but it had 
 more than recovered its quickness, for it was 130. As she had 
 vomited the calomel, jalap, and antimony, she took ten grains of 
 calomel alone, and she was directed to take three drachms of sul- 
 phate of magnesia every other hour, till she was well purged. I 
 saw her the next morning, at nine o'clock ; she had had little sleep, 
 the medicine had operated copiously three times, but the pulse was 
 124 and firm, and the pain as violent as before the bleeding. She 
 was now bled again till she became faint ; twenty-four ounces had 
 been required for this object the first time, fifteen ounces were suffi- 
 cient now. She again experienced great diminution of the pain, yet 
 three hours afterwards it had returned, and the pulse was 124. She 
 now took a dose of calomel and jalap, leeches were applied to the
 
 26 PERITONEAL FEVERS. 
 
 abdomen, and she was to take the sulphate of magnesia if necessary; 
 the purgatives acted plentifully seven times, the pain and tenderness 
 of the belly rapidly diminished, and she was next day much better, 
 but the pulse was still quick, being 120. She now took sudorific 
 doses of antimony, and purgative doses of salts; the next day the 
 pain and tenderness were almost gone ; she continued the antimony 
 and salts for two days longer, and recovered, but remained feeble 
 for some time. 
 
 II. 
 
 A single woman, on the third day after the birth of her first 
 child, was attacked about two in the morning with a severe shiver- 
 ing, which lasted a quarter of an hour, and was followed by heat, 
 perspiration, and pain of the abdomen, with great tenderness. I saw 
 her early the next morning ; the pain and tenderness continued, the 
 lochia had ceased, the pulse was at 120, not vibrating, but firm. I 
 had her bled till she fainted; the faintness was encouraged, and 
 lasted whilst I remained with her, during winch the pulse was slow, 
 feeble, and occasionally ceased ; she took castor oil every four hours 
 till it operated plentifully ; I was prevented seeing her again all that 
 day. The next morning the pain and tenderness, though much 
 less, were not gone; the pulse was 124, and not weak. She was 
 now placed in the upright posture, and bled again to fainting. As 
 soon as she recovered, she took fifteen grains of calomel, and was 
 directed to take half an ounce of sulphate of magnesia every other 
 hour till it operated copiously. The following day the abdomen was 
 quite free from pain and tenderness, she could turn in bed, and 
 bear pressure without uneasiness; her pulse was 104, and soft, and 
 her bowels had been plentifully moved. The saline purgatives were 
 continued two days longer, when, having no complaint, she was 
 considered convalescent, but continued on low diet several days. 
 
 III. 
 
 A general practitioner took me one evening to see Ins daughter, 
 who had been delivered three days of her first child, and was just 
 seized with symptoms of puerperal fever. He had had several cases 
 of the disease among his own patients, and had lost two, so that 
 when the malady attacked his own daughter he was greatly terrified ; 
 the emotions of his heart had deprived him of the use of his head, 
 and he was as helpless as a child, although he was a sensible and
 
 PERITONEAL FEVERS. 27 
 
 experienced man. We arrived at the house at eight o'clock in the 
 evening; she had been shivering, but this had gone off, and she 
 was now rather hot. The pain had begun in the left groin, then 
 extended to the prsecordia, and now was diffused over almost the 
 whole abdomen. She could not turn in bed without pain, and could 
 not bear pressure. Her pulse was 136 in a minute, and small; it 
 felt soft, yet, on compressing it firmly, it struggled under the finger. 
 She was a pale, delicate-looking young woman, subject to nervous 
 complaints in her ordinary health, and apparently a bad subject for 
 bleeding ; but I was assured she was quite well with a pulse under 
 80 only four hours ago, and I had lately seen several fatal cases in 
 which the loss of time and the inactivity of the treatment had been 
 much regretted. I therefore directed several teacups to be brought, 
 and determined to bleed her till she fainted. This required more 
 blood than I expected from the appearance of my patient. Towards 
 the end of the fifth cup I felt her pulse, on which I had kept my 
 finger while the blood was flowing, begin to falter, and in an instant 
 she fainted. Her pillow was removed and her head laid low till she 
 began to revive, then it was raised till she fell faint again, and de- 
 pressed again when she fainted away. I remained with her about 
 half an hour after the closure of the vein. She felt no pain, and 
 her pulse had fallen to 88; the blood had that indigo hue which 
 portends buffing. It was agreed that as soon as she had completely 
 recovered from her faintness she was to take ten grains of calomel, 
 and ten of compound powder of tragacanth, in a teaspoonful of 
 gruel, and four hours afterwards half an ounce of sulphate of mag- 
 nesia, which was to be repeated every other hour until it operated 
 freely; the abdomen was to be kept constantly covered by a bag of 
 scalded bran. I saw her the next morning at twelve o'clock ; during 
 the night she had had a return of pain, with soreness of the abdo- 
 men, and the pulse had risen in frequency, but since the bowels had 
 begun to operate, these symptoms had been abating, and when I 
 saw her at noon I was quite easy about her. She had no pain ex- 
 cepting a minute or two before the bowels were moved. She could 
 turn in bed, and bear pressure on the belly without suffering, and 
 her pulse was 96. She continued the sulphate of magnesia and the 
 bag of scalded bran during the remainder of the day, and at night 
 took twenty drops of laudanum in a saline draught, and when I saw 
 her the following day she was so completely convalescent that I
 
 28 PERITONEAL FEVERS. 
 
 left her under the care of her father and the gentleman who had 
 attended her. 
 
 I have repeatedly found myself, and seen others, at a loss, when 
 bloodletting having been carried as far as I dared, and reduced the 
 general circulation to the lowest ebb, sufficient pain and tenderness 
 were left to make me anxious about the patient, and have found 
 a full opiate and a warm poultice over the abdomen remove these 
 symptoms. 
 
 IV. 
 
 A general practitioner came to me late one night (1820), begging 
 me to go with him to a patient, who was in great danger from peri- 
 toneal inflammation after lying-in; the question about which he 
 hesitated was whether to bleed her again or not. This was the third 
 day of the disease. She had been blooded three times to fainting, 
 thirty leeches had been applied to the abdomen, and she had been 
 well purged with large doses of calomel, followed by sulphate of 
 magnesia, in infusion of senna. I found her bleached as white as 
 the pillow on which she lay, her pulse was 130, feeble, and tre- 
 mulous; she still complained of soreness in the abdomen, so that 
 she flinched from pressure, and could not turn in bed. I should 
 have thought it a hopeless case, but the abdomen was not tym- 
 panitic, she breathed calmly, and her face was not anxious. I ad- 
 vised the practitioner not to bleed her, but to cover the abdomen 
 with a bag filled with scalded bran, and to give her twenty minims 
 of the Liq. Opii sedativus immediately, and repeat it four hours after- 
 wards. We saw her at ten the next morning ; she had taken three 
 closes of the opium, had slept soundly, had lost her pain and tender- 
 ness, and the pulse had fallen below 100. She continued the opiates 
 every six hours for two days longer, and recovered, though she was 
 for a long time pale and weak. 
 
 These cases will be sufficient to show the form of disease winch 
 was very prevalent in the hospital and in London, at several periods 
 between the years 1812 and 1820, the mode in which I treated it, 
 and the result. The practice was so decided, that if it had not been 
 very right it must have been very wrong; if it had not been adapted 
 to the cure of the disease, it would have been positively and mani- 
 festly injurious, as I am well assured by subsequent experience. 
 
 There was one circumstance in which the result of this practice
 
 PERITONEAL FEVERS. 29 
 
 was very different in different cases, even in those which ultimately 
 ended in recovery, and that was the state in which the patient was 
 left when all pain and tenderness were gone; in some the patient 
 was left with a calm pulse, and the recovery was speedy; in others 
 the patient was left with a very rapid pulse, which kept me in 
 anxiety for several days. Sometimes this quick pulse gradually 
 subsided, aud the patient slowly recovered her health; in others, 
 after a day or two of this doubtful state, she became rapidly worse, 
 and died, and on opening the body, the usual morbid appearances 
 were found in the peritoneum. These different results might be 
 commonly anticipated by distension of the abdomen and quick 
 breathing, but not always ; for some cases in which there was no 
 distension terminated fatally. 
 
 Such was my practice when I saw the disease early, and this 
 practice was commonly successful; but it was not always that I 
 could treat it so decidedly and satisfactorily to my own mind. From 
 various causes, quite distinct from the greater malignity of the 
 disease, a physician treats it with much less chance of success in a 
 lying-in hospital than in the lying-in chambers of educated and 
 opulent people; the latter take the alarm at the first moment of 
 attack, and directions are commonly strictly attended to ; the patients 
 too are generally in good health at the time of their delivery ; but 
 those of a lying-in hospital fall ill under very disadvantageous cir- 
 cumstances ; they come in often in broken health, with habits of 
 intemperance which ill fit them for low diet and active depletion ; 
 when they fall ill they often keep it secret many hours, and the 
 \ igi lance of an excise officer would not prevent the friends who visit 
 them from smuggling in spirit. There is another cause : the hos- 
 pital is chiefly intended for the reception of married women, but 
 there are two wards for single women pregnant for the first time. 
 These are persons who have been seduced, but are not hardened 
 in vice ; they often suffer bitterly in mind during the dreary months 
 of their pregnancy ; and if they fall ill after delivery it is under 
 the long influence of depressing passions ; thus it is an old remark 
 of those who have had much experience in lying-in hospitals, that 
 the single women are peculiarly liable to fatal disease after delivery. 
 
 The large closes of calomel which we were in the habit of giving 
 as purgatives, sometimes produced soreness of the gums. All the 
 patients in whom this occurred recovered; there might be, but I do 
 not remember, an exception. In one of these cases, I met the late
 
 30 PERITONEAL FEVERS. 
 
 Dr. John Clarke, the only occasion on which I ever saw him. The 
 patient was the wife of a butler in a family which he attended, and 
 when they heard that she was in danger, they expressed a wish that 
 he should see her. I met him at the hospital ; the patient in the 
 next bed had been attacked by the same disease, and he examined 
 them both carefully, recognised the disease as the genuine puerperal 
 fever, advised me to give bark and ammonia to the patient whom he 
 came to see, remarking that she would never go out of the hospital 
 alive. As she was under the care of Dr. Maton as well as myself, I 
 did not feel justified in changing the treatment so completely, but a 
 slight soreness of the gums, which she had on that day, became the 
 next day a complete salivation, and she left the hospital convalescent 
 a fortnight afterwards. 
 
 I do not remember, and I have no notes of any cases within the 
 hospital in which I gave the oil of turpentine, as recommended by 
 Dr. Brenan, of Dublin ; but I gave it to four out-patients, and the 
 result did not encourage me to give it to any more. In these cases 
 the disease was so far advanced that I had no hope from bleeding. 
 
 Two drachms of oil of turpentine were given in a little gruel every 
 four hours, for three doses, and with the last dose half an ounce of 
 castor oil. Every one of these patients complained that it occasioned 
 an increased burning pain in their bowels ; they were freely purged 
 by the medicine, but they all died. As an external rubefacient it 
 was sometimes used in the hospital with considerable benefit. In 
 one case, in which bleeding had been carried as far as we dare, with- 
 out subduing the symptoms, and we thought very ill of the case, a 
 piece of flannel was soaked in hot oil of turpentine, and spread over 
 the whole abdomen. It had been on about twenty minutes, and I 
 was just leaving the hospital, when my attention was arrested by a 
 clamorous voice from the ward in which the patient lay. On going 
 in with the matron, we found her vociferating most furiously that 
 the turpentine had killed her. It had, indeed, produced extensive 
 redness over the whole abdomen, but a few hours afterwards, when 
 the superficial pain produced by the turpentine had subsided enough 
 to enable us to inquire about the deeper pain and tenderness of the 
 disease, we found them gone. She had been smartly purged, and 
 the pulse had fallen below 100. I need scarcely add that she 
 recovered. 
 
 Thus the conclusion to which I came was, that the puerperal fever 
 which prevailed on several occasions between 1812 and 1820 was
 
 PERITONEAL FEVERS. 31 
 
 a fever attended by acute inflammation of the peritoneum, that the 
 inflammatory stage was often very short, soon terminating in great 
 and irremediable effusion into the peritoneum, that the disease was 
 curable only in the inflammatory stage by active bleeding and purging, 
 and that although it was impossible to draw the line, and say when 
 the inflammatory stage terminated in that of effusion, because it dif- 
 fered in length in different cases, yet that it was often incredibly 
 short, and that the treatment had not a fair chance of success, unless 
 begun during the early hours of the disease. Thus my experience 
 agreed in all the principal points with that which had been so forcibly 
 stated to the public by Dr. Armstrong and Mr. Hey. 
 
 For some years I supposed that the group of symptoms which 
 indicate puerperal fever always indicated the same disease, differing 
 only in degree; so that if a woman a few days after delivery had 
 diffused pain and tenderness over the abdomen, with a rapid pulse, 
 she must necessarily have a peritoneal fever, for which the oidy 
 remedy was early and active depletion. This, I know, was the 
 common opinion of the profession, and may be the common opinion 
 now, although some practitioners may have arrived at a different 
 conclusion. The first case which led me to suspect that there were 
 exceptions to this rule, and afforded me some light on this difficult 
 and important subject, was the following : 
 
 V. 
 
 The patient was a lady, twenty-six years of age, habitually tliin, 
 and long subject to occasional pains in the pelvis, which she called 
 spasms of the womb, and which she reHeved by opiates. She also 
 frequently fell into a state of debility from which she was always 
 restored by steel medicines, or chalybeate waters. This lady was 
 delivered of her third child, after a short, easy, and natural labour. 
 On the second morning after her debvery, being perfectly easy, and 
 complaining of nothing, she took a purgative, as is usual, of salt and 
 senna. It operated plentifully several times ; then the stools became 
 frequent and watery, with severe griping, and gradually the abdomen 
 became painful and tender all over ; the pain was without intermis- 
 sion, and the tenderness so great, that she could not bear the slightest 
 pressure ; nevertheless her skin was cool, and her pulse continued 
 soft and not more than 80. This case occurred at a time when it 
 was the prevailing notion in the profession that puerperal fever was 
 invariably acute inflammation of the peritoneum, for which early, full,
 
 32 PERITONEAL FEVERS. 
 
 and repeated bleedings form the essential remedy, and I found it 
 very difficult to prevent this treatment being adopted in this case. 
 The medical attendant of the family visited her several times a day, 
 insisting that the pain arose from inflammation of the peritoneum, 
 and urging the necessity of bleeding. I succeeded, however, in 
 preventing this measure ; the abdomen was kept constantly covered 
 by a bag of scalded bran ; she took ten grains of compound powder 
 of ipecacuanha, every four hours; the pain soon diminished, and at 
 length subsided ; the tenderness remained longer, but ceased on the 
 second day, leaving her quite free from any symptoms of disease. A 
 few days afterwards, the bowels being confined and mild aperients 
 not acting, she took another dose of salts and senna, which operated 
 as the former, producing another attack of pain and tenderness of 
 the abdomen, which was speedily relieved by fomentations and opium. 
 In this case there was not much danger of going wrong ; the slow, 
 soft pulse was a sufficient guide. AVithout stirring the question, 
 whether the irritation excited by the purgative had excited the 
 symptoms which I have described, the case taught me that a lying-in 
 woman might have a diffused and permanent pain over the abdomen 
 with tenderness, wliich neither I nor the family apothecary could 
 distinguish from the pain and tenderness of peritoneal inflammation, 
 which nevertheless did not depend on inflammation; at least it 
 was unaccompanied by quickness of pulse, and it was cured without 
 depletion, by fomentations and opium. All this was new to me, 
 and interested me much; but I had not been brooding over it long, 
 before I met with the following still more remarkable case : 
 
 YI. 
 
 I was called up at day-break, and taken into the country to a 
 surgeon's wife, who had been delivered a few days, and who was 
 represented to be in great danger from peritoneal inflammation, so 
 that she had already been seen by two medical men beside her 
 husband. When I arrived I collected the following particulars. In 
 her ordinary health she was pale, and subject to fits, either hysterical 
 or epileptic ; she had been confined four days, and her present symp- 
 toms had lasted rather more than one; they were permanent pain 
 all over the abdomen, tenderness, and soreness, so that turning in 
 bed was distressing to her ; she had had no rigors nor chilliness ; 
 her pulse was 116, perfectly soft, and rather languid. One of the 
 medical gentlemen, who had seen her at four o'clock that morning,
 
 PERITONEAL FEVERS. 33 
 
 had taken from the arm two cups of blood; but although it had 
 flowed in a full stream, the surface of the crassamentum was flat and 
 red, and the bleeding had afforded her no relief. I ordered the 
 abdomen to be covered by a linen bag stuffed with hot bread and 
 water poultice, and I gave her twenty minims of laudanum; the 
 poultice was to be renewed often enough to keep up heat ; she was 
 to continue the laudanum in doses of ten minims every four hours, 
 and take nothing for diet but thin hot gruel. I breakfasted in the 
 house; before leaving it, I went up to her chamber, and found that 
 her abdomen was easier, her skin moist, and her pulse had fallen to 
 100. The next day, I received a note from her husband, to tell me 
 that the pain and tenderness of the abdomen were quite gone, and 
 that her pulse had fallen to 90. She now left off her opiates, but 
 continued her fomentations, took a mild aperient, and recovered 
 without any further interruption. 
 
 In this case there was more danger of going wrong than in the 
 former ; for the pulse was quick, and there was that group of symp- 
 toms which, when they attack a woman a few days after delivery, 
 are generally supposed to indicate inflammation of the peritoneum. 
 This was the opinion, not only of the husband of the patient, who 
 was too much alarmed to judge coolly, but of the other practitioners, 
 both experienced men. I was guided here by the previous and 
 habitual constitution of the patient, by the perfect softness of the 
 pulse, by the uninflamed appearance of the blood, and by the bleeding 
 having afforded no relief. This case led me a step further than the 
 former ; it taught me, that a lying-in woman might have diffused 
 and permanent pain and tenderness of the belly, with a rapid pulse, 
 from a state which does not require bleeding, and is not relieved by 
 it, but which is speedily relieved by fomentations and opiates. 
 
 VII. 
 
 I went a considerable distance from London, to a lady who had 
 just been delivered, and who was represented to be in great danger. 
 When I arrived I found two medical men in the house, who informed 
 me that the patient had been delivered that morning, but soon after- 
 wards had had a haemorrhage so violent, that they thought at one 
 Time she was dead, but the hsemorrhage had ceased, and they began 
 to have hopes of her recovery. They then led me to her chamber, 
 where I found a lady about thirty years of age, without the slightest 
 colour in her face or lips, speaking only in a whisper, with a pulse
 
 34 PERITONEAL FEVERS. 
 
 like a thread, and a cold skin, still so faint as to require the frequent 
 use of brandy. The hemorrhage had ceased, and I felt the uterus 
 in the hypogastrium small and firm. There was therefore only one 
 object, and that an urgent one, to revive and support the ebbing 
 powers of life. I remained with her the rest of the day and the night, 
 during which she was supplied with small cups of hot gruel con- 
 taining brandy ; and at shorter intervals, whenever she felt faint, she 
 took a tea-spoonful of pure brandy, or a piece of bread soaked in it. 
 The faintness gradually ceased, the skin became warm, the pulse 
 more distinct. The cordials were therefore withdrawn, and when I 
 left her the following morning, it was agreed that she should take no 
 other diet than milk with toast and gruel. I heard no more of her 
 for three days, when, on the fourth day after her delivery, I received 
 a letter by post, informing me that she was going on well, and that 
 her pulse was at 80. I had not received this letter above two hours, 
 when an express arrived at my door desiring me to hurry to her as 
 fast as possible. When I arrived I found the same medical men in 
 the house, who told me that she had that morning been suddenly 
 attacked with a severe rigor, and violent pain in the abdomen ; that 
 when the rigor went off the skin became hot, and the pulse rapid ; 
 that the belly was painful, and very tender. They lost no time, but 
 opened a vein in the arm, and took away, they told me, thirty ounces 
 of blood, on which she became very faint, and still continued so. 
 When I went up to her chamber, I found her with sharp features, 
 cold and clammy on her forehead and cheeks, with a pulse scarcely 
 to be felt ; the blood was not buffed. She died before I left the 
 house. The body was not opened, but I could not help comparing 
 this case with those which I have previously related, and conjectur- 
 ing, that if, instead of bloodletting, opium and fomentations had 
 been used, the result might have been more fortunate. 
 
 Thus far my knowledge of these cases was confined to the symp- 
 toms during life, and to the influence of remedies ; but it was not 
 long before I had an opportunity of ascertaining the appearances on 
 examination after death. 
 
 VIII. 
 
 A practitioner sent for me to see a patient, of whom he gave me 
 the following account : She was habitually delicate, and subject to 
 hysteria. After an easy labour of her eighth child, her after-pains 
 had been long and severe, but her pulse was not quick. At six in
 
 PERITONEAL FEVERS. 35 
 
 the evening of the second clay it was soft, and under 80. At four 
 o'clock the next morning, the practitioner was called out of his bed, 
 and found her complaining of great pain and tenderness over the 
 whole abdomen. She had been vomiting; her pulse was quick, 
 but small and weak, and her skin temperate. He immediately bled 
 her, letting the blood flow till she fainted. He next gave her five 
 grains of calomel, and soon afterwards a dose of salts and senna, 
 but the latter was vomited. Two hours after the first bleeding, the 
 pain not having been relieved, he bled her again to fainting. Twelve 
 leeches were applied to the abdomen, and a pill was given her con- 
 taining three grains of opium. Having received this account, I 
 went into the chamber of the patient. Her face was ghastly ; it was 
 difficult to keep her out of a fainting fit ; her skin was cold and 
 clammy, and her pulse so quick, small and fluttering, it could not be 
 counted. I took off the leeches and endeavoured to revive her by 
 warmth and cordials, but she died in the evening, about six hours 
 after my visit, and about thirty from the beginning of pain. The 
 body was opened next day. The peritoneum was healthy, but pale : 
 there were between one and two ounces of colourless serum in its 
 cavity ; the abdominal viscera were all healthy, but pale ; the uterus 
 was contracted in the ordinary degree. 
 
 I feel no doubt, that if, instead of bleeding, the belly had been 
 covered with a perpetual fomentation, and an opiate had been given 
 every four hours, this patient would in a few hours have been quite 
 well. 
 
 Of the last four cases, three occurred at a time when there was 
 no prevailing disease in the Lying-in Hospital, and, as far as I 
 knew, none in London or its neighbourhood ; but the second oc- 
 curred in a neighbourhood where I was told puerperal fever was 
 very prevalent, and two women were lying dead of it when I was 
 there. Within a week after I had seen tins case, T was sent for to 
 the same place to see another case of a similar description, which I 
 treated by opium successfully. 
 
 These cases opened to me a new view of the subject ; they 
 taught me that a lying-in woman might have permanent pain and 
 tenderness of the abdomen, with a rapid pulse, independent of acute 
 inflammation of the peritoneum, or any other part; that these 
 symptoms may depend on a state which bloodletting does not 
 relieve, and which, if this remedy is carried as far as it requires to 
 be carried in peritonitis, may terminate fatally ; and that the most
 
 36 PERITONEAL FEVERS. 
 
 effectual remedies are opiates and fomentations. Most of the 
 patients who were the subjects of these attacks were women who in 
 their ordinary health were delicate, and sensitive ; the attack some- 
 times seemed to originate in violent after-pains, gradually passing 
 into permanent pain and tenderness, resembling inilammation ; or 
 in the painful operation of an active purgative ; but it could some- 
 times be traced to no satisfactory cause ; the patient had a common 
 labour, and had experienced no unusual cause of debility or irrita- 
 tion. The pulse in all these cases, although quick, was soft and 
 feeble ; this together with the previous constitution of the patient 
 were my chief guides; when I could trace it to any irritating 
 cause, such as a griping purge, and when blood had been already 
 drawn without relief, and without being buffed, I saw my way still 
 clearer. When I doubted, I applied leeches to the abdomen. 
 
 The cases which I have related, and others similar to them, were 
 speedily and completely relieved by the remedies winch I have 
 mentioned. There seemed to be nothing dangerous in tins form 
 of disease, provided the nature of it was not mistaken, and 
 improper remedies not used; yet it so strikingly resembled 
 peritoneal inflammation, that it was invariably taken for it by the 
 practitioners who witnessed it, all of whom possessed at least that 
 average quantity of sense and knowledge on winch the public must 
 extensively depend. These cases, though sufficiently numerous to 
 attract my notice, aud produce a strong impression on my mind, 
 were nevertheless only occasional occurrences. I had never seen them 
 in numbers at the same time ; they occurred at comparatively long 
 intervals, and at times when there was no prevalent disease among 
 lying-in women ; they resembled sporadic diseases, both in the rarity 
 of their occurrence, and in the facility with which they were cured.' 
 At the hospital I saw two or three cases, in which, after the ordi- 
 nary symptoms of puerperal fever had terminated fatally and the 
 body was opened, the usual morbid appearances were not found ; 
 nothing appeared but a moderate quantity of fluid stained with 
 blood. I thought something, but not much, of these. When cases 
 occur at long intervals, the effect of one fades in the mind before 
 thai of another is made, so that they do not mingle, and produce a 
 distinct impression; but when they come in clusters at the same 
 time, they rouse the thinking powers of the mind; one case casts a 
 strong light upon the other, and the result is the formation of de- 
 cided opinions. 

 
 PERITONEAL FEVERS. 37 
 
 In the winter of the year 182i, puerperal fever was prevalent and 
 fatal in London and its neighbourhood. I had resigned my office at 
 the Westminster Lying-in Hospital, and did not know, or do not 
 remember, what was going on there ; but I saw this disease repeat- 
 edly in consultation, and heard of it among my medical friends. 
 Several instances occurred of its prevalence among the patients of 
 particular practitioners, whilst others who were equally busy met 
 with few or none. One instance of this kind was very remarkable : 
 a general practitioner in large midwifery practice lost so many 
 patients from puerperal fever, that he determined to deliver no more 
 for some time, but that his partner should attend in his place. This 
 plan was pursued for one month, during which not a case of the 
 disease occurred in their practice. The elder practitioner being 
 then sufficiently recovered, returned to his practice ; but the first 
 patient he attended was attacked by the disease and died. A 
 physician who met him in consultation soon afterwards about a case 
 of a different kind, and who knew nothing of his misfortune, asked 
 him whether puerperal fever was at all prevalent in Iris neighbour- 
 hood ; on which he burst into tears, and related the above circum- 
 stances. 
 
 Among the cases which I saw this season in consultation, four 
 occurred in one month in the practice of one medical man, and all 
 of them terminated fatally. 
 
 IX. 
 
 The first case occurred in a lady, who had been delivered of her 
 first child, after a long and severe labour, not from deformity of 
 bones, but from rigidity of the soft parts and the bulk of the child ; 
 it occupied nearly three days. When visited the day after delivery, 
 she was found complaining of considerable pain in the abdomen, 
 great tenderness, oppression at the prsecordia, and difficult breathing. 
 The pulse was rapid, but the most remarkable symptom was immense 
 distension of the abdomen, which separated the recti muscles to the 
 distance of two hands' breadth, and protruded between them the 
 anterior wall of the abdomen to a considerable elevation. The 
 projection was returned into the abdomen, and supported by straps 
 of adhesive plaster. The feebleness of the pulse, the exhausted 
 state of the patient, prevented blood from being drawn, but a gentle 
 purge was given. After this had operated, the pain being worse, 
 twenty drops of laudanum were given, and repeated every two hours
 
 38 PERITONEAL FEVERS. 
 
 for several closes ; but she sunk quietly, and died on the third day 
 after delivery. The body was opened the next day. The intestines 
 were found enormously distended with air, but in the peritoneum 
 there was neither redness, adhesion, nor effusion of any kind. 
 
 X. 
 
 The second case occurred after a common labour of the fourth 
 child. An opiate was ordered for the after-pains, and the patient 
 was quite well when visited on the second day. On the evening of 
 the third she was found to have a diffused pain and tenderness of 
 the belly, with pulse of 140, and not weak. The symptoms had 
 not lasted six hours, the bowels had been emptied by a purgative, 
 fourteen ounces of blood were taken away immediately, and two 
 grains of calomel, with five of compound powder of ipecacuanha, 
 were given every four hours. A few hours afterwards, the pain and 
 tenderness continuing, ten ounces more of blood were taken away, 
 by which she was much relieved. The next day she was not so 
 well, the belly was distended and uneasy, the pulse was quick and 
 weak, and the aspect of the patient very unpromising. A blister 
 was applied, and the calomel was continued, but she sunk rapidly 
 and died, little more than two days from the commencement of the 
 symptoms. The body was opened the next day, but there was 
 neither redness nor adhesion of the peritoneum, nor effusion of any 
 kind into its cavity. 
 
 XI. 
 
 In the third case, the symptoms began thirty-six hours after 
 delivery. The remedies employed were a bleeding of twelve ounces, 
 an emetic, a purgative, and the opium and calomel, with a view of 
 affecting the constitution as soon as possible with mercury ; but the 
 rapidity of the disease baffled all these remedies, and the patient 
 died on the third day. The body was opened the following day, and 
 no vestiges of inflammation were found in the peritoneum. 
 
 XII. 
 
 In the last case the patient was delivered after a labour attended by 
 no unusual circumstances. She was seen in the evening of the second 
 day, when she appeared quite well, complained of nothing, and had 
 a slow pulse. She continued well till seven the next morning, 
 when she was seized with pain and tenderness of the belly, but it 
 was not swelled. 1 saw her at ten o'clock, that is, three hours from
 
 PERITONEAL FEVERS. 39 
 
 the commencement of the attack. Her pallid and weakly appear- 
 ance, the feebleness of her pulse, the total absence of those symptoms 
 in which 1 had formerly been so successful with the lancet, and its 
 unfavourable effects in the cases in which I had seen it employed 
 this season, made me unwilling to employ it. But the patient's 
 husband was anxious that some leeches should be applied ; because 
 a few years before she had recovered from what appeared to him a 
 similar illness, under the care of a very eminent physician, from the 
 use of leeches ; and the aspect of the case was so decidedly unpro- 
 mising, that we were unwilling to deprive him of this consolation. 
 Twelve, therefore, were applied to the abdomen, without loss of 
 time, and twelve more subsequently. 
 
 Ou the evening of the second day of her illness, when I went into 
 her bed-chamber, I found her medical attendant at the bed-side 
 with a decanter of wine, of which he was giving her a spoonful. 
 She was free from pain, calm, and clear-headed ; but she was pale, 
 faint, breathless, cold, and had little pulse. Excepting only rest- 
 lessness, she looked exactly like a woman dying from haemorrhage. 
 The cordials revived her for a few hours, but she died the next 
 morning at four o'clock. The last lying-in patient whom her nurse 
 had attended had died of a similar disease, ecpially rapid in its 
 course. 
 
 I do not relate these cases to prove the inefficiency of full and 
 early depletion, for in two it was not used, and in the others not 
 carried to an extent which would satisfy the advocates for this prac- 
 tice. The treatment was chiefly conducted by one of the best prac- 
 titioners I have ever known, but who had already lost confidence in 
 the lancet in the epidemic then prevalent ; but I produce them on 
 account of the appearances on dissection, winch indicate a disease 
 very different to that winch occasions a copious effusion of lymph 
 and serum into the peritoneum. 
 
 Most of the cases I saw tins season were the patients of others, 
 and I visited them only occasionally; the task of watching and 
 superintending the treatment of course devolving on the ordinary 
 attendant. But I will relate one case winch I saw from beginning 
 to end, and winch bore a striking resemblance to the others. 
 
 XIII. 
 
 The patient was a lady, whom I had attended in several confine- 
 ments, but who was tin's time to lie in at a short distance from town,
 
 40 PERITONEAL FEVERS. 
 
 under the care of the neighbouring surgeon. She was a plump, pale, 
 relaxed woman, with a languid circulation, and subject to nervous 
 attacks. She had a weak stomach, was often troubled by flatulence, 
 at which times dry friction with the hand along the spine would 
 produce the expulsion of a prodigious torrent of air from the mouth 
 with an extraordinary noise ; tins was her state in her ordinary 
 health. Her labour was very quick ; when visited on the second 
 evening she was quite well ; the following morning, being still well, 
 she took the usual purgative of salts and senna ; it operated violently 
 and painfully, and this was followed by diffused pain and tender- 
 ness of the abdomen with a rapid pulse. She could neither turn in 
 bed nor bear pressure on the abdomen ; but her skin was not hot, 
 and her pulse not hard. Tins was the state in winch I saw her about 
 eight hours from the commencement of pain. I gave her twenty 
 minims of Battley's laudanum, to be repeated every two hours for 
 three doses ; and I ordered the abdomen to be covered with a bag 
 of scalded bran. I saw her in the evening at eight o'clock ; the 
 pain of the abdomen was easier, but the pulse was rapid ; she could 
 not bear to turn, or to be pressed upon ■ the belly was larger than 
 in the morning, and the breathing hurried. I now explained to her 
 husband the danger of her condition, and said that if he wished for 
 a consultation, in justice to the patient and to the physician, it 
 ought to be now, not later ; about two hours afterwards we succeeded 
 in procuring the attendance of an eminent and able physician. The 
 chief question was about bloodletting ; the aspect of the case was 
 very unfavourable, and I believe the consideration that, if it termi- 
 nated fatally, more regret would be felt at the neglect of bloodletting 
 than at the employment of it, in the prevalent state of medical 
 opinion on the subject, determined us to use it. As it was now, if 
 ever, that bloodletting was to be useful, we determined to carry it 
 to faintness. The gentleman who blooded her did not practise mid- 
 wifery, and had no experience of such cases ; but when he felt the 
 pidse before bleeding, he remarked that though quick (it was nearly 
 130) it was soft. The blood spouted from the arm during the filling 
 of the first two cups, and the fifth cup was more than half full before 
 she felt faint ; twelve leeches were next applied to the belly, and 
 these were succeeded by the bag of scalded bran ; she took a full 
 opiate that night, and the following morning two drachms of sulphate 
 of magnesia every four hours. When we met, however, the following 
 day, she was much worse; her belly was tumid, her breathing short,
 
 PERITONEAL FEVERS. 41 
 
 her pulse quick and tremulous, and her mind rambled. An attempt 
 was now made to support, her with cordial diet, but she became 
 rapidly worse, and died in the middle of the next night, less than 
 forty-eight hours from the commencement of her symptoms. The 
 body was not opened. 
 
 In all these cases, the striking circumstances were the rapidity of 
 the disease, which was shorter than three days, and the absence of 
 morbid appearances in the peritoneum after death, although during 
 life the whole surface of the abdomen had been painful and tender, 
 and the pulse had been rapid as in puerperal fever. Death came on 
 like faintness j the patients got weaker and weaker, hour by hour, 
 and then died. 
 
 "Whilst this form of disease has been going on in London and its 
 neighbourhood, it has not been unknown in other parts of the island. 
 In Dr. Farre's Journal of Morbid Anatomy,* Mr. Dalrymple, of 
 Norwich, has described a marked case of this kind. 
 
 XIV. 
 
 The patient, forty-two hours after a very quick labour, was seized 
 with shivering, succeeded by heat, a hard pulse of 130, great pain 
 and tenderness of the abdomen, with some swelling. She was seen 
 Jive hours from the attack, and eighteen ounces of blood were taken 
 from the arm ; a calomel purge was given, followed by a mixture of 
 salts aud senna. Six hours afterwards she was visited again ; her 
 pulse was now quick but weaker, and her abdomen more tumid, and 
 exquisitely tender. Twenty-four leeches were applied to the lower 
 part of the abdomen ; an ample blister to the upper ; aud fifty drops 
 of the sedative solution of opium were given at a dose. In the 
 evening the pain was less violent, but the tenderness undiminished. 
 Mercurials, with saline aperients and hyoscyamus, were given, but 
 the next morning she was found sinking. At noon the collapse 
 was general, and she seemed unconscious of what was going on 
 around her in the chamber. At five in the afternoon she died, only 
 forty-five hours from the commencement of the disease. On opening 
 the body, no increased vascularity of the peritoneum, no adhesion of 
 its contiguous surfaces, no abundant effusion of lymph and serum 
 were found ; the only morbid appearances were slight redness along 
 the Fallopiau tubes, and about two ounces of turbid serum iu the 
 
 * No. I, page 38.
 
 42 
 
 PERITONEAL FEVERS. 
 
 cavity of the peritoneum. "Within seven weeks seven similar cases 
 had occurred to different practitioners in the neighbourhood of 
 Norwich, and all died within fifty hours of the attack. The patient, 
 whose case I have related, was the wife of a farmer, in whose dairy 
 apartment a number of cows after calving had been attacked by a 
 disease similar to puerperal fever, and she had taken great interest 
 in the treatment of the sick animals. This occurred in the winter 
 of 1827 and 1828. 
 
 These are the chief facts in the case, related by Mr. Dalrymple ; 
 but, being anxious to know the leading points in the other seven 
 cases, I wrote to him for them, and the following is the substance 
 of his answer, which I shall throw into the form of a table, in which 
 the reader will see at one view the character of the pulse, the time 
 at which bloodletting was employed, the extent to which it was 
 carried, and the appearance of the blood. 
 
 Case. 
 
 1 
 
 2 
 3 
 
 4 
 5 
 6 
 
 7 
 8 
 
 Pulse. 
 
 Time of 
 Bleeding. 
 
 Quantity. 
 
 Appearance of 
 Blood. 
 
 hard 
 
 hard 
 quick, hut not hard 
 
 soft 
 
 not hard 
 
 f very quick and "1 
 
 1 feeble J 
 
 quick and feeble 
 
 5 hours 
 
 4 hours 
 very early 
 
 7 hours 
 
 J 8 ounces, 24 
 \ leeches 
 
 42 ounces 
 J 18 ounces, and 
 X leeches 
 J" bled from arm, 
 \ and leeches 
 
 24 ounces 
 J" 18 ounces, and 
 X leeches 
 
 very large 
 
 very large 
 
 f less buffed and 
 < cupped than 
 L was expected 
 buffed and cupped 
 
 V not cupped 
 
 J neither buffed 
 X nor cupped 
 cupped and buffed 
 J neither buffed 
 X nor cupped 
 
 In the winter of 1827 and 1828 cases of peritoneal fever were 
 very common among the in- and out-patients of the Westminster 
 Lying-in Hospital ; and a journal was kept, and an account of them 
 published, by Mr. J. A. Hingeston, who was then residing as house- 
 surgeon of the hospital.* These cases were all attended by pain 
 and tenderness of the belly, with a rapid pulse; the pain remitted, 
 the skin was moist, and the pulse full and compressible. Most of 
 them were cured, without the lancet, by keeping the abdomen co- 
 vered with a large, thin, hot linseed-meal poultice, and giving ten 
 
 * See London Medical Gazette, No. XI.
 
 PERITONEAL FEVERS. 43 
 
 grains of compound powder of ipecacuanha, repeated till the pain 
 was gone. If the bowels were constipated, a purgative was pre- 
 viously given; if they were not so, the purgative was postponed 
 till the pain had subsided. In one case, the dry skin and sharp 
 pulse indicating that the affection of the peritoneum was acutely 
 inflammatory, twenty ounces of blood were drawn from the arm; 
 ten grains of compound powder of ipecacuanha, with two of calomel 
 were given, and calomel alone was repeated every six hours ; twelve 
 leeches were applied to the abdomen, and afterwards a linseed-meal 
 poultice. The gums became sore in twenty-four hours, and the 
 patient recovered ; but after the bleeding she had frequent faintings 
 for several hours, and ' life was reduced to a low ebb.' A striking- 
 contrast this to the way in which bleeding to double this extent was 
 borne in the peritoneal fevers from 1810 to 1820. Mr. Hingeston 
 thinks that these cases, which are cured by opium, are the first stage, 
 a lower degree of that acute inflammation which requires the lancet. 
 
 For the following particulars I am indebted to Dr. Ferguson, one 
 of the present physicians to the Westminster Lying-in Hospital. 
 
 During the late autumn and winter, there has been much sickness 
 for so small a hospital. To say nothing of the out-patients, sixty- 
 two in-patients were admitted between September 11, 1828, and 
 February 20, 1829; of these, twenty-eight (that is, nearly half the 
 number) had peritoneal fever ; and of these, seven died, that is, one 
 in four. A large proportion of them were cured at once by ten 
 grains of the compound powder of ipecacuanha, every three or four 
 hours for three doses, and a hot linseed-meal poultice over the whole 
 belly. Sometimes this treatment removed the pain, but not the 
 soreness ; but this was generally removed by the application of leeches. 
 As soon as the symptoms were subdued, the bowels were opened by 
 a mild purge ; when these remedies failed the case was a bad one. 
 It may be said by the advocates for bloodletting, that these bad 
 cases might have been saved if they had been blooded and purged 
 early and actively; but in those in which the lancet was used, how- 
 ever early, its effect was discouraging. The patients fainted after 
 losing a few ounces, the blood bore no marks of inflammation, and 
 the remedy was followed by great and immediate exhaustion ; even 
 leeches, when applied in considerable numbers, and when they bled 
 profusely, in some cases seemed to occasion great exhaustion. But 
 in the cases which I have related from my own experience the lancet 
 was used as early and actively as the warmest advocate for depletion
 
 44 PERITONEAL FEVERS. 
 
 could wish. Case No. 6 was blooded without relief, and was imme- 
 diately relieved by opiates and fomentations. Cases 7 and 8 were 
 blooded immediately on the attack of pain, the former to thirty 
 ounces at ounce, the latter twice to faintness, besides leeches, calomel 
 and senna mixture, and they immediately and speedily sunk under 
 the remedies. Of the four cases which occurred to one practitioner, 
 No. 10 was blooded immediately after the attack in the evening, 
 and the bleeding was repeated the following morning. The Case 
 No. 13 began during the violent operation of a purgative; the pa- 
 tient was blooded to faintness about fourteen hours after the attack, 
 the blood was not buffed, and she never rose out of the exhaustion 
 which followed. Iu the case related by Mr. Dairy mple the patient 
 was blooded freelyfive hours from the attack, and the effect was similar. 
 
 In Dr. Farre's remarks, introductory to his Journal, he states 
 that ' at the east end of London, not far from the river, this disease 
 ' (puerperal fever) proved still more fatal during the month of March 
 ' (1825). One surgeon informed the editor that he had lost seven, 
 ' another four, in all of which the disease was treated at the instant 
 ( of its formation by active bloodletting. A physician-accoucheur, 
 1 who attended in consultation many of these cases, stated to him, 
 ' that out of thirteen cases eleven died ; that all which had been 
 ' bled died ; and that the only two which recovered had not been 
 ' bled, having been treated by turpentine/ 
 
 From a severe illness this winter, which has unfitted me for the 
 active duties of my profession, I have seen little of the peritoneal 
 fevers of this season, but of what I did see the following case seems 
 to me worth relating. 
 
 XV. 
 
 Mrs. had had, after a former lying-in, a loosening of the bones 
 
 of the pelvis, from which she had suffered long, but had completely 
 recovered, and was in good health and strong on her legs up to the 
 moment of her present labour. She was delivered on Saturday morn- 
 ing at seven o'clock, and continued quite well till Sunday afternoon 
 at two. She had then a shivering, which lasted about twenty minutes, 
 succeeded by dry heat, a quick pulse and pain all over the abdomen ; 
 for this she took a purgative, which operated fifteen times. On Mon- 
 day afternoon at two o'clock she had another shivering, and continued 
 feverish and restless. Opiates and aperients were given, and during 
 Monday and Tuesday the pain of the abdomen had so nearly subsided
 
 PERITONEAL FEVERS. 45 
 
 that it attracted no notice : still she never felt quite easy in that 
 part. On Tuesday evening she was feverish, restless, and had pain 
 of the head, for which leeches were applied ; and afterwards, late 
 at night, six ounces of blood were taken from the arm. At this 
 time she complained of no pain either in the belly or back, and could 
 turn in bed with perfect ease ; her symptoms were merely fever, rest- 
 lessness, and head-ache. Early the next morning (Wednesday) her 
 attendant was called up to her, and found that she had passed the 
 night without sleep, and that new symptoms were added to her former 
 ones ; they were pain and tenderness of the abdomen, and still more 
 pain in the sacrum, where the bones of the pelvis had formerly 
 separated. As the pulse was 120, and hard, fourteen ounces of 
 blood were taken from the arm, and I saw her for the first time tins 
 day at one o'clock. The pain and tenderness of the abdomen were 
 still so severe, especially in the right iliac region, that she could not 
 breathe without stopping and crying out ; and turning from her side 
 to her back was so painful, partly from the tenderness of the belly, 
 and partly from the pain of the sacrum, that it occupied a minute or 
 two ; the uterus was large, and could not bear pressure; above the 
 umbilicus the abdomen was soft, and without tension : the breasts 
 contained no milk, the lochia were scanty, the pulse, which before 
 the bleeding in the morning had been hard, was soft, and 120 ; the 
 bowels had been freely purged, and had acted that morning. The 
 treatment agreed upon now was as follows : Twelve leeches were to 
 be applied to the paiuful part of the abdomen ; it was then to be 
 kept constantly covered with a linseed-meal poultice, and when the 
 bites ceased to bleed, fourteen more leeches were applied, succeeded 
 by the poultice. She took twenty minims of the sedative solution of 
 opium immediately ; she was to take two grains of calomel every 
 three hours, and five grains of the compound powder of ipecacuanha 
 every six hours, that is with every other dose of the calomel. 
 When we met the next day (Thursday) every symptom was 
 better excepting the pulse ; the pain and tenderness of the abdomen 
 were gone, and she could bear firm pressure, and could breathe 
 without inconvenience; the belly was soft and un distended ; the 
 uterus was much smaller, and the lochia copious. She was in a 
 warm perspiration, and her breasts were full of milk, but her pulse 
 was still at 120. As the bowels had not acted for thirty hours, the 
 compound powder of ipecacuanha was discontinued, and a dose of 
 salts and senna given ; this was at two in the afternoon. At eleven
 
 46 PERITONEAL FEVERS. 
 
 in the evening, when her attendant visited her, she was not so well : 
 she was in no pain, but her cheek was red, she was in a great heat 
 and perspiration, and there was something about her aspect which 
 he did not like. When I went the next day (Friday) to the con- 
 sultation, I found the family in alarm, and was told that there had 
 been a great change in the patient for the worse. The pain and 
 tenderness of the abdomen had never returned, but her mind was 
 confused; she was distressed with excessive flatulence, and the 
 abdomen had suddenly become large and tympanitic ; yet the pulse 
 was only 116 ; the purgative had operated copiously, the gums were 
 sore, and the tongue swelled. I had omitted to say that there was 
 an inflammation about the right wrist which threatened to break. 
 Prom the state of the mouth the calomel was withdrawn, and a dose 
 of turpentine and castor oil ordered every three hours. In the evening 
 she was still worse, bursting with flatulence, more confused in mind, 
 and with a quicker pulse — 128. She had had many little fluid 
 motions, with a vast quantity of wind. The danger seemed so near 
 that we made no appointment for the next day, and I never saw her 
 again. She died that morning at seven o'clock, that is, about fifty 
 hours from the second attack of pain of the belly. 
 
 The body was opened the next day by Mr. Stanley. Putrefaction 
 had made rapid progress for the time. The orifice in the vein of the 
 arm, made four days before, had opened after her death, and dis- 
 charged about half a pint of blood. On opening the abdomen the 
 intestines were found immensely distended with air ; there was no 
 redness of peritoneum, no adhesion of its surfaces. In the lower 
 part of the abdomen there was about three ounces of a bloody trans- 
 parent fluid. In both ovaries the internal glandular structure was 
 entirely gone, leaving only a hollow empty caj^sule ; in that of the 
 right ovary there was an aperture. The Fallopian tube on both 
 sides contained pus, not at the uterine, but at the fimbriated end. 
 There was no pus in the uterus ; tins organ was perfectly healthy : 
 its veins were examined, and were undiseased ; its inner surface was 
 of a bright pink, more irregular at the part where the placenta 
 generally adheres. The joints of the pelvis were next examined; 
 the symphysis pubis moved readily : on cutting into it the cartilages 
 were sound, but the space between them contained a bloody fluid. 
 The sacro-iliac joints were still more affected; the sacrum projected 
 from the ossa innominata half an inch; within the joint was a 
 bloody fluid mixed with some loose lymph.
 
 PERITONEAL FEVERS. 47 
 
 Iii reflecting on the above narrative it is natural and important 
 to ask, what occasioned the fair prospect which presented itself on 
 Thursday to he on Friday so suddenly overcast ? Two things were 
 done ; the opium was withdrawn, and a purgative of senna and salts 
 was given. "Would it have been better to have merely withdrawn 
 the opium, and left the calomel alone to act as a purgative ? or if a 
 purgative had been given, would a different kind, such as aloes, have 
 been less liable to bring on this enormous flatulence of the alimen- 
 tary canal ? Whoever thinks that a copious effusion of serum and 
 lymph is the essential appearance after death in puerperal fever, 
 will of course conclude that this lady did not die of that disease, but 
 of disease in the joints of the pelvis. Let him reflect, however, 
 1st, that a loosening of the joints of the pelvis is common as a 
 chronic disease, but comparatively rare as an acute one which is 
 rapidly fatal ; 2nd, that the history of the case during life is exactly 
 that of puerperal fever ; and 3rd, that the scanty effusion of bloody 
 serum, instead of a copious effusion of serum and lyniph, is exactly 
 the appearance after death which has been found in the puerperal 
 fever of tins and the last few years. I am inclined to believe that 
 it was a case of puerperal fever, made irreparable by being compli- 
 cated with disease in the sacro-iliac joints ; but these are questions 
 which it is easier to put than to answer, and they will be answered 
 by readers more or less confidently, not in proportion to the accuracy 
 and extent of their knowledge, but in proportion to the confidence 
 of their disposition. 
 
 The foregoing facts, and many others similar which I could relate, 
 permit me no longer to doubt that there is a form of peritoneal fever 
 in child-bed, winch, although it has the ordinary symptoms — pain 
 and tenderness of the belly, with a rapid pulse — is very different 
 from the peritoneal fevers winch prevailed between 1810 and 1820 ; 
 different in its duration, which is much shorter ; in the way in 
 which it is affected by bloodletting; and lastly, in the morbid 
 appearances discovered after death. This form of the disease, like 
 the acute inflammatory form, may occur only occasionally or spora- 
 dically, when it is readily and speedily cured by opiates, fomenta- 
 tions, gentle aperients, and sometimes leeches ; or it may become 
 prevalent or epidemic, and consecpiently more malignant ; in other 
 words, more fatal and difficult to cure. 
 
 The most remarkable circumstance which the experience of the 
 last few years has taught us about peritoneal fevers is, that they
 
 48 PERITONEAL FEVERS. 
 
 may occur in their most malignant and fatal form, and yet leave 
 few or no vestiges in the peritoneum after death. The state of this 
 membrane, indicated by pain and tenderness of the abdomen, with 
 a rapid pulse, appears to be not one uniform state, but one which 
 varies so much in different cases, that a scale might be formed of 
 its several varieties ; this scale would begin with little more than 
 a nervous affection often removable by soothing remedies, and when 
 terminating fatally, leaving no morbid appearances discoverable after 
 death. Next above this, a state in which tins nervous affection is 
 combined with some degree of congestion, indicated in the cases 
 which recover, by the relief afforded by leeches, and in the cases 
 which die, by slight redness in parts of the peritoneum, and a slight 
 effusion of serum, sometimes colourless, sometimes stained with 
 blood. Above this might be placed those cases in which there are, 
 in the peritoneum, the effusions of inflammation without its redness, 
 namely, a pale peritoneum and no adhesions, lymph like a thin 
 layer of soft custard, and a copious effusion of serum rendered turbid 
 by soft lymph. Lastly, the vestiges of acute inflammation of the peri- 
 toneum, namely, redness of this membrane, adhesion of its continuous 
 surfaces, a copious effusion of serum, and large masses of lymph. 
 
 The experience of the last few years has brought me to this con- 
 clusion : that the sanguine hopes which were entertained, a few 
 years ago, that the peritoneal fevers of lying-in women are always 
 of an acute inflammatory type, and always to be cured by early 
 bleeding and purging, as they were not borne out by the reasoning 
 employed, so they have not been confirmed by subsequent expe- 
 rience. 
 
 It is useless to look back on the past, unless for the purpose of 
 guiding our conduct in the future. How are we to act, when new 
 epidemics arise among lying-in women, so as to diminish as much 
 as possible their fearful mortality ? 
 
 The first and most important object — that without which all 
 others will be useless — is to make such arrangements as will ensure 
 to the practitioner a sight of the patient immediately after the 
 attack. I believe that half the mortality which these epidemics 
 occasion depends on delay, on so much time being lost before effi- 
 cient treatment is employed, that the curable stage is over before 
 this treatment has began. "Whatever may be the nature of the case
 
 PERITONEAL FEVERS. 49 
 
 or epidemic, and whatever may be the remedies essential to its 
 cure, they have not a fair chance of success unless employed during 
 the first hours of the disease. The arrangements necessary to pre- 
 vent delay must depend on those who have the immediate charge of 
 lying-in women, namely, the physicians of Lying-in hospitals, and, 
 in private families, on those who deliver the patients and have the 
 charge of them. These must depend on the more immediate attend- 
 ants, nurses, commonly a most intractable race ; but no pains ought 
 to be spared to make them understand the symptoms which demand 
 attention, and no temptations to induce them to send for the prac- 
 titioner the instant these symptoms appear. The latter must not, 
 for fear of being troubled by false alarms, shrink from a plan so 
 essential to the life of his patients, to his success, his reputation, 
 and, I should think, his peace of mind. 
 
 During the first day or two of the disease, while active remedies 
 are employed, and the life of the patient is hanging in the balance, 
 the practitioner can hardly do his duty without seeing the patient so 
 often that he almost lives with her, and becomes not only her phy- 
 sician, but her nurse. I shall be told that this is impossible; so 
 much the worse ; it is not the less urgently necessary. 
 
 The next thing that I would urge on practitioners of midwifery, 
 is, to undertake the treatment of these diseases with the belief that 
 they depend not on one and the same state, acute inflammation of 
 the peritoneum, demanding one and the same treatment, bleeding and 
 purging, but that they depend on different states in different cases, 
 and epidemics, which require so much caution and discrimination to 
 distinguish, that the most cautious and discriminating practitioner 
 will sometimes err. They should approach the subject in the spirit 
 of their great master, Sydenham, who, in speaking of epidemic 
 diseases, tells us that l their difference is apparent, not only from 
 ' their peculiar symptoms, but also from the different methods of 
 ' cure they respectively require ; that though they seem to agree in 
 ' their external face, and certain symptoms in common, they are in 
 ' reality of very different and dissimilar natures ; that the same 
 ' method which cures in the middle of the year may possibly prove 
 ' destructive at the conclusion of it ; and that, when a new species 
 ' arose, he was doubtful how to proceed, and, notwithstanding the 
 ' utmost caution, could scarce ever preserve one or two of his first 
 ' patients from danger/ There are no diseases to winch these 
 
 E
 
 50 PERITONEAL FEVERS. 
 
 remarks are more applicable than the peritoneal fevers of lying-in 
 women. 
 
 Lastly, I would urge practitioners of midwifery to make themselves 
 familiarly acquainted with those modes of treatment which appear on 
 competent testimony to have been, at times at least, most successful, 
 so as to have them ready to apply when the occasion occurs. In 
 most of the epidemics which I have read of or witnessed, many cases 
 occurred, and many lives were lost, before the practitioners, who 
 were concerned about them, had time to overcome the panic which 
 they produced, to put their knowledge in order, and proceed to 
 the treatment of the disease with clear and methodical views. Much 
 of this would be avoided if they previously made up their minds, out 
 of what remedies their selection ought to be made. In acquiring 
 this knowledge it is not superfluous to say, that it will be of no 
 value unless it is rigidly and scrupulously accurate, consisting of a 
 minute knowledge, not only of the remedies themselves, but of the 
 times for employing them, the extent to which they ought to be 
 carried, and all the circumstances on which their successful employ- 
 ment depends. A want of this strict and minute accuracy is one of 
 the causes why remedies, winch have been so successful in some 
 hands, so often fails in others. 
 
 The remedies for the efficacy of which there is most evidence are, 
 1st, bleeding and purging; 2d, emetic doses of ipecacuanha; 3d, 
 opiates internally, and poultices externally to the abdomen; 4th, 
 mercury given so as to affect the constitution ; 5th, oil of turpentine. 
 
 I. There is a class of peritoneal fevers in which the affection 
 of the peritoneum is acute inflammation, and that of the con- 
 stitution is inflammatory fever, although this inflammatory state 
 often lasts only a few hours. These cases may occur not only 
 occasionally or sporadically, but become prevalent or epidemic. On 
 this point, those who wrote toward the end of the last century were 
 in an error, supposing that whenever the disease was epidemic, it 
 was of a low typhoid type ; there can be no doubt, that among the 
 peritoneal fevers of lying-in women there are inflammatory epidemics, 
 but how are we to know that the case or the epidemic is of this kind ? 
 by attending to what Sydenham called the ' Constitution of the 
 year/ that is, in plain language, the prevailing state of the human 
 body indicated by its prevailing diseases, and by the modes of treat- 
 ment which these diseases bear and require; by the character of the
 
 PERITONEAL FEVERS. 51 
 
 pulse during the early hours of the disease, and by the effect of 
 depletion. Thus, when the prevailing diseases are inflammatory, 
 and are best cured by depletion, when the pulse at the beginning of 
 the disease is vibrating, hard, or, although small, is incompressible, 
 when the skin is not only hot, but dry, and when, after the treat- 
 ment of a few cases, it appears that those have recovered best in 
 which bleeding and purging have been used early and freely, there 
 is every reason to believe that we have lighted on an inflammatory 
 epidemic, and that depletion is the means on which we must depend 
 for the cure. I have said so much about the necessity of employing 
 it early, and with sufficient activity to extinguish the disease during 
 the first day, that I need not repeat it. Some able practitioners, after 
 the first full bloodletting, have advised the pulse to be closely 
 watched, and as soon as it has recovered its quickness and hardness, 
 to open the vein again, and draw a small quantity of blood, and so 
 on at short intervals till the pain is gone and the pulse ceases to 
 be hard; this, of course, will not be necessary many times. M. 
 Husson, of the Hotel Dieu, who is so distinguished for his skill 
 in puerperal diseases, after one bleeding of fifteen or twenty 
 ounces, repeats a smaller bleeding of eight or ten ounces, once 
 in six hours, during the first day, till the inflammation is 
 subdued. 
 
 II. Emetics of ipecacuanha, once so successfully employed by 
 M. Doulcet, in the Hotel Dieu in Paris, have such strong evidence 
 in their favour, that they deserve a fuller trial than they seem ever 
 to have received in this country ; the form of the disease in which 
 M. Doulcet employed them, was that which occasions profuse effusion 
 into the peritoneum. The conditions under which they ought to be 
 given are these : 1, they are to be used at the instant of attack ; £, 
 they are to be repeated every day till the symptoms are subdued ; 
 3, in the intervals between the operation of the emetic a potion is 
 to be given, composed of oil of almonds, syrup of marshmallows, and 
 Kermes' mineral ; 4, the diet is to consist of nothing but linseed tea, 
 or something ecnially bland and unheating. I see no chance of this 
 practice being fairly tried, without entrusting the first emetic to the 
 constant attendants of the lying-in patients, giving them a strict 
 charge to send immediately afterwards to the practitioners. Those 
 who have criticised this mode of treatment have been dissatisfied by 
 the circumstance, that the disease was extinguished so completely in 
 embryo, that it was impossible to be certain what it was ; but this is
 
 52 PERITONEAL FEVERS. 
 
 a feeble objection contrasted with the fact, that every patient so 
 attacked died of the disease before the remedy was employed, but 
 after its employment every patient so attacked, and so treated, 
 recovered. 
 
 III. The power of mercury as a remedy for inflammation has been 
 so clearly made out in inflammation of the eye, the liver, and the 
 pericardium, and not only its power, but the inadequacy of blood- 
 letting to overcome inflammation in these organs without the aid of 
 this remedy, that it deserves a fair trial in peritoneal fevers. I have 
 never given it systematically in a number of cases, but what experi- 
 ence I have is in its favour. In the Westminster Lying-in Hospital, 
 when ten or twenty grains of calomel used to be given every day, 
 with purgatives, the gums sometimes were affected, and these patients 
 invariably recovered. During the last winter it was tried in a few 
 cases ; when the gums became affected the patients recovered ; but in 
 others the disease was more rapid than the remedy, and the patients 
 died without the mercury having affected them. The method of 
 using it is to give two grains of calomel every two hours, until the 
 gums become sore, or without this effect, until there is evidence 
 that the circulation is drawn from the peritoneum to other surfaces, 
 especially the bowels, the kidneys, and the skin ; and this is attended 
 by a subsidence of the disease, indicated by a diminution in the 
 frequency of the pulse, a cessation of the pain, and the patient being 
 able to turn in bed, and bear pressure. During the use of the 
 calomel, opium generally requires to be used at longer intervals, as 
 five or ten grains of the compound powder of ipecacuanha once in 
 four hours. The symptoms which call for its use are severe pain, 
 profuse purging, or a sinking in the general circulation. When the 
 gums are sore, or the disease has yielded, the calomel should not 
 be withdrawn suddenly, but given at longer intervals, or in smaller 
 doses, and so gradually withdrawn. This is the way in which it has 
 been used successfully by Dr. Farre. 
 
 IV. There is a class of cases attended by pain and tenderness of 
 the abdomen, with a rapid pulse, which does not require bleeding, 
 which does not bear it to the extent to which it is necessary in the 
 inllammatory peritoneal fevers, and which is speedily and effectually 
 cured by opiates internally, with hot poultices to the belly, aperients, 
 and sometimes leeches. There is reason to believe that this form of 
 the disease is present when the patient in her ordinary health is 
 delicate and nervous — when the pain and tenderness have followed
 
 PERITONEAL FEVERS. 53 
 
 any irritating cause, such as severe after-pains, or a griping-purge — 
 when the pulse, although quick, is perfectly soft, and even weak, 
 and this opinion is strengthened if blood has been drawn without 
 relief, and without the signs of inflammation on its surface. The 
 best way of treating these cases is to wash out the large bowels by a 
 very large glyster, to give ten grains of compound powder of ipeca- 
 cuanha every three hours, till the pain is gone, to keep the abdomen 
 constantly covered with a warm linseed-meal poultice, and after the 
 pain lias ceased, if the abdomen continues sore and the pulse quick, 
 to apply leeches, and give a mild purge. When I doubt the nature 
 of the case, I apply leeches at the beginning. 
 
 V. Although I have been unsuccessful in the use of turpentine 
 in peritoneal fevers, the testimony of competent witnesses convinces 
 me that there is a class, or perhaps a stage of these fevers, in which 
 oil of turpentine given internally is sometimes higlily efficacious, and 
 that cases apparently hopeless have been recovered by it. I would 
 advise the reader to consult those who have been successful with it 
 for the mode of giving it. There are two questions : one about the 
 stage of the disease at which it is proper, the other about the dose, 
 and whether a single or several doses. On these important points I 
 leave the reader to consult those who have used it successfully.
 
 54 DISORDERS OE THE MTM) 
 
 CHAPTER II. 
 
 THE DISORDERS OF THE MIND IN LYING-IN WOMEN. 
 
 In the year 1819 I wrote a paper on puerperal insanity, which the 
 College of Physicians did me the honour to publish in the sixth 
 volume of their ' Transactions/ Since then ten years have elapsed, 
 during winch I have seen more of the disease than I had before ; 
 and although in revising my paper at this distance of time, and 
 comparing my subsequent experience with my former statements, 
 I can see no great errors to correct, yet I find some obscurities which 
 require to be explained, some opinions which deserve to be enforced, 
 and much additional information which I think worth communi- 
 cating. I have, therefore, written almost a new paper on the subject, 
 retaining out of the former only the cases, and those views which I 
 still entertain, and which I am unable to state more explicitly. My 
 object is chiefly to relate my own experience of this disease, to 
 describe what I have seen of its progress, how I have observed it to 
 be affected by remedies, and what I have thought about its nature. 
 If my statements of fact are different from those of other writers, 
 I can only say that I have observed with as much care, and related 
 what I have observed with as much accuracy as I could. As to my 
 reasonings, they must take their chance. 
 
 During that long process, or rather succession of processes, in 
 which the sexual organs of the human female are employed in form- 
 ing, lodging, expelling, and lastly feeding the offspring, there is no 
 time at which the mind may not become disordered ; but there are 
 two periods at which this is chiefly liable to occur, the one soon after 
 delivery, when the body is sustaining the effects of labour, the other 
 several months afterwards, when the body is sustaining the effects 
 of nursing. 
 
 I have repeatedly seen the commencement of mania and of 
 melancholia in women who were in child-bed, or who had recovered
 
 IN LYING-IN WOMEN. 55 
 
 from their delivery, and were nursing. I will give a specimen of 
 each rather than a general description. Such descriptions are com- 
 monly formed of a bewildering multiplicity of circumstances which 
 
 never occurred together in one and the same instance, so that they 
 are pictures which resemble nothing in nature, like the abstract 
 ideas of the old metaphysicians. 
 
 A lady, who, I was told, had had a ' brain fever' after her former 
 lying-in, came to London to be attended by me in her next confine- 
 ment, and took a furnished house in a street near Cavendish-square. 
 She had a short and easy labour, a good supply of milk, nursed her 
 child, and continued to do well for so many days, that her friends 
 concluded all danger was over; nevertheless, from the circum- 
 stances of her former confinement, I visited her twice a day, but 
 I detected nothing which indicated the approach of disease; her 
 pnlse was not quick, her nights were disturbed only by occasionally 
 suckling the child, and her manner and appearance were unaltered. 
 On the tenth day after her delivery, the shop of a piano-forte maker 
 in Oxford-street caught fire ; this occasioned a great bustle in the 
 neighbourhood ; but as her sitting-room did not look into the street, 
 it was kept from her knowledge during the day, but in the evening, 
 while she was standing at her window, which looked into a yard at 
 the back of the house, a piece of burning matter fell within her 
 sight ; I saw her about two hours afterwards, at nine in the evening ; 
 she was not herself; her manner was agitated; on being questioned 
 about her feelings she kept silent for some time, and then answered 
 abruptly ; her pulse was quick, and her look and manner odd and 
 unnatural. I slept in the house. At four o'clock in the morning 
 the nurse waked me, and said that her mistress had had no sleep; 
 that she was sitting up in bed talking to herself, but that instant 
 had expressed a wish to see me. I rose and went to her ; there was 
 only a rush-light in a remote part of the chamber ; as soon as she 
 saw who I was she told me to sit down and look at her : I said, 
 'I do/ 'What do you see?' ' Nothing but yourself/ ' Look at 
 'my head/ f I do/ 'Do you see nothing particular there?' 
 ' Nothing/ ' Then I was presumptuous. I thought that a glorious 
 ' light came to my temples, and shone about my head. I thought 
 ' I was the Virgin Mary V It is curious that the immediate cause 
 of the disturbance was a lighted body, and that the first hallucina- 
 tion was concerned about light. She was put under the care of a 
 nurse accustomed to such patients, and an eminent physician saw
 
 56 DISORDERS OF THE MTID 
 
 her with me. Her pulse was soft, and never very quick, and her 
 face pale ; nevertheless, from a fear of congestion in the brain, her 
 head was shaved, and ten ounces of blood were extracted from the 
 scalp by cupping-glasses, without diminishing in the slightest degree 
 her violence and incoherence; her conjunctiva was yellow, her 
 tongue furred, and her bowels costive ; hence she was moderately 
 purged, and about three weeks from the commencement of the 
 illness she returned to her country seat well. She was confined 
 again about fifteen months afterwards, without any recurrence of the 
 disease ; about a week before this latter delivery she had the jaun- 
 dice, of which she was cured by calomel and aloetic purgatives, 
 before she fell in labour. It is practically important to notice, that 
 she had the jaundice at the time of her first confinement, and became 
 maniacal ; that she had a slight degree of it during her second con- 
 finement, and suffered the same disease; that she was completely 
 jaundiced before her third confinement; that it was removed by 
 purgatives before labour, and that she this time escaped her mental 
 derangement. 
 
 In this case the disease appears to have been excited by sudden 
 agitation, and therefore came on suddenly ; in other cases, in which 
 no such cause occurred, and the disease arose spontaneously, its 
 approach was more gradual, several or even many days elapsing, 
 during which nothing more was observed than a pulse rather quick, 
 restless nights, and a something quick and peculiar in the patient's 
 manner. 
 
 n. 
 
 One of my patients, almost from the clay of her delivery, was 
 observed to have restless nights, a quick pulse, and an irritable temper, 
 compared with her natural one. She scolded the nurse about the 
 merest trifles ; one minute sent for the child to suckle, and the next 
 ordered it angrily to be taken away. She would superintend her 
 housekeeping, though she was entreated not to do it, and sent for 
 the cook up into her chamber several times a day to inquire into 
 the consumption of the family, and to give directions about its 
 regulation. She talked almost incessantly, with disproportionate 
 earnestness, and complained that her husband was not attentive to 
 her; ;il length she accused him of incredible things, and soon after 
 became so violent as to require confinement. Her passions of mind 
 were all violent, not of a gloomy character. Her friends were kept 

 
 "N LYING-IN WOMEN. 57 
 
 away from her; she never saw any body but her nurses and her 
 medical attendants; she had a rapid pulse, much above 100, but 
 she was not blooded, and she recovered in little more than a month. 
 I have repeatedly seen the commencement of mental derangement 
 in women who had recovered from their confinement, and had been 
 suckling several months. Nearly all these cases were instances, not 
 of mania, but of melancholia. They occurred in women who had 
 been debilitated by nursing. The disease at this period has been 
 attributed to weaning; but in all the cases I have seen, the disease 
 has begun before the weaning, and this measure has been resorted to 
 because the patient had neither milk nor strength to fit her for a 
 nurse. There was a peculiarity about the commencement of the 
 disease which I have never or seldom noticed at the commencement 
 of mania. There was an incipient stage in which the mind was 
 wrong, yet right enough to recognise that it was wrong. 
 
 III. 
 
 A pale, delicate lady, nursing an infant four months old, told me 
 that she scarcely knew what was the matter with her : her sight 
 was so impaired that she could not read; her powers of attention 
 were so much impaired that her household accounts were burthen- 
 some to her ; that she often rang for the footman, and when he came 
 she had forgotten what she had rang for. She said she had a good 
 husband, sweet children, ample property, everything to make her 
 happy, yet she felt no interest in life. She added, that if this went 
 on thus, she should lose her senses. She had lost flesh, and had 
 little milk. After a short time she took it into her head that she 
 had a fatal disease, and I was called out of my bed several nights to 
 see her die. She told me that I was quite mistaken about her case ; 
 thai she was sure she was dying, and that if I would sit down for 
 five minutes I should see her expire. She next began to accuse her 
 friends, especially her husband, whom she charged with infidelity, 
 and an intention to poison her ; and it became necessary to separate 
 her from her family, and place her in that state of seclusion and 
 control usually employed under such circumstances. She continued 
 in this state many months, but ultimately recovered, and has had a 
 child since without a recurrence of the disease. 
 
 I shall not attempt to give an account of the symptoms and pro- 
 gress of mania and melancholia in women who are lying-in and 
 nursing, partly because the cases which I have related, and shall
 
 58 DISORDERS OF THE MIND 
 
 have occasion to relate in the progress of this paper, will give a more 
 faithful picture of the aspect and symptoms of these diseases than 
 any vague general description, and partly because there is nothing 
 peculiar in them. If a physician was taken into the chamber of a 
 patient whose mind had become disordered from lying-in or nursing, 
 he could not tell by the mere condition of her mind that the disease 
 had originated in these causes. I do not mean to represent the 
 disease as strictly uniform — cases sometimes occur under a peculiar 
 form, but these are not the rule, but the exceptions. Thus I have 
 seen it strikingly similar to that form of disease called delirium 
 tremens, one instance of which I shall have occasion to relate, and 
 in the following case catalepsy occurred in the progress of the 
 disease. 
 
 IV. 
 
 Mrs. — is twenty-nine years of age; she has long been un- 
 usually subject to the common forms of hysteria ; I have seen her 
 after being strongly excited in conversation sink down insensible, 
 and a few minutes afterwards recover with choking and sobbing; 
 her husband tells me that he has often seen her whilst sitting at 
 the dinner-table become apparently insensible, with her eyes open, 
 still sitting up, continue in this state several minutes, and then come 
 to herself again, but totally unconscious of what had taken place in 
 the interval. She married nine years ago, has been pregnant many 
 times, but has only borne one living child ; every other time she has 
 either miscarried during the early months, or, what was more common, 
 the child has died without any obvious cause, about the sixth or 
 seventh month, and premature labour has come on a week or two 
 afterwards. A few days after her last delivery, of a dead child, at 
 the seventh month (a circumstance which was attributed to some 
 domestic agitation), she was seized with a violent head and face-ache, 
 which was confined to the left side, and which subsided under the 
 use of hemlock, but she continued to suffer flatulence of stomach, 
 had a quick, weak pulse, and was much depressed in spirits; one 
 evening she told her husband that she had never discharged the 
 duties of a wife as she ought to do, and that her death would be 
 n happy release both to him and her; the next morning she made 
 an unsuccessful attempt to cut her throat. I now saw her in con- 
 sultation with Dr. Sutherland; she was put under the care of a 

 
 IN LYING-IN WOMEN. 59 
 
 regular attendant, and was at times so violent that it was necessarj 
 to confine her with a waistcoat. 
 
 A few days after our first visit we were summoned to observe a 
 remarkable change in her symptoms ; the attendants said she was 
 dying, or in a trance ; she was lying in bed motionless, and appa- 
 rently senseless ; it had been said that the pupils were dilated and 
 motionless, and some apprehensions of effusion on the brain had been 
 entertained, but on coming to examine them closely, it was found 
 that they readily contracted when the light fell upon them; her eyes 
 were open, but no rising of the chest, no movement of the nostril, no 
 appearance of respiration could be seen; the only signs of life were 
 her warmth and pulse ; the latter was, as we had hitherto observed 
 it, weak, and about 120 ; her fasces and urine were voided in bed. 
 
 The trunk of the body was now lifted so as to form rather an 
 obtuse angle with the limbs (a most uncomfortable posture), and 
 there left with nothing to support it; there she continued sitting 
 while we were asking questions and conversing, so that many minutes 
 must have passed. 
 
 One arm was now raised, then the other, and where they were 
 left, there they remained; it was now a curious sight to see her, 
 sitting up in bed, her eyes open, staring lifelessly, her arms out- 
 stretched, yet without any visible sign of animation ; she was very 
 thin and pallid, and looked like a corpse that had been propped up, 
 and had stiffened in this attitude. We now took her out of bed, 
 placed her upright, and endeavoured to rouse her by calling loudly 
 in her ears, but in vain ; she stood up, but as inanimate as a statue ; 
 the slightest push put her off her balance ; no exertion was made to 
 regain it ; she would have fallen if I had not caught her. 
 
 She went into this state three several times : the first time it 
 lasted fourteen hours, the second time twelve hours, and the third 
 time nine hours, with waking intervals of two days after the first fit, 
 and one day after the second. After this the disease resumed the 
 ordinary form of melancholia,, and three months from the time of 
 her delivery she was well enough to resume her domestic duties.* 
 
 I n giving an opinion about the probable result of any case there 
 are two questions — the one whether there is any danger to life, the 
 
 * Dr. Sutherland, with whom I attended this case, related to me several others, 
 similar, hut far more extraordinary for the time which they lasted. One was a young 
 lady who continued in this state for several months, and was preserved only by great 
 vigilance and management in feeding her.
 
 60 DISORDERS OF THE MIND 
 
 other, if the patient lives, how long is the disease likely to continue, 
 and what chance is there of its becoming permanent and incurable. 
 With regard to the first of these questions, I remember the time 
 when it was the prevalent belief among medical men — not, it is true, 
 those who had paid peculiar attention to the subject, but men of 
 great general eminence — that they were diseases which were never 
 fatal. Whilst I was attending the near relation of one of the most 
 eminent and experienced of the provincial practitioners of this island, 
 a letter arrived from him, begging the family to have no fears, that 
 he had seen many such cases during his long life, and never saw 
 one die ; and even the late Dr. Baillie, when consulted about a case, 
 remarked, f that the question was not whether she was to get well, 
 'but when she was to get well/ The latter patient died within a 
 week after this prognosis. There can be no doubt that a very large 
 proportion of cases of disordered mind in lying-in women and nurses 
 ultimately recover, but it is equally certain that some of them die, 
 and there are two modes of calculating the probability of death in 
 any individual case : the one is to ascertain the proportion of deaths 
 to recoveries in as large a number of cases as possible ; the other is 
 to endeavour to discover some symptoms, the absence or presence of 
 which indicates safety or danger. As to the former of these modes, 
 it is very difficult to procure trustworthy information. M. Esquirol, 
 of Paris, has given an account of ninety -two patients in the Salpe- 
 triere who had become deranged whilst lying-in or nursing. Of 
 these, six died, that is, one in fifteen ; but this estimate must give 
 the mortality in chronic cases rather than recent ones. Dr. Burrows 
 has published a table of fifty-seven cases, of which ten died ; this is 
 a mortality of more than one in six. The best mode of forming an 
 estimate of the mortality of this disease would be to procure state- 
 ments from a great number of practitioners, extensively employed in 
 the practice of midwifery, of how many cases of puerperal insanity 
 they had met with in their practice, and of these how many had 
 died. This would be the best mode, although none but those who 
 have tried to procure information in this way can have a notion of 
 the difficulty of procuring answers scrupulously accurate. But 
 however accurate the estimate may be, it must afford a very loose 
 prognosis for any particular case. To a question about the probable 
 Eate of a patient, it would be a vague answer to say that the mor- 
 tality is as one in fifteen. It would be more like the opinion of the 
 actuary of an insurance office than of a practical physician. The
 
 IN LYING-IN WOMEN. 61 
 
 question would naturally occur, are there no symptoms in this as in 
 other diseases by which to judge whether or no the life of the 
 patient is in danger? Now, on this question, there is a passage in 
 the manuscript copies of Dr. William Hunter's Lectures, so much 
 more valuable than any remark in any printed book upon the sub- 
 ject, that I shall introduce it here. 
 
 ' Mania/ says Dr. Hunter, f is not an uncommon appearance in 
 ' the course of the month, but of that species from which they gene- 
 ' rally recover. When out of their senses, attended with fever like 
 ' paraphrenias, they will in all probability die ; but when without 
 ' fever it is not fatal, though it (i. e. fever) generally takes place 
 ' before they get well. I have had several private patients, and 
 ' have been called in where a great number of stimulating medicines 
 ' and blisters have been administered; but they have gone on as at 
 ' another time, talking nonsense till the disease has gone off, and 
 * they have become sensible. It is a species of madness they gene- 
 ' rally recover from, but I know of nothing of any singular service 
 ' in it.' 
 
 Making allowance for the loose language of extemporaneous lec- 
 tures, and allowance also for some inaccuracy in the notes of these 
 lectures, and putting together this statement of Dr. Hunter, with 
 my own experience, I extract from it the following meaning : that 
 there are two forms of puerperal mama, the one attended by fever, 
 or at least the most important part of it, a rapid pulse ; the other 
 accompanied by a very moderate disturbance of the circulation : that 
 the latter cases, which are by far the most numerous, recover ; that 
 the former generally die. This agrees closely with my own experience. 
 Cases VIII, IX, X, which terminated fatally, were all attended 
 by a very rapid pulse. None of those with a slow or only mode- 
 rately excited pulse died. Some which, were attended with a quick 
 pulse recovered ; but none of these were treated for paraphrenitis. 
 
 One evening, several years ago, a surgeon called on me, wishing 
 me to return with him. many miles into the county, to see his wife, 
 who had become maniacal a few days after her delivery. I was at 
 that time attending a lady in her first labour, whom I could not 
 leave, but I offered to go with him if he would wait till the labour 
 was over. It was going on wearily, there was no prospect of its 
 being over before the morning, and as he was anxious to return 
 home, he took another physician whom I recommended. Before 
 leaving me, however, he said he should like to talk with me
 
 62 DISORDERS OF THE MIND 
 
 about the case. I took down a volume of Dr. William Hunter's 
 manuscript lectures, and showed him the passage which I have quoted 
 above. He said he was sorry to read it, for that his wife's pulse was 
 very rapid. About a week afterwards I heard that she was dead. 
 
 There are some other circumstances to be taken into the account 
 of the prognosis : the form of the derangement, and the period at 
 which it occurs. Mania soon after delivery is more dangerous to 
 life than melancholia beginning several months afterwards. Nights 
 passed in sleep, a pulse slower and firmer, even though the mind 
 continues disordered, promise safety to life. On the contrary, 
 incessant sleeplessness, a quick, weak, fluttering pidse, and all the 
 symptoms of increasing exhaustion, portend a fatal termination, even 
 though the condition of mind may be apparently improved. In the 
 cases which I have seen terminate fatally, the patient has died with 
 symptoms of exhaustion, not with those of oppressed brain, except- 
 ing only one case. 
 
 But supposing the patient to live, how long will the disease last ? 
 and what danger is there of its becoming permanent ? Experience 
 shows that mania is a less durable disease than melancholia ; it is 
 more dangerous to life, but less dangerous to reason. The best 
 answers to these questions, however, would be a knowledge of the 
 results of a vast number of cases. Unfortunately we have no such 
 documents taken under satisfactory circumstances. The records of 
 hospitals contain an account of cases which have been admitted, only 
 because they were unusually permanent : they are the picked 
 obstinate cases, and can afford no notion of the average duration of 
 the cases of all kinds ; the cases of short duration, which last only 
 a few days, or a few weeks, which form a large proportion, are totally 
 lost in the estimate of a lunatic hospital. Of the ninety-two cases 
 mentioned by M. Esquirol, only fifty-five recovered, and six died, 
 leaving thirty-one as the number of incurables, that is, one in three. 
 Of those which recovered thirty-eight did so in less than six months. 
 Dr. Haslam says, that of eighty-five admitted into Bedlam only fifty 
 recovered, leaving thirty-five as the number of the incurable ; of 
 Dr. Burrows' fifty-seven cases only thirty-five recovered, eleven 
 remained uncured ; of the thirty-five which recovered twenty-eight 
 did so in little less than six months. I am persuaded, however, 
 that these tables throw little light upon the question, and present a 
 prospect unnecessarily gloomy and discouraging. Of the many 
 patients about whom I have been consulted, I know only two who
 
 IN LYING-IN WOMEN. 63 
 
 are still after many years disordered in mind, and of these one had 
 already been so before her marriage. 
 
 Before leaving this part of the subject, there is still another 
 question which requires to be thought of, and that is, whether a 
 patient who has been disordered in mind after one lying-in, is likely 
 to be so after another ? I believe the chances are much against it ; 
 there is a sufficient possibility of such an event to call for the utmost 
 degree of -care not only in the next, but all subsequent confinements ; 
 but this care being taken, the proportion of cases in which the disease 
 occurs twice is small. I have attended many patients who came to 
 town to be confined because they had been deranged after their 
 former lying-in in the country, and, excepting Case No. I, not one 
 of these patients had a return of their disease. 
 
 I come now to consider the causes of puerperal insanity, that is, 
 what occasions it to arise; and when arisen, in what it consists 
 mentally and corporeally. Of the cases which I have seen, a large 
 proportion have occurred in patients in whose families disordered 
 mind have already appeared. The patients too were of susceptible 
 dispositions, nervous, remarkable for an unusual degree of that 
 peculiarity of nerve and of mind, which distinguishes the female 
 from the male constitution. In some instances they had been long 
 under the influence of depressing passions, or were suddenly assailed 
 by some cause of mental agitation ; but in many, no such circum- 
 stances had occurred, they had lately been delivered, or they were 
 nursing, and that was all; scarcely any of them had ever been 
 deranged before, or were ever deranged on any other occasion than 
 on this. There is, therefore, something in the state of the constitu- 
 tion induced by lying-in or nursing capable of producing the disease 
 in predisposed constitutions. What is this something? In my 
 former paper on this subject, I endeavoured to express it by saying 
 ' that peculiar state of the sexual system, which occurs after 
 1 delivery! This has been noticed as an unsatisfactory explanation, 
 and when I read it now, ten years after it was written, I am willing 
 to confess that it was not sufficiently explicit. What I meant was 
 this, the sexual system in women is a set of organs which are in 
 action only during half the natural life of the individual, and even 
 during this half they are in action only at intervals. During these 
 intervals of action they diifuse an unusual excitement throughout 
 the nervous system ; witness the hysteric affections of puberty, the 
 nervous susceptibility which occurs during every menstrual period,
 
 64 DISORDERS OP THE MIND 
 
 the nervous affections of breeding, and the nervous susceptibility of 
 lying-in women. I do not mean that these appearances are to be 
 observed in every instance of puberty, menstruation, pregnancy, and 
 child-bed, but that they occur sufficiently often to show that these 
 states are liable to produce these conditions of the nervous system. 
 Dr. Marshall Hall thinks, that the susceptibility of the puerperal 
 state is to be explained by mere exhaustion, and does not at all depend 
 on the influence of anything specific in the condition of the sexual 
 organs at that time ; but would an equal or a greater degree of ex- 
 haustion at any other time occasion the disease ? — this is a question of 
 fact, which I should answer in the negative. I have seen patients who 
 have been deranged in child-bed, and who had recovered, at a future 
 period much more exhausted by illness, and much more agitated in 
 mind, without the slightest appearance of mental derangement. 
 
 Among the causes of this disease, there are two others which 
 require notice — the one a disordered state of the organs of digestion, 
 the other weaning. As to the first, it was very manifest in some 
 cases, in others less so. Mental derangement is said to be often 
 produced by weaning, that is, by the sudden suppression of the 
 secretion of milk. I have no right to deny the experience of others, 
 but my own would never have led me to such a conclusion. Among 
 the fashionable women of this town nothing is so common as not to 
 nurse their children ; the milk comes in about one or two days after 
 delivery, and the breasts become as hard as stones, but not a drop is 
 extracted ; and sometimes by cold-spirit lotions constantly applied 
 to the breasts, sometimes by embrocations of oil and brandy, some- 
 times by poultices (according to the whim of the nurse, the patient, 
 or the medical attendant), with gentle aperients, the milk is suppressed 
 in a few days. I must have known this done in more than a hundred 
 instances during the first week after delivery, a time much more 
 liable to disordered mind than a later period, and in not one did 
 it occasion puerperal insanity. In all the cases winch I have seen 
 months after delivery, the weaning has been the consequence of the 
 disease, not the disease the consequence of the weaning. The patients 
 had been reduced in health by nursing, their memories had become 
 enfeebled, their spirits depressed, and their minds ultimately dis- 
 ordered ; and they were directed to wean their children because they 
 had neither milk nor strength to enable them to nurse. 
 
 But whatever may be the causes winch excite these diseases, the 
 most important question still remains to be considered — what is that
 
 IN LYING-IN WOMEN. 65 
 
 morbid state of organization on which the disorder of the mind 
 depends? this is the proper object of medical art. We have no 
 power by medicinal agents of relieving a disordered mind, excepting 
 indirectly through the disorder of the body with which it is con- 
 nected. It is impossible, therefore, to stir one step in the treatment 
 of the disease without first ascertaining what this disorder is; or if 
 different in different cases, what they are, how to discriminate them, 
 and whether experience shows that one is more common than the 
 other. 
 
 There is a strong disposition, not only popular but professional, 
 to attribute raving of the mind to inflammation of the brain. 
 Perhaps it originates in this — that the disorder of the mind with 
 which we are most familiar is drunkenness, which is known to be 
 caused by spirits, and to be cured by temperance. Mania is called 
 brain-fever, and the sight of a raving patient instantly suggests the 
 thought of cupping-glasses, iced-caps, low diet, and purgatives. 
 This view of mania is, when it occurs in child-bed, still further 
 corroborated by the popular notions about lying-in women. If a 
 woman becomes deranged in child-bed, it is said not only that she 
 lias a brain-fever, but that the milk has flown to her brain, hence 
 the term mania laclea. Dr. Denman says, that in his time it was 
 a prevalent notion among the people, but an obsolete one in our 
 profession, and formerly it was usual to attempt relieving the disease 
 by restoring the milk and the lochia. It would be as good pathology 
 to attribute puerperal fever to a suppression of the milk, and as 
 good practice to attempt to cure it by drawing the breasts, foment- 
 ing the pelvis, or using any other local means for restoring these 
 secretions. 
 
 But experience and reflection lead to very different conclusions ; 
 they teach us that a disorder of the mind may be connected with 
 very opposite states of the circulation, sometimes wdth inflammation 
 or active congestion, for which depletion is the shortest and surest 
 remedy; sometimes with an opposite condition of the circulatioii, 
 which depletion will only aggravate. 
 
 Cerebral excitement does not necessarily depend on inflammation 
 or congestion ; nor is depletion, however moderate, necessarily the 
 proper remedy. Cerebral excitement is often aggravated by deple- 
 tion ; and in some cases, as I shall have occasiou to relate, abso- 
 lutely brought on by it. Now the cpiestion, what is the morbid 
 state of organization on which puerperal insanity depends, must be 
 
 p
 
 66 DISORDERS OF THE MIND 
 
 determined in the usual way. There is only one safe mode of work- 
 ing the problem, by observing the causes which brought on the 
 disease, the bodily symptoms which accompany it, the way in which 
 it is affected by remedies, and the morbid appearances discovered 
 after death. These points can be learned only by an attentive and 
 thoughtful observation of cases, and will be best communicated by 
 the relation of them. 
 
 V. 
 
 I went down twice to , — miles from London, to see a 
 
 lady who had become deranged a few days after her delivery: her 
 labour had been attended by an alarming haemorrhage. She was 
 sitting up in her easy chair, looking first to one side then to the 
 other, talking incoherently, and would not, or could not, answer 
 questions ; but she was not violent, and required only the gentlest 
 restraint. Her face and even lips were colourless, and her pulse 
 small and quick. The circumstances under which the disease had 
 come on precluded all thought of depletion. Nothing more was 
 done than to prevent constipation by the mildest aperients, to soothe 
 her, and support her with nutriment without stimulants. She slowly 
 regained her health, and with it the faculties of her mind. I give 
 this case chiefly to show that mania may occur in that bloodless 
 state of the body which uterine haemorrhage so often occasions. 
 
 VI. 
 
 A lady in good health was delivered after an easy labour of her 
 eighth child, but the placenta adhered, and was separated by the 
 hand. The after-pains were severe and long-continued ; opiates 
 diminished their violence, but the intervals between them became . 
 shorter, till at length, on the second day, she was found to have 
 permanent pain and tenderness in the hypogastrium, with a small, 
 sharp pulse of 116, the lochia ceased, and she had a slight shivering. 
 A very eminent physician was now consulted, and it was recognised 
 and treated as a case of inflammation of the uterus. For three 
 days bloodletting, general and local, was employed with consider- 
 able activity, yet on the third evening her state was unsatisfactory. 
 She still complained of uneasiness in the uterus, and could not bear 
 to have it pressed, but she was so much reduced both in strength 
 and pulse that her physicians feared another bleeding. Another 
 opinion, therefore, was requested, and the residt of this consultation 

 
 IN LYING-IN WOMEN. 67 
 
 was that she should be blooded again to faintness. The patient's 
 head was placed low; the fifth tea-cup was nearly full before she 
 complained of faintness; the first cups buffed, the latter did not. 
 I slept in the house. AVIien I left her at one in the morning, she 
 was still rather faint. At four o'clock the nurse waked me to say 
 that her mistress 'was much changed/ and she thought was dying. 
 I found her cold and clammy, with a thread-like pulse, and pale, 
 sharp features ; her mind too rambled a little. I mixed some wine 
 and hot water, gave it her by spoonfuls, and in about an hour, her 
 skin being warmer, and her pulse more distinct, I directed a spoon- 
 fid to be given every fifteen minutes for another hour, and then went 
 and laid down again. When her medical attendants mustered at 
 breakfast-time, she was so far recovered that they could scarcely 
 believe what I told them of her state during the night. The pain 
 and tenderness of the uterus were gone, and they were much satis- 
 fied with the result of the bleeding. In the afternoon, however, a 
 hurried message was sent off for her medical attendants. I arrived 
 first, and found her sitting up in bed, talking incessantly and inco- 
 herently, and now and then expressing a wish that she could hold 
 her tongue. She was in a profuse warm sweat, and her pulse was 
 much above 140. I again mixed some wine and water (I had better 
 have given her an opiate), but after getting down about a wine-glass- 
 ful of tins diluted wine by spoonfuls, I found that both her tongue 
 and pulse became slower. Her physicians now one after another 
 arrived. Towards the evening she was much calmer, but obviously 
 not herself in mind. The next morning every one recognised 
 puerperal mania. In this state she continued several weeks, during 
 which it was often necessary to put on the strait waistcoat, in order 
 to keep her in bed. In less than a month she was convalescent 
 from her mania, and for a week or two it was supposed that she was 
 out of danger; but now her abdomen began to swell, and she died 
 dropsical in the eleventh week after delivery. The body was not 
 opened. Here was mania depending on what is called cerebral 
 excitement, which leads most practitioners to employ cupping, cold, 
 low diet, and purging, coming on in a state in which the circulating 
 system was reduced to the lowest ebb. 
 
 VII. 
 
 I was sent for late one night to see a lady who had been delivered 
 of her first child about a week before. She was constitutionally
 
 68 DISORDERS OF THE MIND 
 
 nervous — her milk had been deficient, and she had had slight fever, 
 for which she had lived unusually low; but nothing had occurred to 
 create the smallest anxiety about her till this evening, when her 
 husband, who had left her as well as usual in the morning, came 
 home and found her incoherent in mind. When I went into the 
 chamber and approached her bed-side, I found her lying with her 
 cheek on the pillow, her eye apparently fixed intently on some ob- 
 ject. She paid no attention to the questions that were put to her, 
 and could not be prevailed on to speak whilst I was in the room. 
 She was in a profuse perspiration, winch stood in large drops upon 
 her face and forehead — her pulse was 140, small and weak. "Whilst 
 I was feeling it, her hand was affected by spasmodic twitches, and 
 she picked at the bed-clothes, as if endeavouring to take up some- 
 thing which she saw there. What was the cause or nature of these 
 symptoms ? It was impossible to look at them without alarm. Was 
 it the last scene of some eventful disease which had been stealing 
 on unsuspectedly, or was it a sudden attack of puerperal mania ? 
 Although the mind was incoherent, it did not exactly resemble the 
 ordinary form of that disease; it was more like delirium tremens. 
 After talking over the subject with two medical men, who were 
 there, it was at length agreed, that all active treatment for the re- 
 moval of supposed inflammation of the brain should be postponed 
 at least for a few hours, and that we should try the effect of opium. 
 Thirty drops of the sedative solution of opium were divided between 
 two draughts — one was to be taken directly, and the other two hours 
 afterwards, if she was not asleep. I went the next morning at nine 
 o'clock, and found the two medical men, who were there the night 
 before ; they met me with cheerful countenances, and the agreeable 
 sentence, ' she is cmite well/ I then learnt the events of the night. 
 The second draught had put her into a sound sleep, and she awoke 
 in the morning with a calm, clear mind, and a pulse of 80. I went 
 up into the chamber with one of the medical gentlemen. As soon 
 as she saw us she began to talk incoherently, and her pulse rose 
 nearly to 100. Suspecting that our presence was doing harm, we 
 retreated into the drawing-room. When her husband came down, 
 he told us that all this agitation had been produced by her per- 
 ceiving a striking likeness between myself and her dead father, and 
 between my medical companion, who was a florid, healthy -looking 
 man, and a dead friend of hers. The agitation, however, subsided as 
 soon as we left the chamber. She had no return of it, and recovered 

 
 IN LYING-IN WOMEN. 69 
 
 from her confinement without another untoward circumstance. 
 Depletion would easily have converted this into a dangerous and 
 perhaps a fatal case. 
 
 VIII. 
 
 Mrs. — was delivered of her first child after a natural labour, 
 attended, however, by rather more than the usual loss of blood. 
 From the first her manner appears to have been excited and unnatural. 
 Her nights became restless, her mind more excited, and about three 
 weeks after her delivery she became maniacal. Her pulse was 140 
 before any active remedy was employed. She was put upon low diet, 
 leeches were applied to the head, and she was freely purged with 
 calomel and castor oil. The symptoms not abating, and the patient 
 becoming very violent, a cupper was sent for, who took ten ounces 
 of blood from the head by cupping-glasses, and the following morning 
 I saw her for the first time. She was sitting up in bed in a strait 
 waistcoat. Whatever was asked her she did not answer, but re- 
 peated it like an echo, ' Have you any headache ? — ' Have you 
 any headache ?' ' Put out your tongue' — ' Put out your tongue' — 
 she would not say anything else. Her tongue was moist and pale — 
 her pulse was between 120 and 130, small and weak — her bowels 
 had been lately freely moved — her skin was not hot, her face was 
 very pale — she had had no sleep for many nights. This being the 
 state of things, I thought it a great object to procure repose. She 
 therefore took twenty minims of the sedative solution of opium, and 
 ten minims in a two-ounce glyster every six hours. This procured 
 six hours of interrupted sleep, and when awake she was more her- 
 self. Some symptoms led her attendant to employ another bleeding 
 by ten leeches to the head, which was shaved, and a blister applied 
 to the crown. When I saw her two days after my first visit, she 
 had had in the night several hours of sleep, and was so much better in 
 mind that her friends were surprised when I told them that she was 
 not out of danger. Her face was very pale, and her pulse so quick, 
 small, feeble, and fluttering, that I remarked to her medical 
 attendants that she would not bear the loss of another ounce of blood. 
 It was agreed that she should continue her small opiate glysters, and 
 that care should be taken to supply her with sufficient nutriment; 
 but the next day the symptoms of exhaustion became more alarming, 
 and when one of her medical attendants visited her in the evening- 
 he found her pale, cold, breathing oidy at long intervals, and witli
 
 70 DISORDERS OF THE MIND 
 
 scarcely any pulse — she died that night. The body was opened the 
 next day by two very experienced anatomists. The veins throughout 
 the body were remarkably empty — the heart contained little blood — 
 the lungs and liver were singularly pale. Within the head there was 
 the same deficiency of blood in the veins of the pia mater, and in the 
 sinuses — under the arachnoid membrane was a little serum. On 
 slicing off the hemispheres the bloody points were unusually nu- 
 merous. 
 
 IX. 
 
 I had no concern in the treatment of the following case, but being 
 in the house where it was, to see another patient, I was taken by 
 her medical attendants into her chamber, where I found her sitting 
 up in bed in a strait waistcoat, with a flushed cheek, a dull eye, 
 and occasionally uttering unintelligible words ; her pulse was much 
 above 100, but I did not count it, and her attendants remarked that 
 it was getting hard. She did not look at all like a person within six 
 hours of her death, so that I was much surprised to hear that she 
 died that evening after being blooded to faintness, which took place 
 when she had lost about eight ounces. I received the following 
 account of the case from those who attended her. 
 
 E. B — , twenty-three years of age, was delivered of her first child 
 on the 30th December. On the evening of the day of her delivery 
 she had a rigor, succeeded by heat of skin, and constant pain at the 
 lower part of the abdomen, increased by pressure. The pulse was 
 180, and weak. An injection was given, a large poultice was applied 
 over the belly, and she took ten grains of the compound powder of 
 ipecacuanha. Her bowels were opened by the injection; she slept 
 well during the night, and the next morning, the 31st, the pain was 
 gone, but the soreness remained. The next day, 1st January, she 
 complained of tightness of the head, her tongue was furred, her skin 
 hot, her pulse 120, and weak; her bowels had been moved several 
 limes the day before. She now took five grains of calomel, her head 
 was shaved, and six leeches were applied. At two o'clock on the 
 same day she was visited again; her eyes were bright, her face 
 was flushed, her skin hot. She spoke indistinctly, and her mind 
 rambled; her pulse, which in the morning was weak, was now 
 thought to be getting hard, and she was ordered to be blooded from 
 the arm till she fainted. Two grains of calomel were ordered to be 
 taken every two hours. She was blooded at three o'clock in the after-
 
 IN LYING-IN WOMEN. 71 
 
 noon. As the blood flowed, the pulse became so quick it could not 
 be counted ; hence, when she had lost eight ounces, it was stopped, 
 although she did not feel faint. At six o'clock, when the attendant 
 went to give her the calomel, she had scarcely any pulse. At eleven 
 in the evening the pulse could not be felt. She looked deadly pale, 
 the crassamentum of the blood was flat and red, with little serum; 
 her mind wandered, but she knew her mother and relatives, who 
 stood at the bed-side. Attempts were made to revive her by cordials, 
 but she sank rapidly, had a cadaverous smell, a cold skin, and died 
 at four in the morning. The body was examined eleven hours after 
 death. In the abdomen the viscera were healthy, the peritoneum 
 also ; the external and internal surface of the uterus, as also its 
 substance, were examined, and found natural. There was about 
 half a pint of reddish fluid in the peritoneum. In the head the 
 sinuses were thought to be rather more loaded than natural, the dura 
 and pia mater rather thicker than usual ; there was no unusual effu- 
 sion anywhere. The plexus choroides appeared unusually pale ; the 
 substance of the brain was firm, and on slicing it no bloody points 
 appeared. 
 
 X. 
 
 The following case I have alluded to in my paper in the College 
 ' Transactions/ The patient, while in labour of her first child, was 
 seized with puerperal convulsions. She was immediately delivered 
 by perforating the head, and was blooded as largely as is customary 
 in this disease. The convulsions ceased, she came to herself again, 
 and seemed for a few days to be doing well ; yet her pulse from the 
 first continued quick, and a few days after her delivery she became 
 maniacal. This was the case which I have mentioned in a former 
 part of this paper, and about which Dr. Baillie stated that 'the 
 ' question was, not whether she was to get well, but when she was to 
 e get well/ She died three days after the attack. The body was 
 carefully examined by a very eminent anatomist, but no vestige of 
 disease was discovered either in the brain or elsewhere. 
 
 What inferences are we to draw from the foregoing cases relative 
 to the question for the solution of which I have related them, 
 namely, what is the morbid condition of organization on which puer- 
 peral insanity depends ? Let the reader reflect on the leading points 
 of these cases. In No. I the disease occurred in a pale lady, 
 without any heat of skin, or much quickness of pulse, and was not
 
 72 DISORDERS OF THE MIND 
 
 relieved by the loss of Wood. In No. Ill it occurred in one whose 
 constitution was drained and enfeebled by nursing. In No. IV it 
 occurred in a pale woman, habitually hysterical, subject to bear dead 
 children from want of power to afford them life for nine months. 
 In No. V it occurred in one who had been drained by flooding. In 
 No. VI in one in whom, for urgent reasons, the circulation had 
 been reduced to the lowest ebb consistent with life. In No. VII in 
 one who had been living very low for a week, with such marked 
 symptoms of the irritation of debility, that at first sight I thought it 
 was the close of some disease that had been overlooked. It was 
 speedily relieved, not by cupping and purging, but by the tranquil- 
 lizing and sustaining power of opium. In No. VIII the disease 
 was treated, though with all possible prudence and moderation, as 
 an inflammatory state of the brain, by leeches, cupping, purging, 
 and low diet ; yet the patient died, not with symptoms of oppressed 
 brain, but with those of exhaustion, and on examining the body 
 the whole venous system was found extraordinarily empty of blood. 
 In No. X the patient fell, as if shot, under the stroke of the lancet ; 
 and on examining the head there was found no effusion, and empty 
 blood-vessels. In No. XI the disease came on after puerperal con- 
 vulsions, a disease generally but not always depending on cerebral 
 congestion, and after one of those enormous bleedings commonly 
 practised in these cases, and no morbid appearances were discovered 
 after death in the brain. 
 
 These cases, if fair specimens of puerperal insanity, lead straight 
 to the conclusion, that the disease is not one of congestion or inflam- 
 mation, but one of excitement without power. I shall be asked, are 
 not these picked cases, selected to prove a point, and forming a small 
 proportion to those of another character ? Their very number gives 
 the negative to this suspicion : ten cases can never form a small 
 proportion of the experience of one individual, however extensive 
 his opportunities of seeing the disease may be ; for puerperal insanity 
 is not like fever, a disease in which an experienced physician counts 
 his cases by hundreds. Dr. "William Hunter said, that in the course 
 of his practice he had met with about twenty or thirty. There can 
 be no mistake, unless, by some extraordinary accident, all my cases 
 have been exceptions to the general rule — an incredible supposition ! 
 It is true I have related those in which the nature of the disease 
 was most distinctly marked, in which the truths I am endeavouring 
 to explain were most legible; but in most of the remainder there
 
 IN LYING-IN WOMEN. 73 
 
 was nothing to contradict these conclusions. It was the same form 
 of disease, only less marked and striking. They surely prove that 
 1 1 lose cases of puerperal mania which are attended by a very rapid 
 pulse, which Dr. William Hunter said generally die, and winch he 
 attributed to paraphrenitis, do not depend on this state of the brain, 
 which requires depletion, but on a more exhausting excitation of the 
 nervous system, which requires soothing and sustaining treatment." 34 ' 
 But I shall be told of the fluid under the tunica arachnoides, and 
 the unusual number of bloody points in the centrum ovale, in 
 C;\*c IX. Are we, then, to shut our eyes to the symptoms during 
 life, to the effect produced by remedies, to the mode in which death 
 came on, that is, with symptoms of exhaustion, and to the remark - 
 
 * I cannot refrain from extracting the following passage, notwithstanding its 
 length, from the works of that sagacious observer and master in the treatment 
 of disease, our own Sydenham : 
 
 'There is a peculiar kind of madness, which sometimes follows upon inveterate 
 ' intermittents, especially quartans ; and yields not to the ordinary method of cure, 
 ' but, after copious evacuations, degenerates into a lamentable kind of folly for life. 
 ' I have often been surprised to find no mention made of this disorder by practical 
 1 writers, as I have frequently met with it; and whereas the other kinds of madness 
 ' usually yield to plentiful bleeding and purging, this will bear neither: for when the 
 'patient is almost recovered, if a glyster only of milk and sugar be given, it imme- 
 ' diately returns ; and if repeated bleeding and purging be used, these evacuations 
 ' may indeed abate the violence of the disease, but will certainly render the patient 
 'an idiot, and quite incurable. Nor will this seem strange, if it be considered that 
 ' the other kinds of madness proceed from the too great spirituousness and richness 
 'of the blood, whereas this arises from its depressed state and vapidity, as I may 
 'term it, occasioned by the long fermentation carried on by the fever, whence the 
 ' spirits become utterly unable to perform the animal functions. I treat this disorder 
 ' in the following manner: I give a large dose of some strong cordial three times a 
 'day; for instance, of Venice treacle, the electuary of the egg, the Countess of 
 ' Kent's powder, Sir Walter Rawleigh's powder, or the like, dissolved in plague or 
 ' treacle water, or any other cordial water. Cordials may also be given in other 
 ' forms. During the course of the cure, a slender but restorative diet, and generous 
 'liquors, must likewise be used; and the patient should keep her room, and lie 
 ' much in bed. This regimen may occasion a costiveness, whence a fever may be 
 ' apprehended, especially from the use of these heating medicines; but there is, in 
 ' reality, no danger of it, because the spirits are so far wasted by the preceding dis- 
 • ease as not to be able to raise a new fever. In a few weeks the disorder will abate 
 ' by degrees, and then the cordials may be omitted for a few days ; but the restora- 
 ' tive method of living must be continued, and the cordials repeated, after a short 
 ' interval, and persisted in till the perfect recovery of the patient. This method has 
 ' sometimes cured a madness that did not succeed intermittents, particularly in cold 
 'and weak constitutions. I was called, last year, to Salisbury, to consult with my 
 ' friend Dr. Thomas, for a lady who was greatly disordered in her senses, and she 
 ' was recovered by it, though she was then in her pregnancy.' — pp. 06, 67.
 
 74 DISORDERS OF THE MIND 
 
 able emptiness of the veins throughout the belly ; and because there 
 was a little serum under the tunica arachnoides, and more bloody 
 points than usual in the medullary substance of the brain, conclude 
 that it was a disease of congestion or inflammation, and that per- 
 haps the patient died because she was not blooded sufficiently? 
 There will be some, perhaps many, who will draw this inference. To 
 my mind, this is one of the cases in which observation of the disease 
 throws more light on its morbid anatomy, than its morbid anatomy 
 on the nature of the disease ; the living symptoms illustrate the 
 dead morbid appearances, better than the dead morbid appearances 
 do the living symptoms. To make the examination of dead bodies 
 conclusively instructive, it requires to be done by those who possess 
 two requisites : an eye familiar with the difference between natural 
 and morbid appearances, and a mind capable of interpreting the 
 hieroglyphic characters left by disease. These qualifications are 
 never found, except in those who are, or at least have been, for a 
 considerable portion of their lives continually employed in these 
 examinations. A man whose experience in morbid anatomy amounts 
 to five or six examinations in the year, is neither a competent 
 witness of appearances, nor a competent judge of their meaning. 
 To understand what these appearances mean, it is necessary to 
 know the history of the case during life, the symptoms by which 
 it was attended, and the way in which it was affected by remedies. 
 Those pathologists who consider increased vascularity of the brain, 
 and an effusion of fluid, however slight, as infallible signs that con- 
 gestion or inflammation existed during life, and that depletion was 
 the essential remedy, will do well to read Dr. Kelly's paper ' On the 
 Pathology of the Brain/ and Dr. P. M. Latham's f Account of the 
 Epidemic at the Milbank Penitentiary/ 
 
 The essay of Dr. Kelly, which describes the appearances dis- 
 covered in dissecting animals bled to death, is well known : it proves 
 that when the general circulation has been drained to death, the 
 vessels of the brain are still full of blood ; but a far more instructive 
 experiment was made a few years ago, at the Penitentiary at Mil- 
 bank, of course with no evil intentions, and no suspicion of danger, 
 not on sheep and dogs, but on men and women. The Penitentiary 
 si amis on a spot made for the production of malaria, a swamp below 
 I lie Level of the river, which runs within a hundred yards of the 
 prison. The prisoners were, with what object and for what reason 
 does not appear, suddenly put upon a diet from which animal food 

 
 IN LYING-IN WOMEN. 75 
 
 was almost entirely excluded. An ox's head, which weighs 8 lbs., 
 was made into peas soup for 100 people, which allows 11 ounce of 
 meat to each person. After they had been living on this food for 
 some time, they lost their colour, flesh, and strength, and could not 
 do as much work as formerly. The men could not grind as much 
 corn or pump as much water as they once could, and the women 
 fainted at their work in the laundry. At length this simple debility 
 of constitution was succeeded by various forms of disease — they had 
 scurvy, dysentery, diarrhoea, low fever, and lastly affections of the 
 brain and nervous system. To show the causes and nature of these 
 diseases, it is necessary only to mention the striking fact, that while 
 the prisoners who fed on this diet were growing weak and falling 
 into disease, the officers of the prison, with their families and 
 servants, who resided on the same spot, but lived well, entirely 
 escaped ; and the still more striking fact, that about twenty of the 
 prisoners who were employed in the kitchen, and had an ample 
 supply of meat and food, with two or three exceptions, continued 
 healthy. The affections of the brain and nervous system which 
 came on during this faded, wasted, weakened state of body, were 
 headache, vertigo, delirium, convulsions, apoplexy, and even mania. 
 When bleeding was tried, the patients fainted after losing five, four, 
 or even fewer ounces of blood, and ' were not better, but perhaps 
 worse/ Leeches to the temples were equally useless — in some cases 
 these patients died very slowly, after the circulation had remained, 
 for a day or two, almost though not epiite extinct ; yet, on examining 
 their bodies after death, there was found increased vascularity of 
 the brain and sometimes fluid between its membranes and in its 
 ventricles. 
 
 But the reader will ask, is there no such disease as phrenitis in 
 lying-in women? If I may judge from my own experience, phre- 
 nitis, that is, furious delirium from inflammation of the brain, is a 
 rare disease in child-bed. It is true, inflammatory headaches are 
 not uncommon, and these are occasionally attended by delirium; 
 but these cases are very different in their aspect and progress to 
 those which I have related in this paper; the patients have head- 
 ache, vertigo, singing in the ears, a flushed cheek, and a quick 
 pulse. In most of them there is no disorder of the mind whatever, 
 and when there is, it follows and is the effect of the inflammatory 
 state of the brain ; and it is never equal in degree, nor similar in 
 kind, to the disorder of the mind in mania and melancholia. It is
 
 76 DISORDERS OF THE MIND 
 
 pain of the head, with fever, followed by delirium. To show the 
 reader that I am not insensible to the existence of inflammatory 
 diseases of the brain in child-bed, and that when I meet with them, 
 I am ready to treat them actively, and to afford him a specimen of 
 these cases, I will relate one. 
 
 XII. 
 
 I was taken by a medical gentleman some miles from London, to 
 see a lady who had been delivered about a week of her first child. 
 She had looked forward to her confinement with a strong apprehen- 
 sion that she should die in it ; but her labour, though severe, ended 
 well, and she continued free from illness for several days. She was 
 a plump and rather florid woman. She began to complain at first 
 of a dull headache and thirst — this was succeeded by throbbing in 
 the head and giddiness ; her face was red, her skin hot, and her 
 pulse quick. She was kept on low diet, and purged well with 
 calomel and senna, but during the night before I saw her she had 
 become somewhat delirious. At times she was herself, and answered 
 questions clearly ; at others her mind rambled about absent things 
 and persons : this was the account I received from her medical 
 attendant. I found her sitting up in bed with eight gorged leeches 
 hanging from her temples ; her cheek was red, and her pulse full, 
 firm, and throbbing. She told me that her headache was so dis- 
 tressing that she should go out of her senses ; that she believed she 
 had already been so during the night. I told the surgeon that I 
 thought local bloodletting was quite inadequate to this case ; that 
 it was in vain to empty the small blood-vessels of the brain, whilst 
 the heart and large arteries were pumping it into them with so much 
 rapidity and force, that nothing would do but reducing the violence 
 of the general circulation ; and I advised him to bleed her to syn- 
 cope. He bled her from the arm in the recumbent posture — the 
 sixth cup was full, and for want of another the blood had already 
 begun to flow into the hand-basin before her pulse began to falter, 
 and her face to blanch. On closing the vein and raising her head, 
 she fainted completely — when she recovered she was still faint, and 
 said that her headache was gone : the blood in the tea-cups was 
 buffed and cupped in the highest degree. In the evening the head- 
 ache returned a little; twelve leeches were applied, she took five 
 grains of calomel at night, and a black dose in the morning ; she 
 passed a tranquil night, woke with no headache, and a clear mind;
 
 IN LYING-IN WOMEN. 77 
 
 and when I saw her the next day she was so well, I took leave of 
 her. I saw her medical attendant about a fortnight afterwards, who 
 told me that she had no return of her symptoms. In this case the 
 bodily symptoms indicative of inflammatory affection of the brain 
 were sufficient guides to depletion without any disorder of the mind. 
 
 These febrile headaches, whether attended by delirium or not, 
 require great care and prompt depletion carried as far as is necessary 
 to remove them. I have seen these symptoms, when neglected or 
 treated inefficiently, end in one case in hemiplegia, in another case 
 in hydrocephalus, in a third in furious delirium, speedily followed by 
 coma and death. I had written these cases with an intention of 
 inserting them, but they would lengthen this paper, already too 
 long, and lead me too far out of my road. 
 
 From this digression on the inflammatory affections of the brain 
 in child-bed, I return to the proper subject of tins paper, puerperal 
 insanity. The alimentary canal is generally disordered in its secre- 
 tions — the symptoms which indicate this are a furred tongue, an 
 offensive breath, and above all, dark and offensive stools. These 
 symptoms exist in very different degrees in different cases ; in some 
 they are scarcely perceptible, in others they exist in a most remark- 
 able degree ; in these latter cases they seem to be the link on which 
 the disease hangs, for as soon as they are removed the patient is 
 well. Case No. I affords some illustration of this principle, but the 
 following is a far more remarkable instance. 
 
 XIII. 
 
 A lady, twenty-two years of age, clever, susceptible, and given to 
 
 books, was confined with her first child at , miles 
 
 from town ; she was anxious to nurse it, but several days passing 
 with little appearance of milk, doubts began to be entertained 
 whether she woidd be able; she thought that she would; her nurse 
 and surgeon thought that she would not : this led to irritating dis- 
 cussions, her manner became sharp, quick, and unnatural, and at the 
 end of a few days she was decidedly maniacal. I and another 
 physician were now sent for : we found her in a strait waistcoat, 
 incessantly talking or reciting poetry ; her skin was hot, her pulse 
 full and much above 100; her tongue covered with a dark, thick 
 fur; her bowels were confined, and her stools excessively dark and 
 offensive ; she took a dose of calomel and jalap, followed by small 
 doses of sulphate of magnesia ; these produced a few evacuations,
 
 78 DISORDERS OF THE MIND 
 
 but they were followed by no relief; she talked almost incessantly, 
 scarcely ever slept, and was so violent it was impossible to keep her 
 in bed without the strait waistcoat. Thus three days passed from 
 our first consultation. The physician who attended with me, think- 
 ing the case would be protracted, withdrew, and I was directed to 
 take Dr. Sutherland down with me. As the purgative had operated 
 very moderately, and the tongue and stools were as unnatural as at 
 first, he proposed a more active purge. The next morning, there- 
 fore, she took a strong dose of senna and salts, made still more 
 active by the addition of tincture of jalap; after this had been 
 taken about three hours it procured a very large evacuation, nearly 
 black, and horribly offensive; this was, as usual, discharged into 
 the bed without any notice on the part of the patient ; it acted again 
 an hour or two afterwards, but now the nurse, who was sitting by 
 the bed-side, was surprised to see her turn round, and in a calm and 
 natural manner request to be taken up, as her medicine was going 
 to operate ; her waistcoat was immediately loosened and she was 
 taken out of bed, when she voided a stool of prodigious size, as dark 
 and offensive as the first, and then walked back to her bed calm 
 and collected : we saw her not many hours afterwards ; her waist- 
 coat was off, she was lying on her sofa perfectly trancp_iil, answered 
 questions correctly, manifested no vestige of her complaint, except- 
 ing some strangeness in the expression of her countenance, and a 
 timidity and abstinence from conversation which was not natural to 
 her ; she recovered rapidly and uninterruptedly. 
 
 It remains for me only to explain the method of treatment neces- 
 sary for these diseases. In the cases which I have related, I have 
 said so much about the remedies employed for their relief, and the 
 effects these remedies produced, both beneficial and injurious, that 
 I have little else to do than to collect the rules of conduct dictated 
 by them, and put them in a compact and orderly shape. 
 
 I. The constant attendants on the patients ought to be those who 
 will control her effectually but mildly, who will not irritate her, and 
 will protect her from self-injury. These tasks are seldom well per- 
 formed by her own servants and relatives. 
 
 If the disease last more than a few days, and threatens to be of 
 considerable duration, her monthly nurse and own servants ought to 
 be removed, and a nurse accustomed to the care of deranged persons 
 placed in their stead. Such an attendant will have more control 
 over the patient, and be more likely to protect her from self-injury.
 
 IN LYING-IN WOMEN. 79 
 
 She should never be left alone, and everything should be carefully 
 removed with which self-injury can be effected ; such as cutting-in- 
 strument s, garters, handkerchiefs, towels. The windows of her 
 chamber ought to be carefully secured. With regard to the removal 
 of her husband and relations, this also will be a question if the dis- 
 ease threatens to be lasting j it is generally right. Interviews with 
 relations and friends are commonly passed in increased emotion, 
 remonstrance, altercation, and obviously do harm ; large experience, 
 also, is decidedly favorable to separation as a general rule, yet there 
 may be exceptions which the intelligent practitioner will detect by 
 observing the effect of intercourse. The husband ought never to be 
 left alone with his deranged wife, for obvious reasons. I have known 
 more than once a neglect of tins rule produce consequences which 
 left in the minds of those concerned a never-ending regret. On tins 
 subject a serious appeal ought to be made to the sense and feeling of 
 the husband. 
 
 II. The next rule regards the diet of the patient. It ought never 
 to be very low ; the lowest ought to consist of nutritious and un- 
 heating fluids, such as equal parts of gruel and milk, or gruel and 
 good veal broth, or milk alone ; and of these a quart ought to be given 
 in the twenty-four hours. If there is any heat or thirst, the broth had 
 better be omitted ; but the cases in which this diet requires to be 
 reduced are few ; it even sometimes requires to be mended. If the 
 patient is pale, and the temperature of the skin lower than natural, it 
 is useful to add to the above diet two ounces of wine daily, mixed with 
 gruel. When the patient is in such a state of mind as not to ask for 
 support, and even object to take any, a thoughtless nurse will allow 
 hours, and even days, to pass with no other food than a cup of tea or 
 w T ater gruel, at long intervals — a neglect which I have known to be of 
 serious consequences : but if the disease after many days continues un- 
 abated, a daily portion of solid meat may be necessary, and the rule for 
 it is tins : if there is nothing in the bodily symptoms, separate from 
 the disorder of the mind, which forbids it, this state of the mind is no 
 objection to, but rather an argument for it. Hospital patients are 
 sometimes clearly benefited by a cup of caudle several times a day; 
 but to them diffusible stimulants are more safe and necessary than 
 to persons of temperate habits. After being long accustomed to a 
 daily supply of gin, they come into a lying-in hospital, suffer pain, 
 lose blood, live on water gruel, and take purgative medicines. If 
 mania attacks them under these circumstances, a moderate quantity
 
 80 DISORDERS OF THE MIND 
 
 of wine is sometimes strikingly beneficial. Thus I would manage 
 the diet in mania winch occurs soon after delivery ; but when 
 melancholia attacks a woman long after delivery, who has been 
 drained and enfeebled by nursing, a nutritious, and even cordial 
 diet is necessary in all cases. She should take meat every day, 
 with about four ounces of wine. Cupping, low diet, and purging 
 would confirm her disease, and perhaps convert it into idiotism. 
 Lastly, if mania attack a woman after sudden weaning, so that there 
 is reason to believe that the disorder of the mind has been caused 
 by the sudden suppression of milk (a case very different to that 
 which I have last described, and one which I have not witnessed), 
 there would be reason to suspect an inflammatory affection of the 
 brain ; but this must be determined, and the treatment regulated, 
 not by the disorder of the mind, but by the bodily symptoms winch 
 accompany it. 
 
 III. The third rule relates to the medicinal agents necessary in 
 the treatment of these diseases. These are — 1st. Such as reduce the 
 force of the circulation, especially bloodletting. 2d. Such as 
 evacuate gastric and intestinal impurities, and amend the secretions 
 which flow into the alimentary canal, as emetics and purgatives. 
 3d. Such as give sleep during the night, and calmness during the 
 day : these are the various narcotics. 4th. Such as sustain the 
 vital powers, as tonics and stimulants. These are not all necessary 
 in each case, but it is out of these a selection must be made adapted 
 to the circumstances of each case. 1st. With regard to bloodletting, 
 the chief means of reducing the force of the circulation, the result of 
 my experience is, that in puerperal mania and melancholia, and also 
 in those cases winch more resemble delirium tremens, bloodletting is 
 not oidy seldom or never necessary, but generally almost always per- 
 nicious. I do not say that cases never occur which require this 
 remedy; no man's experience extends to all the possibilities of disease, 
 but I never met with such cases; and I would lay down tins 
 rule for the employment of bloodletting — never to use it as a remedy 
 for disorder in the mind, unless that disorder is accompanied by 
 symptoms of congestion or inflammation of the brain, such as would 
 lead to its employment though the mind was not disordered. Even 
 here, however, great caution is necessary; local is safer than general 
 bleeding. In Case X the head was hot, and the face red, and the 
 pulse was said to have become somewhat hard, yet a bleeding of 
 eight ounces was followed by extinction of the pulse within three
 
 IN LYING-IN WOMEN. 81 
 
 hours, and death in less than six. The only cases attended by a 
 very quick pulse which I have seen recover, were those in which no 
 blood was taken. In the really inflammatory diseases of the brain, 
 bloodletting of course is essentially necessary; but these, I think, 
 can never be mistaken for puerperal insanity; they are febrile head- 
 aches, more or less acute. Pain of the head, with fever, is a much 
 better indication for blood-letting than disorder of the mind without 
 these symptoms, :2nd. With regard to remedies which evacuate 
 gastric and intestinal impurities, the activity with which these 
 remedies are employed must depend on the distinctness with which 
 these states are present. If the powers of the constitution are not 
 low, and the gastric symptoms are very marked, namely, a foul 
 tongue, an offensive breath, and a yellow eye, an emetic, not of anti- 
 mony, but ipecacuanha, may be given. Vomiting has sometimes 
 been followed by such signal success in the treatment of mania, that 
 some eminent physicians have considered it the most efficient remedy; 
 but where the face is pale, the skin cold, and the pulse quick and 
 weak, I should fear the depresssing influence of nausea and vomiting. 
 \\ hen the stools are very unhealthy in colour and odour, one or two 
 active purges ought to be given, and a moderate action in the bowels 
 kept up by such purges as empty the alimentary canal without draw- 
 ing fluid from the circulation, such as the compound aloetic pill, or 
 the compound decoction of aloes. Where, however, the gastric 
 symptoms are very slight, and the powers of the system much ex- 
 hausted, active and prolonged purging is injurious; the utmost that 
 is necessary and right is a dose of the aloetic pill, or decoction, 
 sufficient to move the bowels plentifully once a day. 3d. The most 
 \ aluable medicines in the treatment of puerperal mania are narcotics. 
 If given at proper times and in proper doses, they often procure 
 nights of better sleep, and days of greater trancarillity. This calm- 
 ness is most likely to be followed by some clearing up of the disorder 
 of the mind. These remedies produce these salutary effects much 
 ofteuer in the mania of lying-in women than in mania occurring 
 under other circumstances; for it is more uniformly a disease of 
 nervous excitement and debility. If the head is hot, the cheek 
 Hushed, and the patient thirsty, they ought to be postponed; but if 
 these symptoms have been removed, or are not present, sedatives 
 ought to be given, and the most efficient first. After many days 
 and nights passed in perpetual wakefulness, it is an urgent object to 
 procure tranquil sleep. For this purpose, twenty minims of the 
 
 G
 
 82 DISORDERS OF THE M.ND 
 
 sedative solution of opium may be given at once, and repeated in two 
 hours if the patient is not asleep ; even a third dose may be given in 
 two hours more, if the two first doses have failed, but the cases in 
 which opium has been most successful have required at most two full 
 doses. When sleep has once been procured, small doses, such as 
 five or ten minims, should be given at intervals of six hours. If these 
 small doses procure sleep by night, it is unnecessary to return to the 
 larger doses, but these may be used occasionally when the smaller 
 doses fail. Constipation must be prevented by a daily dose of the 
 compound aloetic pill or decoction, or, if these fail, by the compound 
 extract of colocynth, which is made more soluble and active by mix- 
 ing it with one-third of soap. If the sedative solution of opium 
 should produce any of the ill effects which tins drug is known occa- 
 sionally to produce, such as headache, foul tongue, sickness, heat of 
 skin, it should be discontinued, and the milder narcotics tried, of 
 which the best is hyoscyamus mixed with camphor ; five grains of 
 each may be given every six hours, but the night dose should be 
 doubled. It may be dissolved in an ounce and a half of camphor 
 mixture. When once opiates have attained their objects they should 
 be withdrawn, not suddenly, but gradually, diminishing the dose, 
 lengthening the interval, watching the effect of this abstraction of the 
 remedy, mending the diet whilst withdrawing it, and returning to the 
 old doses if the diminution of them occasions any unfavourable symp- 
 tom. 4th. There are cases and times in which medicines which sus- 
 tain the vital powers of the constitution are necessary and useful. 
 When there is a total absence of febrile or inflammatory symptoms, 
 when the face is pale, the skin cool, or even cold, and the pulse very 
 weak, a scruple or half a drachm of the carbonate of ammonia, di- 
 vided into four doses, may be given during the twenty-four hours. 
 The time comes when opiates have been tried and are no longer ne- 
 cessary, or have failed ; the disease threatens to set in for a length of 
 time, and the great object of the physician is to support the patient 
 through a long, wearing, exhausting disease. This is done best by 
 supporting her appetite for food, and in these cases the mineral acids 
 are of essential service. The English physicians, most eminent for 
 the treatment of insanity, employ these medicines much under these 
 circumstances ; they may be given alone or with a light bitter, or 
 even bark, three times a day. 
 
 IV. The last rule I have to mention relates to seclusion and con- 
 trol. There can be no doubt that it is generally necessary and useful 

 
 IN LYING-IN WOMEN. 83 
 
 to separate the patient from all those persons who are sources of 
 excitement of any kind. This, however, can be effected only in one 
 of two ways — either in a separate house, or part of a house where 
 the patient has no other associates but her nurses, or in a receptacle 
 for the deranged, where she has no other associates than her nurses 
 and persons similarly afflicted with herself. This is the only society 
 she has, excepting the short and occasional visits of the physician. 
 Tims the power of controlling her, even by force, is placed in the 
 hands, not of enlightened and benevolent persons, but of uneducated 
 menials. I do not know how it can be otherwise, though I wish it 
 could ; but I think such a charge ought never to be placed in such 
 hands without the most vigilant scrutiny of its exercise. There may 
 be cases, or there may come a time at which some interruption to 
 tins solitary life may be advisable. "When the disease had lasted 
 long, when the patient expresses a strong wish to see some near friend, 
 when she entertains illusions which the sight of some one may efface, 
 the admission of such a person is worth a trial.* I shall be told, 
 that when patients are mending, or have recovered, the most com- 
 mon cause of relapse is too early an introduction to friends, and too 
 early a return home. When the patient is recovering, or has reco- 
 vered, I do not recommend these measures. It is when the patient 
 has not recovered, and is not recovering, that I advise them to be 
 tried; when month after month passes without any amendment, and 
 her mental delusions assume a shape accessible to moral impressions, 
 then it is that I would advise an interview with a friend. To illus- 
 trate what I mean, I relate the following case : on its accuracy in 
 every part the reader may rely. I offer it respectfully to the con- 
 sideration of those physicians who undertake not only the medical 
 management of the insane, but who receive them under their roofs. 
 I may be told that tins case was rare, and may never occur again. 
 I do not believe in such rare cases — even lusus naturae occur in suffi- 
 cient numbers to require classing, and these unique cases are unique 
 only because we are not watchful enough to detect their fellows. 
 
 * ' It is my opinion that confinement is too indiscriminately recommended and 
 persisted in.' * * * * 'In many instances an intercourse with the world has dispelled 
 those hallucinations, which a protracted confinement in all probability would have 
 added to, and confirmed. In its passive state, insanity has been often known, if the 
 expression be allowable, to wear off, by permitting the patient to enjoy his liberty, 
 and return to his usual occupation and industrious habits.' — Haslam, on the Moral 
 Management of Insane Persons, pages 14 and 15.
 
 84 DISORDERS OE THE MIND 
 
 X. 
 
 A lady, twenty-eight years of age, of good constitution, but sus- 
 ceptible mind, became affected with melancholia a few months after 
 her second lying-in : towards the end of her pregnancy a frightful 
 incident had occurred to a near relation, which affected her so deeply 
 that she often spent the night sleepless, sitting up in bed, thinking 
 of her misfortune, and dreading that she should lose her reason after 
 her confinement. Having nursed her child without feeding it for 
 three or four months, with much unnecessary anxiety and exertion, 
 she grew thin and weak, complained of sinking at the stomach and 
 aching in the legs, and experienced so much confusion of mind, that 
 she could not arrange her domestic accounts; she became low-spirited, 
 she knew not why : she was advised to wean her child, took some 
 light tonic and gentle laxative, and went down to the sea-side, but 
 at the end of a month she returned home, having derived little 
 benefit from her absence; her spirits became gradually more de- 
 pressed, and it was impossible to persuade her that she had not some 
 fatal disease : one day it was a cancer ; another, inflammation in the 
 bowels ; and to such a height did her apprehensions rise, that her 
 husband was often brought home by some alarming message, and 
 found her with a solemn air, and, in a low whisper, giving directions 
 to her servants whom she had assembled round her, what to say if 
 she should expire before their master arrived. She now grew much 
 worse ; there was no longer any doubt about the nature of her com- 
 plaint ; she was seen by a physician of extensive experience in these 
 diseases, and sent into the country : many weeks passed ; sometimes 
 she was better, sometimes worse, now accusing herself of the deepest 
 depravity, and meditating schemes of self-destruction; then again, 
 convinced of the absurdity of her notions, and struggling against 
 the load which for a short time every day weighed on her heart. In 
 this way many weeks passed ; at length the disease came upon her 
 with more violence than ever, and in her self-examination and con- 
 demnation she became quite ferocious. 
 
 She was now put under the care of an experienced attendant, 
 separated entirely from her husband, children, and friends, placed 
 in a neat cottage surrounded by agreeable country (it was the finest 
 season of the year), and visited regularly by her physician. 
 
 Tor several weeks she manifested no improvement : sometimes 
 she was occupied with one notion, sometimes with another, but they 
 were always of (he most gloomy description ; at length it became
 
 IN LYING-IN WOMEN. H5 
 
 her firm belief that she was to be executed for her crimes in the 
 most public and disgraceful way; every noise she heard was that of 
 the workmen erecting the scaffold, every carriage the officers of 
 justice' assembling at the execution; but what affected her most 
 deeply was, that her infamy had occasioned the disgrace and death 
 of her children and husband, and that his spirit haunted her. As 
 soon as the evening closed she woidd station herself at a window at 
 the back of the cottage, and fix her eyes on a white post that could 
 be seen through the dusk ; this was the ghost of her husband : day 
 and night he was whistling in her ears. 
 
 Several weeks passed in this way ; the daily reports varied, but 
 announced nothing happy; at length her husband became impatient 
 and begged to have an interview with her, thinking that the best 
 wax to convince her he was not dead was to show himself; this was 
 objected to : he was told the general fact, that patients are more 
 likely to recover when completely separated from their friends, that 
 if she saw him she would say it was not himself but his ghost ; but 
 the husband was obstinate, and an interview was consented to. 
 When he arrived at the cottage, he was told that she had had 
 a tolerable night, was rather more tranquil, but that there was no 
 abatement of her gloomy notions. ' As soon as I entered the 
 ' drawing-room, where she usually spent the day/ (I copy his own 
 statement, which I have now before me, and which he wrote down 
 at the time of the occurrence,) ' she ran into a corner, hid her face 
 ' in her handkerchief, then turned round, looked me in the face, 
 ' one moment appearing delighted at the thought that I was alive, 
 ' but immediately afterwards assumed a hideous expression of coun- 
 ' t. nance, and screamed out that I was dead and come to haunt her. 
 
 ' This was' exactly what Dr. had anticipated, and for some 
 
 ' minutes I thought all was lost. 
 
 ' Finding that persuasion and argument only irritated and con- 
 ' firmed her in her belief, I desisted, and tried to draw off her atten- 
 ' tion to other subjects ; it was some time since she had seen either 
 ' me or her children; I put her arm under mine, took her into the 
 ' garden, and began to relate what had occurred to me and them 
 ' since we parted; this excited her attention, she soon became 
 1 interested, and I entered with the utmost minuteness and circum- 
 ' stantiality into the affairs of the nursery, her home, and her friends. 
 ' I now felt that 1 was gaining ground, and when I thought 1 had 
 1 complete possession of her mind, 1 ventured to ask her in a joking
 
 86 DISORDERS OF THE MIND IN LYING-IN WOMEN. 
 
 ' manner, whether I was not very communicative for a ghost ; she 
 ' laughed ; I immediately drew her from the subject, and again 
 ' engaged her attention with her children and friends. The plan 
 ' succeeded beyond my hope ; I dined, spent the evening with her, 
 ' and left her at night perfectly herself again/ 
 
 He went the next morning, in a state of intense anxiety to know 
 whether Ins success had been permanent, but her appearance at the 
 window with a cheerful countenance soon relieved Iris apprehensions : 
 
 while he was there Dr. came in ; he went upstairs without 
 
 knowing the effect of the interview, and came down, saying, 'It 
 looks like magic '/ With a view of confirming her recovery, she was 
 ordered to the sea-side to bathe ; as soon as the day of her departure 
 was fixed, she began to droop again, the evening before it she was 
 very low, and on the morning of her setting off was as bad as ever ; 
 this state continued for several weeks, in spite of sea air and 
 bathing, and ceased as suddenly as it had done before, apparently 
 in consequence of interviews with friends, calculated to remove the 
 apprehensions by which her mind was haunted. She has since then 
 continued perfectly well, and has had another child without the 
 slightest threatening of her former malady. 
 
 The conclusion winch I deduce from the foregoing case is, not 
 that violent mama is curable by conversation, (if it should occasion 
 the irruption of relatives during the height of the disease, the com- 
 munication may do more harm than good,) but there is a stage 
 approaching convalescence, in which the bodily disease is loosening 
 its hold over the mental faculties, and in which the latter are 
 capable of being drawn out of the former by judicious appeals to 
 the mind. 
 
 I know too well that striking cases give an inaccurate notion of 
 the average influence of remedies to expect that similar conduct will 
 often be followed by similar success, yet I would ask these questions : 
 How long would this patient have remained in a disordered state of 
 mind, if she had not been treated in this way? and again, how many 
 persons are there at this time in a similar state, who (although those 
 who have the care of them do not suspect it) are capable of being 
 restored in a similar way to their natural views and feelings ? 
 
 If the reader will attend, not only to the case itself, but to the 
 remark which follows it, he will not attribute to me any disposition 
 to deny the efficacy of seclusion and control in ordinary cases, and 
 in the active states of the disease.
 
 ( 87 ) 
 
 THOUGHTS ON INSANITY AS AN OBJECT OF MOlfAL SCIENCE. 
 
 It is a popular belief that insanity is a disease not in our physical 
 but our moral constitution. This is not a speculation merely, but 
 leads to various practical conclusions : that it is a subject rather for 
 metaphysical than for medical inquiry; that a physician is requisite 
 for a madhouse only as he is for a school or a prison ; that the true 
 theory of these mysterious diseases will be found in some extraor- 
 dinary oblicpiities of thought, the true cure in some moral regimen, 
 some training system for the weak or crooked faculties of the under- 
 standing.* 
 
 There are many diseases in which some of the faculties of the 
 mind in a certain degree deviate from their natural state : such are 
 the incubus or nightmare ; severe and habitual indigestion, so often 
 attended by lassitude of mind and depression of spirits ; the hypo- 
 chondriasis of liver disease ; the strange and different forms of hys- 
 teria ; and lastly, but most remarkably, fever attended by delirium ; 
 no one supposes these to be moral diseases ; no doubt is entertained 
 that the mind is affected by disease of the body; the mental symp- 
 toms are universally considered as the natural effects and signs of 
 disturbance in the brain ; a man of plain sense, therefore, familiarly 
 acquainted with these facts, woidd naturally look upon insanity in 
 the same light, unless some solid reasons can be given him to the 
 contrary ; where are such reasons to be found ? 
 
 I. One cause of the belief that insanity is a moral disease is, that 
 it is often produced by passions or efforts of mind ; as the cause and 
 the ultimate effect are both mental, it has been thought that the 
 
 * ' Of late, however, it has been seriously proposed in a great degree to remove 
 ' both the medical treatment and moral management of insane persons from the care 
 ' of physicians, and to transfer this important and responsible department of medicine 
 ' into the hands of magistrates and senators.' ' Most persons who have not received 
 * a medical education have been fully persuaded they could arrange and compose it 
 ' in its utmost state of distraction.' — Haslam, on the Moral Management of Insane 
 Persons, pp. 2, 6.
 
 ko THOUGHTS ON INSANITY 
 
 disease must necessarily be a moral one. A very little observation, 
 however, will teach us that no causes operate more distinctly upon 
 our bodily organs than violent efforts and agitations of mind ; will 
 not terror so enfeeble the muscles as to make us as tired as after a 
 toilsome walk ? will not the anxiety of a few hours deprive us of 
 appetite for the next meal ? will not long-continued grief or intense 
 study so impair the process of nutrition as to emaciate the body and 
 bleach the cheek ? will not mental agitation set the heart beating, 
 the pulse throbbing, and crimson the countenance ? Those states of 
 mind which are capable of producing insanity, act distinctly upon 
 the bodily organs ; and if they are capable of disturbing the muscles, 
 the stomach, the organs of nutrition, the heart and blood-vessels, 
 even to the little blood-vessels of the cheek, with which the mind is 
 only secondarily connected, where is the difficulty of supposing that 
 they may act physically upon the brain, with which it is imme- 
 diately connected ? If mental effort or agitation induces physical 
 disturbance in the brain, this physical disturbance will show itself 
 by an unnatural state of the mind ; thus the cause may be. mental 
 and the ultimate effect mental, yet the intermediate process itself 
 may be essentially a physical one. 
 
 II. Another cause for the moral theory of insanity is, the sup- 
 position that the bodily disease which accompanies it is too slight 
 to occasion the mental derangement ; but this will no more bear 
 examination than the former. Yov, first, the bodily disease which 
 accompanies insanity may not be so striking as that wliich accom- 
 panies delirium ; it may not be so noticeable as a hot skin, a quick 
 pulse, a furred tongue, and helplessness of limbs, yet it may be 
 equally, or even more capable of disturbing the actions of the brain. 
 A little black bile, which none would notice but an explorer of 
 hepatic secretions, may be more capable of disordering the faculties 
 of the mind than loss of appetite and prostration of strength, which 
 every one would notice. It is certain that puerperal insanity depends 
 on a peculiar state of the bodily constitution, yet this state, so far 
 from being obvious, is often known to exist only by a disordered 
 condition of the mind. This objection is founded on the supposition 
 thai bodily disease is only capable of disturbing the brain of the 
 patient in the same degree that it strikes the senses of an observer, 
 which is a manifest absurdity. Besides, in the delirium of fever we 
 ; hi. ider thai the deranged state of the mind is the effeel of a dis- 
 ordered state of the brain; why then should not the same symptoms
 
 AS AN OBJECT OF MORAL SCIENCE. 89 
 
 prove the same thing though unconnected with the same extent of 
 disease? 
 
 III. It is well known that strange habits of mind, long continued, 
 are capable of generating great singularity of opinion and feeling; 
 between this moral eccentricity and insaiuty there is sometimes a 
 striking resemblance. It is not easy to confound boisterous madness 
 with healthy singularity, but when a lunatic is harmless in conduct, 
 insane only on one point, and talks so rationally on all others that 
 it is not easy to detect his infirmity, his state of mind is wonderfully 
 like those eccentric and absurd opinions which intellectual habits are 
 capable of producing, and wlrich often cause their possessors to be 
 called mad, half in joke yet half in earnest: a little insight into the 
 mode of their production will enable us to judge whether tins resem- 
 blance is apparent or real. 
 
 It is so well known that the mind may brood over a subject till it 
 loses the power of seeing it in a right point of view, that it is com- 
 monly said a man may tell a lie till he believes it. ' 1 wish/ says 
 Dr. Johnson, rebuking Boswell for the zeal into which he had 
 worked himself about the history of Corsica, 'I wish there were 
 r some cure Hke the lover's leap for all heads of wlrich some single 
 'idea has obtained an unreasonable and irregular possession/ 
 Objects which have had frequent access to the mind, seem to have a 
 double power over it : viz., they not only produce the natural effect 
 of a single application, but they revive the traces or recollections of 
 their former impressions. This is the case not only with objects of 
 fancy, but with propositions which, appeal to the understanding; an 
 opinion produces effect partly in proportion to the manifest proof 
 which it contains, and partly to the frequency with which it has 
 been so presented to the mind as to excite the feeling of approval or 
 conviction ; every time it is so applied it leaves (if I may so express 
 myself) a stratum of belief in the mind, this is capable of incalculable 
 accumulation, till at length the object produces an effect and gains 
 a power over the individual totally different to what it possesses over 
 one less frequently impressed by it. Objects by repetition lose their 
 power over the senses, for the senses have no memory, while they 
 incalculably augment it over the understanding and the affections, 
 li is on this principle that so many trifles acquire an influence over 
 us so disproportionate to their importance; that with the generality of 
 mankind opinions owe their power more to habit than to evidence; that 
 an old song, howe\ er bad, pleases more than a new one, ho\vc\ er ij,ood ;
 
 90 THOUGHTS ON INSANITY 
 
 that a wag tickles those who are accustomed to him more than those 
 who are not ; that the ploughman prefers his coarse and awkward 
 mistress to the loveliest lady in the land ; that the constant dropping 
 of daily circumstances on the character wear in it deeper channels 
 than the transient torrents of persuasion. 
 
 It is this striking similarity between the erroneous opinions 
 of the insane, and the singular opinions of the eccentric, and 
 this power of habit to generate, even in healthy minds, something 
 so similar to the essential features of insanity, which has been, 
 I suspect, one of the principal causes for the belief in the moral 
 nature of this disease. Yet any one who is familiar with human 
 nature, both sane and insane, would perceive an important difference 
 between the two cases : it is this, that the errors of the eccentric are 
 the result of long habits, continued for a great part of their lives, 
 and fabricated by slow and almost imperceptible degrees, while the 
 errors of the insane spring up suddenly, within a few months or even 
 weeks. The patient has suffered some mental agitation, received a 
 blow on the head, has been lying-in, or is recovering from a fever ; 
 the mind becomes confused and hurried, and in a few weeks, or even 
 days, there arise the wildest and most absurd beliefs. In these cases 
 there is neither time nor peculiarity of habits adequate to explain 
 such effects by the intellectual processes above alluded to. Between 
 the erroneous opinions of the insane and the singular opinions of the 
 eccentric, there is the same difference as there is between that per- 
 manent readiness of argument, imagery, and language, which is the 
 result of study and practice, and those sudden and temporary gusts 
 of elocpience produced by a bottle of wine. 
 
 IV. It is possible that the reader may be satisfied about the fore- 
 going points, yet there remains another consideration which may 
 induce him to believe that insanity is at least sometimes a moral 
 disease : the consideration is this, that the cure of insanity is some- 
 times effected by a method both moral in its nature and moral in its 
 operation ; thus patients have been relieved from their hallucinations, 
 and restored at once to complete sanity, by a well-contrived incident, 
 a well-expressed argument, or a well-managed conversation. Here 
 the cure is as much an intellectual process as the conviction of a 
 sophist, or the conversion of an infidel ; in fact, they are identical 
 processes. Now I would first remind the reader of the general truth 
 of (lie opposite statement, the total inefficacy of argument, persuasion, 
 and all appeals (o the mind during the violence of the disease; but
 
 AS AN OBJECT OF MORAL SCIENCE. 91 
 
 granting it to the full extent of the truth, do we not witness the 
 same effects brought about by the same means in affections whose 
 origin is confessedly physical? If a person low-spirited from ill- 
 health should suddenly receive some joyous news, he would for a 
 time at least be restored to the hilarity of health ; would forget his 
 low-spirits in his bright prospects ; the physical would yield to the 
 mental impulse. A more striking example sometimes occurs in 
 delirium ; a person in the height of fever, who, if left to himself, 
 would stare vacantly and talk incoherently, will sometimes at a loud 
 question wake up, answer collectedly, be himself for a short time, 
 and then relapse into his former incoherence. Here is a menial 
 cause removing, by a mental operation, a state of mind avowedly 
 physical. From such facts what are we to infer ? Not that insanity 
 is a moral disease, because it is sometimes benefited by moral treat- 
 ment, but that though the unnatural state of the mind arises from a 
 diseased condition of the body, there are times and states in which 
 the mind begins to regain the capability of being acted upon in the 
 natural way by its natural mental objects. 
 
 "V . There is another circumstance which cannot be numbered 
 among the reasons for the moral theory of insanity, but winch I 
 suspect has greatly contributed to it; I mean the fear that the 
 opposite notion would favour the doctrine of the materiality of the 
 soid. A moment's reflection, however, will show that the physical 
 theory of insanity is not more likely to lead to tins conclusion than 
 the physical theory of delirium, which no one doubts. If the effect 
 of bodily disease on the mental faculties is likely to have a dangerous 
 influence, the danger is not in this or that instance, but in the 
 principle. As the present question, however, is not what is the 
 safest doctrine, but what is the truest; as the example of insanity 
 adds nothing to the danger of the principle, and as this is not the 
 place for discussing the question how far it is compatible with the 
 immortality of the soul, I shall not enter into. I may be allowed, 
 however, to remark, that the whole danger rests on this proposition, 
 that if the diseases of the body disorder the faculties of the mind, 
 then the faculties of the mind must be the functions of the body. 
 But where is the proof of this ? Disease in the liver impairs diges- 
 tion ; is digestion a function of the liver ? Defects in the cornea 
 confuse the perceptions of the retina; is vision a function of the 
 cornea ? It is plain, therefore, that disease in a part may disorder 
 actions which are not the functions of that part. The mind is affected
 
 92 THOUGHTS ON INSANITY 
 
 by the state of the stomach, of the liver, of the uterus ; we know, 
 therefore, that it may be affected by the state of organs with which 
 it communicates, but of which no one pretends it is the function. It 
 maybe said that the mind and these organs can never be seen apart, 
 and that although it is not supposed to belong to them in the same 
 way as a function belongs to an organ, we have no proof that they 
 can exist separately: true, but take another instance. A hand shat- 
 tered by the bursting of a gun will produce fever and delirium ; let 
 the limb be removed at the proper period, the constitution regains 
 its tranquillity, and the mind its powers : it is clear, therefore, that 
 the mind may be affected by disease in a part not only of which it is 
 not the function, but from which it may be separated ; that such is 
 the construction of the living body, that one thing may affect another 
 with which it has only a temporary connexion ; where, then, is the 
 danger of the principle, that the diseases of the body disorder the 
 faculties of the mind ? Whoever has convinced himself by other 
 considerations of the immortality of the soul, will find no difficulty 
 in this principle ; and so far from shrinking from it, will rather see 
 in it a reason for believing that ' in a separate state of existence it is 
 ' highly probable that the soul works clearer, and understands brighter, 
 'and discourses wiser, and rejoices louder, and loves nobler, and de- 
 * sires purer, and hopes stronger, than it can do here/* 
 
 It appears, therefore, that emotions of mind are capable of dis- 
 turbing the organs of the body, and that, though moral causes in 
 themselves, they may be physical in their operation; that the ade- 
 quacy of bodily disease to disorder the mind is not to be estimated 
 by the degree in which it strikes the attention of the observer ; that 
 although the erroneous opinions of the insane are very similar to the 
 singular opinions of the eccentric, they are very different in their 
 nature and origin ; that causes, moral both in their nature and ope- 
 ration, are capable of influencing diseases which are avowedly physical, 
 and that consequently their inlhience in insanity is no proof that it 
 is a moral disease : lastly, that the physical theory of insanity is no 
 more a proof of materialism than many avowed instances of the 
 influence of body over mind. I conclude, therefore, that there is 
 no ground for the reasons which have led to the belief in the moral 
 nature of insanity; if we take into the account the influence of 
 physical causes in its production, as injuries of the head, parturi- 
 tion, drunkenness, the sun's heal, and the influence of medicinal 
 
 * Jeremy Taylor's seinion on tlie death of the Countess of Carberrv.
 
 AS AN OBJECT OF MORAL SCIENCE. 93 
 
 remedies in abating or removing it, can we avoid taking it from the 
 solitary and singular station which it holds as a moral affection, and 
 replacing it among those in which an unnatural state of mind attends 
 on bodily disease ? 
 
 If this was merely a speculative question, an inactive scepticism 
 might be philosophical and justifiable; but it is one of the many we 
 meet with in life which cannot be answered with mathematical cer- 
 tainty, but which should be settled as well as we are able, because 
 they are necessary for action. It is no less a question than whether, 
 in onr search after a better theory and a more successful treatment 
 of these diseases, we shall occupy ourselves in investigating the 
 causes and treatment of disease in the brain, or in discussing whether 
 insensibility is an error of the perception, the imagination, or the judg- 
 ment. In applying the inductive mode of reasoning to its intellectual 
 phenomena — who are the persons best fitted for prosecuting the 
 inquiry? those who are familiarly acquainted with the causes, pro- 
 gress, and treatment of diseases in general, and among them of the 
 diseases of the brain, or those whose only qualifications for the task 
 arc their benevolence, their zeal, and their metaphysics? 
 
 In considering insanity as an object of legal medicine, it often 
 becomes a question, and sometimes a puzzling one, whether the 
 peculiarity in the mind of the person who is the subject of investi- 
 gation does, or does not, constitute unsoundness of mind ? On these 
 occasions, it is often said that the peculiarity is not madness, but 
 eccentricity. To form a proper opinion on this question, it is neces- 
 sary to have an accurate conception, not only of what we mean by 
 the word insanity, but also of what we mean by the word eccen- 
 tricity. 
 
 Now, the persons who have passed for eccentric, and whom I have 
 had opportunities of observing, I would divide into three classes. 
 1st. Those who differ from the rest of mankind chiefly in their 
 objects and pursuits. Instead of desiring and aiming at the common 
 object of human wishes, namely, rising in life, the attainment of 
 a competence, the acquisition of wealth and power, they are con- 
 tented in these respects to remain stationary, and they dedicate the 
 whole of their time and talent to the cultivation of their minds and 
 the acquisition of knowledge. This peculiarity of pursuit, unless
 
 94 THOUGHTS ON INSANITY 
 
 counteracted by much intercourse with polished society, generates 
 various peculiarities in their appearance, habits, manners, and modes 
 of expression; they are careless, often slovenly in their dress, awk- 
 ward in their manners, singular, and often pedantic in the topics 
 and language of their conversation. Such persons are called eccen- 
 tric, but their eccentricity consists only in their pursuits and man- 
 ners ; it is the simplest and most unquestionable form of eccentricity, 
 and is compatible with the healthiest, happiest, and most vigorous 
 state of mind. 2d. The second class consists of persons who differ 
 from the rest of mankind in the singularity of their opinions. With 
 the same materials they draw inferences widely different from those 
 of sensible and competent judges ; they are persons of great confi- 
 dence in their own judgment, defective either in knowledge or in 
 comprehensiveness of mind, and by separating those facts winch are 
 favourable to their opinions, by frequent meditation on them, and 
 by keeping out of sight the opposite facts, they at length attain the 
 firmest conviction of their peculiar notions. Tins process will some- 
 times carry a man a great way. There is at this time, in America, 
 a Captain Symes, who is convinced that the earth is perforated from 
 pole to pole, that the sea flows through, that the perforation is 
 navigable, and he is said to be planning a voyage to explore it. 
 This form of eccentricity, in a minor degree, is very common ; the 
 persons subject to it are often clever and zealous, but they never 
 possess very superior minds; they have the zeal for knowledge 
 without corresponding sagacity; still they are eccentric, not mad, 
 for they arrive at their conclusions through an intellectual process, 
 though a crooked one : it is a law of the human understanding, that 
 a little evidence perpetually presented to the mind will produce as 
 much conviction as a greater quantity presented rarely. 3d. There 
 is still another class of persons who are called eccentric. Those 
 whom I have had an opportunity of observing closely have been 
 remarkable for a high opinion of themselves, quite disproportionate 
 to their apparent powers or actual achievements, for rashness of 
 conduct never corrected by experience ; some of them have had sin- 
 gularly calm and sweet dispositions; others have been of stormy 
 tempers, subject to violent gusts from trifling provocations; they 
 have had singular opinions without any intelligible reasons for them, 
 and have most of them had a peculiarly formal and solemn manner. 
 After continuing many years in this state, and passing among their 
 (Vicnds for eccentric characters, they have ultimately become de-
 
 AS AN OBJECT OF MORAL SCIENCE. 95 
 
 ranged. I need scarcely say that this peculiarity of mind, although 
 constantly mistaken for eccentricity, is, in truth, slumbering, unde- 
 veloped madness. The signs which ought to create suspicion of this 
 state are these : insanity being more or less prevalent in the fainity; 
 a singularity of manners, opinions, and actions, inexplicable by the 
 peculiar pursuits of the individual; enormous self-esteem; mis- 
 chievous schemes obstinately persisted in, and uncorrected by expe- 
 rience. 
 
 When the body is healthy and the mind sane, our beliefs, 
 emotions, and actions, are produced by mental processes, more or 
 less complete in different individuals, but still in all by mental pro- 
 cesses. We believe such a proposition because we have some 
 evidence for it, good or bad; we experience angry or sorrowful 
 emotions, because something irritating or depressing has occurred to 
 our minds ; we inflict punishment upon another from a vindictive 
 emotion excited by a real injury; but in madness, these beliefs, 
 emotions, and actions, seem no longer to be the results of mental 
 processes, but to be under the influence of a peculiar bodily state. I 
 have conversed with those who have recovered from derangement on 
 the subject of their delusions, and have asked them what could have 
 led them so firmly to believe such absurdities or impossibilities, what 
 real or imaginary reasons they had ; and they have told me that they 
 had no reasons at all, that there was the thought in their mind, 
 accompanied by the most undoubting confidence of its truth, but how 
 it came there they knew as little as how it went away. Persons on 
 the verge of melancholia will often declare that they are wretched, 
 they know not why ; that they have everything to make them happy, 
 and yet they feel no interest in life, a distaste for all their ordinary pur- 
 suits and pleasures, a wretchedness for which they can give no reason 
 to themselves. In these extraordinary cases in winch persons have 
 committed murder on those who have never offended them, and 
 towards whom they felt no antipathy, it seems that they were some- 
 times urged by some strange impulse totally different to the sense of 
 injury, and thirst for revenge, which impels the sane man to commit 
 such acts. If we are right in supposing that the instincts of animals 
 consist of reasonable acts, not preceded by any reasoning process, but 
 subservient to some bodily sensations in the animal, there would be 
 a striking analogy between the two conditions, and insanity might
 
 96 THOUGHTS ON INSANITY 
 
 be said to be the temporary conversion of human into animal nature. 
 This has long appeared to me to be the most reasonable conjecture 
 on this dark and mysterious subject. 
 
 It has been stated by legal authority, that, to make out insanity, 
 it is necessary to prove ' insane belief/ But what is the definition 
 of ' insane belief ?' Is it the belief of something either physically 
 impossible, or utterly groundless and unreasonable ? If so, it will 
 apply, indeed, to the greater number of hallucinations, but will not 
 reach them all. 
 
 I knew a captain of an East Indiaman who became deranged 
 during a lawsuit about his father's will, and who believed that he 
 had come into possession of £100,000 a year; he spent money 
 lavishly, drove about the streets in a carriage with a mistress, told 
 me that he should restore the feudal system in all its glory, offered 
 to give me a pair of carriage horses, and at length went abroad to 
 dethrone the Grand Sultan, promising that if I went with him he 
 would make me his Grand Vizier, and give me a magnificent seraglio. 
 In this case the predominant notion was utterly groundless and un- 
 reasonable ; but what shall we say to those cases in which the 
 predominant notion is such, that it is more reasonable to believe it 
 than to disbelieve it, or is an actual truth? yet such cases there 
 are. 
 
 In religious melancholy the patient thinks that he is the object of 
 Divine anger. In this case is the prominent belief utterly ground- 
 less and unreasonable ? Christianity, as represented to us in the New 
 Testament, clearly leads to the belief that only a small part of the 
 human race is to be saved : consequently the chances are much 
 against any particular individual, and I know few persons who have 
 not reason to doubt whether they have ever attained that strength 
 of faith, purity of heart, and entire repentance, which are held out 
 as the necessary conditions of salvation. When we consider the 
 certainty of death, and the magnitude of the cmestion, it seems 
 more reasonable to feel anxiety, and even terror about it, than indif- 
 ference; yet experience shows that people, as long as they keep 
 their sound senses, bear the thought with sufficient lightness for all 
 the uses of this world. Dr. Johnson, who seldom touched any 
 subject without Lighting on the truth, perceived this, as appears by
 
 AS AN OBJECT OF MORAL SCIENCE. 97 
 
 the following opinion recorded by Boswell. ' Madness frequently 
 ' discovers itself merely by unnecessary deviation from the usual 
 ' modes of the world. My poor friend Smart showed the disturb - 
 ' ance of his mind, by falling upon his knees, and saying his prayers 
 ' in the street, dr in any other unusual place. Now, although, 
 ' rationally speaking-, it is greater madness not to pray at all, than 
 ' to pray as Smart did, I am afraid there are so many who do not 
 ' pray, that their understanding is not called in question/ 
 
 Here the insanity consists, not in the groundlessness and unreason- 
 ableness of the predominant belief, but in its affecting the mind in 
 a different way to what it does that of sane persons. I attended a 
 deranged lady, whose predominant belief was, that her husband was 
 unfaithful to her; the notion, so far from being unreasonable, was, 
 I believe, true, and she had known it for many years without any 
 unnatural disquietude, but now it engrossed all her thoughts ; she 
 neglected her ordinary pursuits, took a dislike to her friends, felt no 
 interest about her children, and sat silent and motionless from 
 morning to night. After continuing deranged several months, she 
 recovered, although she still retained the same opinion. In what, 
 then, consisted her insanity ? not in the groundlessness and un- 
 reasonableness of the predominant belief, but in its withdrawing her 
 attention from all other thoughts and pursuits, in its overwhelming 
 influence over her feelings and conduct. 
 
 H
 
 CHAPTER III. 
 
 THE MODE OF DISTINGUISHING PREGNANCY FROM THE DISEASES 
 WHICH RESEMBLE IT. 
 
 It is a common opinion, that the symptoms of pregnancy are so 
 certain, that no one who is not either inattentive or ignorant can 
 possibly mistake them ; and whenever any error of this kind occurs, 
 the person who has committed it is an object of ridicule : yet not 
 only are women and their nurses often wrong, but so are practitioners 
 of considerable experience ; nay, even those who have paid especial 
 attention to the subject, and who have the largest experience of 
 obscure cases of this kind, are sometimes at a loss, and sometimes 
 err. For want of clear notions of the subject, and a very attainable 
 degree of tact, practitioners are frequently incurring disgrace, patients 
 are subjected to active courses of medicine for the reduction of 
 tumours, for which the natural remedy is parturition ; and in some 
 instances, pregnant women have been supposed to be dropsical, and 
 actually tapped, to say nothing of other blunders.* I know of no 
 account of the subject at all adequate to its difficulty and import- 
 ance ; t and I think I shall be doing a service to a numerous class 
 of practitioners by giving a full and connected account of the symp- 
 
 * ' We saw at Paris, in the year 1666, a miserable example of this kind in a woman 
 ' who was hanged and afterwards dissected publicly. She was found to be pregnant 
 ' with a child of four months, notwithstanding the report of the persons who had 
 ' visited her by order of the judge before her execution, who assured the judge that 
 ' she was not so. What deceived them was that this woman had menstruated in 
 1 some degree. This affair made so much noise at Paris, that it came to the know- 
 ' lege of the King and all his court, by whom those persons were greatly blamed, 
 1 who by their ignorance had been the cause of the rash execution of this poor 
 
 • unfortunate, with whom had perished her infant, which was innocent of the crimes 
 ' of its mother Besides the death of such innocent little creatures, they deprive 
 
 * them of eternal felicity by making them die in the belly of their mother without 
 1 receiving the baptism which would have procured them so great a good.' — Mauri- 
 ceau sur les Maladies des Grosses Femmes, 4to. 1721, tome i. liv. 1, pp. 71 and 72. 
 
 t The fullest account of the subject is contained in a German work, entitled ' Dr. 
 ' Willielm Joseph Schmitt's Sammlung Zweifelhafter Schwangerschaftsfalle nebst 
 ' einer kritischen Einleitung iiber die Methode des Untersucheus.' Vienna, 1818. 

 
 SYMPTOMS OF PREGNANCY. 99 
 
 toms of pregnancy, the degree in which they may be relied on, the 
 mode of distinguishing pregnancy from the cases which resemble it, 
 and the various forms of disease to which it requires to be applied. 
 
 In learning the symptoms of pregnancy for the elucidation of 
 doubtful cases, it is necessary to attend, not merely to the symptoms 
 themselves, but to the order in which they succeed one another, and 
 to the time of their appearance. 
 
 The first symptom of pregnancy is the omission of menstruation. 
 The patient may have been pregnant a week or two already, but she 
 cannot know it till that period of the month arrives when she is 
 accustomed to menstruate ; and then, when she expects to be unwell, 
 she finds that she is not so. This is soon followed by sickness ; it 
 commonly occurs on rising in the morning, and diminishes, and at 
 length ceases, as the day advances; it generally continues during 
 the first half of pregnancy, and subsides about the time when the 
 movements of the child begin to be felt. "When three months have 
 elapsed without menstruation, the abdomen begins to enlarge ; this 
 is at first very slight, the patient rather feels distended than shows 
 any visible enlargement ; but it gradually increases, so that after 
 the fourth month the prominence of the abdomen can be perceived 
 externally. By the fifth month this prominence is so considerable, 
 that when the patient is standing, no one can overlook it, and from 
 this time it gradually increases till it attains the well-known bulk 
 of a person near her delivery : thus the visible enlargement of preg- 
 nancy does not last more than five months; if it has lasted nine, 
 that alone is a reason for doubting whether it arises from pregnancy. 
 The next symptoms are enlargement and shooting pains in the 
 breasts, darkness of the areola, and enlargement of the follicles 
 round the nipples. In women with dark eyes and hair, this dis- 
 colouration is very distinct; in women with light hair and eyes, 
 it is often so slight that it is difficult to tell whether it exists or no. 
 The last symptom I have to mention is the most important, because, 
 if really present, it is the most conclusive — I mean the child's move- 
 ments. These begin to be felt when four months have passed 
 without menstruation. At first the sensation is only slight; it is 
 like a pulse or a fluttering in the abdomen, and lasts only a few 
 seconds at a time ; it may be felt one day and then cease for several ; 
 but gradually this sensation becomes stronger and more frequent, 
 till at length, if a hand happens to be laid on the abdomen at the 
 moment when the child moves, it can be felt externally. Towards
 
 100 SYMPTOMS OF PREGNANCY, 
 
 the end of pregnancy its movements are so strong, that whilst the 
 patient is sitting, the heaving of the abdomen may sometimes be 
 seen through her dress. 
 
 Thus, the ordinary signs of pregnancy are a cessation of men- 
 struation, morning sickness, enlargement and shooting pains in the 
 breasts, darkness of the areola, enlargement of the abdomen begin- 
 ning about the third month, and gradually increasing till the ninth ; 
 the movements of the child after the fourth month gradually growing 
 stronger till the ninth. 
 
 It is clear that if these symptoms always accompanied pregnancy, 
 we should always know when it existed ; and if they never accom- 
 panied any other state, we could never mistake any other state for 
 pregnancy. But unfortunately they possess neither of these requi- 
 sites for infalb'bility ; they may be absent in patients who are preg- 
 nant, and present in those who are not so ; and thus give occasion 
 to frequent errors. 
 
 I. Many women assert that they have menstruated regularly 
 during the early months of pregnancy : whether this is really men- 
 struation, or a periodical haemorrhage from partial separation of the 
 ovum, is not the question, but whether, during the first months of 
 pregnancy, there may not occur a monthly discharge of blood which 
 in period and duration so far resembles menstruation, that the 
 patient is unable to distinguish it ; and about this there can be no 
 doubt. As to sickness, there is an infinite variety in the degree in 
 which it occurs in pregnancy: some patients are sick day and night, 
 during all the nine months ; others never feel the slightest nausea 
 from the moment of conception to that of delivery. In thin women 
 the enlargement of the breasts is often very slight; and in fat 
 women the breast forms so small a proportion of the bosom, that 
 any enlargement of the former is scarcely perceived. In very fair 
 women, with light hair and eyes, the discolouration of the areola is 
 often so sbght, that it is difficult to perceive ; and in brunettes who 
 have already borne children, the areola remains dark ever after- 
 wards, so that this ceases to be a guide in all subsequent pregnan- 
 cies. The enlargement of the abdomen from the third month to 
 delivery, is in all cases present and progressive whilst the foetus is 
 alive ; but it may die, and yet be retained till the ninth month, in 
 which case the enlargement will not be progressive. The same may 
 be said of the movement of the foetus ; it will not move if not alive, 
 and there arc cases, though rare, in which it has not moved during
 
 AND DISEASES RESEMBLING IT. 101 
 
 the whole of pregnancy, although it has been born alive and vigor- 
 ous; of (his 1 have known one instance, and read of others. Tims 
 a woman may be pregnant though she seems to herself to continue 
 to menstruate, has no sickness, or enlargement about the breasts, or 
 darkness of the areola, or progressive enlargement of the abdomen, 
 or perceptible movement of the foetus. Such a complete assemblage 
 of omissions, however, is not likely to meet in the same case. 
 
 II. A woman may have apparently all the symptoms of pregnancy, 
 and yet not be pregnant ; menstruation may be stopped by other 
 causes ; when it ceases suddenly in a woman of healthy constitution, 
 wdio had previously menstruated with perfect regularity, it is a strong 
 symptom, but there are w r omen of feeble constitutions who, without 
 being pregnant, frequently pass months without menstruating ; in 
 such a person the omission of menstruation proves nothing. Sickness 
 may be produced by other causes besides pregnancy ; and when it 
 arises from a weakness of stomach, the morning is the time when it 
 is most distressing. The bosom may enlarge because the patient is 
 growing plump. Some have laid great stress on the darkness of the 
 areola, thinking that no other state besides pregnancy is capable of 
 producing it. I saw two young and newly-married women within 
 two days, who had made preparations for lying-in, and who were not 
 pregnant. In both, the areola was dark, though (if their history is 
 to be trusted) they had never had children. I believe, however, that 
 darkness of the areola rarely depends on other causes, and that when 
 it exists it may generally be looked upon as a sign either that the 
 patient is pregnant, or has been so formerly.* The abdomen often 
 
 * ' Obstructions and pregnancy are both accompanied by a stretching fulness in 
 4 the breasts, but in the last only (pregnancy) may be perceived the areola or brown 
 ' ring round the nipples, from which in the last months a thin serum distils ; but this 
 1 circle is not always so discernible as in the first pregnancy, and even then is un- 
 ' certain as well as the others.' — (Smellie, vol. i., p. 187.) 
 
 'Dr. Hunter had great faith in this sign, insomuch that he asserted that he could 
 ' always judge by it whether or not a woman was pregnant; he once evinced how 
 ' much dependence was to be placed on it. A subject was brought to him for ana- 
 1 tomical purposes, but on looking at the breast, from the appearance of the areola 
 ' he declared that the female died while pregnant. One of his pupils examined the 
 ' genitals, and found that she had a hymen ; this seemed a contradiction, but the 
 • Doctor still adhered to his opinion, and thought more attention due to the former 
 ' than the latter appearance. On opening the body his assertion proved just, for the 
 ' uterus was found impregnated.' — (Lowder, MS. Lectures.) 
 
 ' The areola, or brown circle round the nipples, has been represented as an indu- 
 ' bitable mark of pregnancy. This is not, however, suspected to be a primary conse- 
 ' quence of a particular affection of the uterus, but of the preceding enlargement and
 
 102 SYMPTOMS OF PREGNANCY, 
 
 enlarges from flatulence, dropsy, and other diseases, so as to equal 
 or exceed the bulk of pregnancy. As to the movements of the child, 
 it is very important to distinguish between these movements as felt 
 internally by the patient, and as felt externally by a hand applied to 
 the surface of the abdomen ; the latter, if really felt, is an infallible 
 sign of pregnancy, but the former are often felt when there is no 
 child. Thus a woman may cease to menstruate, have sickness, 
 enlargement of the bosom, and darkness of the areola, a progressive 
 enlargement of the abdomen, and sensations which resemble those 
 produced by the movements of the 'child, without being pregnant. 
 
 But if the ordinary symptoms of pregnancy are so far from being 
 infallible, what, it will be asked, is the result in practice ? It is this 
 — that although they are sufficient guides in most cases, and under 
 ordinary circumstances, yet that they are often insufficient. One 
 person is pregnant who has no right to be so, and obstinately denies 
 it ; another is pregnant who has no cause to be ashamed of it, but 
 from some peculiar circumstance, reasonable or unreasonable, dis- 
 believes that she is so. One thinks that she is pregnant merely 
 because she is sick, another because she is not regular, a third 
 because her belly swells, and a fourth because she wishes to be so — 
 and these erroneous denials and erroneous suspicions are imparted 
 from the patient to the medical attendant, and influence his con- 
 duct. Of these errors some are the result of ignorance or thought- 
 lessness, but some are committed by men of sense, experience, and 
 attention. 
 
 How then are we to act in doubtful cases ? To wait till the doubt- 
 ful state is sufficiently advanced to enable us to ascertain two points ; 
 1st, whether the enlargement of the abdomen depends on enlarge- 
 ment of the uterus, and if so, 2d, whether the enlarged uterus 
 contains a fetus ; these are the ultimate objects of what is called 
 examination by touch ; and the several indications winch are sought 
 for, are important only as they elucidate these two questions. 
 
 Those who have had most experience in obscure cases of this 
 kind agree, that it is difficult to decide about them by touch during 
 
 1 alteration of the breasts ; and though it generally occurs in pregnancy, it may be 
 1 produced by any cause capable of giving to the breasts a state resembling that 
 1 which they are in at the time of pregnancy, of which it can only be esteemed a 
 ' doubtful sign. The areola is therefore found in many of the complaints which 
 ' resemble pregnancy, and though generally, not universally, I think, in pregnant 
 ' women.' — (Denman, Jntrod. to Midwifery, vol. i, p. 251.)
 
 AND DISEASES RESEMBLING IT. 103 
 
 the early months, and that the longer the examination is postponed, 
 the more conclusive it is. Dr. William Hunter, who possessed at 
 least more than the average quantity of experience and tact, used to 
 express himself thus in his lectures on the subject : ' I find that I 
 ' cannot determine at four months, I am afraid of myself at five 
 ' months, but when six or seven months are over, I urge an 
 ' examination/ 
 
 Having chosen the time for examination, the next question is, how 
 to perform it ? What are we to seek for, and how shall we detect 
 them ? Our object is to ascertain the state of the uterus, and this 
 may be felt in two ways — externally through the walls of the ab- 
 domen, and internally through the vagina. In examining externally 
 through the walls of the abdomen, the bladder should be empty, the 
 patient in bed, in her night dress, on her back in a posture between 
 sitting and lying, with the knees slightly drawn up. These are the 
 most favourable circumstances for the external examination ; but we 
 are often obliged to examine without these advantages. 
 
 The first thing to notice is the situation, consistence, and figure 
 of the tumour which is distending the abdomen. In pregnancy the 
 uterus does not rise out of the pelvis before the third month — by the 
 sixth it is up to the umbilicus — by the seventh it is a little above 
 the umbilicus — by the eighth month it is half-way between the 
 umbilicus and scrobiculus cordis — and in the ninth month it has 
 reached the scrobiculus cordis, its highest elevation : thus, if we are 
 examining a patient about the sixth month of pregnancy, we shall 
 feel a circumscribed tumour occupying the front of the abdomen, 
 from the brim of the pelvis to the umbilicus, of an oval form and 
 firm consistency, much firmer than the abdomen above and on its 
 sides, where it is occupied by the intestines. All this can be made 
 out clearly if the walls of the abdomen are thin and relaxed ; if they 
 are fat, tins is difficult, and often impossible ; but even then we can 
 notice whether the enlargement is firm or soft : the former will be 
 the case if the patient is pregnant. 
 
 The next thing to notice is the umbilicus. In the unimpregnated 
 state it is sunk below the surface, forming a shallow pit; but in 
 pregnancy, when the uterus has arisen to or above the umbilicus, this 
 part projects above the surface of the abdomen;* this, however, 
 
 * ' Those who are pregnant have the abdomen always much more eminent before, 
 ' and the umbilicus much more elevated, than in false pregnancy; so that in a 
 ' doubtful suspicion of pregnancy advanced four or five months, or more, if we find
 
 lOi SYMPTOMS OF PREGNANCY, 
 
 depends on- the period of pregnancy at which we are examining ; it 
 will scarcely be found before the sixth month, and the further the 
 pregnancy is advanced the more distinct will it be. The firmness of 
 the abdomen and the projection of the umbilicus depends on one and 
 the same cause, that is, the firmness of the tumour which is dis- 
 tending the abdomen; but any other tumour equally firm may 
 occasion both these symptoms; their presence alone proves little, 
 but if the state which we are investigating is advanced as far as the 
 seventh or eighth month, their absence proves a great deal ; for if the 
 umbilicus is depressed, and the abdomen, though enlarged, is soft 
 and yielding, these alone prove that the patient is not pregnant. Let 
 not the practitioner, however, give an opinion till he has collected all 
 the proofs. 
 
 The next thing to attend to is, the movement of the child. If 
 the hand is laid on the naked abdomen, between the pubis and the 
 umbilicus, the foetus will sometimes be felt to stir. As, however, it 
 moves only occasionally, this may not happen during the examination. 
 It is said,*- that by dipping the hand in cold water, and laying it 
 suddenly on the naked abdomen, the foetus may be made to move. 
 As I have long had the cold hand of a dyspeptic sufferer, I have no 
 occasion to dip my hand in cold water ; it is always cold enough to 
 make the patient shrink, and by laying it suddenly on the naked 
 abdomen, T have sometimes felt the child move, but this has been 
 only an occasional occurrence. If distinctly felt, it is of course the 
 most conclusive symptom. 
 
 Having examined the uterus through the walls of the abdomen, 
 we proceed next to examine it through the vagina : for this the 
 patient should be turned on her side ; and here again there are three 
 things to observe, the state of its neck, the state of its body, and the 
 movement or rather tine mobility of the foetus. 1st, in the unim- 
 pregnated state, the neck of the uterus projects into the vagina about 
 two-thirds of an inch, like a thick, firm, fleshy nipple. At the 
 termination of pregnancy, a few days before labour, this neck is 
 completely obliterated, the portion of uterus, which lies over the top 
 
 ' the navel of the woman sunk and the orifice of the womh small and hard, we may lie 
 ' assured by these two signs that she is not pregnant, for, in true pregnancy, advanced 
 ' to the period which I have named, the navel appears always more raised, and the 
 ' internal orifice more tumefied, supple, and soft, than in false pregnancy.' — 
 (Manriccait, t. i. p. 93.) 
 
 * Morgagni de Scd. ct Causis, Epist. 48. § 3. — Dr. J. Hamilton.
 
 AND DISEASES RKSE.MBLINtt IT. 
 
 105 
 
 of the vagina, no longer projecting into its cavity, lml forming a flat 
 roof. This obliteration begins about the fifth mouth, the neck 
 becoming gradually softer, broader, and shorter; by the seventh 
 mouth it is much altered, and not at all like the neck in the unim- 
 
 A the neck of the uterus before the fifth month, when it has undergone no change 
 
 in its length. 
 B the neck at the sixth or seventh month, when it has begun to shorten. 
 C the neck in the eighth month, when it is nearly obliterated. 
 D the neck at the end of the ninth month, when it is quite obliterated. 
 
 pregnated state, being very soft, broad, and short. It is now calcu- 
 lated to have lost three-fourths of its length; but it is not quite 
 obliterated till the last week of pregnancy, so that if a false alarm 
 about labour, two or three weeks before delivery, gives the practi- 
 tioner an opportunity of examining the uterus, he will find a soft, 
 short nipple still remaining. 
 
 As the neck of the uterus remains unchanged till after the fifth 
 month, it is a good reason for postponing examination till a later 
 period ;* yet although tins statement is generally correct, especially 
 
 * ' It is generally impracticable to discover by a touch in the vagina, whether or 
 ' not the uterus is impregnated, till after the fourth month.' — (Smellie, vol. i, p. 181.) 
 ' The stretching of the uterus and upper part of the neck cannot be perceived till the
 
 106 SYMPTOMS OF PREGNANCY, 
 
 in first pregnancies, it has been stated far more strictly than is true. 
 An anatomical teacher will show a preparation of a uterus in the 
 fifth month of pregnancy, with an unshortened neck, and think the 
 question settled by anatomical demonstration; but a uterus in a 
 bottle is only one case, and proves no more than the examination 
 of a uterus in a living subject ; and the examination of many has 
 taught me, that the neck of the uterus is as much altered in some 
 women at the fourth month, as in others at the sixth, especially in 
 those who have had several children, in whom the neck yields more 
 readily than in first pregnancies."* 
 
 2d. The next thing to observe is, whether the body of the uterus 
 is enlarged : this may be ascertained by pressing up the finger be- 
 tween the neck of the uterus and the pubes : here in the unim- 
 pregnated state there is nothing but what is soft and yielding ; but 
 where pregnancy has advanced several months, this space is occupied 
 by a large, firm tumour. A practised hand will immediately detect 
 the difference ; but I think the young practitioner finds more diffi- 
 culty in satisfying himself about this symptom than about any other 
 which is detected by touch. 
 
 There is a combination of the external and internal examinations, 
 which in thin persons gives a very accurate knowledge of the nature 
 of the tumour. Tor this purpose, the finger of the right hand is to 
 be applied against the tumour which is felt in the vagina, and the 
 left hand is to be applied on the outside of the abdomen, to the 
 upper part of the circumscribed swelling. Now, by alternately 
 pressing the tumour up, by means of the finger in the vagina, and 
 down by means of the hand on the abdomen, the practitioner be- 
 comes certain that the tumour, which is felt through the walls of 
 the abdomen, is the same as that which is felt through the vagina; 
 the most satisfactory proof that it is an enlarged uterus. This 
 method is applicable as early as the fourth or fifth month. 
 
 3d. In the pregnant uterus the foetus floats in a bath of liquor 
 
 ' fifth, and sometimes the sixth month ; and even then the uterus must be kept down 
 ' by a strong pressure upon the belly. — Ibid., vol. i. p. 183.) ' From that time it 
 ' (ihe projecting part of the neck of the uterus) grows broad and soft by degrees till 
 ' the sixth month or thereabouts; after which it begins to diminish in all its dimen- 
 ' sions in proportion as the womb extends. So that when the woman approaches the 
 ' end of pregnancy, it is quite flat, and confounded with the globe of the uterus.' — 
 (Mauriceau, tome i. p. 97.) 
 
 * ' The neck of the womb will in some be felt as long in the eighth as in others in 
 ' the sixth or seventh month.' — (Smellie, vol. i. p. 1S5.)
 
 AND DISEASES RESEMBLING IT. 107 
 
 amnii. TThen the patient is in the upright posture, its head rests 
 over the top of the vagina. If the practitioner applies his finger to 
 the uterus just in front of the neck, and gives it a push, the foetus 
 will float for an instant, and the next instant fall with perceptible 
 weight on the point of the finger ;* this sensation, if once felt, cau 
 never be mistaken ; it is scarcely inferior in conclusiveness to the 
 muscular movements of the child, and has this advantage over the 
 latter, that it can be felt whether the foetus is alive or dead. The 
 patient ought to be placed almost in an upright position ; the best 
 period of pregnancy for detecting it is from the fifth to the seventh 
 month — earlier the foetus is too light to be felt, and later it is often 
 too closely packed to be moved. 
 
 Having described the mode of examination by which pregnancy 
 may with certainty be known, and by which, consecpiently, it may 
 be distinguished from the diseases which are often mistaken for it, 
 it will be useful to consider the different kinds of cases about which 
 the practitioner will be consulted, and to which he will find it neces- 
 sary to apply this test. 
 
 I. Single women sometimes have the common symptoms of preg- 
 nancy, yet obstinately deny the possibility of their being so ; this 
 denial is generally so positive and apparently sincere, that the young 
 practitioner is sure to be influenced by it, but experience will teach 
 him to turn a deaf ear to it. It appears difficult to explain the 
 obstinacy of assurances which those who make them know to be 
 false ; but I suspect they deny to the last that they can be pregnant, 
 because they hope to the last that they are not so. Another cir- 
 cumstance likely to bias him is the respectability of the patient; 
 but this, too, must be disregarded. Single women sometimes become 
 pregnant in all ranks of life, not only among the low, but among 
 the high ; and not only among these, but in the middle ranks ; and 
 the practitioner, in his intercourse with the world, will often be 
 placed in puzzling situations, and have to listen to very curious 
 disclosures. 
 
 * ' In the seventh month the head of the child is frequently felt resting against 
 ' the lower part of the uterus, between the pubis and os internum ; and being pushed 
 1 upwards tosvards the fundus, sinks down again by its own gravity.' — Smellie, 
 p. 188.) 'Sometimes the head is not felt till the eighth or ninth month, and in 
 1 some few cases not till after the membranes are broken, when it is forced down by 
 ' the contraction of the uterus and strong labour-pains. This circumstance may be 
 ' owing to the head's resting above the basin, especially in a narrow pelvis. — 
 {Smellie, p. 188.)
 
 108 SYMPTOMS OF PREGNANCY, 
 
 I. 
 
 A genteel woman called on me one morning, and related to me 
 the symptoms of her complaint, which were exactly those of preg- 
 nancy. She was healthy, had always menstruated regularly till 
 seven months ago, when she suddenly ceased to do so, and about 
 three months afterwards her abdomen began to enlarge. She was 
 now about the ordinary size at the seventh month of pregnancy. 
 As she had not told me whether she was married, I asked her 
 whether it was possible for her to be pregnant ? she said, ' certainly 
 not/ for she was not married. I then asked her whether I should 
 give her a mere conjecture about the nature of her symptoms, or 
 whether it was important for her to know it with certainty. She said 
 that she must not leave the house without knowing it with certainty. 
 I then told her that there was only one way of determining it, which 
 I explained. After a little agitation, she consented to an examina- 
 tion. I found the abdomen firm, the umbilicus prominent, the neck 
 of the uterus nearly obliterated, its body enlarged, and I could make 
 the foetus float, and feel it fall heavily on the point of my finger. 
 After a little pause, I told her, as inoffensively as I could, that she 
 was not only pregnant, but not more than six or eight weeks from 
 the time of her confinement ; and I then repeated my question, ' is it 
 possible V She answered, she thought not. She then told me that 
 she was privately married, that it was of the utmost importance it 
 should be kept secret, and that her husband had assured her, and 
 she was sure believed himself, that if he avoided injuring the hymen, 
 it was impossible for her to become pregnant. Whilst examining 
 by the vagina, I had noticed that this membrane was imperfectly 
 torn. I never saw her again for several months, when one day she 
 appeared among my morning patients ; her size was gone, she was 
 looking well, but she came to consult me about some nervous symp- 
 toms. I asked whether the opinion I had given her about her 
 former state was correct ; she said " quite/' and that the certainty 
 of it had induced her to make arrangements which had preserved 
 her from discovery. 
 
 II. 
 
 A few days after my first interview with this lady, another came 
 to consult me about a tumour of the abdomen; she said that she 
 had been seen by several surgeons, who pronounced it to be an 
 enlarged ovary; but the last person she consulted (Mr. Copeland), 
 suspecting something different, sent her to me. She was not only
 
 AND DISEASES RESEMBLING IT. 109 
 
 pregnant, but from the complete obliteration of the neck of the 
 uterus, I concluded thai she was within a few days of her confine- 
 ment. She told me that she was a widow, under the protection of a 
 gentleman; and her reason for denying or disbelieving that she was 
 pregnant was, that she had never had a family by her husband. 
 
 When, as in these cases, a healthy woman who had always men- 
 struated with perfect regularity suddenly ceases to do so, and a few 
 months afterwards has a progressive enlargement of the abdomen, 
 there is the strongest reason to suspect her of pregnancy, whatever 
 may be her station in life. But however strong this presumptive 
 evidence, no prudent man will venture an opinion on it without 
 testing that opinion by a careful examination by touch. 
 
 Not only are unmarried women often pregnant without its being 
 believed, but the same is sometimes the case with married women. 
 When, after many years of barren matrimony, they at length become 
 pregnant, as sometimes happens, they conclude it to be disease ; and 
 even their medical men often adopt and act on this supposition, of 
 which I could give numerous instances. 
 
 III. 
 
 A woman came to me one morning with a note from a practitioner 
 containing the following statement : her age was forty-two ; she 
 had been married twenty -two years without ever being pregnant. 
 About seven months ago she had ceased to menstruate; a few 
 months afterwards the abdomen began to enlarge, and was now 
 nearly equal to that of full pregnancy. Tor several months her 
 practitioner had been using various means for reducing the tumour, 
 but in vain. She was too fat for me to detect any circumscribed 
 tumour ; but the enlargement of the abdomen was very firm, the 
 umbilicus prominent, the neck of the uterus almost obliterated, its 
 body enlarged, and the areola round the nipple was dark. I wrote 
 an answer enumerating these symptoms, adding, that I concluded 
 his patient was pregnant. About seven weeks afterwards she 
 brought forth a child. 
 
 I met a physician and an apothecary in consultation about a 
 married lady who had a circumscribed tumour of the abdomen, 
 which was supposed to be an elarged ovary, for the reduction of 
 winch various means had been employed. For many years she had 
 ceased to bear children, and the tumour was inclined towards the 
 right side. After learning these particulars from her medical
 
 110 SYMPTOMS OF PREGNANCY, 
 
 attendants, we went into her chamber and heard her own account. 
 She had suddenly ceased to menstruate, and the swelling had begun 
 to appear a few months afterwards. When I was alone with her 
 physician and apothecary, I remarked that the cpiestion about what 
 the tumour was, would be much narrowed by determining what it 
 was not — that it was not pregnancy, and I advised them to allow 
 an examination by touch ; for this purpose she was undressed and 
 put to bed. I found the tumour distinctly circumscribed, and 
 sufficiently lateral in its position to justify the supposition that it 
 was an ovary ; it had not risen high enough to protrude the umbi- 
 licus, and I could feel no movement within ; the neck of the uterus 
 was soft, broad, and had lost two-thirds of its length ; its body was 
 enlarged and firm, and by placing her in a sitting posture, and 
 thrusting the finger up against its anterior parts, I felt that I had 
 displaced a moveable body, which the moment afterwards fell heavily 
 on my finger. I communicated my conviction that she was pregnant 
 to the physician and apothecary ; and about three months afterwards 
 she was delivered of a child. 
 
 A puzzling class of cases is that in which pregnancy really takes 
 place, but after a time the foetus dies and is still retained. Here 
 some of the symptoms of pregnancy are present, but others are absent, 
 and the state becomes more doubtful by being not progressive. 
 
 V. 
 
 A lady, after the ordinary symptoms of pregnancy for four months, 
 had a slow haemorrhage for many days. No ovum came away; the 
 haemorrhage stopped ; but though her abdomen was enlarged, from 
 that time forth it did not continue to increase. In this state and 
 without menstruating, she continued five months longer, when, at 
 the end of the ninth month from her first calculation, labour-pains 
 came on, and expelled a shrivelled foetus of the size of the third 
 month. There can be little doubt that it had died before the 
 haemorrhage. The fact that her labour occurred just at the end of 
 the ninth month is one of the best proofs that labour commences at 
 that time, not from distension of the uterus, but as a law of nature. 
 It is curious that the same process took place in her next preg- 
 nancy ; the foetus was blighted about the same period, and yet was 
 retained during the natural length of pregnancy. In such doubtful 
 cases as the above, the most prudent plan is to avoid giving a decisive 
 opinion, and, if pushed hard, to state the impossibility of doing so.
 
 AND DISEASES RESEMBLING IT. Ill 
 
 VI. 
 
 A poor woman, in doubt about her state, came to consult me. 
 She was healthy, with very regular menstruation when not pregnant, 
 but it had suddenly ceased about six months ; her abdomen was 
 large, and she had milk in her breasts. The enlargement of the 
 abdomen was very firm. She was too fat for me to detect any cir- 
 cumscribed tumour ; the umbilicus projected, the neck of the uterus 
 was very short, and what little was left of it very soft ; the body of 
 the uterus, too, was considerably enlarged, but she felt no movement 
 of the child ; and though I examined her in the upright posture, 
 I could not feel its displacement and subsequent fall. She had not 
 enlarged for the last month. The opinion I gave was, that she was 
 pregnant, and that the child was dead ; but I could not explain my 
 not finding the foetus moveable. The result of the case explained 
 this. About seven weeks afterwards she was delivered of a dead 
 child, the placenta being attached over the orifice of the uterus. 
 "When in my previous examination I had pushed up the fetus, it 
 had fallen on the placenta, the thickness and softness of wliich pre- 
 vented the impulse, at the moment of its fall, from being communi- 
 cated to my finger. 
 
 There are two other circumstances in wliich the practitioner will 
 often be pressed for an opinion, in both of which it is generally 
 impossible to give one : thus, some women are very liable to pass 
 over the natural period of the month without menstruating by one, 
 two, or three weeks, and then to have a violent and somewhat 
 painful haemorrhage, during which nothing visible passes away but 
 coagula of blood. These cases are commonly said to be early abor- 
 tions, but this is a mere conjecture without proof. 
 
 Another circumstance, in which it is difficult and often impossible 
 to form a decided opinion, is when a haemorrhage has occurred in 
 early pregnancy, and has ceased without any ovum having been 
 detected. This is no proof that it has not passed away, for it may 
 be so small as to be overlooked in the coagula. Has the patient 
 aborted, and is she no longer pregnant ; or has she retained the 
 ovum, and is her pregnancy going on ? It is generally impossible 
 to tell with certainty till some time has elapsed ; and the more we 
 refrain from decisive opinions, the less are we likely to give errone- 
 ous ones. 
 
 II. The next class of cases which I shall describe consists in a 
 torpid state of the uterus, with a flatulent state of the intestines :
 
 112 SYMPTOMS OF PREGNANCY, 
 
 this is most liable to occur near fifty years of age, when the uterus 
 is about discontinuing its function. At this time menstruation will 
 often cease for several months, and the abdomen becomes distended 
 with a flatulent tumour ; the air moving about the bowels gives an 
 inward sensation which is mistaken for the child; there is often 
 slight nausea, various nervous feelings, and an anxiety to believe in 
 pregnancy as a test of youthfulness. About this age, also, the 
 omentum and parietes of the abdomen often grow very fat, forming 
 what Dr. Baillie once called ' a double chin in the belly/ This assem- 
 blage of symptoms at this age frequently leads to the supposition of 
 pregnancy, but I have met with many similar cases in young women. 
 I have repeatedly known those who, on the return of their husbands 
 after a long absence, have suddenly ceased to menstruate, and grown 
 large about the belly, conclude that they were pregnant, and make 
 preparations for their confinement. I have known the same happen 
 to single women, who had been secretly incurring the risk of preg- 
 nancy ; they were generally women of sickly constitutions, who were 
 very subject to obstructed menstruation ; and it is probable that in 
 these cases the puzzling assemblage of symptoms was the result 
 rather of mental agitation than of sexual intercourse. 
 
 VII. 
 
 A well-dressed young woman came to me one evening, and after 
 a long silence and much agitation, told me that she was unmarried ; 
 that a gentleman with whom she was intimate had some months ago 
 taken advantage of her, since which she had never been unwell, and 
 she was now so large that her parents talked of consulting a phy- 
 sician. As she had passed only four months without menstruating, 
 and as I was unwilling to give anything but a conclusive opi- 
 nion, I advised her to come to me that day month; and to prevent 
 any danger from her alarm, encouraged her to believe that her 
 anxiety was groundless. Exactly that day month, in the evening, 
 a carriage drove to my door, and the same lady was shown into my 
 library. She was excessively agitated, and had come without her 
 stays. As soon as I placed my hand on the abdomen, I was con- 
 vinced that she was not pregnant; the tumour was so soft and 
 yielding that I could bury my hand in it almost to the spine. I 
 nc\1 examined the uterus through the vagina, and found its neck 
 long and firm, and its body unenlarged. I told her that she was not 
 pregnant : on hearing which she fainted away.
 
 AND DISEASES RESEMBLING IT. 113 
 
 VIII. 
 
 I was introduced by an eminent physician to a very young mar- 
 ried lady, for the purpose of attending her in her approaching con- 
 finement, of which her projecting abdomen gave visible intimations; 
 and I was directed to call on her occasionally, that she might become 
 accustomed to me before the time for my attendance arrived. During 
 these calls I learnt gradually the particulars of her marriage. She 
 had been attached to a young man, her equal in station, but so pro- 
 fligate that her parents forbade him the house; nevertheless, the 
 lovers continued to meet by stealth, and one fatal evening they 
 became as man and wife, in all but the marriage ceremony. After 
 this intercourse had been going on a few months, the young lady 
 observed that her belly was enlarging ; it was at length noticed by 
 her mother : this led to an inquiry, and the young lady confessed 
 all. The discovery, of course, produced a great uproar in the family : 
 her parents agreed that as the young couple had gone so far, it was 
 absolutely necessary that they should go a little further : the lover 
 was called upon, and as the young lady had brothers who understood 
 the use of the pistol, the young couple were soon married and placed 
 in furnished lodgings. It was at this period when I was first intro- 
 duced to them. I continued to call on the bride for some time; 
 but, after two months, I one day remarked that although she still 
 continued large, she was not larger than when I first saw her. When 
 I pressed the abdomen it had not the firmness of pregnancy, and she 
 felt no internal motions ; when I inquired about her menstruation, 
 I was told that she had never menstruated in her life; menstruation 
 had not ceased, simply because it had never begun. I now expressed 
 strong suspicions that she was not pregnant, and advised the ques- 
 tion to be settled by an examination. It was so. I found the 
 umbilicus sunk, the abdomen distended by a soft flatulent tumour ; 
 the neck of the uterus of its full length, its body not in the slightest 
 degree enlarged. I told my patient and her sister that she was not 
 pregnant, but they would not believe me, and directed a consultation 
 with the same eminent physician who had introduced me to them. 
 He met me ; and as he was one of the very few medical physicians 
 who are expert at vaginal examinations, he was soon as well satis- 
 fied as myself that the young lady was not pregnant. The commu- 
 nication occasioned great disappointment in the family, but in no 
 one so much as in the young husband, whose rage was boundless at 
 
 i
 
 114 SYMPTOMS 01' PREGNANCY, 
 
 discovering that he had been compelled to marry her on a false 
 supposition. 
 
 Of the extent to which fatness of the abdomen and omentum, 
 and flatulence of the intestines, can cause a tumid belly, resembling 
 pregnancy or enlarged ovary, a striking instance occurred at Edin- 
 burgh a few years ago, and is related by Mr. Lizars in his work on 
 ' Tumours of the Ovary/ 
 
 IX. 
 
 The patient was a poor woman with a large abdomen, and was 
 seen by numerous practitioners. Some thought that she was preg- 
 nant, others that she had an enlarged ovary; at length, on the 
 latter supposition, an incision, eight inches long, was made into the 
 abdomen, the cavity of which was thereby laid open : it was then 
 discovered that there was no tumour, and that the enlargement 
 depended on a very fat omentum, and intestines distended with air : 
 the wound was closed and secured, and the patient recovered. 
 
 X. 
 
 I saw a similar case about two years ago in Guy's Hospital, under 
 the care of Dr. Bright. The patient was a young woman who had 
 been in the same hospital some time before, for what was supposed 
 to be ovarian dropsy, but purgatives removed the tumour, and she 
 went out of the hospital cured. A few months before I saw her, 
 having a return of the enlargement, she consulted an enterprising 
 surgeon, who assured her that she had a tumour in the ovary, which 
 could be removed only by extirpation : for this purpose he made an 
 incision in the linea alba six inches long, by which the cavity of the 
 abdomen was exposed; it was then discovered, as in the case 
 at Edinburgh, that there was no tumour, and that the enlargement 
 depended entirely on flatulence and fat ; the wound was closed and 
 healed; but the patient's health sustained great injury, for the 
 recovery of which she was under Dr. Bright' s care. I saw the scar 
 of the incision, which in healing had contracted to four inches, and 
 the marks of the stitches by which the wound had been secured. 
 
 XL 
 
 It is now nearly fifteen years ago, since Joanna Southcott, an 
 aged and virgin prophetess, astonished the town and nation by de- 
 claring that she was pregnant by supernatural means. Many medical
 
 AND DISEASES RESEMBLING IT. 115 
 
 men were consulted about her. As the case excited an extraordinary 
 degree of attention, and affords a curious example of that form of 
 spurious pregnancy which I am now describing, I have thought it 
 worth while to select out of the published narratives those particulars 
 which form the medical history of the case, in order to show the 
 extent to which even medical men may be deceived, and the symptoms 
 by which, in such cases, competent judges arrive at the truth. The 
 fullest account of this curious case is a ' Statement of the last Illness 
 and Death of Mrs. Southcott, by Richard Reece, M.D./ who was 
 consulted about the case, and was present at the examination of her 
 body, and who has given not only the appearances discovered by 
 dissection, but the symptoms during life, and the opinions that were 
 given about them, both by himself and others. His narrative is 
 candid. The first time he saw her was on the 7th of August, 1814, 
 in consultation with several other medical men, when Joanna de- 
 scribed her reasons for believing that she was pregnant; begging 
 them to form their opinion by her symptoms, not by her age — as if 
 she was a young woman of twenty-five ; truly a very reasonable re- 
 quest. She was sixty-four years of age, and had ceased to menstruate 
 for fifteen years; she had lost her appetite, and was sick; her 
 bosom and belly were much enlarged, and she had felt the move- 
 ments of the child ever since the month of May. She was willing to 
 submit to any examination, excepting the internal one through the 
 vagina. Dr. Walshman proposed it, but Joanna said that f her 
 warning spirit had desired her not to submit to it/ on hearing 
 which the doctor refused to see her. Dr. Reece says that her breasts 
 were ' full, plump, and expanded/ ' In that part occupied by the 
 ' womb there was a firm, circumscribed tumour, as large as a man's 
 ' head, bearing the shape of the womb ; and I have no doubt/ he 
 says, ' of its being an enlargement of that organ/ The opinion he 
 gave was, that ' the fulness of the belly appeared to be produced by 
 ' enlargement of the womb, but whether it was the effect of pregnancy 
 ' could only be established by the motion of the child/ To detect 
 tins, he kept his hand on the abdomen for some time, but no move- 
 ment of the child could at first be felt ; a piece of peach was given 
 her ; ' on which/ says the doctor, ' I felt something move under my 
 ' hand, possessing a kind of undulating motion, and appearing and 
 ' disappearing in the same manner as a foetus/ He adds, ' When 
 ' these symptoms (enlargement of the breasts and abdomen) were 
 ' accompanied by a sensible motion of the womb, I never could
 
 116 SYMPTOMS OF PREGNANCY, 
 
 ' hesitate in pronouncing it a case of pregnancy, and this was actually 
 ' my opinion of her situation/ A similar opinion appears to have 
 been given by several other medical men, among whom was Dr. 
 Adams, the well-known author of the ' Essay on Morbid Poisons / 
 and some of them held themselves in readiness to be present at her 
 labour, and witness the birth of her child. 
 
 Hitherto Joanna had been seen only by medical men, who, what- 
 ever may have been their intelligence and general knowledge of their 
 profession, had never paid any especial attention to the subject, and 
 were not extensively consulted on cases of doubtful pregnancy ; but 
 on the 18th of August she was visited by a most competent judge, 
 Dr. John Sims ; and on the 3d of September he published a letter 
 in the ' Morning Chronicle/ stating his opinion and the grounds of 
 it : he describes the breasts as large, but more like those ' of an old 
 ' woman grown corpulent, than those of a pregnant woman/ The 
 areola round the nipple was pale, the enlargement of the abdomen 
 was less hard than that of pregnancy, except at the lower part, 
 ' where there appeared to be a solid tumour, reaching not far above 
 ' the pubes/ ' I proposed/ says he, ' to put my finger upon the navel 
 ' without any covering, which was permitted : this part I found 
 ' sunk in, not at all protruded, as in pregnancy/ No motion was 
 felt. Dr. Sims adds, f I did not hesitate to declare it to be my 
 ' opinion that Joanna Southcott was not pregnant/ 
 
 The period of her expected delivery now approached, when she 
 was visited by Professor Assalini, who was at that time in London, 
 with the numerous foreigners who came to England, after the first 
 capture of Paris. The professor ' examined her belly/ and told her 
 that her stomach complaint would go off as soon as she was delivered, 
 — a promise he might safely make, and from what I know of him, 
 was most probably ironical. At length Joanna began to think that 
 not her labour but her death was aj:>proaching, and she sent for Dr. 
 Eeece to give him her instructions. He seems to have had some 
 thoughts of saving the child by the Csesarean operation; for he 
 asked, ' if apoplexy should supervene, whether I should not make 
 ' an effort to save the life of the child ?' But Joanna refused; she 
 continued to suffer much from vomiting, took scarcely any nourish- 
 ment, and became very weak. Towards the close of the scene, Dr. 
 Reece, finding her belly reduced in size, was convinced that he had 
 been wrong, and that she was not pregnant ; and some of her other 
 medical attendants began also to doubt. She died on Monday, the 2Gth
 
 AND DISEASES RESEMBLING IT. 117 
 
 of December. For four days the body was kept warm, in hopes 
 that she would revive; but putrefaction beginning, leave was at 
 length given to open the body, which was done on the 30th of 
 December, 1814, in the presence of several medical men, among 
 whom were Dr. Adams and Dr. Sims. The body was very putrid ; 
 the womb, instead of being enlarged, appeared smaller than natural; 
 it was free from disease, and ' neither the promised Shiloh nor any 
 ' other foetus was found in it/ The walls of the abdomen were four 
 inches thick, from fat; the intestines were distended with air; the 
 omentum was nearly four times its usual size, and ' one lump of 
 fat/ There were a number of stones in her gall-bladder, which were 
 most probably the cause of her vomiting and her pain. Dr. Eeece 
 conjectures that the circumscribed tumour, which he took for the 
 enlarged womb, was the bladder distended with urine, and that 
 Joanna had learnt to retain it in order to produce the swelling. The 
 apparent motion of the child he attributed to a quick movement of 
 the abdominal muscles, which he also thinks she accpiired the art of 
 producing, and that to such an extent that ' it was felt in different 
 parts like the appearance of twins/ Mr. Matthias* thinks that 
 ' the life within her' must have been the movement of flatus. She 
 had, indeed, lived a life well calculated to produce it. She had for 
 some time taken no exercise, kept her bed, and, as her appetite was 
 capricious, pampered it with quantities of improper food. On one 
 occasion, when asparagus was extremely dear, she ate at one meal 
 160 heads. t 
 
 III. Another class of cases liable to be confounded with preg- 
 nancy, are tumours of the ovary; this organ, which in its healthy 
 state is smaller even than the unimpregnated uterus, is often more 
 enlarged by disease than the uterus is by pregnancy, and forms, like 
 the latter, a circumscribed tumour, which rises out of the pelvis to 
 various heights in the abdomen. These tumours are sometimes 
 mistaken for pregnancy, but this mistake can hardly be committed 
 by a careful and a competent judge. In most of the cases which I 
 
 * Case of Joanna Southcotf, by P. Matthias, Surgeon and Apothecary. 
 
 f Not only old women, but even children, have been erroneously supposed to be 
 pregnant. Smellie saw in Mary-le-bone workhouse a girl twelve years old, supposed 
 to be in the eighth month of pregnancy. Several medical men had examined her ; 
 one had offered to deliver her gratis; others had made interest to be present at her 
 delivery; the case had been advertised, and the matron had got money from num- 
 bers who went to see her. It turned out to be a case of enlarged liver. — Smellie, 
 vol. ii, p. 220.
 
 118 SYMPTOMS OF PREGNANCY, 
 
 have seen, the duration of the tumour already much beyond nine 
 months is alone a sufficient guide, if it was ever safe (which it 
 never is) to be guided by one circumstance. Another guide is a 
 fluctuation which can generally be felt on striking the abdomen ; 
 but the tumour may not have lasted nine months, and may be too 
 solid to afford fluctuation. Under these circumstances the examina- 
 tion of the uterus through the vagina at once settles the question. 
 If the tumour has lasted a few months, and already distends the 
 abdomen to a visible magnitude, the neck of the uterus, if pregnant, 
 would be short and soft, its body enlarged, and the moveable foetus 
 would be capable of being felt. On the contrary, when this tumour 
 is an enlarged ovary, the neck of the uterus is long and firm, and 
 its body unenlarged. 
 
 When a large ovary is mistaken for pregnancy, the error is a 
 harmless one ; but pregnancy is sometimes mistaken for dropsy of 
 the ovary, and the patient has been tapped. A woman was taken 
 into the operation-room of a well-known hospital for this purpose, 
 but the surgeon, on learning that she had not been examined, sent 
 her back to her ward : this caution was fortunate, for before the 
 next operation-day she brought forth a child. I have heard several 
 instances of this mistake. 
 
 But a woman may have enlarged ovary and yet conceive. 
 Morgagni has said that one ovary might be diseased throughout, and 
 the other nearly so, but provided a portion remained healthy con- 
 taining, one vesicle, the woman was capable of impregnation. I 
 have known several instances in which the ovary was enlarged by 
 disease, and the uterus by pregnancy in the same person ; the two 
 tumours went on growing side by side to the full time, and the 
 patients were delivered of living and healthy children, leaving the 
 abdomen still distended with the ovary. Of these patients one has 
 borne three children since her ovary (the right one) had attained 
 considerable magnitude.* She is still alive, but has ceased to 
 
 * ' We see women who, although hydropsical, nevertheless have children ; fn 
 ' proof of which I will allege the example of the wife of M. Duvieux, my colleague, 
 4 who, having hecome dropsical after delivery, was treated during several months 
 ' with all the usual remedies, without any henefit ; after which, without suspecting 
 1 it, she discovered that she was pregnant notwithstanding her dropsy, which, far 
 ' from diminishing after her delivery, increased and lasted nine years. During this 
 ' time she had three other children, the one a girl, who at the age of five years and 
 ' a half looked as if she was seven years old; another a healthy boy.' — Mauriceav, 
 tome i, p. 73.
 
 AND DISEASES RESEMBLING IT. 119 
 
 breed. In these cases no serious error was committed ; the patients 
 were doubtful of their state, till il was far advanced, when the strong 
 movements of the child, felt externally by the hand, informed them 
 that they were pregnanl ; hut 1 can easily suppose that such cases 
 uii^ht sometimes be very puzzling : the cessation of menstruation 
 would prove nothing, for it is a common occurrence in ovarian 
 dropsy; the enlargement of the uterus might be mistaken for the 
 progressive enlargement of the ovary; the child might be still or 
 dead; the protrusion of the umbilicus attends both pregnancy and 
 enlargement of the ovary. Under these circumstances the true 
 nature of the case could be detected only by examination through 
 the vagina, when the obliterated neck, the enlarged body of the 
 uterus, and the moveable foetus, would immediately discover it. The 
 .bare possibility of such cases is a strong reason for never tapping a 
 married woman without having the uterus previously examined by 
 a person skilful in such examinations.* 
 
 IT. In the cases resembling pregnancy already described, the 
 cause which distends the abdomen is external to the uterus, and by 
 discovering that this organ is not enlarged we know that the patient 
 is not pregnant. But sometimes the cause which distends the abdo- 
 men is within the uterus. The enlargement of the abdomen may 
 depend on enlargement of the uterus, and yet the patient may not 
 be pregnant. The bodies which sometimes form within the uterus, 
 and distend it to a size equal to that of pregnancy, are, fortunately 
 for the facility of diagnosis, rare, compared with the other causes of 
 spurious pregnancy. Those which have been mentioned by writers 
 are air, water, hydatids. Tympanites of the uterus has been de- 
 scribed under two forms ; in one the air is formed in the cavity of 
 the uterus, is retained for several months, distends it to a consider- 
 able magnitude, and is then expelled : of this I have never seen one 
 
 * 'When a retention of urine takes place in the latter months of pregnancy, as the 
 ' water accumulates the bladder cannot enlarge equally in all directions, because of 
 ' the resistance which it meets with posteriorly from the gravid uterus ; it therefore 
 ' assumes a flattened form, and spreads upwards and laterally to great extent over 
 ' the anterior part of the uterus, at the same time giving under percussion an evident 
 ' sense of fluctuation to the hand, insomuch that the case has been mistaken tor 
 ' a dropsy. An unfortunate instance of this kind happened to a practitioner in 
 4 Ireland, who tapped his patient for this supposed dropsy; death was the conse- 
 ' quence, and on examination it appeared that the trochar had passed through both 
 • sides of the bladder, through the uterus, and even into the head of the child.' — 
 Lowder, MS. Lectures.
 
 120 SYMPTOMS OF PREGNANCY, 
 
 instance; for the other form, of which I have known several 
 examples, a better name would be flatus of the uterus. Air is 
 formed in this organ, but instead of being retained so as to distend 
 the uterus, it is expelled with noise many times a day. It has been 
 doubted whether it really came from the uterus, but in one of my 
 patients there was a circumstance conclusive on this point : she was 
 subject to this infirmity only when not pregnant, but she was a 
 healthy and breeding woman, and the instant she became pregnant 
 her troublesome malady ceased. She continued entirely free from it 
 during the whole of her pregnancy, but a few weeks after delivery 
 her malady returned. Of dropsy of the ttterus I have never seen a 
 case; there are many on record. The reality of this disease has 
 been often doubted, but an instance related in the ' Medico-Clnrur- 
 gical Transactions/ by Dr. A. T. Thomson, serves to verify the 
 cases of the older observers. The testimony of a contemporary, 
 whom we know and can trust, produces more effect on our minds 
 than that of twenty witnesses in remote times and places. 
 
 Of hydatids in the uterus I have met with several instances ; the 
 patients had the ordinary symptoms of pregnancy, only with some 
 peculiarity which led them to doubt it, such as the absence of move- 
 ment in the abdomen, the enlargement of the abdomen being dis- 
 proportionate to the period of pregnancy, or after advancing rapidly 
 becoming suddenly stationary. In other cases the patient, after 
 supposing herself pregnant, had a discharge, sometimes of blood and 
 sometimes of water, winch led her to suppose that she was mis- 
 carrying. 
 
 XII. 
 
 I was sent for to , a few miles from London, to see a lady, 
 
 who having ceased to menstruate for one month, and becoming very 
 sick, concluded that she was pregnant; the next month she had a 
 slow haemorrhage from the uterus, which had continued incessantly 
 a month when I saw her : she kept nothing on her stomach. On 
 examining the uterus through the vagina its body felt considerably 
 enlarged, and there was a round circumscribed tumour in the front 
 of the abdomen, reaching from the brim of the pelvis nearly to the 
 umbilicus. I saw her several times at intervals of a fortnight, 
 during which the haemorrhage and the vomiting continued unrelieved; 
 the peculiarity about the case was the uterus, which was greater 
 than it ought to be at this period of pregnancy ; it felt also less firm
 
 AND DISEASES RESEMBLING IT. 12J 
 
 than the pregnant uterus, more like a thick bladder Ml of fluid. 
 Eleven weeks from the omission of menstruation she was seized 
 with profuse haemorrhage j towards evening there came on strong 
 expelling pains, during which she discharged a vast quantity of 
 something which puzzled her attendants. The next morning I 
 found her quite well, her pain, haemorrhage, and vomiting having 
 ceased. I was then taken into her dressing-room and shown a large 
 wash-hand basin full of what looked like myriads of little white 
 currants floating in red-currant juice; they were hydatids floating 
 in bloody water. 
 
 XIII. 
 
 A few weeks after the termination of this case a lady came from a 
 distant part of the country to London, to consult me about her state, 
 which she at first had supposed to be pregnancy, but now began to 
 doubt it ; it had lasted for eight months ; she had ceased to men- 
 struate at that time, and her abdomen had been gradually growing 
 large, but she felt no movement in the abdomen, and for the last 
 month it had not increased. I examined the uterus both externally 
 and internally ; the umbilicus was so flat, and the abdomen though 
 large had so little firmness, that I began to suspect it was distended 
 by air, but on examining the uterus through the vagina, I found its 
 neck obliterated and its body large ; though large, however, it felt 
 soft, and reminded me of the case of hydatids, still fresh in my 
 memory. I therefore told her that her size depended on enlargement 
 of the womb, but what the womb was enlarged by must be a subject 
 of conjecture, which I explained by relating the former case. She 
 returned to the country, and about six weeks afterwards I received a 
 letter from her medical attendant, informing me that my conjecture 
 had turned out to be correct, for after several hours of labour-pains, 
 and a great discharge of blood and water, she had expelled half a 
 pailful of uterine hydatids. 
 
 In the progress of these cases I believe it impossible to come nearer 
 the truth than this : that the abdomen owes its enlargement to a 
 distended uterus, but what this organ contains is uncertain. The 
 following case was at first supposed to be pregnancy, and afterwards 
 suspected to be hydatids ; the result showed that it was neither the 
 one nor the other, yet I do not see how this could have been known 
 during the progress of the case.
 
 122 SYMPTOMS OF PRKGNANCY, 
 
 XIV. 
 
 A lady, the mother of a large family, having ceased to menstruate 
 for several months, and growing large in the abdomen, concluded 
 that she was with child — at length there came on a profuse and 
 perpetual discharge of water, sometimes mixed with blood, by which 
 her strength was so alarmingly reduced, that first one and then 
 another practitioner was consulted about her, and I met a consulta- 
 tion of four. Through the walls of the abdomen the uterus could 
 be felt, about as high as the umbilicus, and in the vagina the neck 
 of the uterus was found obliterated, and its body enlarged. As every 
 attempt to restrain the discharge and support her strength had been 
 unavailing, and she daily became more exhausted, a silver tube was 
 introduced through the orifice of the uterus into its cavity, that if it 
 was distended by an ovum, the liquor amnii might be drawn off. 
 The tube readily passed in, but on withdrawing the wire no liquor 
 amnii came away. A few hours afterwards she was seized with 
 violent expulsive pains, under which she sunk rapidly and died. I 
 was not present at the examination of the body ; but the following 
 statement was sent me by the gentleman who opened it. The uterus 
 was as large as in the sixth month of pregnancy, and its cavity big 
 enough to hold two fists ; it contained neither fcetus nor hydatids, 
 but a mass about the size of a goose's egg of stringy matter, like 
 very soft placenta, and unattached to the inner surface of the uterus ; 
 this surface was red and irregular, like a granulating sore ; its walls 
 were thickened as in pregnancy, of a dark red hue, and a flaccid 
 texture. 
 
 1 It sometimes happens/ says Dr. Baillie, ' though not very often, 
 ' that the uterus enlarges in size, and becomes much harder than in 
 ' its natural state. This change corresponds very much to that of 
 ' scirrlras in other parts of the body, and commonly extends over the 
 ' whole of the uterus. I have seen it in one case as large as the 
 ' gravid uterus at the sixth month ; ulceration, I believe, is com- 
 ' monly wanting/ I extract the following from my note-book with- 
 out alteration, as I cannot abridge it. 
 
 XV. 
 
 The wife of a farmer's labourer came to me under the following 
 circumstances : she is forty-five, and looks fifty-five years old, has 
 been married twenty years, without ever being pregnant ; three years 
 ago, after a jolt in a cart, she suffered profuse menstruation, to which
 
 AND DISEASES RESEMBLING IT. 123 
 
 she has been subject ever since, and from which she has grown thin 
 and weak; about eighteen months ago the abdomen began to en- 
 large ; more than six months ago it became visible through her 
 dress, and since then has increased more rapidly. 1 was permitted to 
 examine both the abdomen and the vagina. On both sides, the space 
 between the ribs and ilium feels soft and flatulent, while the front 
 of the abdomen, from the pubes upwards, is occupied by a circum- 
 scribed tumour of stony hardness; the umbilicus projects; the 
 cervix uteri is broad, and as short as in the seventh month of preg- 
 nancy ; the space between the cervix and pubes is occupied by a 
 tumour of stony hardness. Here were all the symptoms indicating 
 that the enlargement of the abdomen depended on enlargement of 
 the uterus, yet the patient was not pregnant. 
 
 I have now fulfilled the object of this paper, namely, to describe 
 the ordinary symptoms of pregnancy ; to estimate their real value ; 
 to explain the mode of examination by which alone doubtful cases 
 can be decided, and the time proper for its employment ; the causes 
 by which pregnancy, though real, is sometimes obscured ; and the 
 various diseases which resemble it, and are often mistaken for it. If 
 the young practitioner will take the trouble to make his mind master 
 of tins detail, and acquire a little familiarity with the feel of the 
 uterus in the pregnant and unpregnant states, I will venture to say 
 that it will generally guide him right. There will be cases, however, 
 in which he will occasionally doubt, and in which the best policy is 
 caution. Some are of opinion, that this art is a blind tact, to be 
 gained only by practice, not a knowledge to be communicated by 
 instruction ; but this is not true : the period of my life when I 
 improved most rapidly in the art of deciding by examination cases 
 of doubtful pregnancy, was that in which I gained clear and orderly 
 notions of the objects of examination. The faculty of observation 
 recpiires rather to be guided, than to be sharpened ; the finger soon 
 gains the power of feeling, when the mind has accniired the know- 
 ledge of what to feel for.
 
 ( 124 ) 
 CHAPTER IV. 
 
 POLYPUS OF THE UTERUS. 
 
 I believe that polypus of the uterus is a more frequent disease 
 than is commonly supposed, and that those who have had great 
 experience without ever meeting with it have most probably repeat- 
 edly overlooked it. If mistaken and neglected, it occasions the 
 death of the patient ; if detected and removed, she not only lives, 
 but regains perfect health. The cure of polypus of the uterus 
 affords one of the most striking instances of the triumph of our 
 art. 
 
 This disease is commonly for a long time mistaken for profuse 
 menstruation ; the patient, instead of menstruating regularly and 
 moderately, has frequent and profuse haemorrhages from the uterus, 
 and in the intervals a pale discharge. These gradually drain her 
 circulation and injure her health, until she acquires the deadly pale- 
 ness and suffers the complaints which are the ordinary effects of 
 deficiency of blood. The absence of pain in the uterus or pelvis 
 (for there is often none, and never that degree which attends the 
 malignant diseases of this organ,) leads to no suspicion that the 
 haemorrhages depend on a disease of structure. Tonics and astrin- 
 gents are given in various forms ; one practitioner is consulted after 
 another, till at length the uterus is examined, and a polypus is 
 discovered. This is the history of most of the cases which I have 
 met with. 
 
 A polypus of the uterus, when discovered, is a tumour in the 
 vagina attached to some part of the uterus. It is round, smooth, 
 firm, and insensible ; it is quite unattached to the vagina, so that 
 the finger can be pressed round between the walls of the vagina and 
 the surface of the tumour ; but if traced higher up, it is found to 
 terminate in a narrower part or stalk. This stalk is differently at- 
 tached in different cases ; in some it passes through the orifice of 
 the uterus into its cavity, and is attached to the fundus of this 
 organ ; in others, it passes into the cavity of the neck, to one side 
 of which it is attached ; in others it does not enter the orifice, but is 
 attached to one portion of its edge or lip ; hence a distinction of 

 
 POLYPUS OF THE UTERUS. 
 
 125 
 
 polypus of the fundus, polypus of the nock, and polypus of the 
 orifice. This distinction must not be lost sight of, for it is of prac- 
 tical consequence. In ascertaining the nature of the tumour for the 
 purpose of determining the propriety of removing it by an operation, 
 the mode of its attachment is one of our chief guides; and in this 
 respect, what is true of polypus of the fundus is not so of polypus 
 of the neck or lip. 
 
 In polypus of the fundus, the stalk is completely encircled by the 
 neck of the uterus, and if the finger can be introduced into the 
 orifice, it passes easily round between the stalk of the polypus and 
 the encircling neck. 
 
 A, polypus of the fundus, its stalk growing from that part of the uterus, its body 
 down in the vagina, the lower part of its stalk surrounded by the orifice of the 
 u'erus. 
 
 In polypus of the neck, the finger cannot be passed quite round 
 the stalk ; it may be passed partly round it, but it is stopped when 
 it comes to that part where it is attached to the neck, the stalk is 
 only semi-cucled by the neck.
 
 126 
 
 POLYPUS OP THE UTERUS. 
 
 In polypus of the edge of the orifice or lip, the stalk does not 
 enter the orifice, but grows from the edge of it; it feels as if a 
 portion of the lip was first prolonged into the stalk, and then en- 
 larged into the body of the polypus. It is important to remember 
 that there is a polypus, the stalk of which is not encircled by the 
 orifice of the uterus ; if it grows from the orifice, it cannot be en- 
 circled by it. 
 
 C, polypus of the neck of the uterus, its stalk growing from the cavity of the neck, 
 and consequently only setui-circled by the orifice, its body down in the vagina. 
 
 When a polypus grows within the uterus, it dilates its cavity, 
 neck, and orifice, as in pregnancy. Instead of the orifice of the 
 projecting part of the neck forming a narrow chink in a firm, thick 
 nipple, it is a round space with thin edges, as in somewhat advanced 
 pregnancy. In polypus of the neck and that of the lip, the pro- 
 jecting part of the uterus preserves more of its ordinary form and 
 consistence.
 
 POLYPUS OF THE UTERUS. 
 
 127 
 
 The internal structure of polypus, in most cases, exactly resembles 
 the internal structure of the large white tubercle of the uterus, 
 commonly called the fleshy tubercle; 'so that a person looking on 
 ' a section of the one and the other, out of the body, could not dis- 
 ' tinguish between them/" 3 ''" They arc the same disease/ differing 
 only in the seat and mode of their attachment, and consequently in 
 the symptoms which they produce. On cutting into them, we see a 
 hard, whitish substance, intersected by membranous partitions. This, 
 however, is not always its structure; it is sometimes of a much softer 
 and looser consistence, and sometimes has considerable cavitics.f 
 
 B, polypus of the orifice or lip of the uterus ; the orifice is in the front of the stalk, 
 and not at all encircling it, the body of the polypus is down in the vagina. 
 
 The external covering of polypus is the internal covering or 
 mucous membrane of the uterus ; this was long ago made out by 
 
 * Baillie's Morbid Anatomy. Polypus of the uterus, 
 f See Levret, p. 31.
 
 128 POLYPUS OF THE UTERUS. 
 
 dissection. "When the patient is cured by the removal of the poly- 
 pus, it comes away in a putrid state, unfit for minute anatomical 
 examination ; so that when the case terminates as it ought to do, 
 we have not a good opportunity of examining the external covering ; 
 but sometimes the patient dies before the nature of the case is dis- 
 covered, and then the tumour can be examined, attached to the 
 body, and unchanged by an operation. A woman who for many 
 years had been subject to long and profuse haemorrhages from the 
 uterus, but had obstinately objected to the part being examined, one 
 day expired in a fainting fit. On examining the body after death, 
 a tumour was found in the vagina, which grew by a narrow stalk 
 from the fundus of the uterus. Levret examined it in the recent 
 state. ' It was/ says he, ' covered externally by an expansion of 
 ' the membrane which covers the interior of the uterus ; on its 
 ' surface were seen a great number of varicose veins/* 
 
 A polypus of the uterus differs greatly in size in different cases. 
 I have removed several which were as large as the head of a new- 
 born child. They are commonly of a much more moderate size, and 
 I have known several cases in which frequent haemorrhages were 
 occasioned by a polypus not larger than a filbert, attached just within 
 the cavity of the neck of the uterus. That the haemorrhages de- 
 pended on the polypus, however small, was proved by the event ; for 
 they ceased on its removal. 
 
 Often as I have touched and removed a polypus, I never saw one 
 in the living subject till Mr. Brodie operated on a case in St. George's 
 Hospital (June 5, 1828). An attempt was made to. draw the poly- 
 pus out of the vagina before removing it with the knife, but the 
 attempt failed, and the ligature was ultimately applied in the vagina 
 with my instrument. Whilst this was going on, the orifice of the 
 vagina was so far dilated as to expose the tumour to our view ; it 
 was of a pale flesh colour, mottled, or rather streaked with large blue 
 veins, like the round balls of soap at the windows of the perfumers. 
 
 Thus a polypus of the uterus is commonly a round, insensible 
 tumour, growing by a stalk from its fundus, cervix, or lip, in its 
 inner structure like a fleshy tubercle, on its outside covered by a 
 mucous membrane of a pale flesh colour, streaked with veins, and 
 occasioning frequent haemorrhages from the uterus. 
 
 When the polypus grows from the fundus of the uterus, it is at 
 
 * Levret, Sur les Polypes de la Matrice, &c., 8vo., p. 180. 

 
 POLYPUS OF THE UTERUS. 129 
 
 first very small, resides within the cavity of this organ, and for some 
 time occasions no uneasiness or disturbance in its functions, by which 
 its existence might be suspected. I have seen a polypus about the 
 size of a filbert, growing by a narrow stalk, in the uterus of a woman 
 who had died of some other disease, and who, during life, had expe- 
 rienced no symptoms of it. As the polypus grows larger it gradually 
 dilates the uterus, till at length this organ, stimulated by its bulk, 
 begins to contract upon it, protruding it through the dilated orifice. 
 The polypus sometimes passes through the orifice gradually and 
 insensibly, sometimes suddenly during the action of the bowels. I 
 have known several instances in which patients, after this action, 
 have been suddenly seized with retention of urine, and on examina- 
 tion a polypus was found in the vagina, compressing the urethra. 
 
 Whilst the tumour resides within the uterus, it cannot be felt 
 in a common examination, and the nature of the disease is generally 
 overlooked. Of this the following case affords a striking instance. 
 
 I. 
 
 A lady who had been subject to frecpient and profuse haemorrhages 
 from the uterus, had consulted two eminent practitioners in Edin- 
 burgh, without relief. The uterus was examined, but no change of 
 structure was discovered. As she passed through London on her 
 way to the Continent, she consulted me. I examined the uterus, 
 and discovered nothing. She went to Rome, and then to Geneva, 
 at both which places she consulted some of the most eminent prac- 
 titioners, by whom the uterus was examined, but nothing was 
 discovered, excepting that it was a little larger than natural. Thus 
 far the disease was considered as common menorrhagia. After being 
 absent from England a year and a half, she returned to London 
 worse than when she went. A few days after her arrival, she had a 
 recurrence of the haemorrhage, but it was attended by an unusual 
 symptom; the blood came away in large coagula attended with 
 bearing-down pains. As soon as the haemorrhage had ceased, 
 I advised her to allow me to examine the uterus, though I little 
 expected what I was to find. She consented, and the next morning 
 I visited her at her hotel before she was up. As I passed my hand 
 under the bed-clothes I said, ' I fully expect to find nothing/ yet the 
 next instant I had my finger upon a polypus ; it was about the size 
 of a large walnut, with a slender neck encircled by the orifice of the 
 uterus. It was easily removed, the haemorrhages have never returned, 
 
 K
 
 130 POLYPUS OF THE UTERUS. 
 
 and she has since enjoyed perfect health. There can be no doubt 
 that the polypus was expelled into the vagina during the pains which 
 attended the last haemorrhage, and that I had the rare good luck to 
 examine almost immediately after the tumour was discoverable. If 
 I had examined before those pains, I should have overlooked the 
 disease, as I, as well as her attendants at Edinburgh, Borne, and 
 Geneva, had done before. 
 
 When polypus of the fundus descends into the vagina, the stalk 
 drags downwards that portion of the fundus to which it is attached, 
 so that in this stage of the disease it is generally complicated with 
 some partial inversion of the uterus. An inattention to tins im- 
 portant fact has led to fatal consequences. 
 
 When a tumour supplied with vessels, and consequently capable 
 of bleeding, grows from an organ so subject to bleed as the uterus, 
 it is difficult to demonstrate whether the haemorrhage arises from 
 the tumour, or from the uterus. The strong reason for attributing 
 the haemorrhages to the tumour, is this. As soon as a ligature is 
 applied, and tightened round the stalk, the haemorrhage from that 
 time ceases, although it may be several days before the tumour 
 comes away. 
 
 It was an opinion of M. Levret, that a polypus did not bleed 
 whilst it remained within the uterus, but that after its expulsion 
 into the vagina, the orifice of the uterus, by constricting the stalk, 
 impeded the return of blood in its veins, which consequently burst, 
 and bled profusely. This opinion, however, is contradicted by the 
 foregoing case as well as others which I shall have occasion to relate : 
 a polypus of the neck or of the orifice of the uterus projects from the 
 beginning into the vagina; consequently, it does not undergo that 
 expulsion from the uterus, which takes place in polypus of the fundus, 
 and is capable of being detected from the commencement. 
 
 In the treatment of this disease, the chief difficulty is in the 
 diagnosis : when once detected, any surgeon with a proper instru- 
 ment is competent to remove it, but the nature of the case is almost 
 always overlooked, and when a tumour is detected I have known the 
 most experienced practitioners hesitate about its nature, and conse- 
 quently about the propriety of the operation. 
 
 As tumours are often found in the vagina, which somewhat 
 resemble polypus, but which are very dissimilar in their nature and 
 treatment, it is important to learn the marks by which they may be 
 distinguished. The tumours which are likely to be mistaken for
 
 POLYPUS OF THE UTERUS. 131 
 
 polypus, arc, 1. the prolapsed uterus; 2. the inverted uterus; 
 3. malignant excrescences from the uterus. 
 
 It is not likely that any man of moderate knowledge and expe- 
 rience should mistake prolapsus for a polypus of the uterus. In 
 prolapsus, the tumour has its most depending part a palpable 
 orifice,, that of the uterus, into which a probe or bougie can be passed 
 several inches ; the tumour is sensible, so that if pricked or scratched 
 the patient feels it ; the tumour grows broader the higher the finger 
 is passed, and it cannot pass high, for it is soon stopped by the angle 
 where the vagina is attached round to the uterus. The higher the 
 tumour is pushed the easier does the patient become. In all these 
 particulars the polypus is just the opposite : it has no orifice, it is 
 insensible, so that if pricked or scratched, the patient does not feel 
 it ; the finger can be passed very high, and the higher it is passed 
 the narrower becomes the tumour ; the higher the tumour is pushed 
 the more easy becomes the patient. I have seen many cases of 
 this kind which gave occasion to doubts, but never one in which it 
 became a question whether the tumour was prolapsus, or polypus of 
 the uterus. 
 
 Inverted uterus being a rarer occurrence, is less likely to be met 
 with ; but when it is, it is more likely to be mistaken for polypus. 
 When the uterus is only partially inverted, that is, when its fundus 
 only is drawn down through its orifice into the vagina, and the 
 patient has survived for many months, the tumour feels exactly like 
 a polypus of the fundus. The distinguishing marks are the time of 
 its first appearance, which must have been immediately after deli- 
 very, and its sensibility. In the smoothness of its surface, the 
 roundness of its body, the narrowness of its neck, and its being 
 completely encircled by the orifice of the uterus, it sometimes exactly 
 resembles polypus of the fundus, of which the following case affords 
 
 an example. 
 
 II. 
 
 The first time I saw the patient was in consultation with Dr. 
 Clarke, and Dr. Henry Davies ; she had been delivered some months 
 before at St. Omer, and immediately after the removal of the pla- 
 centa, which had been extracted with some violence, a tumour had 
 been felt projecting from the uterus into the vagina, since which she 
 had not only had no haemorrhages, but had not had even ordinary 
 menstruation. When we examined the tumour, we found it about 
 the size of a small apple, with a smooth surface, a somewhat narrow
 
 13.2 POLYPUS OF THE UTERUS. 
 
 stalk, which was completely encircled by the orifice of the uterus, 
 exactly like a polypus, but its quick sensibility to touch, and the 
 circumstances under which it made its first appearance, inclined us 
 to believe that it was an inverted uterus, and not to recommend its 
 removal, particularly as she was losing no blood, and her health was 
 sustaining no injury from it. She returned to the Continent, and 
 I did not see her again for two years, when she again came to 
 London, to place herself under the care of Dr. Granville, who had 
 recommended her to submit to an attempt to revert it, and I now 
 saw her in consultation with the doctor. Since my former inter- 
 view with her, she had become subject to frequent and profuse 
 haemorrhages, which had bleached her face and broken her health, 
 and it now became an urgent object to afford her relief even at some 
 risk. We agreed, therefore, that the attempt should be made to 
 revert the tumour ; but if this failed, which appeared most likely, 
 we proposed to her husband the removal of the tumour by the liga- 
 ture, stating to him that such an operation had been done success- 
 fully, but that it was attended with considerable risk. This both 
 he and the patient were willing to incur ; the attempt at reduction 
 failed, but before applying the ligature, her former attendants, Dr. 
 Clarke, and Dr. Henry Davies, were consulted, and all of us agreeing 
 to recommend the operation, the ligature was applied by Dr. Clarke ; 
 it was tightened every other day, and each time occasioned so much 
 pain as to require a large opiate to quiet it. At length on the 
 fourteenth day both instrument and tumour came away : there were 
 times when I had a strong suspicion that it was a polypus, but a 
 sight of the tumour proved that it was the fundus of the uterus, for 
 it was a hollow cup, the size of a small apple, in the cavity of which 
 could be seen the Fallopian tubes. Excepting the pain and some 
 vomiting, the patient had no bad symptoms during the progress of 
 the cure, and several months afterwards her husband called on me 
 to say she was quite well. 
 
 A more frequent subject of doubt is, whether the tumour which 
 projects from the uterus into the vagina is a common polypus, which 
 admits of removal and permanent cure, or a malignant excrescence, 
 which, if removed, grows again, and terminates fatally. On this 
 question I shall say little at present, because I shall return to it in 
 the second part of this paper, where I speak of some unusual forms 
 of polypus. All I shall remark here is, that whenever the tumour has 
 a stalk, which can be included in a ligature without any danger of
 
 POLYPUS OF THE UTERUS. 133 
 
 including the neck or fundus of the uterus, I would apply it ; it 
 succeeds in an immense proportion of cases. I have known it 
 succeed in several, where, from the cauliflower roughness of the 
 tumour, others had been deterred from it, and even if the excres- 
 cence should return, the patient is not worse off than she was before. 
 She has had the only chance which art can afford her, and has lost 
 nothing even if it fails. 
 
 If polypus of the uterus is overlooked or neglected it ultimately 
 destroys the patient. Frequent haemorrhages drain the circulation 
 to the lowest point compatible with life, till at length a fresh 
 haemorrhage occasions a fainting fit or convulsions, in which the 
 patient dies. It is a practical rule, therefore, of vital importance, 
 that whenever hcemorrhages from the uterus resist the ordinary 
 means, the nature of the case should be certified by examination. I 
 have heard of several fatal cases from a neglect of this rule, and 
 many are recorded in books.* 
 
 When haemorrhages from the uterus arises from a polypus, medi- 
 cines are useless. The only effectual way to cure the haemorrhages 
 is to remove the polypus. This may be done either with the knife, as 
 is practised in Paris, or by applying a ligature round the stalk, and 
 tightening it until the tumour falls off. I have never used any 
 other means than the latter, and, as it has served me successfully 
 for many years, and in numerous cases, so that I wish I had as good 
 cure for all diseases, I shall not abandon it for the knife, which, if I 
 may judge from cases which have been related to me, is not always 
 so safe and successful. 
 
 It may be easily supposed, and if an attempt is made, it would 
 soon be found, that to pass a ligature round a tumour, situated in a 
 deep and narrow canal like the vagina, is not an easy task without 
 an instrument adapted for the purpose.t That which I use consists 
 
 * See Dessault's surgical works, edited by M. Roux, vol. iii. Memoires sur les 
 Polypes. Medico-Chirurg. Journal and Review, for December, 1816. Levret, Sur 
 les Polypes de la Matrice, p. 180. 
 
 f How difficult tliis operation sometimes is if not facilitated by some mechanical 
 contrivance may be seen in the case published by Dr. Denman. He describes 
 himself, Case the 4th, as making many and strenuous attempts to pass the ligature, 
 but without success. At length the ligature was applied, but the patient died before 
 the polypus came away, and appears to have been lost from the unsuccessful attempts 
 of the operation. In Dr. Hunter's museum there is a large polypus, with the state- 
 ment that after many attempts to pass the ligature the patient died. — (See Denman' s 
 Midwifery, vol. i., p. 100.)
 
 131 POLYPUS OF THE UTEFvUS. 
 
 of two tubes, capable of being separated and joined, and was originally 
 contrived by a German surgeon, of the name of Niessen, but has 
 since undergone many changes in the hands of different surgeons, 
 especially Levret. A representation of its latest form has been 
 copied from ' Richter's System of Surgery' into Mr. Samuel Cooper's 
 ' First Lines of Surgery.' In this sketch the two tubes are curved 
 to correspond with the curvature of the vagina and sacrum. 
 
 In this instrument I made two changes, the principal one con- 
 sisted in making the tubes straight instead of curved, the latter form 
 I found unnecessary even with the largest polypi ; and it was liable 
 to this great inconvenience, that when the tubes had been passed 
 round the polypus, so as to meet again on the opposite side, if the 
 upper extremities deviated in the slightest degree from each other, 
 (an accident which it was almost impossible to prevent, and which 
 took place, notwithstanding their lower extremities were perfectly 
 parallel,) it was impossible to slip up the cross part which was to 
 join them together. On the contrary, if the tubes were straight it 
 was necessary only to keep the lower extremities perfectly parallel to 
 insure a similar apposition of the upper, and the cross part could be 
 slipped up without any difficulty. 
 
 The instrument which I use for this purpose, and which in 
 numerous cases has assisted me easily through the operation, con- 
 sists of two silver tubes, each eight inches long, perfectly straight, 
 separate from one another, and open at both ends. A long liga- 
 ture, consisting of strong whip-cord, is to be passed up the one 
 tube and down the other, so that the middle of the ligature passes 
 across from the upper end of one tube to the upper end of the 
 other, and the two ends of the ligature hang out at the lower 
 ends; the tubes are now to be placed side by side, and, guided 
 by the finger, are to be passed up the vagina, along the polypus, 
 till their upper ends reach that part of the stalk round which 
 the ligature is to be applied ; and now the tubes are to be sepa- 
 rated, and while one is fixed, the other is to be passed quite round 
 the polypus till it arrives again at its fellow tube, and touches 
 it. It is obvious that a loop of the ligature will thus encircle the 
 stalk. The two tubes are now to be joined so as to make them form 
 one instrument; for this purpose two rings, joined by their edges, 
 and just large enough to slip over the two tubes, are to be passed 
 up till they reach the upper ends of the tubes which they Lind 
 together immoveably. Two similar rings, connected with the upper
 
 P0L1TUS OF THE UTETtUS. 
 
 135 
 
 by a long rod, are slipped over the lower ends of the tubes so as to 
 bind them in like manner ; thus these tubes, which at the beginning 
 of the operation were separate, are now fixed together as one instru- 
 ment. By drawing the ends of the ligatures out at the lower external 
 ends of the tubes, and then twisting and tying them on a part of 
 the instrument which projects from the lower rings, the loop round 
 the stalk is thereby tightened, and, like a silk thread round a wart, 
 causes it to die and fall off. 
 
 
 ^m 
 
 A, the two silver tubes armed with the ligature, and applied to that part of the 
 stalk which is to be encircled by the ligature ; one tube a little separated from the 
 other on its way round the polypus to meet its fellow tube on the opposite side. 
 
 B, the rings which bind the tubes into one instrument, the upper and lower joined 
 together by a long silver rod ; on the lower the projection or shoulders. 
 
 C, the two tubes joined together by the upper and lower rings ; at the upper end 
 a loop of the ligature round the stalk, at the lower end the ends of the ligatures 
 twisted round the shoulders of the instrument.
 
 136 
 
 POLYPUS OF THE UTERUS. 
 
 The most convenient mode of preparing the 
 instrument for the operation. A, the two 
 tubes armed with the ligature ready to pass 
 up to the stalk of the polypus, and still sepa- 
 rable so as to pass round it. B, the upper 
 and lower rings, connected by a silver rod, 
 already slipped up over the long outer ends 
 of the ligature, and ready to be slipped up 
 over the two tubes as soon as they have been 
 passed round the polypus, so as to encircle 
 the stalk with the ligature; the ends of the 
 ligature made into a knot to prevent this part 
 of the instrument dropping off during the 
 operation.
 
 POLYPUS OF THE UTERUS. l.°>7 
 
 The instrument being thus adjusted is to be left, but every night 
 and morning is to be untwisted from the shoulder of the instrument, 
 drawn tighter, and then fixed again round the projecting part, and 
 this is to be done morning and night. As the instrument projects 
 out of the vagina, if the patient was, whilst turning from side to 
 side, to sit down upon it, she might impale herself on it ; an acci- 
 dent which I have heard once took place, and terminated fatally. 
 To prevent this, the late Dr. Clarke contrived a round flat wooden 
 shield, which is fixed to his instrument so close to the outer orifice, 
 that even if the patient was to sit down on the instrument, it could 
 not be thrust higher in the vagina. I have always satisfied myself 
 with making the patient understand the necessity for care in turn- 
 ing, but such a guard could easily be adapted to my instrument ; 
 if the projecting part or shoulders were made two inches broader, 
 they would answer the purpose. 
 
 The only danger attendant on the operation is, that the ligature 
 may include a portion of the uterus. Dr. Denman passed a ligature 
 round a polypus of the fundus ; as soon as he tightened it, he pro- 
 duced pain and vomiting. As soon as the ligature was slackened, 
 these symptoms ceased; but whenever he attempt jd to tighten it, 
 the pain and vomiting returned ; the ligature was left on, but loose ; 
 the patient died about six weeks afterwards, and on opening the 
 body, it was discovered that the uterus was inverted, and that the 
 ligature had included the inverted portion. Mr. Abernethy in his 
 Lectures states, that he has opened the bodies of several women 
 who had died from the ligature of polypus of the uterus. This 
 accident happened to Dr. William Hunter, and he used to relate it 
 in his Lectures as a warning to others.* 
 
 * ' A young woman,' says he, ' came to me from a man-midwife in the City, desiring 
 ' that I would examine her. I found a monstrously large tumour filling up the 
 ' vagina. I wrote word that I thought she must die, if the tumour was not removed. 
 ' She was a poor servant-girl. With a long instrument I tied it in the best manner 
 1 I could. She complained of vast pain. I had before asked whether she ever had 
 1 a child, and she assured me she had not. I thought the womb could not be inverted, 
 ' as she had not been with child. I therefore begged her to bear the pain, made the 
 1 ligature tight, gave her an opiate, and left her, desiring my friend to visit her; 
 1 from him I learnt that the pain had been violent, but had ceased, and her pulse 
 ' was low and quick. She died ; I examined the body, and found the uterus inverted, 
 ' though she had never had a child, and that I had tied this. In this case my mind 
 ' is easy, for my intentions were upright ; however, for the future I have made it a 
 ' rule, never to make a ligature until I am quite clear that there are no parts of the 
 ' tumour but what may be included.' — See Dr. W. Hunter's Manuscript Lectures — 
 Polypus Uteri.
 
 138 polypus of the uterus. 
 
 III. 
 
 The following case, of which the result was similar, occurred at 
 St. Bartholomew's Hospital in the year 1828. The patient was a 
 poor woman about forty years of age, who had been delivered by 
 the forceps about six months before, on which occasion a tumour 
 was found in the vagina. When I saw her first, she was in the 
 following state : she had a large tumour, which, when she was 
 in the upright posture, protruded externally, but could easily be re- 
 turned. It was as large as the head of a new-born infant, and was 
 attached by a stalk, nearly as thick as the wrist, to the usual seat of 
 the cervix uteri, but I could not feel the orifice of the uterus. The 
 tumour was of a pale flesh colour, had a knotty surface, and felt 
 firm. The patient had a profuse colourless discharge, but she had 
 no haemorrhages, and had for some time ceased to menstruate. The 
 ligature was applied round what was supposed to be the stalk of the 
 tumour : it occasioned little pain when it was first applied, but 
 towards evening it became so severe as to resemble labour. It 
 was relieved by an opiate, so that she passed a comfortable night ; 
 but the next day the pain increased, extending up the loins, and 
 down the limbs. The ligature was tightened every day with a re- 
 currence of pain, which required an opiate : the tumour became livid 
 and the discharge foetid. On the seventh day a violent haemorrhage 
 came on, which occasioned death-like faintings and cold sweats. 
 The haemorrhage was arrested by a local astringent, and the fainting 
 relieved by brandy and ammonia, but she continued to have much 
 pain with vomiting, and at length died on the fifteenth day after the 
 operation. On opening the body, the uterus was found of its 
 natural size and structure ; the tumour grew from the orifice of the 
 uterus all around so as to be continuous with the cervix, and so as 
 to cover the aperture of the uterus, and to make it impossible to say 
 where the neck of the uterus ended, and the stalk of the tumour 
 began. The ligature had been applied so high as to include the 
 projecting neck of the uterus : the posterior part of it had occa- 
 sioned ulceration into the cavity of the peritoneum, in which there 
 was an aperture of about an inch in extent : the inner structure of 
 the tumour was similar to the fleshy tubercle ; there was no inflam- 
 mation of the peritoneum. 
 
 The danger of including the uterus in the ligature may, I think, 
 always be avoided by the following rules : 1st. Instead of aiming 
 at passing the ligature as high as possible on the stalk, to pass it as
 
 POLYPUS OP THE UTERUS. 139 
 
 low as possible, taking care to pass it over the body of the tumour. 
 It is true, by these means a portion of the stalk will be left above 
 the ligature; but I know by experience that it does not grow again ; 
 like the remnant of the umbilical cord, it dies and falls away. These 
 tumours have little life, and die above as well as below the ligature. 
 By a case winch I shall soon relate, it will be shown that this is 
 not a matter of probability, but of certainty. 2d. "When the stalk 
 grows from the cervix, if the os uteri can be felt, it will be the best 
 guide where the neck ends and the stalk begins ; the ligature ought 
 to be applied a little below the orifice, but if it cannot be felt, the 
 next best guide is the ordinary length of the projecting part of the 
 neck, that is, about two-thirds of an inch. "When the polypus is 
 very large, and the vagina closely contracted, it is difficult or im- 
 possible to reach the stalk and the cervix, so as to make anything 
 like an accurate measurement, and the first rule only is practicable. 
 3d. To attend to the sensations of the patient when the ligature is 
 tightened; if it gives much pain, there is every reason to believe 
 that it has included a part of the uterus. 
 
 The time required for the ligature to make its way through, de- 
 pends on the thickness of the stalk, and the frequency with which 
 the ligature is tightened ; this ought to be night and morning ; it 
 most commonly requires four or five days, but sometimes only two, 
 and sometimes as long as ten. As soon as the ligature is tightened, 
 the haemorrhage, if it has continued up to the moment of the opera- 
 tion, generally ceases; a foetid discharge, more foetid every day, 
 comes away, which requires to be washed out by tepid water injected 
 night and morning. "When the polypus is of a moderate size, it falls 
 away, together with the instrument; but when very large, the in- 
 strument drops out, leaving the polypus loose from its attachment, 
 but confined within the vagina, in which case I once found a vectis 
 necessary for its extraction. 
 
 Nothing can be more successful than this operation generally is. 
 A disease which has resisted remedies for several years is removed 
 within a week ; the haemorrhages which had lasted so long, and had 
 occasioned so much debility, suddenly cease ; and the patient rapidly 
 recovers her health. Sometimes, however, this requires to be assisted 
 by the usual restorative remedies, such as pure air, tonics, especially 
 bark, or steel, and sea-bathing, if the season admits of it. 
 
 M. Roux, of Paris, has published, in the third volume of his edi- 
 tion of Dessault's works, a ' Memoire sur les Tumeurs Polypoides/
 
 140 POLYPUS OF THE UTERUS. 
 
 in which he states that polypus of the uterus is generally accom- 
 panied by similar tumours within the substance of the uterus, and 
 that when this is the case, it is in vain to apply the ligature. If 
 this were correct, the result would be, that the operation would 
 generally not succeed, whereas, the truth is, it hardly ever fails. 
 There is perhaps not an operation in surgery more, and few so uni- 
 formly successful, as the ligature of the polypus of the uterus.* 
 
 It is not an uncommon notion, that when the stalk of the polypus 
 is very thick, the ligature is inapplicable. ' Sometimes/ says Dr. 
 William Hunter, ' polypi do not grow by a small peduncle, but by 
 ' a thick root from the uterus, and we cannot well apply the liga- 
 ' ture/f 
 
 ' A young woman died at the poor-house, at : her disease 
 
 ' had not been suspected till a few hours before her death. On 
 ' opening the body, a polypus was discovered eight inches long, 
 ' growing from the fundus of the uterus, by a stalk three inches in 
 ' diameter/ The writer adds, ' Had the precise nature of the case 
 ' been ascertained before death, the extraordinary breadth of the 
 ' base of the polypus would, I conceive, have precluded every well- 
 ' grounded expectation of a fortunate issue from any attempt at 
 ' removal/ % I have repeatedly applied the ligature to very thick- 
 necked polypi, with no other inconvenience than that the ligature 
 was many days making its way through. This fear of polypi with 
 thick necks as unsuitable for the operation is of modern date and 
 not reasonable. M. Levret relates several instances in which the 
 stalk was very thick, yet the operation was successful. In one, the 
 stalk was as thick as the fore arm ; in the other, it was three inches 
 in diameter, the very dimensions of the case which died in the poor- 
 house^ Even supposing the operation attended with greater 
 
 * M. Roux relates the case of a woman who died in the Hotel Dieu from hemor- 
 rhage and convulsions. On opening the body a polypus was discovered adhering to 
 the neck of the uterus, and a tubercle of a similar structure in the anterior wall of 
 this organ. M. Roux asks, ' of what advantage could a ligature have been ? None 
 ■ without doubt ; the other tumour would undoubtedly have caused the patient's 
 1 death. This reasoning applies to all similar cases, of which the number is unfortu- 
 ' nately greater than that of the dispositions favourable to the success of the operation.' 
 It is difficult to say what can have led M. Roux into this practical error, for such it 
 is, and too important a one to pass over. 
 
 i MS. Lectures. 
 
 % Med.-Chirurg. Journal and Review for December, 1816. 
 
 § Memoires de l'Academie Royale de Chirurg. tome iii. p. 537. 

 
 POLYPUS OF THE UTERUS. 141 
 
 difficulty, and the result more questionable than when the stalk is 
 narrow, it affords the only chance of saving the patient, and that a 
 very probable one. 
 
 Having now described the common polypus of the uterus, the 
 symptoms which it produces, and its fatal tendency, the cases with 
 which it may be confounded, and how to distinguish them, the mode 
 of cure, the dangers of the operation, and how to avoid them, I will 
 relate one or two cases, to show the young surgeon the obscurity 
 in which the disease is sometimes involved, and the deplorable cir- 
 cumstances from which he may withdraw his patient by a prudent 
 application of the foregoing rules of practice. These cases I shall 
 select from among the most difficult which I have met with, so that 
 he need not anticipate the same difficulties as of ordinary occur- 
 rence. 
 
 IV. 
 
 A lady between thirty and forty years of age, who had been married 
 many years without ever being pregnant, and resided in a provincial 
 city, became subject to frequent and violent haemorrhages from the 
 uterus. She was attended first by her family surgeon, and next she 
 was seen by one of the most eminent and experienced of the provincial 
 surgeons, by whom her uterus was examined and pronounced to be 
 cancerous. As she w T as one of a religious family, the fatal nature of 
 her complaint was explained to her, and as she suffered much pain, 
 she was resigned to nightly and sometimes daily opiates. As her 
 symptoms neither grew better nor worse, the uterus, after a long 
 interval, was examined again, and it was then discovered that what 
 was supposed to be a scirrlms, was in reality a large polypus. It 
 was thought, however, impossible or unsafe to remove it until it had 
 descended lower ; for it was too high up for the application of the 
 ligature. Months passed, during which she continued to take opium, 
 lose blood, and become anasarcous. A time having been fixed when 
 it would be probable that the tumour woidd be low r enough for the 
 application of the ligature, and that time having arrived without 
 the hoped-for result, she determined to wait no longer, but travel by 
 short and easy journeys to London, where she arrived one evening. 
 I saw her the next morning. She was anasarcous from head to foot, 
 so much so in the face as almost to obliterate her features; pain 
 and sleepless nights required two full opiates every day ; she vomited 
 frequently, and had a quick pulse. I found the vagina filled with 
 a tumour so large, that although I could pass my finger round it,
 
 142 POLYPUS OF THE UTERUS. 
 
 I could not pass it high enough to feel the thickness of the stalk, 
 or the place of its attachment; the smoothness of the tumour, how- 
 ever, and its perfect insensibility, convinced me it was a polypus, 
 and without leaving the house I applied the ligature by means of 
 my usual instrument. There was no difficulty in getting them 
 round, and consequently encircling the stalk with a noose of the 
 ligature, which I took care to apply not as high, but as low as pos- 
 sible on the stalk. Provided the ligature is above the body, the 
 lower it is on the stalk the less likely it is to include a portion of 
 the uterus, which is the only danger to which the operation is liable. 
 I continued to tighten the ligature night and morning for several 
 days ; at length one evening the instrument with the ligature came 
 away ; leaving the polypus still in the vagina ; but about an hour or 
 two afterwards, violent painful contractions of the abdominal muscles, 
 like labour pains, came on, which alarmed her friends ; and when I 
 arrived, I found the tumour at every pain protruding at the external 
 orifice. With a dry towel I grasped the projecting tip of the tumour, 
 and desiring her to strain during the pains, the huge polypus slipped 
 away. It is a curious circumstance, which I have repeatedly wit- 
 nessed, that the tumour, which, during its attachment to the uterus, 
 has never excited expelling pains, should, as soon as it is separated, 
 and is become an extraneous body, excite painful contractions to 
 cast it off. She left off her opium, and did little more than keep 
 her bowels freely open, and return to the country, where in a few 
 months she recovered her health, and is at this time perfectly well. 
 
 V. 
 
 I went ten miles from London to see a lady, of whom I received 
 the following particulars from her family surgeon, Mr. Butler, of 
 Woolwich : — For nearly two years she had been subject to long and 
 profuse menstrual periods, in which she calculated that she lost 
 ten times what she did when she was in health. Fifteen months 
 ago the uterus had been examined by an eminent practitioner, who 
 discovered nothing but that it was larger than was natural. About 
 five months ago, during expulsive pains, a tumour had descended 
 into the vagina, and was now so large as to fill the pelvis, and occa- 
 sion a retention of urine, which required the frequent introduction 
 of the catheter. The haemorrhages were more profuse than ever ; 
 she had lost all colour in her face, and was so weak that she never 
 left her bed. She complained of pains in the pelvis, had a quick
 
 POLYPUS OF THE UTERUS. 143 
 
 pulse, vomited often, and took little food. I found a tumour in the 
 vagina, with a smooth surface and insensible. I coidd pass my 
 finger all round it, but it was so large thai it was imposible to reach 
 above it so as to feel the stalk, and where it was attached. I was 
 driven to this alternative, therefore, either not to apply the ligature, 
 and thereby abandon the patient to a sure death, or to apply it with 
 a good deal of uncertainty about the part which it encircled. I of 
 course preferred the latter, taking all the precautions with which I was 
 acquainted to avoid including any portion of the uterus. I passed 
 up the two canulas side by side, armed with the ligature, kept one 
 as a fixed point, moved the other round the tumour till it arrived 
 again at the other canulae, taking care to pass them only just above 
 the most bulky part of the tumour. This was done with all the 
 facility which this instrument usually gives me. The two canulas 
 were now joined by sliding up the rings, the ligature was tightened 
 and secured in the usual way. Mr. Butler promised to visit her 
 night and morning, and tighten the ligature at each visit ; and I was 
 to see her in two days. When I went I was alarmed at the state in 
 which I found her ; she complained of pain in the uterus, had a pulse 
 of 130, and had vomited frequently. On inquiring, however, I found 
 that these symptoms had troubled her almost daily for many months, 
 only in a less degree. I saw Mr. Butler tighten the ligature ; and 
 it was done so boldly, without any increase of pain, that I was satis- 
 fied that what she did suffer was not caused by the ligature having 
 included a portion of the uterus. She was directed to take a purge ; 
 and if, after that had operated, pain or vomiting should continue, to 
 take a small opiate every four hours. W hen I saw her two days 
 after this, I was told that the day before her pain and vomiting had 
 subsided, her pulse had fallen to 90, and she appeared very well ; 
 but about four o'clock in the morning Mr. Butler had been called 
 out of his bed, and when he went he found her in strong expulsive 
 pains, which had continued occasionally ever since, — that is, till about 
 four in the afternoon, and by which about half the tumour had been 
 protruded externally. In this case nature had been unable to effect 
 the delivery, and we resolved to finish it. I grasped the tumour with 
 a dry napkin, and by a little pulling, assisted by a little forcing on 
 the side of the patient, the whole tumour was expelled. It was as 
 big as two fists ; the stalk was as thick as a wrist, and the ligature 
 had still much of it to cut through. "We therefore determined to 
 remove the tumour by more speedy means. Whilst I grasped it with
 
 144 POLYPUS OF THE UTERUS. 
 
 a towel, to prevent its being drawn back again into the vagina, Mr. 
 Butler cut it off just below the ligature, and then slipped the stalk, 
 with the ligature attached to it, back again into the vagina. Having 
 removed the body of the tumour, I could examine the stalk, and the 
 seat of its attachment ; the orifice of the uterus encircled it, and on 
 introducing the finger between the orifice and the stalk, it passed up 
 barely an inch before it was stopped by the part to which the stalk 
 grew. The polypus, in descending into the vagina., had drawn down 
 the fundus of the uterus, so as to change it from an upright vault 
 into a low flat roof, not more than an inch from the edge of the 
 orifice. The stalk was as thick as a wrist, and hung two or three 
 inches into the vagina. The removal of the tumour was followed 
 by a perfect calm ; the pain ceased, the pulse became moderate, the 
 sickness disappeared, the patient took nourishment, and when I saw 
 her two days afterwards, she was going on so well that I left her 
 under the care of Mr. Butler. I have often been asked what 
 becomes of the stalk when a considerable portion of it has been left 
 behind ; and the only answer I could give was, that it certainly did 
 not lead to a return of the disease, and I conjectured that it withered 
 and fell off. In this case, however, I can give a more precise answer. 
 For several days after the removal of the polypus, fragments, like 
 sloughing cellular membrane, in large quantities, came away with a 
 discharge ; at length this ceased, the discharge subsided, and a short 
 time afterwards she had a natural and moderate menstrual period. 
 The uterus was examined soon afterwards ; its orifice was wide open, 
 and readily admitted the finger to a considerable depth; it was 
 examined again two months afterwards, when the orifice and body 
 were found contracted to their natural dimensions ; she was then 
 menstruating regularly, and had regained the looks, feelings, and 
 functions of health. 
 
 OF POLYPUS OF THE UTERUS, ATTENDED BY UNUSUAL 
 CIRCUMSTANCES. 
 
 I. In a vast proportion of cases — to speak in numbers, in nine 
 out of ten — to whatever part the stalk grows, frequent haemorrhages 
 from the uterus form the symptom of the disease, which attracts the 
 chief attention of the practitioner, and the case is long mistaken for 
 common monorrhagia ; but when the tumour grows from the neck
 
 POLYPUS 01' THE UTERUS. 11.."") 
 
 or lip of the uterus, it sometimes occasions nothing but au obstinate 
 and profuse leucorrluea. The following case shows this, and shows 
 also how liable diseases of this part are to be overlooked for want of 
 examination by touch. 
 
 YT. 
 
 I was sent for one evening to see a lady about thirty years old, 
 and was told that she had been troubled for nearly two years with 
 profuse leucorrhoea. As she was unmarried, I was going to prescribe 
 for her without examination, when I was told this would not be 
 satisfactory. It then came out she had seen another physician that 
 morning, whose statement appeared to her and her mother so in- 
 credible that they would not believe it until it was corroborated by a 
 second medical witness ; but I was not allowed either to meet this 
 physician, or to know what this statement had been. Little as I 
 expected it, I found a small polypus, about the size of a walnut, 
 growing by a slender stalk to the cervix uteri. The ligature was 
 successfully applied, and the patient recovered. 
 
 II. YYomen who have a polypus of the uterus, especially if it 
 grows from the neck or lip of this organ, sometimes become pregnant. 
 Of this I have known two instances. In one the tumour was dis- 
 covered in the fifth month of pregnancy, and was removed by the 
 liu-ature. The pregnancy went on to the ninth month, when the 
 patient was safely delivered. In the other case the tumour was not 
 discovered till the commencement of labour, and occasioned the 
 death of the patient a few hours after delivery. 
 
 VII. 
 
 Mr. Borrett, surgeon at Yarmouth, with whom, when this hap- 
 pened, I was residing as pupil, was called to a lady in labour with 
 her sixth child. On his first examination he found a large fleshy 
 tumour within the vagina. The anterior segment of the os uteri 
 was easily felt, but the posterior was occupied and covered by the 
 attachment of the tumour. After the orifice had dilated, and the 
 membranes had burst, the head of the child not descending, Mr,. 
 Borrett introduced his hand, brought down the feet, and extracted 
 the child. The placenta was expelled spontaneously. The patient 
 now being delivered, and easy, he left her at seven in the morning. 
 At three in the afternoon he found her in strong pains, as if there 
 was another child ; but as the abdomen was flat, and the contracted 
 uterus could be distinctly felt in the abdomen, he was satisfied that 
 
 L
 
 146 POLYPUS OF THE UTERUS. 
 
 there was not, and gave her an opiate. At eight o'clock at night 
 he found that the pains continued violent, with a sensation as of 
 a substance coming away, and on examination he discovered a soft 
 round tumour pressing against the outer orifice. What could it 
 be ? He would have thought that it was the uterus inverted, but 
 it was the same tumour winch he had felt in the morning before the 
 child was born ; there was no haemorrhage ; the placenta had been 
 expelled spontaneously, and the uterus was distinct in the hypo- 
 gastric region. He consulted his medical friends in the town, and 
 sent off to Norwich for Mr. Rigby. The pains continued with 
 violent expulsive efforts all night, and the next morning they found 
 her with a languid pulse and a pallid countenance ; a large fleshy 
 livid tumour had been forced out of the vagina, and every pain 
 brought it more and more in sight : she continued to suffer and 
 to sink through the rest of the day : in the evening Mr. Bigby 
 arrived, but she had expired about half an hour before. As soon 
 as he arrived he examined the tumour, and was convinced that it 
 was the inverted uterus. On opening the body next morning the 
 uterus was found contracted, but its orifice was dragged down as 
 low as the external orifice by a tumour winch grew from it by a 
 thick stalk ; it was attached to the posterior part of the orifice, and 
 some way up the neck, was of a livid colour, and weighed three 
 pounds fifteen ounces. 
 
 What would have been the result of this case, if a ligature had 
 been applied round the stalk of the tumour, and its body cut off 
 just below, as in the case No. V ? 
 
 III. When the polypus grows from the lip of the uterus, and its 
 stalk is very thick, as two or three inches in diameter, the other lip 
 and the orifice of the uterus are quite lost, and cannot be detected 
 by touch. In this case, of winch I have seen several instances, 
 instead of feeling a slender stalk encircled by the orifice of the 
 uterus, or the stalk and the orifice by the side of it distinct from 
 one another, we feel at the top of the vagina, where the neck of the 
 uterus usually projects into its cavity, a thick stalk, which lower 
 down enlarges into a globular tumour, without any vestige of the 
 neck or orifice of the uterus. I have seen the most experienced 
 practitioners in London puzzled to tell what was the nature of the 
 tumour, and what ought to be done for it. 
 
 The following case is a specimen of this puzzling combination of 
 circumstances.
 
 POLYPUS OF THE UTERUS. 147 
 
 VIII. 
 
 A lady, forty years of age, who had never been pregnant, came to 
 London for advice for frequent haemorrhages from the uterus, which 
 had not been relieved by the usual remedies, and had greatly injured 
 
 her health. On examination there was found in the vagina a Large 
 round tumour, terminating in a very thick stalk, which grew from 
 the situation of the neck of the uterus. This stalk, however, was 
 not encircled by the orifice of the uterus, either completely, as in 
 polypus of the fundus uteri, or partially, as in polypus of the neck. 
 No orifice coidd be felt. On passing the linger round the uppermost 
 part of the stalk, it formed, with the adjoining part of the vagina, 
 a blind corner all round, as is felt in passing the finger round the 
 neck of the uterus. For some time the nature of the tumour and 
 the propriety of an operation were much doubted, and on this point 
 I was consulted. On carefully examining it, I felt a little depression 
 at the uppermost and anterior part of the stalk. This, I conjec- 
 tured, was the orifice of the uterus, small, from the patient never 
 having been pregnant, and dragged out of its natural direction, and 
 obscured by the thickness of the stalk. That a thick stalk growing 
 from the edge of the orifice might so obscure that orifice as to make 
 it difficult to be felt, particularly in a woman who had never been 
 pregnant, seemed intelligible and probable. The tumour was insen- 
 sible, smooth, and of the consistence of a polypus. Thus it appeared 
 so reasonable to believe that the tumour was a polypus, so certain 
 that if it was not removed the patient would ultimately die of the 
 haemorrhages, and so probable that the operation would be suc- 
 cessful, that, notwithstanding the obscurities of the case, 1 advised 
 it to be performed : the ligature was applied to the stalk, and it was 
 gradually tightened every day. On the fourth day the ligature gave 
 way, and the instrument came off without the tumour: another 
 ligature was now placed in the groove left by the former, and gradu- 
 ally tightened every day. On the fifth day, having made its way 
 completely through the stalk, it came away with the instrument, 
 leaving the tumour loose in the vagina. It was necessary to intro- 
 duce the whole hand, in order to extract the tumour, which was 
 found to be as large as the head of anew-born child. On examining 
 the vagina a short time afterwards, the neck of the uterus was found 
 in its natural situation, and with its natural orifice. The haemor- 
 rhages ceased, menstruation became regular, the patient rapidly 
 recovered, and has been well ever since.
 
 148 POLYPUS OF THE UTERUS. 
 
 IX. 
 
 Some years before this case occurred I was consulted, together 
 with two of the most experienced practitioners in London, about a 
 lady who had been long subject to haemorrhages from the uterus, 
 by which her health had been broken, and in whom a large round 
 tumour had been discovered in the vagina. On examining it care- 
 fully, the orifice of the uterus could be felt, the anterior lip of which 
 seemed as if it was prolonged into a thick stalk which terminated in 
 a round tumour. As the stalk was not encircled by the orifice of the 
 uterus, it was thought that it could not be a polypus, and we agreed 
 in dissuading from the application of the ligature. This lady died 
 about two years afterwards. If I had known what I do now about 
 the thick -necked polypus of the lip of the uterus, and that there is 
 a large proportion of removeable polypi, of which the stalk is not 
 encircled by the orifice of the uterus, I would have applied the 
 ligature. 
 
 IV. A polypus may have an unusual form, as that of a solid 
 cylinder ; it is generally globular or pyriform, with a stalk like an 
 elastic gum bottle ; but I have seen two cases in which it was cylin- 
 drical, about the size of half the wrist, and the unusual form occa- 
 sioned great doubts about the nature of the case and the mode of 
 treatment. 
 
 X. 
 A woman for a long time had suffered frequent haemorrhages 
 from the uterus, which had resisted the usual remedies and greatly 
 injured her health. At length, one day, a substance of a singular 
 appearance suddenly protruded from the vagina; it hung out 
 beyond the external orifice nearly half a foot ; in form it was like a 
 flattened cylinder, about half as thick as the wrist ; it felt somewhat 
 like an intestine, but on careful examination was found to have no 
 cavity; it was very soft; on tracing it upwards it was found to 
 extend through the vagina, and through the orifice of the uterus, 
 beyond which it could not be traced ; it was firmly attached within, 
 for on pulling at it, it did not come way; it was of the same 
 diameter through its whole length : a ligature was applied to it just 
 below the orifice of the uterus, and in a few days it came away, the 
 patient immediately losing the haemorrhages by which she had so 
 long been weakened. 
 
 V. A polypus is sometimes so small, that it seems incredible it 
 should occasion the frequent haemorrhages which attend it, yet the
 
 POLYPUS OF THE UTERI'S. 119 
 
 haemorrhages cease on the removal of the polypus. L have fell them 
 as small as a filbert without its shell, growing to the neck or lip of 
 the uterus; they were so small that, on being touched, they slipped 
 into the orifice of the uterus, and there remained concealed till the 
 finger was withdrawn, and the patient sat up, and they dropped 
 down again into the vagina. 
 
 I saw an elderly woman with a polypus of this size : the day was 
 fixed for its removal, but before it arrived, whilst she was using a 
 lotion with a long pewter syringe, it fell away, and from that time 
 the haemorrhages never returned. 
 
 XI. 
 
 Dr. Babington took me into the country one evening with my 
 instrument, to remove a small polypus about the size of a walnut, 
 which he had discovered in a lady the day before. He had 
 described the case to me about a week before, when I advised him to 
 examine the uterus, and said that I thought that he woidd find a 
 polypus. She was about fifty-five years of age, and for a year and 
 a half had been subject to frequent haemorrhages from the uterus 
 without pain. We found her in bed, ready for the operation. The 
 polypus was so small, that I took it between my fore and middle 
 lingers, and drew it downwards, on which the stalk broke, and the 
 little polypus came away. Dr. Babington, on examining imme- 
 diately afterwards, was surprised to find no polypus, on which I 
 showed it him in my hand. From this time the haemorrhages never 
 returned. These little polypi are generally too small for the liga- 
 ture; and if they cannot be pulled away with the finger, should be 
 twisted off by a pair of surgeon's dressing forceps. 
 
 OF EXCRESCENCES FROM THE UTERUS WHICH ARE LIABLE TO BE 
 MISTAKEN FOR POLYPUS. 
 
 I will just collect an account of these several excrescences such as 
 I have observed myself, or have been described by competent wil- 
 nesses, and then see whether, amid this variety of description and of 
 denomination, it is not possible to simplify the subject, and reduce 
 them all to one kind and one name. 
 
 ' There arise/ says M. Herbiniaux, l as well in the vagina, as in
 
 150 POLYPUS OP THE UTERUS. 
 
 c the uterus, excrescences which Levret calls vivaces, but which must 
 ' not be confounded with polypi ; they are fungous excrescences 
 ' which, grow from ulcerated surfaces, and are covered with no mem- 
 f brane. It is quite useless either to cut them off, or to apply a 
 1 ligature, for they soon grow again ; they cause little or no pain, 
 ' but frequent haemorrhages, which are ultimately fatal. We com- 
 ' rnonly find several such excrescences at the same time ; commonly 
 ' they remain always in the uterus, they seldom descend into the 
 ' vagina, for they have no stalk ; the orifice of the uterus is com- 
 1 monly more or less open, and within it can be felt the excrescence ; 
 1 it is soft, and less even than a polypus ; it often distends the uterus 
 ' so much, that the abdomen is externally unnaturally large ; pressure 
 ' on the belly causes pain, but the excrescence itself is void of feel- 
 1 nig/* I suppose that the following case, which I saw many years 
 ago, is of the kind which is here described by M. Herbiniaux. 
 
 XII. 
 
 I was sent for thirty miles from London, to see a lady seventy 
 years of age, who a few weeks before had had a sudden haemorrhage 
 from the uterus, whilst she was standing in her drawing-room, so 
 that the blood stood in a little pool on the carpet ; terrified at this 
 occurrence at her age, she was removed to her bed, where she had 
 remained ever since with a slow discharge, sometimes of blood and 
 sometimes of water. I found the orifice of the uterus circular, with 
 thin edges, dilated to the size of half-a-crown, and a substance slightly 
 protruding through it. It had a rough cauliflower surface, and bled 
 on being touched; it was round and large. I could pass my finger 
 within the orifice, and some way up between the thin Malls of the 
 uterus and this globular, spongy body. She complained of violent 
 weight and bearing-down pains in the rectum, which I soon found 
 depended on an enormous collection of hard fasces. This was soon 
 cleared out by the country surgeon who met me, by the aid of a 
 good syringe and some brown soap and water, to the indescribable 
 relief of his patient. The more formidable part of her disease, how- 
 ever, still remained. She came to town, and was attended for some 
 time by Dr. Babington and myself. The tumour never projected 
 enough into the vagina to admit even of its tip end being included 
 in a ligature. After being some months in London, she returned to 
 
 * Richter's Chirurg. Bibliothek. b. G. s. 218.
 
 POLYPUS OF THE UTERUS. 151 
 
 the country, and about a year afterwards I heard that she died drop- 
 sical. Since this case, I have seen two similar to it. Here, then, is 
 a fungous excrescence, by which I understand one of a vascular 
 structure, which is not covered by a smooth thick membrane, like 
 polypus, but has a rough surface, which grows by a broad base instead 
 of a narrow stalk, which, if removed, grows again, which bleeds on 
 being touched, but which is insensible, and which kills by inducing 
 frequent haemorrhages. 
 
 ' There are polypi/ continues M. Herbiniaux,* ' winch are as soft 
 ' as those called vivaces, but they are smooth; they are the mucous 
 ' polypi (schleim polypen) ; they excite haemorrhages, and if you 
 ' apply the ligature to them, there arises a discharge of mucus, and 
 ' the polypus becomes smaller. When it separates, it is nothing 
 ' but an empty skin/ 
 
 The late Dr. John Clarke described one of these tumours under 
 the name of cauliflower excrescence; and Dr. C. M. Clarke has 
 given a clear and forcible description of it in his work on the dis- 
 eases of females. The following are its most remarkable properties : 
 — Instead of having a smooth surface like a polypus, it is granulated 
 like that of a cauliflower. Instead of being covered with a thick 
 mucous membrane like a polypus, it is covered by a fine transparent 
 one; it is of a bright flesh colour, it is quite insensible, it never 
 grows from any part but the cervix uteri ; instead of growing from 
 a narrower part or stalk, it grows from a broad base ; it is attended 
 by a watery discharge and by frequent haemorrhages. It is as liable 
 to occur in young and middle-aged, as in elderly women, and in this 
 respect differs from carcinoma of the uterus. It consists of a collec- 
 tion of small blood-vessels, and in this respect differs from polypus 
 in its internal structure, as well as its external covering. After 
 death it shrinks almost to nothing, so that on examining the body, 
 in place of the tumour which was felt during life, there is found 
 only a soft, flaccid, slimy, whitish substance, which looks like the 
 foetal portion of the placenta of a calf. It undergoes the same 
 change if inclosed in a ligature. It kills, like polypus, by the 
 profuse discharge and frequent haemorrhages which it occasions. 
 During the progress of the case, small pieces of granulated flesh 
 come away, vast quantities of watery fluid and frequent haemor- 
 
 * Traite sur divers Accouchemens laborieux et surles Polypes de la Matrice. See 
 Richter's Cliirurg. Bibliothek. b. 0. s. 218.
 
 152 TOLYPUS OF THE UTERUS. 
 
 rhages, by which the constitution of the patient is slowly under- 
 mined. 
 
 Compare the chief properties of these two excrescences, the 
 one described by Herbiniaux and Levret, and the other by Dr. 
 Clarke :— 
 
 Vivaces. Cauliflower Excrescences. 
 
 A rough surface. A rough surface. 
 
 Grows from a broad base. Grows from a broad base. 
 
 A soft fungus. A congeries of vessels. 
 
 If removed, grows again. If removed, grows again. 
 
 The effect of death not observed. After death or a ligature, shrinks to an 
 
 empty skin. 
 
 Insensible. Insensible. 
 
 Kills by frequent haemorrhages. Kills by frequent haemorrhages. 
 
 By comparing the above parallel columns, the reader will easily 
 see that the essential properties of these two excrescences are almost 
 identical, and that there is no more difference between them than 
 what would naturally arise from two observers describing the same 
 thing : they differ only in the part from which they grow ; that is, 
 not more than polypus of the neck and orifice from polypus of the 
 fundus of the uterus. 
 
 But what is the essential nature of these reproducible excres- 
 cences ? Are they growths confined to the uterus, or are they only 
 individuals of the same tribe which infest other parts of the body ? 
 
 In Mr. Brodie's museum there is a preparation of the uterus of a 
 young woman who died in St. James's Infirmary from cancer of the 
 breast. During the progress of the disease, she had a constant dis- 
 charge from the vagina. The uterus was not examined during life, 
 but after death it was found enlarged and containing a vascular 
 excrescence, which grew from the fundus, and projected into its 
 cavity, and which Mr. Brodie tells me has precisely the appearance 
 of the cauliflower excrescence of the neck of the uterus. 
 
 XIII. 
 
 I saw a poor woman in the Middlesex Hospital, of whose case the 
 following are the particulars : — She was thirty-three years of age, a 
 widow, and had not had a child for thirteen years. She had for 
 a long time been subject to leucorrhoea, but, about four months 
 back, this changed into a profuse, parti-coloured, foetid discharge, 
 with slight appearances of blood every few days. About three weeks
 
 POLYPUS OF THE UTERUS. 
 
 153 
 
 ago she had had a violent haemorrhage, and another since her admis- 
 sion into the hospital. She had slight occasional pains in the loins 
 and thighs. I felt a tumour the size of a small apple ; it appeared 
 to grow from the orifice of the uterus, nearly, hut not quite, 
 all round, leaving a cleft on one side which admitted the finger. The 
 surface was rough. The probability that this was a malignant 
 excrescence was distinctly recognised by Dr. Ley and myself ; but 
 as the only plan which afforded her any chance of recovering, 
 a ligature was applied round the upper part of the tumour and tight- 
 ened every day; it gave no pain. On the sixth day from its appli- 
 cation there came on vomiting and a pulse of 140. The next 
 morning the ligature was removed, the vomiting ceased, but the 
 pulse continued rapid. From this time she continued gradually to 
 sink, and died about four months afterwards. The body was 
 examined by Mr. Herbert Mayo, and I subjoin his account of the 
 dissection, and his sketch of the tumour. 
 
 J, The fungus of the cervix, with a probe introduced through it from the cavity of 
 the uterus. 
 
 B, fungus of the same description, growing from the upper and back part of the 
 vagina. 
 
 C, interior surface of the uterus laid open.
 
 151 POLYPUS OP THE UTERUS. 
 
 ( The body of the uterus was shrunk, pale, and contracted ; the 
 * adjoining portion (half an inch) of the cervix was healthy. The 
 ' last inch in length of the cervix was swollen to the size of a large 
 ' chestnut, and had the texture of a soft pulpy fungus ; a similar 
 ' structure in the place of one of the ovaries, and in a neighbouring 
 ' lymphatic gland, left no doubt that the tumour was of the nature 
 ' fungous hsematodes/ 
 
 The reader will by this time have drawn for himself the following 
 conclusion : that these fungous excresences described by Levret, 
 Herbiniaux, and Dr. Clarke, which I have found in the uterus and 
 in the vagina, and which agree in these leading properties, that 
 instead of a dense firm substance they are of a spongy or vascular 
 structure ; that if removed they grow again, and kill by producing 
 frequent and profuse hsemorrhages ; are only the same growth in 
 different parts of the genital cavity, and are specimens of the same 
 disease which, in other parts of the body, is best known in this 
 country under the denomination of the bleeding fungus, or fungous 
 hsemotodes. 
 
 In all these cases of fungous excrescence in the vagina, the best 
 practical rule I believe to be this : whenever the form of the excres- 
 cence is such that the whole can be removed by a ligature, without 
 including any portion of the uterus, apply it, distinctly stating to 
 the patient or her friends that it is not done with the same confi- 
 dence of success as in a common polypus, but as the only remedy 
 which gives the patient any chance of life, and if it fails by the 
 excresence growing again it does not render the case worse than it 
 was before. 
 
 I do not believe that any man can tell infallibly by touch whether 
 a tumour on the vagina is a malignant excrescence, which is to grow 
 again, or a benign one, which, if removed, will never return. A 
 rough uneven surface is no test. The polypus described in Case 
 No. Ill, which turned out to be a common polypus in structure, 
 and which would have been successfully removed if the ligature had 
 been applied an inch lower, had a rough surface ; and I have suc- 
 cessfully and permanently removed tumours, which because they had 
 uneven surfaces, had been judged by other practitioners to be malig- 
 nant excrescences. It is a prevalent notion among medical men, 
 that these malignant excresences are far more common than they 
 really are. Among the cases about which I am consulted, especially 
 from the country, in which disease of structure is apprehended in 

 
 POLYPUS OL' THE DTERUS. 155 
 
 the uterus, no one is so often named as the cauliflower excrescence. 
 If the surface of the tumour or even the neck of the uterus is a 
 little irregular, if blood follows an examination, and the patient 
 states that she has a watery discharge, by which she means little 
 more than that it is colourless, all which are common occurrences in 
 the diseases of structure in this organ, the case is sure to be set 
 down as cauliflower excrescence. If these suspicions were accurate, 
 this disease would be the most common of the diseases of this organ ; 
 yet the fact is, that it is the most rare. Where we see one case of 
 cauliflower excrescence, we see ten or even twenty of common polypus 
 and fifty of carcinoma, or malignant ulcer of the uterus.
 
 ( 156 ) 
 
 CHAPTER V. 
 
 OF THE IRRITABLE UTERUS. 
 
 The disease which I have ventured to call the irritable uterus, is 
 a painful and tender state of this organ, neither attended by, nor 
 tending to produce, change in its structure. It is now between 
 fifteen and twenty years since I began to notice this disease, and 
 since then I have seen several cases every year. At first it puzzled 
 me much ; I had not seen it described in books. I took it for 
 chronic inflammation, which would end in disorganization, probably 
 of a malignant kind; but experience, whilst it taught me that it 
 was a very intractable disease, taught me also that it was not a 
 disorganizing one. I became familiar with its obstinacy and less 
 apprehensive about its result, for I know cases which have lasted 
 upwards of ten years, in which the structure of the uterus is as 
 unaltered here as it was in the beginning of the disease, as far at 
 least as can be determined by examination during life. Although 
 I often find it still an intractable disease, and wish I had a shorter 
 and surer mode of cure to communicate, yet I think it worth 
 describing, that practitioners may recognise it when they meet with 
 it ; that they may know what they are to expect in obstinacy, and 
 what they need not apprehend in the result ; what will do harm, 
 what will do good, and the mode of treatment, which, however 
 unsatisfactory to the medical attendant and Iris patient, will slowly 
 but ultimately conduct most cases to recovery. 
 
 Pain in the lowest part of the abdomen and loins attends various 
 diseases of the unimpregnated uterus. It is the chief symptom in 
 painful menstruation ; but here it occurs only during the menstrual 
 period, and is quite absent during the rest of the month. It is the 
 most distressing symptom in the descent of the uterus (prolapsus) 
 but here it occurs only in the upright posture and exercise, ceases 
 on lying down, and replacing the organ, and is prevented by sup- 
 porting it in its natural situation. It attends most of the diseases 
 of structure to which the uterus is liable ; but the change of struc-
 
 OF THE IRRITABLE UTERES. 1.17 
 
 ture, which may be ascertained by examination, distinguishes the 
 nature of the pain. 
 
 A patient who is suffering from the irritable uterus complains of 
 pain in the lowest part of the abdomen, alongthe brim of the pelvis, 
 and often also in the loins. The pain is worse when she is np and 
 taking exercise, and less when she is at rest in the horizontal pos- 
 ture; in this respect it resembles that of prolapsus uteri, but there 
 is this difference, that in the latter, if the patient lies down, she 
 soon becomes epiite easy ; but in the complaint of which 1 am speak- 
 ing, the recumbent posture, although it diminishes, does not remove 
 the pain. It is always present in some degree, and severe paroxysms 
 often occur, although the patient has been recumbent for a long- 
 time. If the uterus is examined, it is found to be excpiisitely tender ; 
 the finger can be introduced into the vagina, and pressed against its 
 sides without causing uneasiness ; but as soon as it reaches and is 
 pressed against the uterus, it gives excpiisite pain. This tenderness, 
 however, varies at different times, according to the degree of pain 
 which has been latterly experienced. The neck and body of the 
 uterus feels slightly swollen, but this condition also exists in different 
 degrees, sometimes sufficiently manifest, sometimes scarcely or not 
 at all perceptible. Excepting, however, this tenderness, and occa- 
 sionally this swelling, or rather tension, the uterus feels perfectly 
 natural in structure ; there is no evidence of scirrhus in the neck, 
 the orifice is not misshapen, its edges are not indurated. The 
 patient, finding her pain greatly increased by rising and walking, 
 soon learns to relieve herself by lying on the sofa, and at length 
 spends nearly her whole time there. Notwithstanding this precau- 
 tion, there is always a considerable degree of uneasiness, but this 
 frequently increases to severe pain. These paroxysms generally 
 come on either a few days before menstruation, or (as is the case in 
 many instances) a few days afterwards. If the paroxysm is properly 
 treated, it subsides in a few days to the ordinary and more moderate 
 uneasiness. "Whilst this uneasiness is felt in the substance of the 
 uterus, the general circulation is but little disturbed. The pulse is 
 soft, and not much epiicker than is natural ; but it is easily quickened 
 by the slightest emotion. In a few r instances, however, there has 
 been a greater and more permanent excitement of the general circu- 
 lation; the degree in which the health has been reduced has been 
 different in different cases. A patient, who was originally delicate, 
 who has suffered long, and has used much depleting treatment, has
 
 158 OF THE IRRITABLE UTERUS. 
 
 been (as might reasonably be expected) the most reduced ; she has 
 grown thin, pale, weak, and nervous ; menstruation often continues 
 regular, but sometimes diminishes, or ceases altogether; the func- 
 tions of the stomach and bowels are not more interrupted than might 
 be expected from the loss of air and exercise ; the appetite is not 
 good, and the bowels require aperients; yet nothing more surely 
 occasions a paroxysm of pain than an active purgative. Such are 
 the leading symptoms of this distressing complaint. To embody 
 them in one view, let the reader fancy to himself a young or middle- 
 aged woman, somewhat reduced in flesh and health, almost living 
 on her sofa for months, or even years, from a constant pain in the 
 uterus, which renders her unable to sit up and take exercise ; the 
 uterus, on examination, unchanged in structure, but exquisitely 
 tender ; even in the recumbent posture always in pain, but subject 
 to great aggravations more or less frequently. 
 
 The causes to which this disease has been attributed, and after 
 the application of which it has occurred, are generally considerable 
 bodily exertions at times when the uterus is in a susceptible state. 
 In one patient it came on after an enormous walk during a men- 
 strual period ; in another, it was occasioned by the patient's going 
 a-shooting with her husband not many days after an abortion ; 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 conse- 
 quence of, matrimony. Although, however, the disease followed, 
 and was apparently excited by, these several causes of irritation, yet 
 the patients had previously manifested signs of predisposition to it ; 
 they were all sensitive in body and mind, many of them had been 
 previously subject to the ordinary form of painful menstruation. 
 The disease seemed to consist in a state of the uterus similar to that 
 of painful menstruation, only permanent instead of occasional. 
 
 Long-continued pain in an organ so liable to malignant diseases, 
 invariably leads to the apprehension of disease of structure, to ascer- 
 tain winch, repeated examinations generally take place, but nothing 
 is discovered excepting exquisite tenderness and slight swelling, or 
 rather tension. The disease does not terminate in change of struc- 
 ture. The fact, also, that many of these cases, after having lasted
 
 OF THE IRRITABLE UTERUS. 159 
 
 for years, end in entire recovery, is a sufficient proof that it is a 
 disease only of function. Few such diseases, however, yield so 
 slowly to remedies. Even in those which end in complete recovery, 
 there are often long intervals in which the progress towards amend- 
 ment is most unsatisfactory and dispiriting. By complete repose in 
 the recumbent posture, and proper remedies, the painful paroxysms 
 become slighter and return at longer intervals ; the stationary uneasi- 
 ness becomes gradually less, and at length ceases altogether, and at 
 the end of a few months the patient is left free from pain, but more 
 or less enfeebled. No disease, however, is so liable to relapse. The 
 patient, feeling easy, finding herself feeble, and supposing that air 
 and exercise are necessary to the recovery of her health, rises and 
 goes about again, and after a short interval of caution, throws aside 
 her fears, engages in walks, drives, and gaiety, or takes a journey to 
 the sea, for the recovery of her health. This conduct commonly 
 occasions a complete relapse, and the patient and her attendant are 
 again involved in their former suffering, apprehensions, and diffi- 
 culties. 
 
 What is the nature of this disease ? It is not acute inflammation, 
 for that would run a far shorter course, and end in certain known 
 consequences. It is not chronic inflammation, for that is a disor- 
 ganizing process, and slowly but surely alters the structure of the 
 organ in which it goes on. Both in chronic inflammation, and in 
 the disease which I am describing, there is a morbid state of the 
 nerves indicated by pain, and sometimes at least a morbid state of 
 the blood-vessels indicated by their fulness; but the substances 
 effused by chronic inflammation show, that in this there is some- 
 thing additional in the actions, and consequently in the state of the 
 vessels. The disease which I am describing resembles a state which 
 other organs are subject to, and which in them is denominated irri- 
 tation. Thus surgeons describe what they call an irritable tumour 
 of 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 never 
 terminates in disease of structure. It is represented as a very com- 
 mon disease. Mr. Brodie describes a similar state of the joints.f 
 It occurs chiefly amongst hysterical females ; it is attended by pain, 
 
 * See Sir A. Cooper on Diseases of the Female Breast, 
 t Brodie on Diseases of the Joints, p. 338.
 
 1G0 OF THE IRRITABLE UTERUS. 
 
 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 a little relieved by remedies, occasions a great 
 anxiety, but there never arises any ultimate bad ' consequences/ 
 ' The disease/ says Mr. Brodie, ' appears to depend on a morbid 
 c 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 constitutions which they attack; 
 similar in pain ; in exquisite tenderness ; in resemblance to the com- 
 mencement of organic disease, and in proving ultimately to be only 
 diseases of function. 
 
 The mode of treatment which I have found most useful, (tardy 
 as it may be in efficacy in most cases, and vain as it has been in 
 some,) consists, 1st, in subduing pain; 2d, in restoring the general 
 health. The difficulty is to know when to discontinue the former 
 indication, and when to aim at the latter : whilst aiming at the 
 former, to select and proportion the means to the circumstances of 
 the case ; when aiming at the latter, to take care not to occasion a 
 relapse of the pain by the means employed for the restoration of the 
 health. The remedies for subduing pain, are the horizontal posture, 
 narcotics, warm hip baths, occasional local bleeding, to winch may 
 sometimes be added mercury and counter-irritants. 
 
 In all those cases in which the pain is perpetual, repose should be 
 perpetual. The patient must abstain not only from foot and car- 
 riage exercise, but from the upright posture, which even for short 
 intervals is often sufficient to counteract the cure. As soon as she 
 is dressed in the morning, she should be placed on her sofa with her 
 shoulders as low as the pelvis, and in that posture remain the whole 
 day. At first it is tedious, but she soon learns to amuse and occupy 
 herself in this position, to write, read, work, and draw. This posture 
 more or less strictly observed (the degree of strictness being soon 
 taught by the sensations of the patient) is absolutely necessary for 
 the completion of the cure, not only till all pain lias ceased, but for 
 some time afterwards, and even then must be relinquished with the 
 nl most caution, or rather timidity. 
 
 II. The next measure is to draw blood. — When the general cir- 
 culation is undisturbed, as is most frequently the case, local blood- 
 letting is preferable to general, giving more relief and occasioning
 
 OF THE IRRITABLE UTERUS. 161 
 
 less weakness. Cupping affords decidedly more relief than leeches. 
 The most convenient part for the application of the glasses is the 
 upper part of the sacrum, but L have often found them more effica- 
 cious when applied to the part to which the pain is referred. Leeches 
 afford more relief when applied to the hemorrhoidal vessels, or 
 between the labia pudenda, than to the loins, or the lower part of 
 the abdomen. The quantity drawn must depend on circumstances ; 
 the best guides are the state of the constitution, the duration of the 
 disease, and the relief afforded. The less the constitution is injured, 
 and the shorter the duration of the disease, the larger ought to be 
 the bloodletting, because the less likely it is to be injurious, and 
 the more likely it is completely to remove the pain ; on the contrary, 
 when the disease has lasted long, and the patient is much emaciated, 
 and enfeebled, the more likely is it to be injurious, and the less 
 likely it is to extinguish the pain ; hence the bloodletting ought to 
 be moderate. These, however, like all general rules, admit of excep- 
 tions. Twelve ounces of blood is a large local bloodletting; it 
 seldom requires to be repeated to the same amount ; I have known 
 four ounces afford all the relief which this remedy was capable of 
 effecting. But the pain, if only diminished, will increase; and if 
 removed, will return sooner or later. The bloodletting, therefore, 
 recpiires to be repeated ; and the question is, whether to defer it until 
 the return or increase of the pain, or to anticipate tins return or 
 increase. I think the latter is preferable when the period of recur- 
 rence can be nearly calculated; both reason and experience show 
 that a mode of treatment which prevents an organ from resuming 
 its morbid action, is more likely to remove it permanently, than one 
 which permits the action to recur, and then removes it : the subse- 
 quent bleedings, however, ought not to be so large as the first, and 
 as it may be necessary to repeat these several times, it is important 
 to discover the minimum of blood which will afford relief. 
 
 In determining the extent and the frequency of the bloodlettings, 
 not only the pain, but the state of the constitution ought to Be 
 taken into the account. When they afford decided relief to the 
 part, and inflict no material injury on the constitution, their pro- 
 priety is unquestionable ; but in many cases, after the disease has 
 lasted long, and the body is emaciated and enfeebled, the relief 
 afforded by bloodletting is so slight and temporary, and the debility 
 it occasions is so great, that it must be discontinued altogether. 
 The next remedy which I have mentioned is a narcotic. Of such 
 
 M
 
 162 OF THE IRRITABLE UTERUS. 
 
 medicines, the most useful are, one-third camphor and two-thirds 
 extract of henbane, or hemlock, or poppy, divided into pills of five 
 grains, of which one may be taken two or three times a day, or 
 about ten grains of extract of poppy, dissolved in an ounce of gruel, 
 may be injected into the rectum every day, immediately after the 
 bowels have acted. The solution of poppy, if retained, remains in 
 the rectum till the next evacuation of the bowels, and until that 
 time seldom ceases to soothe. If, however, this should not be the 
 case, the injection may be repeated during the day, and as it is 
 removed every time the bowels are evacuated, should always be 
 replaced by another injection. 
 
 Want of exercise and narcotics almost always occasion constipa- 
 tion, which requires aperient medicines, but these must be of the 
 most unirritating kind. A purgative sufficiently active to operate 
 several times, almost always aggravates the pain, and a long course 
 of such medicines, which I have sometimes seen employed from the 
 belief of disorder in the liver, has produced great and long-continued 
 mischief. That is the best aperient which will act only once plenti- 
 fully and without pain ; and those which have most frequently acted 
 in this way have been the solution of sulphate of magnesia in 
 infusion of roses, castor oil, electuary of senna, sulphur. Of one of 
 these, enough to produce the effect winch I have described should 
 be taken every other day. 
 
 The horizontal posture, small local bloodlettings, and narcotics, 
 are the remedies most invariably useful, and to which, after a long 
 illness, and the vain trial of other remedies, I have most frequently 
 been obliged to attribute all the good that had been done. There 
 are others, however, sufficiently efficacious to deserve to be known 
 and tried. 
 
 One is warm bathing; the hip-bath, at the temperature of 90°, 
 for half an hour, every or every other night, is sometimes very 
 efficacious ; at other times it affords no perceptible relief, and greatly 
 irfcreases the languor and debility ; but the kind of warm bathing 
 Avhich affords most relief, and occasions least debility, is the partial 
 steam bath ; the flannel sack should be drawn up to the prsecordia, 
 so as to enclose the abdomen and lower extremities, and these may 
 be exposed to the action of the steam for half an hour every other day. 
 
 Another remedy is a mild dose of mercury; from three to five 
 grains of blue pill, or compound calomel pill, mixed with five grains 
 of extract of henbane, taken every night for several weeks, or every
 
 OF THE IRRITABLE UTERI S. 1G3 
 
 other night for many Micks, have sometimes, without affeeting the 
 gums, occasioned a very regular action of the bowels; and during 
 its influence, the periodical aggravations of pain have not recurred, 
 
 and the permanent pain lias diminished, and at length ceased alto- 
 gether. \\ hilst the mercury has had this favourable influence over 
 the local disease, it has occasioned no material injury to the consti- 
 tution. This has been its effect chiefly when the health has not 
 been much reduced, and the disease has not lasted very long. On 
 the contrary, in other cases, in which the body has been previously 
 debilitated and emaciated, mercury, although it had a favourable 
 influence over the local disease, occasioned so much wasting, weak- 
 ness and nervousness, as to compel me to discontinue it. Mercury 
 requires to be employed with the utmost circumspection, and its 
 effects in each individual case ought to determine whether it should 
 be persisted in or discontinued. 
 
 Another remedy, which is often useful, is external irritation : this 
 may be produced either by small blisters, the size of a watch, allowed 
 to heal, and then renewed, and so on for many successive blisters; 
 or a caustic issue may be made the size of a dollar, dressed with 
 savin ointment, and slightly touched once or twice a w r eek with 
 lunar caustic. The best place for the issue is the upper part of the 
 sacrum ; the best place for the blisters is the seat of the pain. These 
 artificial irritations, however, in sensitive constitutions, sometimes 
 excite great disturbance without any equivalent benefit, and ought 
 to be employed with caution, especially the caustic issue. 
 
 The practitioner can do no harm, and must do good as long as he 
 confines himself to the employment of the recumbent posture, mild 
 narcotics, warm hip-baths, and unirritating aperients; but with 
 bloodletting and mercury he must be more cautious. I have seen 
 many cases in which the pain was rather aggravated than relieved 
 by bleeding; the patient rendered weak and irritable, and the effect 
 of the remedy was unmixed injury ; in the employment, therefore, of 
 such remedies as bleeding and mercury, the intelligent practitioner 
 will, after a little time, be better guided by his own experience of the 
 case than by any general directions. It is a good rule in the treat- 
 ment of all diseases, whether acute or chronic, when the remedies 
 are affording little benefit, when the constitution rather than the 
 disease seems to be yielding under them, to desist from them ; this 
 is a rule of common sense above the rules of art, and to which the 
 latter ought to be subservient. I know no man whose knowledge
 
 164 OF THE IRRITABLE UTERUS. 
 
 of liis profession is so exact, and whose opinion of a case is so infal- 
 lible, that he may dispense with this rule. 
 
 Lastly, there is a stage or class of these cases which is chiefly 
 benefited by restorative means, especially chalybeate waters. When 
 the disease has lasted long, is not relieved by the above treatment, 
 is accompanied by broken health, cold extremities, and a pale com- 
 plexion, I have often known the disease cured by the waters of 
 Tunbridge Wells or Bath ; the patient gradually losing her pain, 
 regaining the power of sitting up and going about, and acquiring a 
 more healthy appearance. The plan, however, requires great caution, 
 for where the jar of a carriage brings on pain, the journey will often 
 do great mischief; and the chalybeate waters, which in some cases 
 are so efficacious, are in others clearly pernicious. The probable 
 effect of a journey may be known by a few drives, and the effect of 
 the waters ought to be carefully watched; their influence on the 
 pain and on the pulse is the best guide. 
 
 I have thus described the best remedies with which I am 
 acquainted for the treatment of this distressing and often intractable 
 complaint. In my hands the result has been, that some who had 
 been previously ill for several years, recovered after a few months, 
 and continued well, by strictly avoiding for a long time the exciting 
 causes. Others, after a far longer treatment, experienced the same 
 recovery; and this recovery was rendered permanent by the same 
 long-continued caution; others, on the contrary, after sooner or 
 later recovering, have laid aside caution, indulged in unrestrained 
 exercise and exertion, and have experienced a relapse as severe and 
 tedious as the original attack. Lastly, in some cases my best efforts 
 have alleviated but not removed the disease ; and I have had the 
 mortification to see them, at the end of several years, little better 
 than they were at the beginning. The older I grow, however, the 
 fewer instances do I see of this hopeless condition of the disease; 
 and some of which I had begun to despair, have slowly but ulti- 
 mately recovered. I think it an important fact, that in the cases 
 which remained uncured after many years, the patients had, for the 
 relief of their pain, gradually accustomed themselves to a daily 
 enormous allowance of opium. 
 
 Thus have I endeavoured to give a general description of tin's 
 disease, which I have ventured to denominate the irritable uterus; 
 but as general descriptions, though comprehensive, are deficient in 
 distinctness, I will relate a few cases as specimens of this disease.
 
 OF THE IRRITABLE UTERUS. 1G5 
 
 I. 
 
 A lady came to London and placed herself under my care, gi\ ing 
 me a written narrative of which the following is an abridgment. It 
 affords a good instance of the duration of those cases, of their 
 liability to relapse, of the fears which they occasion of disease of 
 structure, of the groundlessness of these fears, of the imprudence of 
 patients, notwithstanding repeated suffering, and after years of illness, 
 of their ultimate recovery. 
 
 Mrs. is now thirty-six years of age; from sixteen she 
 
 suffered pain at every menstrual period, but in other respects was 
 healthy and rather plump. At twenty-four she married, and after 
 her first confinement went to a fashionable watering-place, and there 
 passed a winter of laborious gaiety, her mornings being spent in 
 making calls, and her evenings standing in crowded parties. She 
 lost her appetite, suffered much from languor, and became subject 
 to shooting pains at the lowest part of the abdomen. One day she 
 went on an excursion into the country, during which she was com- 
 pelled to hold her urine for six hours. In the evening she took a 
 long walk, towards the end of which she was seized with severe pain 
 and weight in the lowest part of the abdomen, and a sense of fulness 
 in the womb. She applied leeches, lived low, and was confined to 
 her sofa several weeks, at the end of which time she was supposed to 
 be well ; but when she attempted to walk or ride she felt a return of 
 the pain; nevertheless she took a journey of forty miles, during 
 which she suffered much : the pain was always worse at the men- 
 strual period. Whilst in this state of imperfect recovery she took a 
 drive in a donkey-cart, which was followed by a violent relapse, with 
 great pain and tenderness across the lowest part of the abdomen. 
 She was now confined to her bed, and was bled from the arm four 
 times in one week. At the end of eight weeks she removed from 
 her bed to the sofa, and in three weeks more went out in her car- 
 riage and soon afterwards travelled to . She suffered pain 
 
 during the journey, was not so well on her arrival, and consulted 
 
 Mr. , who examined the uterus, which he described as 
 
 enlarged and tender. 
 
 The narrative now goes on to recount a succession of relapses, all 
 brought on by bodily exertion or agitation, when in a state of imper- 
 fect recovery ; one by the jolting of a carriage in a long journey, 
 another by driving in a rough donkey-cart, another by cantering for a 
 full hour one day when the weather was fine, and she in high spirits,
 
 166 OF THE IRRITABLE UTERUS. 
 
 another by yielding to the solicitations of her friends, who assured her 
 that she ailed nothing, and pressed to exert herself to the utmost, 
 and live like other people . This was to make daily calls from one 
 
 o' clock to half-past four, up and down the steep streets of , 
 
 and going to parties in the evening, where she stood most of the 
 time. For the attacks of pain the principal remedies were strict 
 rest in the recumbent posture for several weeks, and bloodletting, 
 either general or local. On one occasion she was blooded from 
 the arm four times in one week ; twice she became pregnant, 
 and was delivered prematurely of children who had died some 
 time before their birth. The uterus was often examined, and was 
 always found to be tender, sometimes enlarged ; on the last exami- 
 nation some irregularity was felt in the neck of the uterus, which 
 led to apprehensions of disease of structure. Tired of remedies 
 which had afforded such temporary benefit, she continued twelve 
 months without any medical attendant, using no means excepting 
 rest, occasionally going out, but at the end of this time she was not 
 better ; her pulse was full and quick, her pain worse, and subject 
 to periodical aggravations. These attacks came on with, first, low 
 spirits, then shivering, followed by sickness, head-ache and throb- 
 bing pain of the uterus. Nothing relieved them but leeches ; she 
 was always the worse for carriage exercise, and for anxiety of mind. 
 She now set off for London in a horizontal carriage ; on her journey 
 she met her former medical attendant, who had not seen her for 
 many months, and who acknowledged that she was not better than 
 she had been eighteen months before ; she therefore pursued her 
 journey to London and placed herself under my care. I found 
 nothing unnatural in the form or consistence of the neck of the 
 uterus, excepting a very slight irregularity in its orifice, which 
 I have often observed in patients who ultimately recovered; but 
 it was excuiisitely tender, and the increased pain occasioned by 
 the pressure of the finger lasted several hours. She had always 
 some dull uneasiness along the anterior brim of the pelvis; but 
 once every week or ten days she had a greater degree of pain, 
 which generally lasted several days, and when it ceased left behind 
 the ordinary and more moderate uneasiness. She was not defieient 
 in flesh or complexion, her pulse was always about 90, full and 
 strong. After two bleedings of twelve ounces each, which produced 
 excessive languor, without abating the pain, or the disturbance of 
 circulation, she took a grain of calomel and five grains of extract
 
 OF THE IRRITABLE UTERUS. 167 
 
 of henbane twice daily. In about ten days her gums became sore, 
 and cunt i nued so for several weeks; immediately the disturbance 
 of the circulation ceased; the pulse was slow and soft, and never 
 resumed its former excitement. The pain likewise became consider- 
 ably less, and the paroxysms came on at longer intervals ; when 
 they did, they were relieved by cupping, and by solutions of extract 
 of poppy injected into the rectum, immediately after the bowels were 
 moved. I'or a long time her plan of treatment consisted in strict 
 confinement to the horizontal posture, a daily dose of sulphate of 
 magnesia, just enough to excite one plentiful action of the bowels, 
 and no more; and then a small poppy clyster, with an occcasional 
 cupping. I have not room, and it would be tedious, to relate the 
 whole progress of this case: it is enough to say, that the permanent un- 
 easiness gradually became less, and that the paroxysms of pain became 
 seldomer and slighter ; after both the one and the other appeared to 
 have ceased altogether, there were occasional returns of pain, which 
 showed that the disease was not eradicated. After these symptoms 
 had entirely ceased, she continued for many months the same plan 
 with the exception of the bloodletting. At length she was re- 
 moved in a horizontal carriage a little way out of London ; here, 
 having learnt prudence from her former relapses, and having no 
 relations about her to urge her to exertions, she began to make; 
 gradual, even timid, attempts to sit up and walk about. At first she 
 walked with a watch in her hand ; the first day for a very few minutes, 
 adding one minute every day to the length of her walk. When at 
 home she generally reclined on her sofa, sitting up only at meals, or 
 for a short time. At the end of the month of this cautious exercise, 
 her health, which had become feebler, was greatly improved; she 
 has been living most cautiously ever since, and has now been per- 
 fectly well nearly two years. 
 
 This case was written out three years ago; the patient has had 
 no recurrence of her disease, although she has since sustained a 
 heavy and lasting affliction. She is in good health and can walk, 
 drive, ride, and live like other people ; but she has never since been 
 pregnant. 
 
 II. 
 
 Miss , twenty-five years of age, had a constitution natu- 
 rally delicate and sensitive; and this had been increased by nursing 
 her sister during a long and alarming illness. She had been sub- 
 ject to painful menstruation for several years. In this state of
 
 168 OF THE IRRITABLE UTERUS. 
 
 health, she was one day during a menstrual period almost incessantly 
 on foot for many hours, calling on acquaintances and searching for 
 a lodging-house. In the evening of the same day she was seized with 
 severe pain in the lowest part of the abdomen, extending from groin 
 to groin, along the brim of the pelvis, and in the loins. Eest, fomen- 
 tations, opiates, purgatives, and leeches were employed ; but although 
 they diminished, they did not remove the pain. Weeks and months 
 elapsed, and notwithstanding the indefatigable attention of a very 
 intelligent physician, the pain still continued ; she was unable to sit 
 up without aggravating it, and was greatly reduced in health. After 
 nearly twelve months of disappointed expectations and unsuccessful 
 treatment, she was put into one of those horizontal carriages which 
 the London coach-makers let out for the conveyance of invalids, and 
 brought up to town, a distance of about sixty miles. The jolting of 
 the carriage gave her much pain, so that when she arrived in town 
 she was suffering more than she had done for many weeks. I then 
 saw her for the first time in consultation with the physician who had 
 attended her throughout her illness, and with a London physician. 
 She was at this time completely confined to her bed ; she was so much 
 emaciated that I could encircle her arm with my thumb and middle 
 finger, her complexion was like white wax, she had a constant 
 uneasiness in the lowest part of the abdomen and groins ; but every 
 few days she had an attack of what she called her spasms, which she 
 described in the following way : in the lowest part of the abdomen, 
 or a little lower even, than that, internally, she felt first a sense of 
 heat, to this was speedily added a sense of throbbing, then a sense 
 of distension, as if there was a tumour within, which gradually 
 expanded till it felt ready to burst, then began the spasms ; these 
 she described as shootings or electric shocks, darting from the tumour 
 up into the abdomen : they recurred every five or ten minutes, 
 making her start with such violence as to shake the bed. I have 
 been in the adjoining room when she has been in this state, and have 
 perceived the shock ; between the spasms, she felt what she called 
 a convulsive pain. Nothing relieved these spasms but a small local 
 bloodletting ; she used fomentations, simple and medicated, for 
 many hours ; hip-baths ; opium, in draughts and in injections, with- 
 out relief; but as soon as four or six leeches were applied and had 
 drawn blood, the spasms, distension, throbbing, and heat, speedily 
 subsided, leaving behind the dull permanent uneasiness. The uterus 
 was so tender that the examination of it was torture, and left severe
 
 OF THE [RRITABLE UTERUS. 109 
 
 suffering for many hours. Menstruation had ceased for some months, 
 her appetite was capricious, and required tempting by savoury and 
 unwholesome food ; ham and pork were her favourite meats. Of 
 every meal she brought up a portion, her bowels never acted without 
 medicine, yet medicine never acted without aggravating her pain. 
 Her pulse was small, weak, quick, and easily quickened by the 
 slightest emotion. If anything agitated her, it was so quick and 
 sharp as to resemble the pulse of inflammation, yet in a few minutes 
 it would subside to the ordinary state. She had profuse leucorrhcea. 
 As her spasms recurred twice and often three times in a week, and 
 the leeches were applied equally often, they were employed upon an 
 average about ten times a month, and if the quantity of blood drawn 
 at each time is estimated at two ounces, she must have lost about 
 twenty ounces every month. All this while she was taking little 
 nutriment, and of that a large portion was rejected. The paleness 
 of the blood, and the marble colour of her face and skin, showed how 
 the circulating fluid had been drained of its red particles. Such 
 was the condition in which she was when she arrived in town, nearly 
 twelve months from the commencement of her illness. I continued 
 to attend her for many months, with occasional consultations with 
 some of the most eminent physicians of London. Dr. Baillie saw 
 her repeatedly. "When talking about the probability of recovery, he 
 said, that he knew a lady who had been confined to her sofa by a 
 similar state for thirty years. I have not room to tell the various 
 persons who were consulted about her, and the various remedies 
 which were tried for relief; every attempt was made by diet and 
 medicine to remove the irritable state of her stomach; many months 
 elapsed and no advance had been made towards amendment. One 
 day, after an attack of spasms, and the application of leeches, which 
 on this occasion were larger, and bled more profusely than usual, she 
 sunk into a state which led her attendants to think that she was 
 dying. She lay motionless and insensible, her extremities were cold, 
 her pulse was like a thread, and often quite imperceptible ; in this 
 state she lay four hours : when she revived she talked incoherently, 
 and could not see. In this state she continued for nearly two da\ s. 
 In describing it, she says, ' Those days are to me as though I was 
 not alive/ We warmed her limbs, gave her nutriment, and diluted 
 wine, and at length she recovered her sight and collectedness of mind. 
 From this time her spasms ceased, but she was in a wretched state 
 from fretfulness of temper and sleepless nights, and she insisted on
 
 170 OF THE IRRITABLE UTERUS. 
 
 being removed to a more quiet spot, notwithstanding the fear that 
 the motion of the carriage might occasion a return of her spasms. 
 The jolting of the carriage gave her great pain, and the next day 
 the spasms recurred : they continued to recur for several weeks, 
 about once in five or six days, but at length they ceased. She now 
 began slowly to recover her appetite, her food was no longer returned, 
 her bowels were moved by milder aperients : she had colliquative 
 perspirations and sleepless nights ; for these the tepid salt shower 
 bath was used at bed-time with great and immediate benefit ; at 
 this time she took a light preparation of steel twice daily, that is, a 
 drachm of steel wine with equal parts of infusion of quassia and 
 cinnamon water; her pulse became slower and fuller, and a little 
 colour began to be visible on her cheek ; she passed part of the day 
 in the drawing-room, sat up and loitered about the garden ; it was 
 the beginning of summer : the compound steel mixture was substi- 
 tuted for the steel wine. Whilst taking it she began to menstruate 
 after an interval of twenty months, and from that time did so with 
 perfect regularity. I need not pursue the case further in detail. It 
 is enough to say, that her disease has never returned, and that 
 although her health is not robust, and requires prudence, especially 
 with regard to gaiety and exercise, she looks well, and is able to 
 partake in most of the pleasures and pursuits of life. 
 
 Some will think that this diseae has been obstinate in my hands, 
 because it was not treated with sufficient activity, and that if blood- 
 letting had been carried further it would have been cured more 
 speedily and surely ; but these cases are so protracted that they are 
 seldom submitted to only one practitioner. Most of those which 
 I have seen had already passed through the hands of several. In 
 some, active bloodletting had already done its best and its worst. 
 I have seen patients labouring under this disease made to live entirely 
 on vegetable food, cupped every week, and purged frequently : the 
 result was, that they became pale, thin, and weak ; the pain, it is 
 true, was diminished, but not more than it usually is by the recum- 
 bent posture, and gentler remedies, and at the end of several months 
 the health was formidably reduced, and the disease not relieved in 
 an adequate degree ; but the lovers of large bleedings will ask, would 
 they not have effected more ? In answer to this question, I will 
 relate to them a case in which this practice was employed under the 
 most favourable circumstances, that is, when the disease had lasted 
 only a few weeks.
 
 
 OF THE [RRITABLE UTERUS. 171 
 
 III. 
 
 The patient was a young married woman, twenty-five years of 
 age, who had borne four dead children. After the last, when she 
 began to get about again, she fell pain in the pelvis, which was 
 attributed to prolapsus uteri, and for which she wore a pessary. 
 This was followed l>\ a haemorrhage, which at length stopped, and 
 was succeeded by pain in the hypogastric and left iliac regions; her 
 pulse was described to be small and wiry, a very common pulse after 
 haemorrhages from the uterus. She was now blooded four times in 
 less than a week, making- in all eighty ounces, and a number of 
 leeches were applied repeatedly to the hypogastrium. L saw her 
 a lew weeks afterwards: her face and lips were bloodless, her health 
 broken, and she had the local symptoms which I have denominated 
 the irritable uterus, namely, uneasiness in the hypogastrium and 
 iliac regions, so much increased by sitting up and walking about as 
 to compel her to confine herself entirely to the recumbent posture. 
 During examination the pressure of the finger gave no pain till it 
 reached the neck of the uterus, which was exquisitely tender, and 
 the increased pain, occasioned by pressing it, remained for many 
 hours. A far better mode of bleeding actively, so as to reach the 
 disease, is one employed by Mr. Fernandez, of Lamb's Conduit- 
 street : when the disease is recent, when the health is unreduced, 
 and the symptoms are more active than they commonly are in the 
 protracted cases, he has employed cupping till it has produced faint - 
 ness, with great success. This gentleman was the first person whom 
 I ever met with who had recognised the disease which I am describ- 
 ing. It had been an object of his attention for several years before 
 I had noticed it, and he had written a paper about it, which had 
 been read at some medical society, I believe the Westminster ; but 
 his experience chiefly lay among the recent cases, whereas I have 
 chiefly seen the protracted form of the disease. It was from him 
 I learnt the efficacy of mild courses of mercury in a certain state, or 
 a certain class of these cases. 
 
 Some of my readers will think that the name which I have given 
 to this disease is a verbal refinement, and that I had better have 
 called it chronic inflammation; but I have two objections to this : 
 one is, that chronic inflammation, though a slower, is as surely a 
 disorganizing process as acute inflammation, but this is not. Besides, 
 ought the irritable breast described by Sir Astjey Cooper, the hysteric 
 disease of the knee described by Mr. Brodie, and the irritable testicle
 
 172 OF THE IRRITABLE UTERUS. 
 
 well known to practical surgeons — ought these to be called chronic 
 inflammation ? they are of the same family as the irritable uterus. 
 The other objection is, that the name would be a mischievous one ; 
 many men remember the name of a disease only, and forget the 
 history of it, and the term chronic inflammation would lead to 
 a more indiscriminate and active employment of antiphlogistic 
 remedies than is advisable in the protracted cases. Even the beneiit 
 afforded by small local bleedings is not uniform ; in some cases the 
 pain is worse after bleeding, in some the pain is most severe a few 
 days before menstruation, when the vessels of the uterus are most 
 distended; in others, on the contrary, the pain is worse after men- 
 struation, when the vessels of the uterus are most drained ; in some 
 the uterus feels a little swollen, in others not so : it is probable, 
 therefore, that the cases which I comprehend under the term ' irri- 
 table uterus/ may require to be subdivided into several classes, in 
 one of which congestion is an essential part, and bloodletting and 
 mercury may be apt remedies ; in another congestion may be absent, 
 and bloodletting and mercury may be useless and pernicious ; resto- 
 rative means, especially steel, being the aptest remedies. Lastly, 
 another may consist of those interminable cases which nothing 
 relieves, and which, at the end of ten or fifteen years, are as bad as 
 they were at the beginning : in these there may be some disease of 
 structure in part of the uterus out of reach of examination by 
 touch.
 
 ( 173 ) 
 
 CHAPTER V. 
 
 A PECULIAR FORM OF HAEMORRHAGE FROM THE UTERUS. 
 
 Hemorrhage from the uterus, after delivery, is attributed to in- 
 sufficient contraction of that organ. We infer that there is no 
 danger of haemorrhage if the uterus is contracted; and that the 
 uterus is contracted, if it feels small, round, and firm. This I 
 believe to be, generally, the truth ; yet the observing practitioner 
 must have been frequently struck by the little proportion that existed 
 between the want of contraction and the degree of haemorrhage ; 
 having found the uterus bulky without any haemorrhage, and a pro- 
 fuse haemorrhage without greater bulk of uterus. Nay, further, I 
 have witnessed a profuse haemorrhage though the uterus had con- 
 tracted in the degree which commonly indicates security ; and I have 
 ventured to do what is seldom justifiable, separate the placenta before 
 the uterus had contracted without more haemorrhage than after a 
 common labour. What is this circumstance which has so great an 
 influence that its presence can cause a moderately contracted uterus 
 to bleed profusely, and its absence can cause an uncontracted uterus 
 to bleed scarcely at all ? 
 
 After delivery, the contraction of the uterus prevents haemorrhage, 
 by occasioning a sufficient closure of the blood-vessels to resist the 
 ordinary force of the circulation. It appears reasonable to suppose, 
 however, that if the force of the circulation was extraordinarily great 
 it would be able to overcome the ordinary closure of the orifices, and 
 that thus a profuse haemorrhage might arise although the uterus was 
 contracted in the ordinary degree. That this event, so probable in 
 point of reason, is true in point of fact, was first fully disclosed to 
 me by the following case : — 
 
 April 10, 1815, I delivered Mrs. S. W. of her second child; for 
 many hours before the accession of labour she was flushed, and had 
 a very full quick pulse. Abstinence from meat, wine, and warm 
 drinks, a cool room, and a saline purgative, diminished, but did not 
 remove, this state of the circulation, which continued, in a consider-
 
 174 PECULIAR FORM OF HEMORRHAGE. 
 
 able degree, when the child was born : it was expelled very gradually, 
 and after the removal of the placenta the uterus felt in the hypo- 
 gastrium contracted in the ordinary degree; nevertheless, about 
 twenty minutes afterwards there came one of the most frightful 
 haemorrhages I ever witnessed ; by the introduction of the hand, and 
 the application of cold-, however, it was speedily arrested. 
 
 It was somewhat *more than a year afterwards when she informed 
 me that she was pregnant again, and coining to town to lie in. As she 
 arrived only two or three days before she fell in labour, I did not see 
 her till she was taken ill ; but then, as soon as I entered her chamber, 
 I was struck on observing the same state of circulation that had pre- 
 ceded her former labour : she was sitting in her easy chair, with a 
 red face, and a throbbing pulse. I had not been many minutes in 
 the room before the pains became so strong it was necessary to put 
 her on the bed, and soon afterwards the child was born ; it could not 
 be expelled more gradually ; after the head was born another pain 
 expelled the shoulders, another the body, and another the limbs. I 
 cut the cord, placed my hand on the abdomen, and felt the uterus 
 contracting in the usual degree, yet a few minutes afterwards the 
 blood burst out with prodigious impetuosity. The fearful scene 
 which followed, I need not depict ; it is enough to state, that by 
 the introduction of the hand, and the application of cold, the haemor- 
 rhage was speedily suppressed ; yet it bleached her face, and for many 
 days she could not sit up without faintness. 
 
 I had now witnessed two labours in the same person, in which, 
 though the uterus contracted in the ordinary degree, profuse haemor- 
 rhage had nevertheless occurred; let me be understood — after the 
 birth of the child, I laid my hand on the abdomen, and felt the 
 uterus within, of the size and hardness which is generally unattended 
 by, and precludes haemorrhage ; in both instances the labour had 
 been attended by excessively full and rapid circulation. I could 
 easily understand that a contraction of the uterus, which would pre- 
 clude haemorrhage in the ordinary state of the circulation, might be 
 insufficient to prevent it during this violent action of the blood- 
 vessels, and the inference I drew, was, that in this case the haemor- 
 rhage depended, not on the want of contraction of the uterus, but on 
 want of tranquillity of the circulation, and that if ever she became 
 pregnant again, a mode of treatment which would cause her to fall 
 in labour with a cool skin and a quiet pulse, would be the best 
 means of preventing a recurrence of the accident.
 
 PECULIAR FORM OF HEMORRHAGE. 175 
 
 It was not very long before I had an opportunity of trying the 
 truth of my doctrine, and the efficacy of my treatment; for about 
 twelve months after this confinement, she called on me to tell me 
 that in about four months she should require my attendance again. 
 
 The plan I advised was this : to avoid fermented liquors ; to take 
 meat only thrice a week j a purgative of salts and senna twice a 
 week; a scruple of nitre three times a day: this she began two 
 months before she expected to be confined, and continued it up to 
 the full time. I saw her when she was expecting her labour every 
 hour, and had the satisfaction to find her with a cool skin, and a 
 soft pulse under eighty. She was to lie in at her own house, a few 
 miles from town ; I was to attend her there ; for fear I should not 
 arrive in time, the neighbouring surgeon was to be in the house. I 
 was sent for four days afterwards ; when I arrived she was not 
 delivered ; but I was mortified to find that since our last interview 
 her pulse had sprung up, and there was now the old heated skin and 
 hurried circulation, though in a far less degree, and this the surgeon 
 said had been the case for two days. The labour came on, the child 
 was gradually expelled, and after the placenta had separated and 
 was removed, the surgeon had put his hand on the abdomen, and 
 said he had seldom felt the uterus more contracted so soon after 
 deliver)- : yet within a few minutes there came on a flooding ; like 
 what I believed to be the cause : it w r as trifling to what I had formerly 
 witnessed, and was readily suppressed by a cold wet napkin flapped 
 upon the belly; but it was enough to produce syncope, and detain 
 us in the house several hours longer than we should otherwise have 
 remained there. 
 
 In process of time she became pregnant again. She pursued the 
 same plan, with only this addition, that when she came within a 
 fortnight of her confinement, she had twelve ounces of blood taken 
 from her arm, and before a few days of delivery, eight ounces more. 
 She fell in labour, and as soon as I entered the chamber the first 
 thing I did was to feel her pulse; it w r as soft and slow as I could 
 wish. After the birth of the child and the removal of the placenta 
 the uterus contracted not more than in her last labour ; but not the 
 smallest degree either of flooding or faintness took place. 
 
 How r often a disturbance of calculation plays an important part in 
 uterine haemorrhage it is difficult for an individual to know; but I 
 susped sufficiently often to deserve the especial attention of prac- 
 titioners. I advise them when they meet with patients subject to
 
 176 PECULIAR FORM OF HEMORRHAGE. 
 
 haemorrhage after delivery, to notice the state of circulation before 
 labour, and, if disturbed, to employ means for tranquillising it before 
 labour comes on. I advise them, during labour, to use cordials 
 cautiously, lest the placenta should separate during an excited state 
 of circulation. I advise them after delivery, though the uterus may 
 feel contracted, to be slow to leave the patient, if the circulation is 
 greatly disturbed. 
 
 I have thus fulfilled the principal object of my paper, yet there 
 occurred other circumstances in these successive labours which I 
 think worth relating, because they throw light on some important 
 points in the treatment of uterine haemorrhage. 
 
 The first time I attended this lady, after the violence of the 
 haemorrhage was over, although the abdomen was covered with 
 pounded ice, it returned again and again, slightly in a degree, yet 
 sufficiently, in the debilitated state of the patient, to produce alarm- 
 ing occurrences of faintness ; the uterus too, which had become firm 
 and distinct, became so soft it could no longer be felt. In the 
 haemorrhages from the uterus, these alternations of contraction and 
 relaxation with cessations and recurrences of bleeding, are familiar 
 to the observing practitioner. Finding the ice so inefficient, I swept 
 it off, and taking an ewer of cold water, I let its contents fall from 
 a height of several feet upon the belly ; the effect was instantaneons ; 
 the uterus, which the moment before had been so soft and indistinct 
 as not be felt within the abdomen, became small and hard, the 
 bleeding stopped and the faintness ceased ; a striking proof of the 
 important principle, that cold applied with a shock, is a more 
 powerful means of producing contraction of the uterus than a greater 
 degree of cold without the shock. 
 
 After the second labour, at the beginning of the haemorrhage, I 
 found the placenta separated, and lying in the vagina ; I removed 
 it ; the haemorrhage abated, but a few minutes afterwards it returned 
 as violently as at first ; my patient turned white and faint, and said 
 the room was going round with her. I had been talking on the sub- 
 ject with Dr. Rigby, at Norwich, who told me that in haemorrhage 
 from the uterus, after delivery, he had found La Roux's remedy the 
 most effectual, and that it had unquestionably enabled him to save 
 several lives, which must otherwise inevitably have been lost. I took 
 several handkerchiefs, soaked them in vinegar, and passed them one 
 after the other into the vagina, so as completely to fill it j this effec- 
 tually prevented all external haemorrhage; I no longer felt the
 
 FROM THE UTERUS. 177 
 
 blood pouring over my hand; the uterus begun to harden, and my 
 patient complained of pain ; the colour came into her face again, 
 and her faintness she said was gone. These favourable appearances, 
 however, lasted but a short time; the pains ceased, the uterus grew 
 soft and seemed to swell, the pulse became thread-like and weak, 
 and she turned ghastly pale. It was plain that, though I had pre- 
 vented the blood from escaping externally, it was flowing into the 
 uterus in great quantity, and that I had only converted an external 
 into an internal haemorrhage. Feeling herself sinking, she screamed 
 out she should never see her children again, and entreated that she 
 might see her husband, and take leave of him before she died. The 
 next instant I thought she had realized her fears ; she sunk into the 
 pillow pale and senseless, her face became distorted, and her limbs 
 convulsed. 
 
 My belief now is, that when haemorrhage occurs after the removal 
 of the placenta, the quickest way to stop it is, to introduce the left 
 hand closed within the uterus, apply the right hand open to the out- 
 side of the abdomen, and then between the two to compress the part 
 where the placenta was attached, and from winch chiefly the blood 
 was flowing. When the hand is introduced merely as a stimulant, 
 there is an interval of time between its arrival within the uterus and 
 the secure contraction of this organ, during which much blood is 
 often lost. By directing the hand to the very vessels from which it 
 issues, and compressing them as I have described, this quantity is 
 saved. If I may judge by feeling, the blood stops, in a great 
 degree, even before the uterus contracts ; the hand acts first as a 
 tourniquet, then as a stimulant. It is true, we cannot tell with 
 certainty where the placenta was attached, and consequently where 
 the pressure should be applied; but as it is generally attached to or 
 near the fundus, if the pressure be directed there, it will generally 
 be right. Besides, after the child is born, it is often several minutes 
 before the placenta separates and descends ; if, during this interval, 
 we pass up the finger along the chord, and observe, at its entrance 
 into the uterus, whether it turns toward the front, the back, the right 
 or left side, or straight up to the fundus, we shall form a tolerably 
 exact idea of the spot to which the placenta has been attached in 
 this individual case. 
 
 But to return to my patient. As it was my duty no longer to 
 rely on the remedy I was using, I drew out the handkerchiefs and 
 
 N
 
 178 PECULIAR FORM OF HEMORRHAGE. 
 
 applied ray hands as I have described with the most immediate and 
 happy effect ; the bleeding stopped, my patient came to herself, and 
 whilst she complained of pain, / felt the uterus contracting; here 
 was an end of the haemorrhage and the alarm, and though for mam- 
 days her face looked bleached, and she almost fainted in the upright 
 posture, she recovered without any untoward circumstance.
 
 ( L79 | 
 
 CHAPTER VI. 
 
 OF SOME SYMPTOMS IN CHILDREN ERRONEOUSLY ATTRIBUTED TO 
 
 CONGESTION OE THE BRAIN. 
 
 1 kemember when a boy reading a story of two knights-errant, who 
 arrived on the opposite sides of a pedestal surmounted by a shield ; 
 one declared it was gold, the other that it was silver; growing angry, 
 they proceeded to blows, and after a long fight, each Mas thrown on 
 the opposite side of the shield to that where he began the light — 
 when both immediately detected their error; the knight who had 
 said it was silver rinding that on the opposite side it was gold, and 
 the knight who had said it was gold finding that on the opposite 
 side it was silver. This story, a little modified, is a good illustration 
 of the state of medical opinion in this age, perhaps in all ages; 
 medical men have no occasion to tilt, for they all throng on one and 
 the same side of the shield; they look only at the golden side, and 
 never dream of the possibility that on the opposite side it may be of 
 a different metal. 
 
 In observing disease, two sets of symptoms may be noticed, which 
 are mixed together in the case, but which require to be discriminated 
 to form a correct opinion of it : the one consists of the striking 
 symptoms which form what may be called the physiognomy of the 
 disease; the other consists of those symptoms which indicate the 
 morbid state of organization on which the disease depends; the 
 former only are noticed by the common observer, but the latter are 
 the most important, and the skilful physician takes them for his 
 guides in the treatment. ' He notices not only where the hour hand 
 ' of nature's clock points, but also the run of its minute and second 
 ' hands/ 
 
 Two patients complain occasionally of dimness of sight, swimming 
 of the head, singing in the ears, and observe that if they turn the 
 head on one side to look at an object, they feel as if they should fall; 
 but the one is plump, florid, and has a full pulse; the other is pale 
 and thin, has cold hands and feet, and a pulse small and feeble. 
 One practitioner bleeds them both ; the other bleeds the one, but 
 does all he can to give blood to the other. The latter cures both 
 his patients; the former cures the one, but ruins the health of the 
 other; but such is the nature of the human mind, that the cases/or
 
 180 SYMPTOMS IN CHILDREN ERRONEOUSLY 
 
 a preconceived opinion are retained easier than those against it. He 
 remembers his good deed, forgets the other, or calls the case ' ano- 
 malous/ and marches on, without the slightest doubt that bleeding 
 is the universal and sovereign remedy for dimness of sight, swim- 
 ming of the head, and singing in the ears, save and except only in 
 ' anomalous' cases. 
 
 I am anxious to call the attention of medical men to a disorder of 
 children which I find invariably attributed to, and treated as, con- 
 gestion or inflammation of the brain, but which I am convinced 
 often depends on, or is connected with, the opposite state of circula- 
 tion. It is chiefly indicated by heaviness of head and drowsiness ; 
 the age of the little patients whom I have seen in this state has 
 been from a few months to two or three years; they have been 
 rather small of their age, and of delicate health, or they have been 
 exposed to debilitating causes. The physician finds the child lying 
 on its nurse's lap, unable or unwilling to raise its head, half asleep, 
 one moment opening its eyes, and the next closing them again with 
 a remarkable expression of languor. The tongue is slightly white, 
 the skin is not hot, at times the nurse remarks that it is colder than 
 natural ; in some cases there is at times a slight and transient flush : 
 the bowels I have always seen already disturbed by purgatives, so 
 that I can scarcely say what they are when left to themselves : thus 
 the state which I am describing is marked by heaviness of the head 
 and drowsiness, without any signs of pain, great languor, and a total 
 absence of all active febrile symptoms. The cases which I have 
 seen have been invariably attributed to congestion of the brain, and 
 the remedies employed have been leeches and cold lotions to the 
 head, and purgatives, especially calomel. Under this treatment they 
 have gradually become worse, the languor has increased, the defi- 
 ciency of heat has become greater and more permanent, the pulse 
 quicker and weaker, and at the end of a few days, or a week, or 
 sometimes longer, the little patients have died with symptoms appa- 
 rently of exhaustion. In two cases, however, I have seen, during 
 the last few hours, symptoms of oppressed brain, as coma, stertorous 
 breathing, and dilated and motionless pupil. 
 
 I will relate a case as a specimen. A little girl, about two years old, 
 small of her age, and very delicate, was taken ill with, the symptoms 
 which I have above described. She lay dozing, languid, with a cool 
 skin, and a pulse rather weak, but not much quicker than natural. 
 She had no disposition to take nourishment. Her sister having died 
 only a week before of an illness which began exactly in the same 

 
 ATTRIBUTED TO CONGESTION OF THE BRAIN. 181 
 
 way, and which was treated by leeches and purgatives; and some 
 doubts having been entertained by the medical attendant of the 
 propriety of the treatment, Leeches were withheld, but the child not 
 being better at the end of two days, the parents naturally anxious 
 about their only surviving child, consulted another practitioner. 
 The case was immediately decided to be one of cerebral congestion, 
 and three leeches were ordered to be applied to the head. As the 
 nurse was going to apply them, and during the absence of the 
 medical attendants, a friend called in who had been educated for 
 physic, but had never practised it, and who had great influence with 
 the family : he saw the child, said that the doctors were not suffi- 
 ciently active, and advised the number of the leeches to be doubled. 
 Six, therefore, were applied; they bled copiously; but when the 
 medical attendants assembled in the evening they found the aspect 
 of the case totally altered, and that for the worse; the child was 
 deadly pale, it had scarcely any pulse, its skin was cold, the pupils 
 were dilated and motionless when light was allowed to fall on them, 
 and when a watch was held to its eyes it seemed not to see ; there 
 was no squinting. Did this state of vision depend on the pressure 
 of a fluid effused into the brain since the bleeding, and during this 
 exhausted and feeble state of circulation, or did it depend on the 
 circulation of the brain being too languid to support the sensibility 
 of the retina ? It is well known that large losses of blood enfeeble 
 vision. I saw r a striking instance of this in a lady who flooded to 
 death. When I entered the chamber she had no pulse, and she was 
 tossing about in that restless state which is so fatal a sign of these 
 terrific cases. She could still speak, asked whether I was come, 
 (she knew I had been sent for,) and said ' Am I in any danger ? — 
 How dark the room is ! — I can't see/ The shutters were open, the 
 blind up, and the light from the window facing the bed fell strong on 
 her face. I had the curiosity to lift the lid and observe the state of 
 the eye; the pupil was completely dilated, and perfectly motionless, 
 though the light fell strong on it. Who can doubt that here the 
 insensibility of the retina depended on the deficiency of its circula- 
 tion? — But to return to the little patient. The next day she had 
 vomited her food for several times; it was therefore directed that she 
 should take no other nutriment than a dessert-spoonful of ass's milk 
 every hour, and this was strictly obeyed, and continued for several 
 days. The child wasted, her features grew sharp, every now and 
 then she looked fretful, and uttered a faint squeaking cry ; the eye- 
 balls became sunk in the socket, like those of a corpse that had been
 
 182 SYMPTOMS IN CHILDREN ERRONEOUSLY 
 
 dead a month ; the skin continued cool, and often cold, and the pulse 
 weak, tremulous, and sometimes scarcely to be felt. Under this 
 regimen, and in this way, she continued to go on for several days. 
 At times she revived a little, so as to induce those who prescribed 
 this treatment to believe confidently that she would recover, and she 
 clearly regained her sight, for if a watch was held up to her, she 
 would follow it with her eyes. She lived longer than I expected ; 
 a full week, and then died with the symptoms of exhaustion, not 
 with those of oppressed brain. The head was opened by a surgeon 
 accustomed to anatomical examinations, and nothing was found but 
 a little more serum than is usual in the ventricles. 
 
 If the reader has perused the foregoing case attentively, and has 
 reflected on it, he will of course draw his own inferences. I can 
 draw no others than these, — that the heaviness of head and drowsi- 
 ness, which were attributed to congestion of the brain, really 
 depended on a deficiency of nervous energy ; that the bleeding and 
 scanty diet aggravated this state, and insured the death of the child; 
 also, that the state of the eye which so speedily followed the loss of 
 blood, and which resembled that occasioned by effusion, did in reality 
 depend on a deficiency in the circulation of the brain, a fact of con- 
 siderable curiosity and importance. 
 
 I will now relate a case similar in the symptoms, but very different 
 in the treatment and result. I was going out of town one afternoon, 
 last summer, when a gentleman drove up to my door in a coach, 
 and entreated me to go and see his child, which he said had some- 
 thing the matter with its head, and that the medical gentleman of 
 the family was in the house, just going to apply leeches. I went 
 with him immediately, and when I entered the nursery I found a 
 child, ten months old, lying on its nurse's lap, exactly in the state 
 which I have already described ; the same unwillingness to hold its 
 head up, the same drowsiness, languor, absence of heat and all 
 symptoms of fever. The child was not small of its age, and had not 
 been weak, but it had been weaned about two months, since which 
 it had never thriven. The leeches had not been put on. I took 
 the medical gentleman into another room, related to him the fore- 
 going case, and several similar to it, which had been treated in the 
 same way, and had died in the same way. Then I related to him 
 a similar case which I had seen in the neighbouring square, which 
 had been treated with ammonia in decoction of bark and good diet, 
 which had recovered ; not slowly, so as to make it doubtfid whether 
 the treatment was the cause of the recovery, but so speedily that at
 
 ATTRIBUTED TO CONGESTION 0¥ THE BRAIN. 183 
 
 the third visit I took my leave. He consented to postpone the 
 [('relics, and to pursue the plan which I recommended. We directed 
 the gruel diet to be left off, and no other to be given than ass's milk, 
 of which the child was to take, at least, a pint and a half, and at 
 most a quart, in the twenty-four hours. Its medicine was ten 
 minims of the aromatic spirit of ammonia in a small draught every 
 four hours. "When we met the next day, the appearance of the child 
 proved that our measures had been right; the nurse was walking 
 about the nursery with it upright in her arms. It looked happy and 
 laughing; the same plan was continued another day ; the next day 
 it was so well that I took my leave, merely directing the ammonia 
 to be given at longer intervals, and thus gradually withdrawn, the 
 ass's milk to be continued, which kept the bowels sufficiently opeu, 
 with aperient medicine. 
 
 So inveterate is the disposition to attribute drowsiness in children 
 to congestion of the brain, and to treat it so, that I have seen an 
 infant four months old, half dead from the diarrhoea produced by 
 artificial food, and capable of being saved only by cordials, aro- 
 matics, and a breast of milk; but because it lay dozing on its nurse's 
 lap two leeches had been put on the temples, and tins by a prac- 
 titioner of more than average sense and knowledge. I took off the 
 leeches, stopped the bleeding of the bites, and attempted nothing 
 but to restrain the diarrhoea, and get in plenty of nature's nutri- 
 ment, and as I succeeded in this, the drowsiness went off, and the 
 child revived. If it could have reasoned and spoken, it would have 
 told this practitioner how wrong he was ; any one, who from long- 
 defect in the organs of nutrition, is reduced, so that he has neither 
 flesh on his body, nor blood in his veins, well knows what it is to 
 lay down his head and cloze away half the day without any con- 
 gestion or inflammation of his brain. This error, although I have 
 specified it only in a particular complaint of children, may be 
 observed in our notions and treatment of other diseases, and at other 
 periods of life. If a woman has a profuse hemorrhage after deli- 
 very, she will probably have a distressing headache, with throbbing 
 in the head, noises in the ears, a colourless complexion, and a cprick, 
 weak, often thrilling pulse, all which symptoms are greatly increased 
 by any exertion. I have seen this state treated in various ways, by 
 small opiates, gentle aperients, and unstimulating nourishment, with 
 no relief. I have seen blood taken away from the head, and it has 
 afforded relief for a few hours; but then the headache, throbbing, 
 and noises have returned worse than ever: the truth is, that this i>
 
 184 SYMPTOMS IN CHILDREN ERRONEOUSLY 
 
 the acute state of what in a minor degree and in a more chronic 
 form occurs in chlorosis, by which I mean pale-faced amenorrhea, 
 whether at puberty or in after-life. It may be called acute chlorosis, 
 and, like that disease, is best cured by steel, given at first in small 
 doses, gradually increased, merely obviating constipation by aloetic 
 aperients. 
 
 I shall not encumber this paper with a multiplicity of cases, but 
 state that the above are only specimens of a class of which I have 
 seen enough to convince me that they deserve the attention of the 
 profession. If I had any doubt about this, this doubt would be re- 
 moved by the fact, that Dr. Marshall Hall has already recognised 
 them,'* and described them in a paper which has been read at the 
 Medical and Chirurgical Society.f He has therefore anticipated me 
 in announcing them, but so far from regretting tins, I am glad to sup- 
 port my statements by the authority of so observing and reflecting a 
 physician. The only difference between our experience seems to be 
 this — that he attributes the state which I have been describing to 
 the diarrhoea produced by weaning, or to the application of leeches 
 for some previous complaint. In most of the cases I have seen, 
 however, the child has had no previous illness, and the leeches 
 have been applied subsequent to the drowsiness, and as a remedy 
 for it. 
 
 The children who were the subjects of this affection, and were 
 thus treated, died, not with symptoms of oppressed brain, but with 
 
 * Since the above was printed, and just before striking it off, I found the following 
 passage in Dr. Abercrombie's ' Researches on the Brain,' page 310 : ' I have many 
 
 • times, says Dr. Abercrombie (page 310), ' seen children lie for a day or two in this 
 ' kind of stupor, and recover under the use of wine and nourishment. It is often 
 ' scarcely to be distinguished from the coma which accompanies diseases of the brain. 
 ' It attacks them after some continuance of exhausting diseases, such as tedious and 
 ' neglected diarrhoea; and the patients lie in a state of insensibility, the pupils 
 ' dilated, the eyes open and insensible, the face pale, and pulse feeble. It may 
 
 • continue for a day or two, and terminate favorably, or it may be fatal. This 
 ' affection appears to correspond with the apoplexiaex inanitione of the older writers. 
 1 It differs from syncope in coming on gradually, and in continuing a considerable 
 ' time, perhaps a day or two; and it is not, like syncope, induced by surden and 
 ' temporary causes, but by causes of gradual exhaustion going on for a considerable 
 ' time. It differs from mere exhaustion in the complete abolition of sense and 
 ' motion, while the pulse can be felt distinctly, and is, in some cases, of tolerable 
 ' strength.' It does not appear that Dr. Abercrombie opened the heads of any of 
 these children, and therefore it is doubtful what was the state of the brain with 
 regard to the blood-vessels and the fluid in its ventricles. 
 
 t A. short report of the paper will be found in the ' London Medical Uazelte' for 
 1829.
 
 ATTRIBUTED TO CONGESTION OF THE BRAIN. 185 
 
 those of exhaustion, and on examining the head after death, the 
 blood-vessels were unusually empty, and the fluid in the ventricles 
 rather in excess s in two instances, death was preceded by symptoms 
 of effusion, viz. blindness, a dilated pupil, coma, and convulsions ; 
 and after death the ventricles were found distended with fluid to the 
 amount of several ounces, the sinuses and veins of the brain being 
 remarkably empty. I believe the prevalent notion of the profession 
 is, that all sudden effusions of water into the brain are the result of 
 inflammatory action ; but putting aside for a moment this dogma of 
 the schools, consider the circumstances of this case. For several 
 days before death, all that part of the circulating system which was 
 cognisable to the senses, was at the lowest ebb consistent with life, 
 and after death the blood-vessels of the brain were found remarkably 
 empty of blood, and the ventricles unusually full of water. From 
 such facts I can draw no other inference than this, — that this sudden 
 effusion was a passive exudation from the exhalents of the ventricles 
 occasioned by a state of the circulation the very opposite to congestion 
 or inflammation. This is corroborated by the dissection of animals 
 which have been bled to death. Drs. Saunders and Seeds, of Edin- 
 burgh, found that in animals bled to death, whether from veins or 
 arteries, there was found more or less of serous effusion within the 
 head, and Dr. Kelly thus expresses himself : — ' If instead of bleed- 
 ' ing uscrue ad mortem we were to bleed animals more sparingly and 
 ' repeatedly, I have no doubt that we should succeed in draining the 
 ' brain of a much larger quantity of its red blood; but in such 
 ' experiments we shall, I think, find a larger effusion of serum/ 
 * * * * ' Though we cannot, by general depletion, entirely or 
 ' nearly empty the vascular system of the brain as we can the vessels 
 ' of the other parts of the body, it is yet possible by profuse hsemor- 
 ' rhages to drain it of a sensible portion of its red blood, that the 
 ' place of this spoliation seems to be supplied both by extra and 
 ' intra vascular serum, and that watery effusion within the head is 
 ' a pretty constant concomitant or consequence of great sanguineous 
 
 I depletion/* But if this be true, it is of great practical importance, 
 
 * Kelly on the Pathology of the Brain. Trans, of the Med. and Chir. Soc. of 
 Edinburgh, 1828. Part I. 
 
 Dr. Kelly found that the loss of hlood required to kill an animal of a given size 
 was very uniform. A sheep required from 34 to 38 ounces; a dog, weighing 20 lbs., 
 was killed by the lo.->s of 15 ounces; another, weighing between 40 aud 50 lb., was 
 killed by the loss of 37 ounces ; another weighing 18 lbs., was killed by the loss of 
 
 II ounces.
 
 186 SYMPTOMS IN CHILDREN ERRONEOUSLY 
 
 for if we take delicate feeble children, and by bleeding and purging 
 for an imaginary congestion of the brain, reduce their circulation to 
 a very low ebb, and keep it so, we run the risk of producing that 
 very effusion of serum into the brain which we are endeavouring by 
 our remedies to prevent. The following case, though I would not 
 cite it as one of the class which I am describing, still bears upon the 
 question of passive effusion into the brain. 
 
 A little girl, about three years old, small of her age, delicate in 
 health, and wayward in disposition, was taken ill with the following 
 symptoms : she could not hold her head up, lay dozing, for the 
 most part, and complained occasionally of momentary pain at the 
 top of the head. Her skin was cool, she had little disposition for food, 
 her pulse was 76, not remitting, but irregular; neither light nor 
 noise were disagreeable to her. Leeches were applied to the temples 
 twice, and she was purged daily, but the treatment, after a week, 
 had afforded no relief to the symptoms. The vertex was now shaved, 
 and six leeches applied where she complained of pain, a cold lotion 
 was applied frequently to the vertex, and she took a grain of calomel 
 every four hours for two days. The leeches bled well, and the calo- 
 mel operated freely, but without affording any relief to the symptoms ; 
 the pulse too lost its slowness and irregularity ; it became weak and 
 quick, about 130. In this state, the little girl still continuing to 
 complain of pain in her head, six more leeches were applied to the 
 vertex, making in all two dozen, and purging was continued. The 
 next day she appeared much altered ; she was pale and cold, and 
 fainted on being raised. Depleting remedies were now altogether 
 discontinued, and her diet was mended though liquid, but she con- 
 tinued weak and faint, and the next day was convulsed. She was 
 insensible, her limbs were stiff, her eyes drawn to the left side, not 
 both eyes turned towards the nose, but both turned to the left. As 
 she could not swallow, all that was done was to warm her, for she 
 was cold, and to inject a glyster containing spirits of turpentine. 
 After a few hours the convulsions ceased, she came to herself with 
 perfect vision, and the natural appearance of the eye ; she talked, 
 took nutriment, but still complained occasionally of pain on the 
 head. The next day she was so much better that there seemed a 
 fair prospect of her recovery. She was at this time taking no me- 
 dicine, and feeding on equal parts of gruel and milk, or gruel and 
 veal broth. As two days had passed without the bowels being 
 moved, a solution of sails in infusion of senna was given, and this
 
 ATTRIBUTED TO CONGESTION OF THE BRAIN. 187 
 
 not operating after eight hours, she took two drachms of the com- 
 pound decoction of aloes. The next morning she had one stool, but 
 that an enormous one, and soon afterwards became comatose, with 
 a dilated pupil, stertorous breathing, and palsy of the left side. In 
 the evening she died; two weeks and three days from the beginning 
 of her illness. The next morning the head was opened by Mr. 
 King, of Regent-street, formerly Interne at the IIotel-Dieu at 
 Paris, and Teacher of Anatomy, to whom I am indebted for several 
 valuable dissections : the following are his notes of the examination. 
 The vessels of the dura mater were quite empty; along the two pos- 
 terior thirds of the superior longitudinal sinus the two plates of the 
 arachnoid membrane adhered by a white substance like cheese ; it 
 was limited to the extent of the sinus laterally ; there was no in- 
 jection in the vicinity of this lymph; the sinuses were empty; the 
 veins of the pia mater were remarkably empty, and tins membrane 
 was pale; the substance of the brain was remarkably pale; under 
 the arachnoid membrane a thin stratum of limpid serum was effused. 
 The ventricles were full of the same fluid, and a little distended by 
 it. In all, there was not more than an ounce and a half of serum. 
 On the surface of the ventricles two or three veins, rather large, 
 Avere evident. 
 
 How far our opinion upon the nature of the case may be modified 
 by the white cheesy substance in the arachnoid membrane; whether 
 the mode of treatment was wrong, or, on the contrary, right, but 
 not prompt and active enough ; on these points I shall not offer a 
 conjecture; but when I consider, 1st, the low ebb at which the cir- 
 culation was kept for several clays before death ; 2nd, the emptiness 
 of the blood-vessels of the brain discovered after death ; and 3rd, 
 that the symptoms of oppressed brain did not occur more than twelve 
 hours before death; I cannot refrain from inferring that this sudden 
 effusion of water was not an active exudation from vessels in a state 
 of congestion, but a passive exudation from empty and feeble ex- 
 halents. 
 
 I do not expect that medical men will take my word as exclusive 
 evidence for the truth of this paper, neither do I wish it; all I ask 
 is that they will allow my observations and reasonings to induce 
 them to look out for similar cases and judge for themselves. With 
 regard to the point, that heaviness of head and drowsiness of chil- 
 dren often depend not on congestion, but on deficiency of nervous 
 power, and require for their cure not depletion, but support, I am
 
 188 SYMPTOMS IN CHILDREN, ETC. 
 
 quite satisfied that candid observers will find that I am right. With 
 regard to the other point, that sudden effusion of serum may take 
 place in the brain from a state of the circulation the opposite to 
 congestion or inflammation, it is more likely, even if true, to be 
 overlooked ; for such is the force of preconceived opinion, and such 
 the prevalent notions on the subject, that the following will be the 
 process in most minds. A child has been suffering from obscure 
 symptoms for many days, when suddenly and unexpectedly it becomes 
 blind, its pupils are dilated and motionless, it becomes convulsed, 
 comatose, and dies. On opening the head the serum is found in the 
 ventricles, and without any further inquiry it is immediately taken 
 for granted that this effusion was the effect of overlooked inflamma- 
 tion of the brain, and regret is felt that active depletion had not 
 been employed : the inference may be a correct one ; all I contend 
 for is, that it should not be granted, but that those circumstances 
 should be minutely inquired into which throw light on the state of 
 the circulation in which the effusion occurred. 
 
 It is surely impossible for the reader to mistake me so far as to 
 suppose that I am denying the important practical truths, that 
 heaviness of head and drowsiness in children commonly depend on 
 congestion, and are to be relieved by depletion, and that acute 
 hydrocephalus is a serous effusion, the result of inflammation, and 
 capable of being cured only in the inflammatory stage by bleeding 
 and purging. These vital truths I would state as strongly as any 
 man, but there are opposite truths. All that I mean is that these 
 symptoms depend, not on congestion, which is 'to be relieved by 
 bleeding, but on deficient nervous power, winch is to be relieved by 
 sustaining remedies. All I advise is, that not only the heaviness of 
 head and drowsiness should be noticed, but the accompanying symp- 
 toms also, and that a drowsy child, who is languid, feeble, cool, or 
 even cold, with a quick weak pulse, should not be treated by bleed- 
 ing, starving, and purging, like a drowsy child who is strong, ple- 
 thoric, has a flushed face, perhaps swelled gums, and a heated skin. 
 The cases which I have been describing ' may not improperly be 
 ' compared to certain species of plants, by no means uncommon, 
 ' which are liable to be confounded with others by an inattentive 
 ' observer.'* 
 
 * Abernetby's Works, Preface, p. 7.
 
 IS THE PLAGUE 
 
 CONTAGIOUS DISEASE? 
 
 A REVIEW.
 
 PREFATORY NOTICE. 
 
 The following paper on the Plague has nothing to do with the title 
 or the object of tins volume ; but as it may possibly be the only one 
 I shall ever put to the press, I am desirous of preserving this among 
 my other medical papers. The reader may remember that, about 
 the year 1825, great pains were taken to persuade the legislature 
 that the plague is not a contagious disease, and that the quarantine 
 laws are a useless burthen on trade; that two committees were 
 appointed by Parliament to hear evidence on the subject, and that 
 Government was on the eve of modifying and relaxing these laws. 
 There were many persons far more competent than myself to put the 
 question in its true light ; but seeing that no one would undertake 
 it, I wrote the following paper, and published it in the ' Quarterly 
 Review/ as the best pulpit from which to address the Government 
 and the people of England. What may have been the merit of 
 the paper, I, being its author, am no judge ; but this I know, that 
 the materials were collected carefully and honestly, and that the 
 article worked well. I received a communication from his Majesty's 
 ministers, that it had satisfied their minds on the subject, the 
 Quarantine Laws were left untouched, and the subject which had 
 been so actively discussed before has been since scarcely alluded to. 
 This may be ' an accidental coincidence/ In reprinting this paper 
 I have omitted several passages; I do so because I did not write 
 them ; they were inserted by one of the editors. If I had written 
 them, I would not have withdrawn them now. I preserve this paper, 
 that it may have an additional chance of being useful on some future 
 occasion, for Dr. Russell tells us that the belief in the uncontagious- 
 ness of the plague, and the disposition to repeal the Quarantine 
 Laws, is a periodical mania, which comes round after a term of years ; 
 it will most probably rage again before many have elapsed. 

 
 L93 
 
 IS THE PLAGUE A CONTAGIOUS DISEASE? 
 
 De Foe thought life events of the plague in London, in 1665, so 
 full of fearful interest, that he formed them into one of his novels, 
 vet the fictitious narrative is not more terrific than the real one. 
 Dr. Hodges, one of the physicians appointed by government to visit 
 the sick, and who was thus occupied from morning to night for many 
 months, gives the following account of the scenes which he witnessed. 
 The passage is too long to quote entirely, but we give an abridged 
 translation of it. 
 
 1 In the months of August and September, three, four, or five 
 f thousand died in a week, once eight thousand. In some houses 
 ' carcases lay waiting for burial, and in others, persons in their last 
 ' agonies. In one room were heard dying groans, in another the 
 ' ravings of delirium, and not far off relations and friends bewailing 
 ' their loss, and the dismal prospect of their own departure. Some 
 ' of the infected ran about staggering like drunken men, and fell, 
 ' and expired in the streets, others lay comatose, never to be awakened 
 ' but by the last trump; others fell dead in the market while buying 
 1 necessaries for the support of life ; the divine was taken in the 
 ' exercise of his priestly office, and physicians found no safety in their 
 1 own antidotes, but died administering them to others. It was not 
 ' uncommon to see an inheritance pass successively to three or four 
 ' heirs in as many days. The number of sextons was not sufficient 
 ' to bury the dead. The bells seemed hoarse with continued tolling, 
 'and at last ceased. The burial places could not hold the dead, they 
 ' were thrown into large pits dug in waste grounds, in heaps of thirty 
 ' or forty together. It often happened that those who attended the 
 ' funeral of their friends one evening, were the next carried to their 
 ' own long home ; and yet the worst was not certain, for the disease 
 ' as yet had no relaxation/* 
 
 Such was the state of London about one hundred and sixty 
 years ago. 
 
 This scourge of the human race has been believed, by the most 
 judicious physicians who have witnessed its ravages, to be communi- 
 cated from person to person, that is, to be contagious. Quarantine 
 
 * Hodges' Loimologia, paje 16.
 
 IS THE PLAGUE 
 
 laws were therefore instituted. 'Before this/ as Lord Holland 
 sensibly remarked, ' the plague frequently devastated every country in 
 ' Europe ; but since then its returns have been comparatively rare/ 
 
 fore the year 1665, Sydenham remarked that the plague visited 
 t s country only once in forty or fifty years : since that calamitous 
 year this happy land has known nothing of its ravages; and so many 
 generations have lived and died in security, that the clause in the 
 Litany for protection ' from plague and pestilence/ is now uttered 
 by the congregation without thought or feeling. In this blessed, yet 
 dangerous ignorance of the public mind, some persons have started 
 up, who affirm that the wisest of their forefathers, and the most 
 experienced of their contemporaries, have been and are all wrong upon 
 the subject — that the plague is not contagious — that quarantine 
 laws ought to be abolished ; and the public, and even our legislators, 
 seem inclined to believe them. In these critical circumstances it is 
 a duty, which some one ought to perform, to give a clear and faithful 
 account of this momentous question — to state the reasons which have 
 satisfied the most competent judges that the plague is contagious — 
 to expose the ignorance of those who are attempting to mislead 
 the public, and the indiscretion of those who are inclined to believe 
 them. 
 
 Some diseases become prevalent because their causes are so dif- 
 fused as to affect many persons in the same place at the same time ; 
 other diseases become prevalent because the bodies of the sick give 
 out a noxious material, which excites similar diseases in the bodies 
 of the healthy. The former are called epidemic, the latter conta- 
 gious. The causes of epidemic diseases may be either deficient food, 
 as in a general scarcity ; or heat, or cold, or great vicissitudes from 
 one to the other, or noxious states of the atmosphere, which are 
 not perceptible by our senses, thermometers, or barometers. Some 
 of these are understood, as marsh exhalations ; others are involved 
 in great obscurity. The human constitution is a delicate instrument, 
 and can perceive qualities which our philosophical instruments and 
 chemical tests do not enable us to detect. 
 
 The noxious matters produced by the bodies of the sick, which 
 propagate contagious diseases from person to person, may be either 
 something visible and substantial, as that formed in the pustules of 
 small-pox, or the vesicles of the cow-pock ; or something invisible, 
 the existence of which is known only by its effects, as in the measles, 
 the scarlet-fever, the hooping-cough.
 
 A CONTAGIOUS DISEASE? 
 
 The only way in which we can distinguish those diseases whicii 
 are prevalent from an extensive cause acting at the same time on 
 
 a number of people, from those diseases which arc prevalent because 
 they are communicated from person to person, is by certain circu - 
 stances in the mode of their diffusion. Now, the circumstances j 
 which we know that a disease is propagated by contagion, are these : 
 first, that those persons are most liable to the disease who approach 
 those affected with it, and that in proportion to the nearness of the 
 approach ; secondly, that those who avoid intercourse with persons 
 affected with the disease generally or always escape it, and that in 
 proportion to the care with which they avoid them ; thirdly, that 
 the disease is communicable from one to another by inoculation. 
 If all these circumstances can be ascertained in the diffusion of a 
 disease, and each with clearness and distinctness, we have all the 
 evidence which we can have, for believing that the disease is pro- 
 pagated by contagion. The proof is as complete as the nature of 
 the subject admits. But the evidence for the belief that the disease 
 is propagated by contagion, varies much in degree in different cases ; 
 it may amount only to that which creates a strong suspicion — or it 
 may amount to that which creates an absolute certainty. The most 
 decided single proof that a disease is contagious, is inoculation : 
 yet there are several diseases the contagiousness of which is un- 
 doubted, notwithstanding the absence of this proof; as, for instance, 
 the scarlet-fever and hooping-cough. 
 
 But there are occasions when it is necessary to act on the sup- 
 position that a disease is contagious, though the evidence for this 
 opinion is far short of proof. The epiestion is sometimes so difficult 
 — life and health are so precious — and the precautions necessary to 
 prevent the communication of the disease, if it should be contagious, 
 comparatively such trilling evils, that a prudent physician will take 
 care to be on the safe side, and act as if he was certain it was con- 
 tagious, although to an indifferent person, weighing the evidence in 
 the scales of mere speculation, it would appear only a bare possi- 
 bility; and here is the difference between a science, the subjects of 
 which are inanimate things, like alkalies, and a science the subjects 
 of which are flesh and blood, and health and life : that whereas, in 
 the former, the onus probandi lies on him who affirms the proposi- 
 tion, because the disbelief of it leads to no injurious consequence; 
 in the latter, the onus probandi lies on him who denies it, because 
 the disbelief would occasion the neglect of measures which are harin- 
 
 o
 
 194 IS THE PLAGUE 
 
 less even if they be unnecessary, but the neglect of which may be 
 fatal if they be essential. 
 
 live-and-twenty years ago, Dr. Wells published his belief that 
 erysipelas was sometimes contagious. The following is one of several 
 facts which led him to this opinion : — An elderly man died of erysi- 
 pelas of the face. His nephew, who visited him during his illness, 
 was soon afterwards attacked by, and died of the same disease. The 
 wife of the old man was seized with the same disease a few days 
 after his death, and died in about a Aveek. The landlady of the 
 same house was next affected with it, and then her nurse, who was 
 sent to the workhouse, where she died. Dr. Wells mentioned his 
 suspicion to several medical friends, among whom were Dr. Pitcairn 
 and Dr. Baillie, and they related to him several circumstances which 
 had led them to a similar opinion. 
 
 Lying-in women are subject to a disease called puerperal fever. 
 In general it is of unfrequent occurrence, and out of large numbers 
 scarcely one suffers from it. There are times, however, when this 
 disease rages like an epidemic, and is very fatal. At these times 
 circumstances sometimes occur winch create a strong suspicion that 
 the disorder may be communicated by a medical attendant or nurse 
 from one lying-in woman to another. We give the following, out 
 of many authentic instances : A surgeon practising midwifery in a 
 populous town, opened the body of a woman who died of puerperal 
 fever, and thereby contracted an offensive smell in his clothes; 
 nevertheless, surgeon-like, he continued to wear them, and to visit 
 and deliver his patients in them. The first woman whom he 
 attended after the dissection was seized with, and died of, the same 
 disease. The same happened to the second and the third. At 
 length he was struck with the suspicion that he was carrying the 
 disease from patient to patient in his clothes — he burnt them, and 
 not another of his patients was affected. 
 
 These are incidents calculated to make a deep impression on the 
 minds of those who witness them, and to create a strong suspicion 
 that these diseases are, under certain circumstances, contagious. Yet 
 if such evidence as this be contrasted with incidents of an opposite 
 kind, in which free communication has produced no such conse- 
 quences, and be mixed up with the ordinary history of the diseases, 
 the whole statement would produce little effect on indifferent persons 
 — on cold judges like a committee of the House of Commons. 
 
 Pew persons believe that consumption of the lungs is contagious ;
 
 A CONTAGIOUS DISEASE? 195 
 
 it is a question which requires for its solution long and attentive 
 observation. A physician in early, and even in middle life, is an 
 inadequate judge; but there are English physicians of the greatest 
 experience, the highest eminence, and the least fanciful minds, who 
 are convinced that this disease is sometimes communicated from a 
 wife to a husband, or from a husband to a wife, during the long and 
 close attendance which its lingering nature and strong alfection 
 sometimes occasion. It is an opinion, however, which he who en- 
 tertains can never demonstrate to be true to him who rejects it ; yet 
 it is a reason for every precaution which does not interfere with the 
 duties of the healthy to the sick. 
 
 In medicine, and all but the demonstrative sciences, there is often 
 light enough to guide our conduct, when there is not enough to 
 gratify our curiosity ; hence practical men are often compelled to 
 act on evidence which would sound unsatisfactory in the statement. 
 There is no paradox in saying, that he who can give a striking reason 
 for every measure which he adopts is, for that very reason, a bad 
 medical adviser, because he must neglect many which are necessary 
 and useful, but the reasons for which at the outset are extremely 
 obscure. We cannot give a stronger instance of the difference be- 
 tween the evidence which is required to satisfy incompetent judges, 
 and that on which physicians are often obliged to act, than that which 
 is detailed in Dr. P. M. Latham's excellent ' Account of the Disease 
 lately prevalent at the General Penitentiary/ 
 
 Having thus considered the signs by which we distinguish a con- 
 tagious disease — the different degrees of clearness with which these 
 signs show themselves — and the necessity there often is to act on 
 the supposition that a disease is contagious, although the evidence 
 for it is far short of demonstration — we may now go on to consider 
 whether these signs are discoverable in the history of the plague in 
 a sufficient degree to require us to act on that supposition. Now, 
 whoever will carefully examine the accounts of the plague trans- 
 mitted to us by those who have witnessed its ravages, will find ample 
 evidence of the following truths: 1st. That it is most liable to affect 
 those persons who approach patients affected with it, and that in 
 proportion to the nearness of the approach : 2dly. That those who 
 avoid all intercourse with persons affected with the plague generally 
 escape the disease, and that in proportion to the care with which 
 they avoid it. There are few facts, indeed, in medical history, for 
 which there is such a mass of evidence as these, or on which the
 
 196 IS THE PLAGUE 
 
 experience of past and present times is so uniform. The most re- 
 markable examples are afforded by the introduction of the plague into 
 countries which had long been free from it, in consecpience of inter- 
 course with places in which it was then raging. The clearness with 
 which this intercourse has been often traced is truly wonderful, con- 
 sidering the many temptations which travellers or mariners coming 
 from countries infected with the plague have to clandestine intercourse. 
 Of such histories there are so many on record, that the difficulty is 
 which to select; we will begin with the plague at Marseilles, in 1720. 
 For seventy years the plague had never visited this maritime city, 
 when, on the 25th May, 1720, a vessel sailed into the harbour, 
 under the following circumstances : She had left Seyde, in Syria, 
 on the 31st of January, with a clean bill of health, but the plague 
 had broken out a few days ago after her departure, and she had called 
 at Tripoli, not far from Seyde, where she took in some Turkisk pas- 
 sengers. During the passage one of the Turks died, after an illness 
 of a few days. Two sailors attempted to heave the corpse overboard, 
 but before they had time to do so the captain called them away, 
 and ordered it to be done by the comrades of the deceased. In 
 the course of a few days the two sailors who had touched the corpse 
 fell sick, and speedily died. Soon after this two others of the crew, 
 one the surgeon of the vessel, who of course had attended the sick, 
 were attacked with the same symptoms, and died. These occur- 
 rences so alarmed the captain, that he shut himself up in the poop 
 during the rest of the voyage. Three other sailors subsequently fell 
 ill, were put ashore at Leghorn, and died there ; the physician and 
 surgeons of the infirmary certifying that their disease had been a 
 pestilential fever. The vessel arrived at Marseilles, and the crew 
 and cargo were landed at the lazaretto. Soon afterwards the disease 
 attacked another of the crew — an officer put on board the vessel to 
 superintend the quarantine — a boy belonging to the ship — two 
 porters employed in unloading the merchandize — another porter simi- 
 larly employed — three more porters employed about the merchandize 
 — the priest who had administered the last sacrament to the sick — 
 the surgeon of the lazaretto and his whole family. Notwithstanding 
 these events, the passengers, having performed a short quarantine of 
 less than twenty days, were allowed to take up their quarters in the 
 town, and to carry with them their clothes and packages. There were 
 anti-contagionists in those days at Marseilles, as there are now in 
 England, and this conduct was the result of their advice. When
 
 A CONTAGIOUS DISEASE? 197 
 
 passengers after a voyage of nearly four months, and a quarantine of 
 nearly three weeks, are at length let loose in a large city, their first 
 employment is to roam about the streets; they have things to sell, 
 and to buy, and to see ; they come in contact in the streets and in 
 the shops with persons whom they think no more about, and who 
 think no more about them. It is not surprising, therefore, that the 
 exact traces of the disease should soon be lost, and that it should be 
 often difficult, and even impossible, to follow it satisfactorily in every 
 part of its progress. Of its origin and early advances in the town 
 the following account is given by M. Bertrand, a resident physician 
 at .Marseilles at the time : 
 
 ' AYhat is certain is, that the plague was on board the ship of 
 ' Capt. Chataud ; that it was communicated to the infirmary by the 
 1 merchandize with which it was freighted; and that one of the first 
 f who fell sick in the city had been passenger in the ship, and had 
 ' only epiitted the infirmary a few days, with his clothes and mer- 
 ' chandize; and that among the very early victims of the distemper 
 ' were the family of a famous contraband trader, near the convent of 
 ' the Cannes, and those of some other contraband traders who resided 
 1 in the Rue de l'Escale and its neighbourhood ; that the suburb 
 1 adjoining the infirmary was attacked nearly at the same time with 
 ' the Rue de TEscale. I leave my readers to make the reflections 
 1 naturally suggested by these facts/ 
 
 We pass over the terrific scenes which the subsequent progress of 
 the plague occasioned in this ill-fated city ; though they should be 
 read by every one, if any such there be, who may have to legislate 
 on this subject, and not be duly impressed with its fearful importance. 
 We will not represent in detail the early doubts and obstinate denials 
 that the disease was the plague; the fears of the magistrates to 
 alarm the people ; the unwillingness of the people to believe ; their 
 terror at its first announcement, and after a short and deceptive calm, 
 their drunken joy and mad confidence; the contests between the 
 physicians and the magistrates ; the insults offered by the populace 
 to the former ; the scarcity of food ; .the bodies collected in the 
 houses and in the streets, for want of persons to remove them ; the 
 fires lighted in the squares and market-places, and before the doors 
 of every house, for the purpose of burning out the contagion, till the 
 whole city was in a blaze ; the flight of the people from the town ;
 
 198 IS THE PLAGUE 
 
 the immense graves ; cart-loads of bodies tumbled into them in the 
 utmost disorder \ the shops and public places closed, and the deserted 
 streets — all these form a picture which bewilders the mind by the 
 number and horror of the objects — the mere recapitulation of them 
 produces a sensation of giddiness and sickness. 
 
 But of this confusion we must select one or two incidents from 
 which an inference may be drawn. 
 
 The Hotel Dieu contained between three and four hundred found- 
 lings of both sexes, besides the proper officers and attendants. At 
 this hospital, a woman who had escaped from the Rue de FEscale 
 presented herself, stating that she was ill of a common fever. She 
 was taken in and conducted to her bed by two maid-servants of the 
 house; the next day the two maid -servants fell ill, and died in a few 
 hours. The day after, the matron who had visited the patient fell 
 ill, and died almost as suddenly. The disease spread with amazing 
 rapidity ; it destroyed all the children, together with every person 
 belonging to the house — governors, confessors, physicians, surgeons, 
 apothecaries, officers, servants, except about thirty persons, and even 
 these took the infection, but ultimately recovered. 
 
 One of the greatest difficulties was the removal and interment of 
 the dead. At first carts had been hired to carry them away, and 
 beggars and vagabonds were employed in the service. These soon 
 died, and those who followed them in their offices soon followed them 
 in their fate. The magistrates then applied to the officers of the 
 galleys, praying for convicts to carry away the dead : this prayer 
 was granted, and the convicts were promised their liberty if they 
 survived. The first supply amounted to one hundred and thirty- 
 three ; these perished in less than a week. Another hundred were 
 granted. In the course of six days they were reduced to twelve ; 
 and thus, in less than a fortnight, out of two hundred and thirty- 
 three — two hundred and twenty-one perished. 
 
 An official report, transmitted to the Regent, stated that the 
 physicians and surgeons of Marseilles unanimously declared, 'that 
 ' when one person in a family was attacked and died, the rest soon 
 ' underwent the same fate, insomuch that there were instances of 
 ' families entirely destroyed in that manner ; and if any one of an 
 ' infected family fled to another house, the contagion accompanied 
 ' him, and proved fatal to the family where he had taken refuge/ 
 
 While these horrors were going on in the city, where intercourse 
 was almost unrestrained, some places, in which precautions were used
 
 A CONTxVGIOUS DISEASE? 199 
 
 to prevent communication with the infected, escaped either in a 
 great degree, or altogether. When the disease was admitted to be 
 the plague (and some useful time was lost before that admission was 
 made), the galleys were detached from the shore, anchored in the 
 middle of the port, and separated from the rest of the vessels by a 
 barrier. There were two hospitals belonging to the galleys, one for 
 the crews, the other for the convicts ; the former was reserved for 
 the infected, in case the disease should break out, the latter for 
 patients under other diseases. There was a third, or intermediate 
 hospital, to which all doubtful cases were sent, until the nature of 
 their disease manifested itself. The galleys were frequently visited 
 by medical men, and on the slightest notice of indisposition the 
 patient was immediately removed to one of these hospitals. The 
 plague, however, made its appearance, and continued in existence 
 from the beginning of August to the beginning of March; the 
 population of the galleys amounted to ten thousand; yet thirteen 
 hundred persons only were attacked, and of these about half recovered. 
 "We will not speculate on the many modes in which the precautions 
 against intercourse with infected persons may have been evaded, 
 though the particular instance has escaped detection ; but we point 
 our reader's attention to the singular difference between the numbers 
 who took the disorder under one system on land, and under another 
 at sea. 
 
 A certificate, given by the Bishop of Marseilles, states that ' the 
 ' plague has not penetrated into the religious communities, who have 
 ' had no communication with persons abroad, and who have used 
 ' the precautions necessary to prevent them/ Another given by the 
 first sheriff of Marseilles, states that ' the families which were shut 
 ' up, and had not communicated abroad, particularly the nunneries, 
 ' had been protected from this scourge ; which was introduced into 
 ' some of them by communications with strange persons/ 
 
 Before the commencement of this plague, which certain physicians 
 now call a modification of the typhus, the population of Marseilles 
 was estimated at ninety thousand persons. Of these, forty thousand 
 perished ; but it spread to Aix, Toulon, and various other places in 
 Provence, and destroyed in all more than eighty thousand persons. 
 
 If the foregoing narrative does not satisfactorily prove that the 
 disease was propagated from person to person, we know not what will. 
 The contagiousness of the measles, scarlet-fever, and hooping-cough, 
 does not rest upon stronger evidence; and it will become impossible to
 
 200 IS THE PLACxUE 
 
 prove any disease to be contagious, excepting those which are capa- 
 ble of being communicated by inoculation. 
 
 The next plague which we propose to notice, was that which visited 
 Moscow in the year 1771, and of which a short but lucid history 
 was given by Dr. de Mertens, a physician practising in that city at 
 the time of the visitation. The plague had not appeared at Moscow 
 for more than a century and a half. In 1769 war commenced 
 between the Russians and the Turks; the next year the plague 
 appeared in Wallachia and Moldavia, and many Russians died of it 
 in the city of Yassy. The following summer it entered Poland, and 
 was conveyed to Kiow, where it carried off four thousand people. 
 At first all communication was cut off between that city and Moscow, 
 and guards were stationed in the great roads. A colonel, attended 
 by two soldiers, set off from Choczin, where the plague was raging. 
 The colonel died on the road, but the two soldiers pursued their 
 Avay, arrived at Moscow, were taken ill at the military hospital, and 
 died soon after their arrival. This was in November, 1770. Towards 
 the end of this month the Demonstrator of Anatomy at this hospital 
 was attacked by a putrid peteclual fever, of which he died on the 
 third day. The male attendants of the hospital lived with their 
 families in two chambers separated from the others. In one of these, 
 one person after another, to the number of eleven, fell ill with a 
 putrid disease, attended by petechias, and, in some, by buboes and 
 carbuncles ; most of them died between the third and the fifth day. 
 The same disease attacked the attendants who resided in the other 
 chamber. On the 22d December, an official statement was made 
 of these facts, and ten physicians, out of eleven, pronounced the 
 disease to be the plague. The hospital, which was placed without 
 the city, was closed, and a military guard interrupted all communi- 
 cation from without ; the patients affected with the pestilence, 
 together with their wives and children, were separated from the rest, 
 and the clothes and moveables of those who had died of the disease, 
 and those who were still ill with it, were burnt. The weather became 
 intensely cold, and the traces of contagion being lost in the hospital 
 and in the city, the people passed from fear to fearless security. The 
 communications with the hospital were re-opened in Pebruary, but 
 on the 11th of March the physicians were again convoked, when 
 Dr. Yagelsky stated that in a large building, a manufactory of mili- 
 tary clothing, situated in the centre of the city, and where three 
 thousand individuals were employed, eight persons had been attacked
 
 A CONTAGIOUS DISEASE? 201 
 
 with symptoms similar to those observed in the patients at the mili- 
 tary hospital three months before ; that is, with petechia?, carbuncles, 
 and buboes. The work-people likewise declared, that at the begin- 
 ning of January, a woman, who had a tumour in the cheek, had 
 gone to the home of one of the work-people, who was her relation — ■ 
 that since this time the disease 1 had spread in the manufactory, and 
 one hundred and seventeen persons had died of it. The manufactory 
 was closed and guarded; nevertheless, several of the work-people 
 escaped by the windows the following night. We pass over the 
 precautions used to prevent the spreading of the disease, and its 
 abatement — the relaxation of precautions, and the recurrence of the 
 disease. Towards the end of July, the mortality amounted to two 
 hundred daily — by the middle of August to four hundred — towards 
 the end of the same month to six hundred — at the beginning of 
 September to seven hundred — some days afterwards to eight hun- 
 dred, and at length to one thousand. On the evening of the 5th of 
 September, the populace rose, broke open the hospitals, put an end 
 to all restrictions, and restored the religious ceremonies used for the 
 sick — the images of saints were carried with great pomp to the sick, 
 and kissed by every one successively ; the people, according to ancient 
 custom, embraced the dead, and buried them within the city, declar- 
 ing that human precautions were odious to the Divinity — they hunted 
 down the physicians, broke their furniture, and sacked their houses. 
 This riot lasted only a few days, but it was followed by an addition 
 of two or three hundred to the daily mortality — almost all the priests 
 perished. In October the disease began to decline, and at length 
 ceased together with the year. The total mortality was estimated at 
 more than eighty thousand persons, exclusive of that in the towns 
 and villages to winch it had spread, which cannot have been less 
 than twenty thousand. These places, however, suffered much less, 
 because the inhabitants, taught by the miserable example of Moscow, 
 readily permitted precautions to be used. Criminals were employed 
 to bury the dead, and when these perished, the poor were hired to 
 do it. To each were given a cloak, gloves, and mask of oil-cloth ; 
 and they were directed never to touch a corpse with naked hands, 
 but they paid no attention to this advice. Most of them became ill 
 about the fourth or fifth day, and great numbers perished. The 
 plague committed its greatest ravages among the poor ; the nobles, 
 gentlemen, and merchants, generally escaping. ' It was communi- 
 ' cated/ says Dr. Mertens, ' only by the touch of infected persons or
 
 202 IS THE PLAGUE 
 
 ' clothes ; when we visited the sick, we approached them within the 
 ' distance of a foot, using no other precaution than this — never to 
 ' touch their bodies, clothes, or beds/ The physicians, who only 
 inspected the patients, generally escaped the disease; but of the 
 surgeons, who were obliged to touch them, two died in the city, and 
 a number of assistant-surgeons in the hospitals. While the disease 
 was raging in the city, the Foundling Hospital afforded a signal 
 example of the salutary effects of seclusion. It contained one thou- 
 sand children, and four hundred adults. All communication with 
 the people was cut off, and the plague never penetrated within the 
 building. One night four attendants, and as many soldiers, escaped 
 from the hospital. These, on their return, were attacked by the 
 disease, but they were separated from the rest of the house, and it 
 spread no further. Compare the fate of this establishment with that 
 of the Foundling Hospital at Marseilles ; the contrast of the two 
 cases is one of the most striking circumstances on record. 
 
 The last plague which we shall notice is that of Malta, in the 
 year 1813, of which the history has been given by Dr. Calvert in 
 the ' Medico-Chirurgical Transactions/ and by Sir Eobert Brook 
 Faulkner, both of them eye-witnesses. "Valetta had not been visited 
 by the plague for one hundred and thirty-seven years, when a 
 vessel, called the San Nicolo, having left Alexandria, where the 
 plague was prevalent, arrived at Malta on the 29th of March, 1813. 
 During her voyage, two of her crew had died of a rapid disease, one 
 with a black tumour on his neck. In consequence of these deaths, 
 the hatches were shut down, and the crew kept on deck during the 
 rest of the voyage. Upon the arrival of the vessel, the crew were 
 sent ashore to the lazaretto, the captain and his servant being sepa- 
 rated from the rest. The day after, the captain was seized with 
 headache, giddiness, and other symptoms of the plague, and died in 
 thirty-six hours. His servant, who had assisted the two sick men 
 during the voyage, was seized with similar symptoms, and died in 
 the same length of time. These circumstances created considerable 
 alarm in Valetta, but the rest of the crew continued well, and the 
 San Nicolo having returned to Alexandria with a new crew, the 
 apprehensions of the Maltese soon subsided. On the 19th of April, 
 however, a Maltese physician was taken to visit a child of the name 
 of Borg, which had been ill for five or six days, and was dying with 
 a carbuncle on its breast. On the 1st of May he was sent for to 
 see the mother of the dead child, who was ill with fever, and a
 
 A CONTAGIOUS DISEASE? 20 
 
 painful tumour in the groin ; she was pregnant ; on the third day 
 of her illness she was seized with premature labour, delivered of a 
 seven months' child, which died directly, and died herself the next 
 morning with another tumour in the other groin. During the 
 illness of the mother, another of her children was taken ill, but 
 recovered. On the -fth of May, Borg, the father of the family, was 
 seized with fever, attended by glandular swellings in the axilla and 
 groin. The physician now reported these circumstances to the Depu- 
 tation of Health. Borg, his whole family, and those who were 
 known to have communicated with them, were removed to the laza- 
 retto. The courts of justice, the theatre, and the public places, 
 were shut up, and the city was inspected by physicians. When 
 Borg's wife was in labour, a midwife, who lived in another part of 
 Yaletta, where there was no appearance of the plague, was sent for 
 to attend her. She came, and having delivered her patient, returned 
 home. Several days having passed without her appearance, one of 
 her kinsmen went to her house, and knocked at the door for some 
 time, but no one answered. At length he broke it open, w T ent in, 
 and discovered her on her knees by her bedside. She did not move, 
 and, on shaking her, he found that she w r as dead. It seems as if 
 the poor creature, feeling the approach of death, had sought refuge 
 in prayer, and had died in the very act and attitude. AVhen the 
 body w r as sent to the hospital, plague-spots were found upon it. Her 
 kinsman, on making this discovery, immediately ran to the Com- 
 mittee of Health, and stated what he had seen ; on which, he was 
 not allowed to return to his family, but was sent to the lazaretto, 
 where, on the 17th of May, he was seized with the plague, and died 
 in twenty-four hours. A girl, who was accustomed to sleep in the 
 midwife's house, was taken ill with fever and glandular enlarge- 
 ments. Borg and his father died ; another of his children became 
 ill with it, but recovered. Thus far the disease had been confined 
 to the crew of the vessel which came from Alexandria, and to Borg's 
 family, and those who had communicated with them; but soon 
 afterwards it began to appear in the town of Valetta. At first, the 
 medical men contended it was not the plague — the people kept their 
 sickness secret, for fear of being removed to the lazaretto, clamoured 
 against the precautions, and did all they could to thwart them. 
 The disease spread, not only through Valetta, Floriana, and the 
 adjoining towns, but to many villages. 
 
 Whilst the plague was raging in Malta, the efficacy of strict
 
 204 IS THE PLAGUE 
 
 seclusion was exhibited in some striking instances, as at Marseilles 
 and Moscow. The Augustine convent stands in an airy part of 
 Valetta, near the top of one of the main streets, much above the 
 level of the sea, and the greater part of the city, and in a clean and 
 open neighbourhood — its interior accommodations are spacious and 
 airy. When the plague first broke out in Valetta, the strictest 
 precautions were used by the inhabitants of this convent to prevent 
 all communication with the town. At length, however, a servant, 
 contrary to the regulations, went into a part of the town where the 
 disease prevailed, and purchased clothes which were supposed to be 
 infected. Soon after his return, he confessed what he had done, on 
 which he was immediately shut up, together with one of the brother- 
 hood, who volunteered to attend him. Both of them were taken ill 
 and died of the disease, but no other person in the convent suffered. 
 When the plague was at Malta in 1675, Cavallino, who described 
 it, states that all public establishments, which cautiously shunned 
 intercourse with the community, enjoyed perfect exemption from the 
 disease ; as did the prisons and monasteries ; besides all the vessels 
 in the harbour. In the late plague it was the same — the hospital 
 of St. John of Jerusalem, the prison, and several public offices and 
 private houses, which early adopted and steadily kept up a rigid 
 system of insulation, were not less fortunate. 
 
 In a large building in the town, the ground-floor was divided into 
 seven separate apartments, occupied by as many Maltese families, 
 wlule the upper stories were used as a military hospital for patients 
 affected with common diseases. While the plague was raging in 
 Malta, it penetrated into the ground-floor, destroyed the inhabitants 
 of four of these apartments, and, in the other three, two only of each 
 family escaped. While this was going on below, the sick tenants of 
 the upper stories were shut in — all communication was cut off — and 
 every individual among them escaped the disease, although it was 
 raging in the habitations round about the hospital, and penetrating 
 from the lower to the upper stories. Dr. Greaves, whose house was 
 within a few feet of the hospital, and on whose authority this fact 
 is stated, related it to Dr. M'Lean when he was at Valetta, and led 
 him over the hospital ; but no mention has been made of it by this 
 impartial historian. 
 
 Thus (to return for a moment to the commencement of the 
 plague) we find it attacking, first, two sailors in a vessel which had 
 come from a city where the plague was prevailing; and next, after
 
 A CONTAGIOUS DISEASE? 205 
 
 » 
 
 her arrival, the captain of the same vessel, together with his servanl 
 
 ■ — then the family of Borg, nominally a shoemaker, but really a 
 smuggler — his children, his wife, himself, and his father — the mid- 
 wife who attended his wife whilst she was ill of the plague — a young 
 woman who slept in her house — a kinsman who entered her chamber, 
 and touched her body — the child of the master of a wine-house near 
 the quarantine harbour, where many persons resorted, and among 
 others the servant of the Health Office who guarded the San Nicolo 
 in the harbour — some of the guards of the San Nicolo themselves, 
 with whom Borg the smuggler had frequent dealings. While the 
 plague was attacking, successively, the above-mentioned persons, it 
 appears, by official statement, that there were no other individuals 
 affected with it in any other part of Malta. Is the reader not 
 satisfied with this evidence ? That there was any communication 
 between the crew of the San Nicolo and the family of Borg, there is 
 no decisive proof, nothing but a rumour that a piece of cloth had 
 been conveyed from the vessel to Borg's house. Great stress has 
 been laid on this ; and the belief that the San Nicolo communicated, 
 the plague to Malta, in spite of this defect in the chain of evidence, 
 has been loudly scoffed at as unphilosophical credulity. What 
 evidence are we to expect under such circumstances as these ? The 
 parties, be it remembered, are a crew under quarantine, and a 
 cunning smuggler — both under penal restrictions which they daily 
 and hourly, but of course secretly, elude by frauds and falsehoods. 
 What other evidence of communication between such people, so cir- 
 cumstanced, are we to expect, unless the Devil on Two Sticks had 
 been employed as a spy, and, from his lofty station, at night had 
 actually seen the piece of cloth conveyed from the San Nicolo into 
 the boat, from the boat to the shore, from the shore over every inch 
 of ground, till it arrived at Borg's house, and then observed the un- 
 folding of the cloth, and the escape of the contagious vapour ? As 
 this is a point of considerable importance, because the same defect 
 in the chain of evidence, which is here complained of, will be found 
 in the other histories of the plague which we have laid before our 
 readers, we shall run the risk of tiring them with a few' remarks. 
 
 Now r suppose that a vessel, with the plague among its crew, 
 arrives in the Thames, and comes up the river. There is a rumour, 
 but no proof, of communication with the shore ; but a week after- 
 wards, the disease breaks out in the contiguous neighbourhood, in 
 the house of a smuggler, and in an ale-house frequented by sailors ;
 
 206 IS THE PLAGUE 
 
 and after spreading among the relations and friends of the first 
 sufferers, as well as those who have had casual communication with 
 them, is found in London, where it has not been for one hundred 
 and sixty years, gets into the houses of deluding doctors, and deluded 
 legislators, and carries off thousands and tens of thousands of the 
 inhabitants ; if such a calamity were speedily to follow the arrival 
 of a vessel under such circumstances, who would doubt that the 
 disease had been communicated from the vessel to the metropolis, 
 because he could not track every footstep that it had taken ; because, 
 in other words, he could not do that, which the lapse of a single 
 week, a single day or hour, in carelessness and unsuspicion, would 
 make it impossible to do ? But, although the case may strike us 
 more by being brought near home, it is not really stronger than 
 the introduction of the plague into Malta ; for Malta had been free 
 from it almost as long as London has. Let not the people of 
 London hug themselves on their long immunity ; Malta had been 
 free for one hundred and thirty-seven years, and Moscow for nearly 
 one hundred and seventy. 
 
 The plague of Malta, in 1813, either arose from a noxious state 
 of the air, or it was introduced by contagion imported by the San 
 Nicolo. Now granting that there is some difficulty to be overcome 
 in either supposition, which is the greater — to believe that the crew 
 of the San Nicolo had communicated with the family in which the 
 plague first appeared in Valetta, with which family the captain was 
 intimate, although this communication cannot be proved ; or that 
 the air of Valetta, which had continued free from plague for nearly 
 a century and a half, should, on a sudden, assume a pestilential con- 
 dition, and that by an accidental coincidence, about a week after the 
 San Nicolo sailed into the harbour with the plague on board ? To 
 find a difficulty in believing the former, but none in believing the 
 latter, is to strain at a gnat and swallow a camel. 
 
 The foregoing accounts afford ample proof of the two propositions 
 which we set out by stating ; and, consequently, that the plague is 
 communicable from person to person; but they form not one- 
 twentieth part of the evidence to this effect. It is impossible, in 
 the space allotted to us, to do justice to this part of the sub- 
 ject. We might content ourselves with stating, that every com- 
 petent person who had opportunity of observing this tremendous 
 malady, had come to the conclusion that it was contagious, and 
 that there had been fewer dissentient voices than might have been
 
 A CONTAGIOUS DISEASE? 207 
 
 expected, considering the nature of the subject and the wanderings 
 of the human intellect; hut as general statements produce little 
 impression, we shall trouble our readers with a few instances. 
 
 Dr. Murdoch Mackenzie resided at Constantinople and Smyrna 
 for twenty years, in the middle of the last century. During this 
 time scarcely a year passed in which there was not some appearance 
 of the plague in one or both of these cities. In 1751 it broke out 
 at Constantinople, raged with great violence, and carried off, as it 
 was estimated, one hundred and fifty thousand people. His observa- 
 tions on this disease he communicated from time to time, by letters, 
 to Dr. Clephane and Dr. Meade ; they were read before the Royal 
 Society, and are published in tine forty-seventh volume of the 
 ' Philosophical Transactions/ The following extract from these 
 letters will show the facts which he observed, and the opinions which 
 he formed on the causes of the plague : 
 
 ' I can't see any other apparent cause of the virulency of the 
 ' disease this year, beside the occasion of greater communication. 
 ' In the months of February, March, April, and May last, the dis- 
 ' temper was so strong at Cairo, as appears by letters from the English 
 ' consul there, that no doors were opened for three months. In the 
 f mean time there arrived here in May last, four ships laden with 
 ' Cairo goods, which goods and men being landed, spread the in- 
 ' fection over all the city at once, after which one conveyed it to 
 ' another by contact. In the village where we lived there died only 
 ' sixty persons of the plague. The French ambassador's palace, 
 ' next door to us in the village, was infected, because five of his 
 ' people went at midnight to a bawdy-house, where the father 
 ' Demetry, the mother, and daughter, at the same time had the 
 ' plague, and died of it afterwards, all three ; so that two of Ins 
 1 Excellency's servants were infected by them, one of whom died and 
 ' the other recovered, and is still living, after taking a vomit, some 
 ' doses of the bark mixed with snake-root and Venice treacle, by my 
 ' advice. We found this last time, and upon all such occasions, 
 ' that whoever kept their doors shut ran no risk, even if the plague 
 ' were in the next house, and the contact was easily traced in all the 
 f accidents which happened among the Franks. Comte Castellane 
 f had, for three years running, persons attacked in the same room, 
 ' in the months of July and August, notwithstanding all possible 
 ' precaution used in cleansing the room, and even whitewashing it.
 
 208 IS THE PLAGUE 
 
 ' At last, by my own advice to his Excellency, grounded upon the 
 ' above theory, he built a slight counter-wall, since which there has 
 ' been no accident in that room, now five years ago. I could give 
 ' so many such examples as " delassare valeant Fabium." ' 
 
 Orrseus, who was physician to Catherine, Empress of Russia, and 
 was sent to advise during the plagues at Yassy and Moscow, states, 
 that the most common mode of contracting the disease was by con- 
 tact. Sainoilowitz, surgeon to the military hospital at Moscow, who 
 had also extensive experience of the plague in Poland, Moldavia, and 
 Wallachia, before he witnessed its tremendous ravages in Moscow, 
 says, in the preface to his c Memoire sur la Peste/ ' it is certain 
 ' that the plague is developed and propagated only by contact/ All 
 the assistant-surgeons who were employed under him (fifteen in 
 number) took the disease, and all died excepting three ; while the 
 physicians who walked among the sick without touching them, 
 generally escaped. When Mr. Howard, in the year 1785, went 
 abroad to visit the principal lazarettos in Prance and Italy, he 
 carried with him a set of questions concerning the plague, drawn up 
 by Drs. Aikin and Jebb, which were to be submitted to the most 
 experienced practitioners in the places which he visited. When he 
 returned, Dr. Aikin methodised and abridged the answers, and the 
 result is given in Howard's celebrated work on the lazarettos of 
 Europe. We have no room for it, and yet it deserves to be read by 
 all those who are in search of information on the subject. ' They 
 1 all/ says Mr. Howard, 'in the most explicit manner concur in 
 ' representing the plague as a contagious disease, communicated by 
 ' near approach to, or actual contact with, infected persons or 
 ' things/ 
 
 During the late war (as we used to call it) in Egypt, now a quarter 
 of a century ago, the medical officers both of the French and English 
 armies had ample opportunities of observing the plague, and they 
 almost unanimously came to the conclusion that it was a contagious 
 disease. Dr. Edward Bancroft, a man of unquestionable learning 
 and talent, yet prone enough to dissent from received opinions, 
 accompanied the British army during part of the Egyptian campaign. 
 His testimony is particularly important, because, by his essay on the 
 yellow fever, which he believes not to be contagious, he had shown 
 himself fully prepared to adopt a similar opinion about the plague, if 
 he had met with sufficient proofs of it. He thus expresses himself :
 
 A CONTAGIOUS DISEASE? 209 
 
 ' The facts which prove the necessity of actual contact with some 
 'infected person or thing to communicate the plague, are so nume- 
 ' rous, and many of them so notorious, that it must be unnecessary 
 'for me to enter upon a detail of them, after what Dr. Russell and 
 ' others have published, and after the experience of the British army 
 'in Egypt, which invariably demonstrated this necessity, by showing 
 'that all those who avoided contact invariably escaped the disease, 
 ' whilst those who did otherwise, in suitable conditions, were ver\ 
 ' generally infected. Nor was there, so far as I have been able to 
 ' discover, any instance, in the French Egyptian army, of a cornmu- 
 ' nication of the disease without contact, though the physicians to 
 'that army who have written on the subject do not, I believe, 
 ' positively assert the impossibility of such communication/ 
 
 Mr., now Sir James M'Grigor, surgeon to the Indian army in 
 Egypt, during the Egyptian campaign, in his medical sketches of 
 that expedition, gives the following account of the arrangements at 
 the pest-houses, and their result : — 
 
 ' In the pest-houses of the army thirteen medical gentlemen 
 ' did duty, who in the Indian army might be said to have had the 
 ' post of liouour. They were Mr. Thomas, Mr. Price, Mr. Rice, 
 ' Dr. Wayte, Mr. Grysedala, Mr. Adrian, Mr. O'Farrel, Mr. Wliyte, 
 ' Mr. Dyson, Mr. Angle, Mr. Moss, Dr. Buchan, and Dr. Henderson. 
 ' In order to take from our medical gentlemen in the pest-houses 
 ' some of the most dangerous part of the duty, it was my wish to 
 ' procure some of the Greek doctors of the country to reside in the 
 ' pest-house, to feel the pulses there, draw r blood, open and dress 
 ' buboes, &c. The most diligent search was made for those people, 
 ' and very high pay was promised to them, but we could tempt none 
 ' of them to live in our pest-houses : a plain proof of the opinion 
 ' which they entertain of the contagious nature of the disease. The 
 ' thirteen gentlemen first mentioned were those only that were 
 ' directly in the way of contagion, for it became their duty to come 
 'into contact with the infected, and seven of them caught the 
 ' infection and four died. To the atmosphere of the disease all the 
 ' medical gentlemen of the army were exposed, as they saw and 
 ' examined the cases in the first instance; but, except from actual 
 ' contact, there never appeared to be any danger/ 
 
 The medical officers of the French army came to similar conclu- 
 sions. Desgenettes, chief physician to the French army in Egypt, 
 
 p
 
 210 IS THE PLAGUE 
 
 in his ' Histoire Medicale de l'Armee d'Orient/ thus sums up his 
 opinion on the subject of the plague : — 
 
 ' The plague is evidently contagious, but the conditions of the 
 ' transmission of this contagion are not more exactly known than its 
 ' specific nature. The dead body has not appeared to transmit it — 
 ' the animal body in a heated state, and still more in a state of febrile 
 ' moisture, has appeared to communicate it more easily; the contagion 
 ' has been known to cease in passing from one bank to another of the 
 c Nile ; a simple trench made before a camp has been known to stop 
 ' its ravages ; and on observations of tins kind is founded the useful 
 ' insulation of the Pranks, the practice of which has been sufficiently 
 1 detailed by different travellers/ 
 
 Baron Larrey, the principal surgeon to the French army, and the 
 distinguished author of the ' Memoirs of Military Surgery/ states a 
 similar opinion : — 
 
 ' But however strong/ says he, ' may have been these affections 
 ' (moral), their effects cannot be compared to those which resulted 
 ' from the communication of the healthy with the sick, or to the 
 ' effects of contact with contaminated objects. "We maybe convinced 
 ' of this truth by the ravages which the plague made in the year 9, 
 ' (1S01,) among the Fatalist Mussulmen; * * * it were to be 
 f wished that, on the first days of the invasion of the plague its true 
 ' character had been presented to the army. This would have 
 ' diminished the number of victims, instead of which the soldier, 
 1 imbued with the opinion which was at first propagated, that this 
 ' disease was not pestilential, did not hesitate to seize and wear the 
 ' effects of his companions dead of the plague. The pestilential 
 ' germ developed itself in these individuals, who often sunk under 
 ' the same fate. It was only when they had gained a perfect know- 
 ' ledge of this disease, that many preserved themselves by the pre- 
 ' cautions which were indicated/ 
 
 Dr. Sotira, another of the physicians of the French army in 
 Egypt, relates the following striking circumstance : — 
 
 1 In the seventh year of the French republic, about eighty medical 
 ' officers died of the plague. In consequence of this mortality an 
 ' order was issued to employ Turkish barbers in the pest-houses to 
 ' dress the patients, and to undertake all the medical treatment 
 ' which required actual contact. The result was that during the
 
 A CONTAGIOUS DISEASE? 211 
 
 'next two years only twelve of the medical officers died of the 
 ' plague, but half the Turkish barbers caught it/ 
 
 Thus far have we drawn our information from medical men, eye- 
 witnesses of the facts which they relate. But as there are many per- 
 sons whimsical enough to think that medical men arc the worst judge-, 
 and that the less a man knows on a subject, the more likely is he to 
 come to a right conclusion about it, we will give them the experience 
 and the opinion of the late Sir Thomas Maitland, who witnessed the 
 rise, progress, and cessation of four different plagues in the Mediterra- 
 nean ; those of .Malta, Gozo, Corfu, and Cephalonia. In a letter to 
 Lord Bathurst, dated Corfu, April, 1819, which was published at 
 length in the 'Morning Herald' of June 29th, 1825, and is remarkable 
 for its practical good sen^e and manly spirit, he states it as his firm 
 opinion that the plague is taken only by contact. ' I have invariably 
 'found/ says he, 'that preventing contact stops the disease, and 
 * that so long as contact is permitted it uniformly increases. If the 
 ' absence of contact stops the plague, the allowing of contact must 
 'be the cause of it/ On this belief he acted in organizing measures 
 for the suppression of the disease. Although Sir Thomas Maitland 
 was bred neither as a logician nor as a physician, it would be difficult 
 for the former to reason better, or for the latter to act more skilfully. 
 In the system of police by which he invariably succeeded in suppress- 
 ing the plague — 'the exclusive object of the troops was to prevent 
 ' contact ; every family was shut up in their own houses, fed at 
 ' their own doors, and sent to the lazaretto the moment the disease 
 ' appeared. The soldiers employed in this sendee scarcely ever 
 ' contracted the disease. In the few instances that occurred, and 
 ' they were extremely few, it was uniformly observed of each soldier 
 ' that took the plague that he was loose in his conduct, and neglectful 
 ' of the necessary precautions. Those, on the contrary, who attended 
 ' to these precautions never took it. They were sent into several 
 ' villages, many of them with streets but a few feet wide; they did 
 ' the severest night-duties of all kinds in these villages ; they lived 
 ' in exactly the same atmosphere as the inhabitants, yet they never 
 'caught the disease, though it was raging in the villages; they 
 'were stationed within a yard or two of camps and hospitals in 
 'which the plague was raging with great violence, and they never 
 'caught it; and lastly, they were exposed to all those hard duties, 
 'which in all infectious diseases are known to give a predisposition
 
 212 IS THE PLAGUE 
 
 ' to the most violent and fatal type of the prevailing disease, and 
 ' yet they never caught the plague/ 
 
 We pause for want of room, not for want of matter ; for we have 
 not produced one-twentieth part of the trustworthy evidence on 
 record. On this part of the subject there is a perfect glut of proof, 
 in examining which the mind gets so inured to the most decisive 
 facts, that its sense of evidence becomes blunted, and it often puts 
 aside proofs, as feeble and inconclusive, wbich, on any other occasion, 
 would strike with instantaneous conviction. But enough has been 
 said on this head to make out our first two propositions - ; namely, 
 that those persons are most liable to the plague who approach those 
 affected with it, and that those generally escape the disease who avoid 
 those affected with it. This is enough to prove that it is communicable 
 from person to person ; we have no other proof of the contagious- 
 ness of the hooping-cough, scarlet-fever, and, in the experience of 
 the present generation, of measles. But we shall proceed to the 
 third test of a contagious disease, inoculation, and inquire whether 
 the plague can be communicated artificially, like the small-pox and 
 cow-pox. Under this head we must not expect very abundant 
 evidence. People consent to the inoculation of small-pox because 
 they can generally have it only once in their lives, and because, by so 
 doing, they substitute a disease which is fatal only once in some 
 hundred cases, for a disease which is fatal in one case out of four. 
 There are not the same temptations to submit to the inoculation of 
 the plague ; for, even if experience should prove that inoculation 
 diminished the force of the plague as much as it diminishes that of 
 small-pox, it would not afford security from subsequent attacks. 
 We must not expect, therefore, that many persons should have been 
 so rash as voluntarily to inflict this disease on themselves. But a few 
 such there have been, and we proceed to relate their experiments. 
 
 During the campaign in Egypt in 1801, the French troops were 
 much depressed by their dread of the plague. To convince them 
 that their alarms were unreasonable, Desgenettes attempted to ino- 
 culate himself with the disease, but to secure himself from the 
 danger of the experiment, he washed the part with soap and water. 
 We will give his own account of this experiment, from the failure of 
 which such erroneous inferences have been drawn : 
 
 ' [t was to restore the spirits and exhausted coinage of the army 
 ' that, in the middle of the hospital, I dipped a lancet in the pus of
 
 A CONTAGIOUS DISEASE? 213 
 
 c a bubo belonging to a convalescent patient, and made a slight 
 ' puncture in the groin and in the neighbourhood of the axilla, with- 
 ' out using any other precaution than washing myself with soap and 
 'water. I had, for more than three weeks, two little points of 
 ' inflammation, corresponding to the two punctures, and they were 
 ' still very tender when, on my return from Acre, I bathed in the 
 ' presence of the army, in the bath of Cesaree. This incomplete 
 ' experiment, of which I have been obliged to give some details, be- 
 ' cause of the noise it made, proves little, and does not refute the 
 ' transmission of contagion, demonstrated by a thousand examples.' 
 
 Soon after this, Dr. Whyte, a medical officer in the English army, 
 hearing that Desgenettes had made the experiment with impunity, 
 but not hearing of the precaution which lie had used, repeated the 
 former, without the latter, in the pest-house at El Hammed, on the 
 2d January, 1802. He was an anti-contagionist, and wished to 
 verify his doctrine by showing that the disease could not be com- 
 municated by inoculation. The experiment and the result are thus 
 related in a letter from Mr. Rice, then doing duty in the pest-house 
 at El Hammed, to Mr., now Sir James, M'Grigor : — 
 
 ' Dr. Whyte came here last night, January 2d, 1802; soon after 
 ' he came in he rubbed some matter from the bubo of a woman on 
 ' the inside of his thighs. The next morning he inoculated himself 
 ' in the wrists with a lancet, with matter taken from the running 
 ' bubo of a sepoy/ 
 
 In subsequent letters Mr. Rice states, that ' Dr. Whyte continued 
 * in good health on the 5th, and all day on the 6th, till the evening, 
 ' when he was attacked with rigors and other febrile symptoms/ He 
 continued to have shiverings, succeeded by heat and perspiration, 
 much affection of the head, tremor of the limbs, a dry black tongue, 
 great thirst, a full, hard, irregular pulse, a great debility, and great 
 anxiety. ' He still persisted that the disease was not the plague, 
 ' and would not allow his groins or arm-pits to be examined/ He 
 became delirious on the 8th, and died on the 9th, in the afternoon. 
 
 Dr. Valli was an Italian physician, who resided for some time in 
 Turkey. He distinguished himself by a work on the plague, and 
 has since, we believe, died of yellow fever, to investigate which he 
 went to the West Indies. During his residence at Constantinople . 
 he is known to have made experiments on the inoculation of the
 
 2J4 
 
 IS THE PLAGUE 
 
 plague, and in the 'Journal de Medecine/ for May, 1811, we find 
 the following statement, which the editor says he received from one 
 of his correspondents. Yalli diluted the pestilential matter with 
 small-pox matter, or with the gastric juice of frogs, or with oil. 
 This compound he called his pommade. If a Mussulman came to 
 consult him for an ophthalmia, he ordered him some of his pommade 
 to rub upon his eyelids ; if another came complaining of a pain in 
 the bowels, he ordered some of his pommade to rub upon his belly. 
 In this rascally way he gave the disease to thirty persons. These 
 facts M. Yalli is said to have communicated to the Medical Society 
 at Geneva, ' and doubtless/ says the reporter, ' he will one day pub- 
 ' lish them in detail!' Valli, however, never did publish them, 
 probably ashamed of the result, for it is said that these experiments 
 went to such a mischievous extent, that the Turkish government at 
 length interfered, and arrested, not Valli, but a pharmacopolist, who 
 vended the pommade, burnt his drugs, and cut off his head. 
 
 We have now made out our three propositions — the first two by 
 overwhelming evidence — and the last, by all the evidence which the 
 nature of the proposition would lead us to expect, and of which the 
 least that can be said is, that it furnishes strong ground for belief. 
 We pause, therefore, and ask, whether there is not sufficient reason 
 for believing that the plague is contagious, to justify us in acting 
 upon this supposition — to make it unjustifiable to act upon any 
 other? Considering the terrific nature of this disease, one would 
 suppose that the bare possibility of its being contagious would in- 
 duce us to act on that supposition, and that men woidd lay down as 
 a maxim, 'Take it for granted that it is contagious, till you are 
 ' certain that it is not/ But when we consider the immense mass of 
 evidence for the foregoing propositions, the clearness and distinctness 
 with which they are made out, the small number of dissentient 
 voices, and the tremendous importance of the stake at issue, one 
 would suppose it impossible that there should be men not merely 
 incredulous enough to dissent from this opinion, but mad enough to 
 wish to act on their dissent. Yet such is the fact. 
 
 ' However indisputable the fact of the plague being contagious 
 ' may be deemed by modern physicians, it may be remarked, that it 
 ' has been strongly opposed as often as the subject of quarantine lias 
 ' fallen under the deliberation of the legislature; and the public at 
 1 such times have been constantly pestered by an inundation of
 
 A CONTAGIOUS DISEASE? 215 
 
 ' pamphlets which, without advancing anything new, merely retailed 
 
 • arguments which have long before been refuted/ 
 
 These are the words of Dr. Patrick Russell, physician to the 
 British factory at Aleppo, about the year 1700, so applicable to the 
 present state of things, that they might seem to have been written 
 to-day, and with express reference to it. The Levant Company, 
 finding the quarantine laws inconvenient, resolved, a few years ago, 
 to take a medical opinion upon the necessity of 'the restrictions 
 which they imposed. They accordingly selected and sent to Con- 
 stantinople a physician of the name of M'Lean, a gentleman well 
 suited to their purpose, who, although he knew nothing of the 
 disease by experience, was thoroughly convinced that it was not 
 contagious, and consequently that the restrictions were as unneces- 
 sary as they were inconvenient. Going out with these previous 
 opinions, which we suppose we must not presume to call prejudices, 
 he found an experience of seventeen days sufficient to satisfy his 
 mind, and he has ever since been incessantly active in propagating 
 liis belief. Zeal and activity are the virtues of a sect, and Dr. M'Lean 
 with his few followers are entitled to the praise of possessing them ; 
 in the shape of petitions to Parliament, articles in reviews, paragraphs 
 in newspapers,* and speeches in Parliament, they have kept their 
 view of the subject incessantly before the public, and the result has 
 been, that the legislature has appointed Committees of Inquiry on 
 the subject,t and ultimately consented to a modification of the 
 quarantine laws. 
 
 We proceed, therefore, to inquire what reasons have been dis- 
 covered sufficiently weighty to set aside the experience of so many 
 generations, and of so many witnesses, together with all the infer- 
 ences and precautions to which they have led. Those reasons are 
 
 * It is amusing to notice the things on this subject produced in the daily papers. 
 The ' Morning Chronicle' for September 7th, 1829, which is now lying before us, con- 
 tains an account of a sitting of the Royal Academy of Sciences, at Paris, in which 
 a M. Lassis, an unbeliever in the contagiousness of the plague, is represented as 
 saying that ' he denied the existence of contagion in every species of disease, ex- 
 ' cepting only the measles and syphilis !' Then the small-pox and cow-pox are not 
 contagious — diseases which we can propagate at will by the point of a lancet, with 
 matter which we can see and feel ? Where will the folly of man stop ? 
 
 t ' Report from the Select Committee on the Doctrine of Contagion in the 
 Plague.' 1810. 
 
 ' Second Report from the Select Committee appointed to consider of the Means of 
 Improving and Maintaining the Foreign Trade of the Country. Quarantine.' 1824.
 
 216 IS THE PLAGUE 
 
 to be found in Dr. M 'Lean's work 'on Epidemic and Pestilential 
 Diseases/ in his evidence before a Committee of the House of 
 Commons, and in a dissertation on the subject by a writer in the 
 Westminster Review.* 
 
 By way of introduction to the discussion, it is first laid down 
 that, on the question of contagion, medical men are the worst 
 judges, and that the best are ' men of general science, whose minds 
 ' are accustomed to weigh evidence/ but who are unacquainted with, 
 and consequently unprejudiced on the subject. The only reason 
 given for this remarkable, but very convenient proposition, is, that 
 the students of medicine are the slaves of authority, which, in after- 
 life, as physicians, they seldom outgrow; but if it be common for 
 the student to be oppressed by the authority of eminent teachers, it 
 is not impossible for the ignorant to be deceived by the misstatements 
 of plausible reasoners. The question of contagion, like every other, 
 requires two qualifications in those who are to pronounce a judg- 
 ment upon it ; a knowledge of the whole truth as to matters of fact, 
 and a capability of reasoning rightly upon that knowledge. It is 
 obvious that men of science who know nothing of medicine can 
 possess only one of these qualifications ; and a sufficient reason why 
 they must be incompetent judges is, that although they can appre- 
 ciate what is neat in point of statement, and plausible, or even accu- 
 rate, in point of reasoning, they are no judges whatever of what is 
 true in point of fact. Hence, when they listen to a man who is little 
 scrupulous about the accuracy of his facts, they are entirely at his 
 mercy. It requires no great sagacity to perceive that the real 
 motive for this appeal to those who are not physicians is, not because 
 they are likely to be the best judges, but the most docile listeners 
 — because they are likely to detect the errors of their teachers. 
 It is easy to argue triumphantly about law with a physician, about 
 physic with a lawyer, about theology with either — in short, on any 
 subject with any person who knows nothing about it. 
 
 Prom this introduction we pass to the first argument produced to 
 prove that the plague is not contagious, which is, that it is not 
 governed by the laws of contagious, but of epidemic diseases. This 
 argument, which is announced with great parade, explained most 
 elaborately, and referred to again and again as the corner-stone of 
 the system, is an attempt to lay down the laws by which contagious, 
 
 * See Nos. V. and VI.
 
 A CONTAGIOUS DISEASE? 217 
 
 and those by which epidemic diseases are governed; and then, 
 having ascertained by what laws the plague is governed, to deduce 
 whether it is an epidemic or a contagious disease. This isamazingh 
 well suited to take in the ' men of gem ral science/ the minds 'accus- 
 ' tomed to weigh evidence/ for it has a logical air which they can 
 readily appreciate, whilst it reposes upon facts of which they are 
 entirely ignorant. If the reader will take the trouble to compress 
 and comprehend it, he will find that it comes to this : — 
 
 Contagious diseases (as small-pox, measles, and scarlet fever) are 
 very uniform in their symptoms and duration — affect a person only 
 once in his life — the patient is not subject to relapses — and they 
 may be propagated at all times and seasons. On the contrary, 
 epidemic diseases are very irregular in their symptoms and length — 
 appear and disappear at certain times of the year — are most preva- 
 lent in certain countries, or even neighbourhoods — may affect a 
 person repeatedly in life, and the sufferer is liable to relapses. Now, 
 as the plague is very irregular in its symptoms and length — appears 
 and disappears at certain seasons — is most prevalent in certain 
 countries, and even neighbourhoods — can affect a person repeatedly 
 — and as relapses occur — as the plague lias all these qualities in 
 common with epidemic diseases, it is plain that it must be an epi- 
 demic and not a contagious disease. 
 
 Now, the first sophism discoverable in this argument is, that the 
 contagious or non-contagious nature of a disease is here made a 
 question of inference to be determined by reasoning, which in truth 
 is a question of fact to be determined by experience. Let any man 
 who has the smallest pretensions to understanding say which is the 
 right mode of discovering whether or not a disease is contagious — 
 to find out that it is uniform in its symptoms and progress — that it 
 affects a person only once in life — that when convalescent he is not 
 liable to relapse — and thence to infer that it is contagious — or to go 
 among the sick, to observe and watch the way in which it spreads, 
 and thus to ascertain whether it is contagious. When Gall first 
 broached his craniological doctrines in Germany, they were ridiculed 
 on the stage — a master is represented hiring his servants according 
 to the shape of then skulls — he feels their heads — finds the bumps 
 which constitute a good servant — infers that they are sober, honest, 
 and industrious — hires them without characters, and in the end 
 finds them drones, profligates, and thieves. Themodeof proceeding, 
 which in this instance was only an imagined absurdity, is absolutely
 
 218 IS THE PLAGUE 
 
 practised by Dr. M'Lean and his followers in judging of the con- 
 tagiousness of diseases. 
 
 But not only is the question resolved by reasoning which ought 
 to be resolved by experience, but even in the conduct of the reason- 
 ing there is a fresh sophism, or rather blunder. One class of con- 
 tagious diseases, the eruptive fevers, is assumed to be the only class — 
 its laws are described, and every disease whieh is not governed by 
 them is inferred not to be contagious ; whereas the question at issue 
 is, whether the eruptive fevers are the only contagious fevers ? If to 
 determine whether negroes were human beings, we were to take a 
 particular people, as Europeans, and, describing among their quali- 
 ties a fair complexion, were to infer that because negroes were not 
 fair they were not human, would not this be begging the question ? 
 yet this is precisely the line we adopt when, in a dispute about 
 what are contagious fevers, we take the eruptive fevers as the only 
 examples. 
 
 Another argument against the contagiousness of the plague is, 
 that it breaks out at a eertain season, lasts for a certain time, and 
 then subsides, and remains dormant till the favourable season returns. 
 On the other hand, we are told that ' contagious diseases can be 
 ' propagated at any time, and among any number of persons/ — 
 ' That a disease depending upon a specific contagion must prevail 
 ' alike in all seasons, in a pure as well as in an impure atmosphere, 
 ' amongst the rich as readily as amongst the poor; and that the 
 ' only influence of these adventitious circumstances would be to 
 ' render the disease more or less severe/ We could not produce a 
 stronger instance how unsafe it is to trust these discussions into the 
 hands of those who are ignorant of medicine ; for no well-educated 
 physician could ever have penned such a statement, and no compe- 
 tent judge could ever for a moment have listened to it. 
 
 Take the diseases which are unquestionably eontagious : — What 
 is the fact with hydrophobia ? Sometimes it is so rare, and excites 
 so little attention, that dogs run about without restraint, and the 
 public almost forget that there is such a disease. At other times it 
 is so prevalent, and the bite of dogs is so often followed by this 
 terrific disease in man, that the public are kept in perpetual alarm ; 
 the walls are placarded with orders to tie up the dogs, and their 
 appearance in the streets occasions the timid to fly, and the mis- 
 chievous to follow them with stones and clubs. As the contagion is 
 always in existence, and the animals susceptible to it always alive,
 
 A CONTAGIOUS DISEASE? 219 
 
 whence comes it that it is more active and diffusive at one time than 
 at another? It is plain that, beside the specific contagion, (here is 
 a diffused cause which renders the disease more communicable at 
 one time than at another. Whether it is a peculiar condition <>{' the 
 atmosphere, as is commonly believed, and if so, how it acts, whether 
 by rendering the poison more active, or the bodies of animals more 
 susceptible to it, it is unnecessary for our present purpose to inquire. 
 It is enough to know that hydrophobia, which ' depends on a specific 
 ' contagion/ is not ' propagated ecpially at all times/ and does not 
 ' prevail alike in all seasons/ The same fact may be stated, and 
 the, same inference may be drawn, with regard to the hooping- 
 cough. Parents well know that at one time it is almost a forgotten 
 disease, at another time they can scarcely go into a family without 
 coming in contact with it; and experienced physicians know that it 
 generally prevails in cold damp seasons, as the end of autumn and 
 winter, and is little heard of in the warm dry days of summer. 
 Measles are generally most prevalent in spring, and disappear in 
 summer. 
 
 ' The scarlet fever/ says Sydenham, ' though it may happen at 
 ' any time, yet it most commonly comes at the latter end of suin- 
 ' mer/ — 'The measles of 1670/ says the same distinguished phy- 
 sician, 'began very early, that is, at the beginning of January, and, 
 ' increasing daily, came to their height in March ; afterwards they 
 1 gradually decreased, and were quite extinguished in the following 
 'July/ 
 
 With regard to the small-pox and cow-pox, it is necessary to 
 distinguish between the artificial and the natural propagation of 
 contagious diseases. It is quite true that contagious diseases, which 
 are propagated by inoculation, can, generally speaking, be propa- 
 gated in this way ' at any time, and among any number of persons / 
 but leave them to be propagated in the natural way, and it is quite 
 notorious that they spread readily at one time, and scarcely at all at 
 another. The small-pox has been so much restrained, first, by the 
 introduction of inoculation, and, secondly, by that of vaccination, 
 that we of the present day know little of its natural course; but 
 before the introduction of the one, and the discovery of the other, 
 the small-pox used to he dormant — then appear — rage for a time — 
 and then subside — like epidemic diseases. Sydenham, who lived 
 before the time of inoculation and vaccination, describes the small-
 
 220 IS THE PLAGUE 
 
 pox as at one time appearing rarely, or not at all ; then beginning 
 to show itself at the approach of the vernal equinox; spreading 
 more and more every day, becoming epidemic about autumn, abating 
 on the coming on of winter, returning again in the following spring, 
 and prevailing till checked by the subsequent winter. The accounts 
 which this admirable physician gives of the small-pox in different 
 years read exactly like accounts of an epidemic disease. 
 
 Boerhaave, speaking of the same disease, says, ' this disorder is 
 ' generally epidemic, beginning early in the spring, increasing in 
 ' summer, abating in autumn, ceasing almost entirely the following 
 ' winter, to return in the spring, and reign again in the same order/ 
 Van Swieten, who, though a commentator on Boerhaave, wrote from 
 experience, after describing Sydenham's account of the rise, progress, 
 and subsidence of small-pox, adds, ' I have seen many variolous 
 ' epidemic constitutions, and they agreed in most things with the 
 ' observations of Sydenham/ Sydenham, Boerhaave, and Van 
 Swieten, saw the small-pox before inoculation was introduced, when 
 it was propagated in the natural way, and we see it used to run its 
 course just like epidemic diseases. 
 
 Sydenham lived, and was practising in London, in the year 1665. 
 He saw something of the dreadful plague of that year, and he had 
 frequent opportunities of seeing the small-pox propagate itself in the 
 natural way. Now it is curious, that so far from there being any 
 striking difference between the progress of the plague, and the 
 progress of contagious diseases, as the anti-contagionists assert, he 
 selects these two as strikingly similar in their mode of appearing aud 
 disappearing. 
 
 ' That such a disposition or texture happens to the mass of the air 
 ' as occasions various diseases at different times, is manifest to every 
 f one that but considers, that one and the same disease kills an 
 ' infinite number of men at some certain seasons, and at another 
 ' time seizes only here and there a man, and goes no farther ; and 
 ' this is very apparent in the small-pox, especially in the plague, the 
 ' argument of this chapter/ 
 
 "When Dr. Jenner first disclosed his discovery of vaccination, and 
 everybody was anxious to verify it by experiment, the London 
 physicians could procure no matter, because, as they were told, the 
 disease was extinct. 
 
 'Unfortunately,' says Dr. "Woodvillc (the physician to the Small-
 
 V CONTAGIOUS DISEASE ? 221 
 
 Pox Hospital), c at the time Dr. .Tenner's publication appeared, no 
 ' cow-pox matter could be procured, for the disease then had become 
 ' extinct, nor was it expected to return till the spring, the period at 
 ' which it usually affects the cows. Towards the latter end of 
 ' January last, I was informed that the cow-pox had appeared 
 ' among several of the milch-cows kept in Gray's Inn Lane, and 
 1 about four-fifths of them were eventually infected.' 
 
 It appears, therefore, that contagious diseases prevail much at one 
 time, and little at another, and, consequently, that two things are 
 requisite for their ready propagation j the one, the contagious matter 
 itself, the other, a diffused cause, supposed to be a state of the 
 atmosphere favourable to its action. Let it never be forgotten, that 
 this is the case with diseases unquestionably and notoriously con- 
 tagious, and, therefore, that when it is found to be the case with the 
 plague it can be no objection to the belief of its being also contagious. 
 Are the anti-contagionists ignorant of these facts ? In tins, and 
 other instances which we shall have occasion to notice, the error is 
 so extraordinary, that it is really difficult to refer it to ignorance. 
 But we go on. 
 
 The anti-contagionists, describing epidemic diseases, say, 
 
 1 People are attacked, not in proportion as the inhabitants of the 
 ' affected mix with those of the unaffected places ; but, in propor- 
 ' tion as the inhabitants of unaffected expose themselves to the 
 1 air of affected places. The visits of the sick to unaffected places 
 1 is [are] followed by no increase of disease ; the visits of the in- 
 1 habitants of an unaffected, to an affected place, is [are] attended 
 f with a certain degree of sickness. On their removal from a 
 ' noxious to a pure air, the sick often rapidly recover ; but they do 
 ' not communicate the disease to the inhabitants of a pure atmo- 
 ' sphere ; in the history of all the epidemics which have ever prevailed, 
 ' in all parts of the earth, there is not on record a single example of 
 ' the communication of the disease from the sick to the healthy in a 
 ' pure atmosphere.' — West. Rev. Xo. V. p. 1 15. 
 
 Here are, put only in several forms, two propositions : — First, 
 that when the people of healthy districts visit the affected districts, 
 they take the disease, not from the sick, but from the air. Secondly, 
 that when the sick move from an affected to a health} district, they 
 speedily recover, and do not give the disease to others. Let us take 
 these propositions, and try them in their application to the plague.
 
 222 IS THE PLAGUE 
 
 If those who come out of a healthy into an affected district, took tlic 
 disease, not from the sick, but from the air, then those who avoided 
 the sick would be as liable to the disease as those who approached 
 and touched them. Is this the fact with the plague ? so notoriously 
 the contrary, that all modern observers have come to the conclusion 
 that absolute contact, either with infected persons or infected clothes, 
 is necessary for the communication of the disease. Hence the security 
 of those who, while the plague is raging, shut themselves up in the 
 very town in which it is raging, and avoid all intercourse with the 
 sick. "Why did the religious communities at Marseilles, which 
 practised this seclusion, escape ? "Why did the Foundling Hospital 
 at Moscow, winch was strictly shut up, escape, while the Foundling 
 Hospital at Marseilles, which admitted a patient with the plague, 
 was swept of its population? "Why at Malta, in 1813, was the 
 plague kept out of the Military Hospital, although it was raging in 
 the ground-floor, while, in the houses in the immediate neighbour- 
 hood, the disease was not only getting access to the ground-floors, 
 but climbing to the very garrets ? Why did the French medical 
 officers, in Egypt, die in crowds, whilst they dressed the patients, 
 and as soon as the task of touching and dressing them was put upon 
 the Turkish barbers, why was the mortality transferred from the 
 surgeons to the barbers? Why did the troops employed by Sir 
 Thomas Maitland to suppress the plague at Malta escape the disease, 
 although they were, not only in the same district, but in the same 
 streets in which it was raging ? In short, for we might have saved 
 ourselves this recitation of facts, why is the practice of seclusion, or 
 shutting up, as it is called, practised by the European factories in 
 places liable to the plague, an effectual preventive of the disease ? 
 If it is said that those persons keep aloof in the healthy districts, 
 then are the healthy and sick districts often separated by a distance 
 only of a few feet — then is the definition of a healthy district, a place 
 in which the healthy shut themselves up ? then is a man able to 
 plant himself in the midst of a sick district, draw round him a magic 
 wand, and say to the noxious atmosphere, So far shalt thou come, 
 and no farther ? Moses's rod had not more power over the waters 
 of the Red Sea, than is here attributed to human volition over a 
 contaminated atmosphere. 
 
 Now for the second proposition, that ' the visits of the sick to un- 
 ' affected places is [are] followed by no increase of disease. In the
 
 A CONTAGIOUS DISEASE? 223 
 
 ' history of all the epidemics which have ever prevailed in all parts 
 ' of the earth, there is not on record a single example of the com- 
 1 munication of the disease from the sick to the healthy in a pure 
 
 ' atmosphere.' 
 
 Our readers will bear in mind that the writer's own description of 
 a pure atmosphere is, the atmosphere of unaffected places ; otherwise, 
 if, when the visits of the sick to unaffected places are followed by 
 the propagation of the disease, that fact be taken as a proof of the 
 impurity of the atmosphere, it would be reasoning in a circle — a 
 mere juggle, instead of an argument. ]\ T ow, taking the proposition 
 in this sense, a more daring and outrageous misstatement was never 
 penned. Excepting only places where the disease is endemic, nearly 
 all the plagues which have ever devastated the world have followed 
 the visits of the sick to unaffected places — the only difficulty in 
 producing ' a single example,' is the difficulty of choosing among a 
 multitude. The plague of Malta in 1813 followed the visit of the 
 sick in the San Nicolo from Alexandria, an affected place, to Malta, 
 an unaffected place, unaffected for one hundred and thirty-seven 
 years. The plague at Gozo followed a visit from Valetta, an affected 
 place, to Gozo, an unaffected place, an elevated little island, only a 
 few miles long. The plague at Marseilles in 1770 followed the 
 visits of the sick from Seyde in Syria, and from Tripoli, affected 
 places, to Marseilles, an unaffected place, unaffected for more than 
 half a century. The plague of Moscow in 1 7 7 1 followed the sick from 
 Choczin, an affected place, to Moscow, an unaffected place, unaffected 
 for more than a century and a half. So far from being in want of 
 a single instance, we have no room for the number which press on 
 us ; but we will give one winch may serve better than any on a larger 
 scale, and in more populous districts, because no stress can be laid 
 on the impurity of the air. When the plague was raging in London 
 in the year 1665, the visit, not of the sick, but of the clothes of the 
 sick from London, an affected place, to a village on the Peak of 
 Derbyshire, an unaffected place, was followed by the appearance of 
 the disease in the pure air of that remote and elevated spot. We 
 find the following mention of this fact by Mr. Howard, in his account 
 of the principal lazarettos of Europe. 
 
 'When the plague raged in London, in the year 1665, the 
 ' infection was conveyed by means of a parcel of clothes to the remote 
 ' village of Eyam, near Tidewell, in the Peak of Derbyshire. In
 
 224 IS THE PLAGUE 
 
 ' this place it broke out in September, 1665, and continued its 
 1 ravages upwards of a year, when two hundred and sixty of the 
 ' inhabitants had died of it. The worthy rector, Mr. Mompesson, 
 1 whose name may rank with those of Cardinal Borromeo of Milan, 
 ' and the good Bishop of Marseilles, at its breaking out resolved not 
 ' to quit his parishioners, but used every argument to prevail with Ins 
 ' wife to leave the infected spot. She, however, refused to forsake 
 1 her husband, and is supposed to have died of the plague. They 
 ' sent away their children. Mr. Mompesson constantly employed 
 ' himself during the dreadful visitation in his pastoral office, and 
 ' preached to his flock in a field where nature had formed a sort of 
 ' alcove in a rock, which place still retains the appellation of a church. 
 ' He survived ; and the entries in the parish register relative to this 
 ' calamity are in Ins handwriting. In the fields surrounding the 
 ' town are many remains denoting the places where tents were 
 * pitched ; and tombs are still existing of large families entirely 
 ' swept away by tins devouring pestilence/ — p. 24<.* 
 
 The statement, then, is utterly false j but that is not all — it is 
 equally inconclusive. If we were to admit that the removal of the 
 sick to places unaffected with the plague is often followed by speedy 
 recovery, and by no spread of the disorder, we should only admit 
 what is true with regard to diseases unquestionably contagious, as the 
 small-pox. Van Swieten, who saw the small-pox when it was pro- 
 pagated only in the natural way, writes thus : — 
 
 ' I have sometimes observed large towns to be free from the small- 
 ' pox, whilst it raged epidemically in the neighbouring villages ; and, 
 ' on the contrary, some large towns universally visited by the com- 
 ' plaint, whilst the villages in the neighbourhood remained in health, 
 
 * The anti-contagionists have been in the habit of affirming that the plague had 
 never penetrated into Arabia. We have received the following communication from 
 Dr. Benjamin Babington, who came overland from India, and in whom the soundest 
 sense and the most cautious observation are hereditary qualifications. It bears 
 immediately on this part of the subject. ' The plague had never been in Arabia till 
 ' the middle of 1815, when Mahomed Ali Pasha of Egypt sent his troops across the 
 ' Desert into Arabia, on an expedition against the Wahabees. On this occasion it 
 ' visited Yambo and Jedda, and crept down the coast as low as Gamfada. Each of 
 ' these towns lost nearly half its population. When I was at Milo, in the end of 
 ' 1815, a vessel came into the port having one person on board ill with the plague. 
 ' This vessel was ordered by the Greek authorities to quit the harbour. S'ne put into 
 ' Mitylene, where those in command being less cautious, allowed the sailors to land, 
 ' several of whom had by this time become infected. The disease immediately after- 
 ' wards broke out among the islanders, and many fell victims to it.'
 
 A CONTAGIOUS DISEASE? 225 
 
 ' though the inhabitants of both mixed daily with each other. T 
 ' also perfectly remember that I once removed two patients of mine 
 ' from a place where the small-pox raged to a large town, without 
 ' propagating the contagion there; and many excellent physicians, 
 ' with whom 1 have cultivated a friendly commerce with respect to 
 ' medical knowledge, testify that they have observed the same thing.' 
 A similar fact is mentioned by Sir John IVingle, in his 'Account 
 ' of Diseases of the Army/ where it is stated that ' the small-pox 
 ' being carried into the camp by some new raised recruits, quickly 
 ' disappeared without becoming general, although it is notorious that 
 ' other camp-diseases are but too apt cpiickly to spread themselves/ 
 Again, the late and learned Dr. Odier, in a letter from Geneva to Dr. 
 llaggarth, says — ' We have frequently innoculated at Geneva a great 
 ' number of children in the years during which the small-pox was 
 ' not epidemic; these children have gone out every day, even after 
 ' the eruption had broken out — they have been in the streets, and 
 ' in the public walks — they have communicated freely with other 
 ' children susceptible of the infection, and, not only the small-pox 
 ' did not spread, but there did not occur, to my knowledge, any dis- 
 f tinct instance of the communication of the disease from one indi- 
 ' vidual to another in the streets or promenades/ 
 
 When Sir James M'Grigor was at Bombay, the small-pox was 
 raging in the houses contiguous to the Barracks, yet not one adult 
 or child in the regiment was affected by it. In Africa, when the 
 Harmattan blows no contagion is active, not even that by innocula- 
 tion of the small-pox. 
 
 We pass on to an observation which deserves more attention, 
 because it is one of the few which are not founded in misstatement. 
 It is this — that the plague, when raging violently, sometimes sud- 
 denly abates at the very time when the supposed sources of infect ion, 
 contaminated persons or contaminated things, are most numerous. 
 In the great plague of London in 1665, Sydenham states that 'the 
 1 number of deaths, which had increased to some thousands in one 
 ' week in August, decreased and almost stopped at the latter end of 
 1 November/ It must be obvious to the thoughtful reader, that this 
 circumstance, ou which so much stress is laid, is only anot her instance 
 of a general accident of contagious diseases which we have already 
 weighed and considered, viz., that they are propagated readily at 
 one time and with difficulty at another. This has generally been 
 explained by the supposed existence or non-existence of some quality 
 
 Q
 
 226 IS THE PLAGUE 
 
 in the atmosphere favourable to the propagation ; if the atmosphere 
 can suddenly assume such a quality, it is easy to understand how it 
 may as suddenly lose it. If some changes are capable of increasing, 
 other changes may be capable of diminishing the prevalence of a 
 disease. There is no more mystery in the sudden diminution than 
 there is in the sudden increase in the number of the sick, and there 
 is no mystery in either to one who duly considers that two things 
 are required for the ready diffusion of a contagious disease — the one 
 the contagious matter or effluvium ; the other, a particular state of 
 the atmosphere favourable to its action. 
 
 Other circumstances may contribute to the decline of contagious 
 diseases. A man must have had little experience in medicine who 
 does not know that some persons are more susceptible of disease than 
 others. When a contagious disease first breaks out, it of course 
 seizes the most susceptible subjects — they are the tinder, which 
 takes fire readily and burns rapidly. The disease spreads easily 
 and widely, as long as this combustible matter is abundant, but as 
 soon as it is consumed the fire burns dimly, and at length goes out. 
 Something, too, may depend upon this, that the contagion may lose 
 its pungency by passing through many individuals, and at length 
 wear out. The vaccine matter fresh from the cow produces a more 
 painful disorder than after it has passed for some time through the 
 human subject by inoculation; and if vaccination be now less 
 effectual than formerly as a preventive of small-pox, it may be 
 because we have neglected too long to vaccinate with matter taken 
 immediately from the animal. When syphilis was first brought 
 from America to Europe it was so virulent and terrible, that we can 
 hardly recognise in the descriptions left of it by our ancestors, the 
 comparatively mild and tractable disease of the present day. 
 
 The last argument of the anti-contagionists which we think 
 entitled to any notice is, the circumstance that, when the plague 
 is prevalent, so many persons are exposed to the contagion without 
 being affected. This argument is founded upon the supposition, 
 that because almost everybody is susceptible to the contagion of 
 small-pox, measles, and scarlet fever, therefore almost everybody 
 must be susceptible to the contagion of the plague, if it be con- 
 tagious; in other words that the laws which govern the eruptive 
 contagious fevers, must be the same as govern all contagious fevers. 
 This argument we have already destroyed, by observing that it takes 
 for granted the very point in dispute, that the eruptive contagious
 
 A CONTAGIOUS DISEASE? 227 
 
 fevers are the only contagious fevers. If because many who are 
 exposed to the contagion of the plague escape it, we are to infer that 
 the exposure is not the cause of the plague, let us see to what con- 
 clusions we shall arrive. Of those who are bitten b\ a rabid animal, 
 many are not affected by hydrophobia — therefore, the bite of a wild 
 animal is not the cause of hydrophobia. Of those exposed to a cold 
 and variable season, many are not affected with pulmonary inflam- 
 mations — therefore, cold and variable weather is not the cause of 
 pulmonary inflammations. Of those oppressed by the intense heat 
 of the season, many are not seized with the cholera — therefore, a 
 hot season is not the cause of cholera. But a truce to this; the 
 causes of disease are not things which invariably produce them, but 
 which produce them sufficiently often to leave no doubt that they 
 are the causes. Everybody is susceptible to small-pox, measles, 
 ami scarlet fever; but then, having had them once, he never has 
 them again. Many people are not susceptible, at least for a time, 
 to the plague; but then, having had it once, they may have it 
 repeatedly — singleness of attack is a compensation for universal 
 susceptibility — frequent insusceptibility is a compensation for the 
 liability to repeated attacks. Nature,' or rather Providence, abounds 
 in those compensations. 
 
 We might now leave the subject, but there are a few statements 
 of the auti-contagionists which it will be useful to notice, not as 
 important in themselves, but as showing the structure of the minds 
 of those who advance them ; how little they are to be trusted even 
 in the statement of a fact, and how unfit they are as guides on so 
 momentous a subject. A writer in ' Blackwood's Magazine/ alluding 
 to the anonymous expositor of Dr. M 'Lean's whims, says, ' it is 
 ' true I know nothing of the subject, but the article appears to me 
 ' to be quite conclusive! It is impossible to put it more happily — 
 the exposition does appear cpiite conclusive to one who knows nothing 
 of the subject. The most potent arguments are facts, and when the 
 teacher cares little, and the student is totally ignorant whether thej 
 are accurate or no, the business of conviction is an easy task. An 
 instance or two will show what we mean. 
 
 ' The small-pox secretes a contagious matter which is contained in 
 ' its pustules — the measles secretes a contagious matter which is 
 ' contained in its vesicles. Apply a portion of the fluid contained 
 ' in the pustules of the one and the vesicles of the other to a lualiln
 
 228 IS THE PLAGUE 
 
 1 person, it will excite in the latter the same train of symptoms as 
 ' existed in the individual in whom the contagions matter was 
 ' secreted/— West. Rev., No. V, p. 138. f And again: The small- 
 1 pox is never without its pustules, the measles is never without its 
 ' vesicles. — Ibid. p. 139. 
 
 In readingthese passages, what f man of general science/ accustomed 
 to weigh evidence, would suspect that the measles has no vesicles ; 
 that though vesicles sometimes occur during the progress of measles, 
 they are by no means the essential or characteristic eruption of 
 the disease ; the characteristic eruption of measles is a rash, 
 containing no matter to inoculate with, and no one ever thought 
 of producing the measles 'by applying a portion of the fluid 
 contained in its vesicles/ Dr. Francis Home, of Edinburgh, who, 
 in the year 1759, attempted to inoculate the measles, expressly 
 says, ' there was no matter/ and therefore he was obliged to employ 
 the blood/ Again, — 
 
 ' Were epidemic diseases really propagated by contagion, it could 
 ' possibly be matter of controversy ; the facts establishing the 
 ' truth would be so clear, so numerous, so overwhelming, as to place 
 c it beyond all question. ~Na one can doubt, no one ever did doubt, 
 1 that tJie small-pox is contagious. This alone must be sufficient to 
 ' decide the matter in the judgment of every philosophical mind/ — 
 West. Rev., No. V, p. 147. 
 
 Now, we beg leave to inform the ' philosophical minds' to whom 
 an appeal is here made, that some one did doubt that the small-pox 
 was contagious ; and that no less a person than the greatest 
 physician England ever produced, Sydenham. He saw the small- 
 pox when its natural mode of diffusion was not interrupted by 
 inoculation or vaccination, as it now is, and yet this great man had 
 no suspicion that it was contagious. In his time a belief in the non- 
 contagiousness of small-pox was not only the medical, but the popular 
 opinion. Gadbury, the astrologer, in his ' London's Deliverance 
 Predicted/ published in the year 1665, says, ' I say, then, it (the 
 plague) ought not to be deemed infectious at all, at least not more 
 ' infectious than small-pox, scurvy, pleurisy, ague, gout/ This 
 blunder of the anti-contagionists has been well exposed by Dr. 
 Macmichael, in his tract ' On the Progress of Opinion on the Subject 
 ' of ( Vmtagion/
 
 A CONTAGIOUS DISEASE ? 229 
 
 Misstatements, however, of the kind which we have just noticed, 
 are not matter of surprise, for the argument is not addressed to 
 medical men; it appeals from their judgment to that of men of 
 genera] science acquainted with the laws of evidence. We conic 
 now to a different class, and we suspect that for the future even a 
 knowledge of the laws of evidence may be found an inconvenient 
 qualification in the men of science who are to decide the question. 
 For example, we are told that ' it is the custom in Turkey for the 
 ' relations of those who died of the plague, to wear the clothes of 
 ' the deceased, or to sell them at the public bazaar j they are never 
 ' destroyed, they are invariably either worn by the relatives or sold 
 ' at the public market ; there is no instance on record of the disease 
 ' heing communicated by these means. The persons who deal in the 
 f clothes arc not infected, the persons who wear them remain free 
 ' from the disease/ — West. Rev., No. V, p. 160. 
 
 A naturalist who had affirmed that domesticated hogs were 
 infested with a species of vermin which did not infest wild hogs, 
 was asked how he knew it ; whether he had combed all the wild hogs 
 in the world ? So we may ask whether the anti-contagionists have 
 traced all the old clothes which are worn by the relatives or sold at 
 the bazaar ? 
 
 When Dr. M'Lean was examined before the Committee on con- 
 tagion, he said, 
 
 ' I used to walk into the city of Constantinople, even after I had 
 ' the disease, and go through the thickest of the people, visiting the 
 ' coffee-houses and other frequented places ; nor was the disease by 
 1 that means propagated/ 
 
 How does he know? did he inquire into the fate of all the people 
 whom he had jostled hi the streets, and sat by in the coffee-houses ? 
 
 If we admit the fact that many people are exposed to the clothes 
 of the sick without catching the disease, it proves no more than the 
 fact that many are exposed to the sick themselves without catching 
 it j and this we have already considered. Again, were the clothes 
 of the dead worn during their illness ? Were they worn during that 
 stage of the disease which is infectious? To what extent had they 
 been exposed to the air since the death of their owner? A lancet 
 dipped in vaccine matter kept for a few days in the pocket, and then 
 used for vaccination, with all the advantages of intentional immer-
 
 230 IS THE PLAGUE 
 
 sion in the contagious fluid, and careful insertion under the skin in 
 the act of vaccination, is more likely to fail than to succeed in giving 
 the disease; and hence the importance of bringing together the 
 person to be vaccinated with the person from whom he is to be 
 vaccinated, and performing the operation with fresh matter. 
 
 So much for the evidence in support of this sweeping statement, 
 that ' there is no instance on record of the communication of the 
 disease by these means / but there is a little evidence against it. 
 
 ' It is a notion/ says Dr. Russell, ' prevalent at Aleppo, that a 
 1 plague cannot subsist in the city any considerable time without 
 f being imparted to the Jews. Many of that nation are employed 
 ' as brokers and pedlars in most parts of the town, and numbers 
 ' who deal in old clothes daily pass through the streets, purchasing 
 ' their wares from all ranks of people. In this manner it is sup- 
 ' posed the distemper is transported to the Jewish district/ 
 
 And again, says Dr. Russell, — ' if substances tainted by the sick 
 1 should be conveyed into secluded retreats, and persons happen to 
 ' be seized with the distemper, can it be ascribed not to contagion 
 { but to terror ? and the instances here alluded to are not the 
 ' creation of fancy, but strictly consonant to repeated experience 
 1 in Turkey' 
 
 In another place Dr. Russell says, — ' I met with many instances 
 ' of the disease being communicated by coverlids, carpets, and ap- 
 ' parel, purchased from infected houses/ 
 
 Dr. Pugnet, who was with the French army in Egypt, states that 
 at Jaffa, an apothecary dying of the plague, his neckhandkerchiefs 
 were divided among, and worn by, fourteen persons : all these were 
 seized with the plague, and had buboes in their necks. 
 
 The anti-contagionists assert that the plague never was in Hol- 
 land, although the Dutch have no quarantine laws. That singular 
 but laborious writer, Noah Webster, has collected accounts of no 
 less than fourteen plagues which ravaged Flanders and Holland at 
 various periods, in one of which, at Delft, in the year 1557, the 
 dead bodies were so numerous that the people fought for the coffins. 
 As to the absence of cpiarantine laws, if this were true, how happens 
 it that as soon as England only relaxes hers, and thereby approaches 
 the state of law said to exist in Holland, the several powers of the
 
 A CONTAGIOUS DISEASE? 231 
 
 Mediterranean turn round upon her, and compel every vessel from 
 her ports to perform quarantine before entering their ports? — a 
 conduct which they do not observe tow aids the vessels of Holland, 
 which undergo no quarantine at all. On inquiring of the Dutch 
 authorities iu this country, we Irani that the Dutch have quaran- 
 tine laws, but that, when a vessel arrives from the Levant with a 
 clean bill of health, they are not always strictly enforced. Dr. 
 Granville, who seems to have taken much pains to ascertain the fact, 
 gives the following as the result of his inquiries, in bis letter on this 
 subject to the Chancellor of the Exchequer. The Dutch trade in 
 the Mediterranean, in former times, suffered much from the Algerine 
 cruizers ; in consequence of which, the Dutch merchantmen trading 
 in the Mediterranean were, from the early ages of the Republic, 
 directed to assemble at Leghorn, from which port they sailed, under 
 convoy, to Holland. This arrangement leads to considerable deten- 
 tion at Leghorn, which, although originally intended as a security 
 against pirates, served, in point of fact, the purpose of a quarantine, 
 Leghorn being, as is well known, the port, of all others, in which 
 the quarantine regulations were the most perfect, and most rigidly 
 observed. In addition to this, whenever any Dutch vessel quitted 
 a port where the plague was raging, the Dutch consul at that port 
 refused her a 'passe-port cle mer,' without which she was not safe 
 in sailing through the Mediterranean, nor was she admitted into 
 Holland. 
 
 It would be an endless task to go through what may be called 
 the collateral absurdities in the reasoning of the anti-contagionists — 
 yet we must mention one or two instances. Thus, it is said that 
 the doctrine of contagion is selfish and inhuman, and prevents the 
 due performance of the duties of the healthy to the sick; while 
 the doctrine of epidemic diseases remedies the evil. Yet the same 
 persons say, — 
 
 'People are attacked (with the plague) in proportion as the 
 ' inhabitants of unaffected expose themselves to the air of affected 
 ' places. The visits of the inhabitants of an unaffected to an affected 
 ' place is [are] attended with a certain increase of sickness/ — West. 
 Rev., No. V, p. 115. 
 
 Is it possible that they should not see that their objection applies 
 more strongly against this doctrine than against that of contagion;
 
 232 IS THE PLAGUE 
 
 for if the latter teaches us to avoid the sick, the former teaches us 
 to avoid the very air which surrounds the sick. The latter says 
 only, do not touch a patient affected with the plague, or the clothes 
 which he has worn ; you may go within a certain distance of him — 
 observe his symptoms — prescribe for him — carry him medicine and 
 refreshment. But the latter says, if you go into the chamber, or 
 the house, or the very neighbourhood in which the disease is raging, 
 you expose yourself to danger. 
 
 Another absurdity is, that the doctrine of contagion was a ^popish 
 trick, and never heard of before the year 1547, when it was invented 
 by Pope Paul III., as an excuse for removing the Council of Trent 
 to Bologna. Two learned foreigners, Dr. C. P. H. Mark and Dr. 
 Omodei, of Milan, have just published most satisfactory refutations 
 of this statement. That of the former is entitled 'Origines Contagii :' 
 that of the latter is contained in the twenty-second volume of the 
 Milan f Annals of Medicine :' of both an elaborate analysis is given 
 in the ' Edinburgh Medical Journal/ It was hardly necessary to 
 expend so much talent and learning as these gentlemen have dis- 
 played, upon a notion unworthy of serious refutation ; for who does 
 not see that whether the plague was contagious or epidemic, it was 
 equally a reason for removing the Council from Trent? A man 
 removes from a marshy district, not because ague is catching, but 
 because the spot is unhealthy; not to avoid the sick, but the 
 exhalations of the place. Besides, as far back as Thucydides and 
 Aristotle, through a long succession of historians and poets, down 
 to Boccaccio, the notion is traced that pestilential diseases are con- 
 tracted by communication with the sick. Dr. M'Lean is a little 
 sore on this subject, and he has a curious mode of defending himself. 
 When reminded in the Committee of Boccaccio's account of the 
 plague at Florence, in 1348, in which the healthy are represented as 
 flying from the sick, to avoid catching the disease, he says, — 
 
 ' It is necessary to ascertain the precise date of its being printed, 
 ' in order to appreciate the authenticity of the doctrines as being 
 ' those of the writer, or as being introduced by interpolation of 
 ' editors or commentators.' 
 
 What must be the condition of that man's mind who could suspect 
 interpolation on such a subject ? 
 
 In an act of parliament of our Henry VIII, in the year 151-0,
 
 A CONTAGIOUS DISEASE? 233 
 
 seven years before the imaginary popish fraud, barbers arc pro- 
 hibited from practising surgery, and surgeons from practising bar- 
 bery,* ' because persons using surgery often take into their cures and 
 ' houses such sick and diseased persons as have been affected with 
 ' the pestilence, &:c. — do use or exercise barbery, as washing <>i 
 ' shaving, or other feats thereunto belonging, which is very perilous 
 ' for infecting the king's liege people, resorting to their shops or 
 f houses, there being washed or shaven.' 
 
 Are acts of parliament subject to interpolation ? 
 
 But hear what may happen to a non-contagious disease. The 
 typhus fever of England, they say, is not contagious, and is only a 
 milder form of tlie plague of the Levant. The following case is 
 related by Dr. M'Lean's chief disciple :t a poor family in London, 
 consisting of four persons, were attacked with malignant typhus 
 fever ; they all lay in the same bed, in a close and dirty apartment, 
 where they were visited by two physicians ; the one, whenever he 
 entered the room, went to the window, threw it open, observed the 
 sick at a distance, and stayed a short time — he escaped the disease. 
 The other took no precaution, examined the skin of the patients 
 closely, and inhaled their effluvia and breath — he was seized with 
 the disease, and died of it. What is the inference ? that, although 
 the disease was communicated from the patient to the doctor, and 
 although he caught it and lost his life by approaching the sick, yet 
 i hat the process was different to what it is in contagious diseases, 
 and therefore it is not a contagious but a contaminative disease ! ! 
 It would be an insult to the understanding of our readers to offer 
 one comment on such reasoning. 
 
 When Dr. M'Lean was examined by the Committee on the 
 doctrine of contagion, he told them that his opinions were founded 
 on an experience of seventeen days ; but requested them ' to recollect 
 ' how little the value of experience might be commensurate with its 
 ' duration — that the plague was generally fatal in nine cases out of 
 ' ten — but that he could cure it in four eases out of Jive.' When 
 asked to what extent he had tried this triumphant mode of treat- 
 ment, he said upon one patient, and that was himself. When 
 reminded that Dr. Whyte had inoculated himself with the plague, 
 and had died of it, he said f that he took it by a coincidence.' 
 
 * Russell on Plague. t See Westminster Review, No. VI. 
 
 ll
 
 234 IS THE PLAGUE 
 
 When told that the Turks, who used no precautions to avoid the 
 plague, suffer much more from it than the Cliristians, who avoid it, 
 he said that he did not believe it, because he did not see the grounds 
 for it. When asked upon what grounds he concluded that the 
 Turks and Mahometans suffered less than the Christians ? he said, 
 not from actual observation, but from the nature of things, and 
 because there was no evidence to the contrary. He said, he woidd 
 not believe that a person had the small-pox twice, even if he were 
 to witness it ; he should distrust the evidence of his own eyes. 
 When asked at what periods of the year the plague at Moscow in 
 1771 had prevailed and declined? he answered, that his impression 
 was that it began at the usual epidemic season in northern lati- 
 tudes, and ceased at the usual time. Being thereupon asked what 
 he called the epidemic season at Moscow ? he rejoined, that it was 
 the same, or nearly the same, as in this country, judging from the 
 pestilence in 1771. So that the plague at Moscow was epidemic 
 because it raged at the epidemic season ; and that was the epidemic 
 season, because the plague raged at that time. These were a few of 
 the precious statements with which Dr. M'Lean favoured the Con- 
 tagion Committee, and we know not which to wonder at most, the 
 mind of the man who uttered them, or the patience of the Committee 
 who could listen to them. This gentleman has been described, by 
 an enlightened member of parliament, as one of those extraordinary 
 persons who will be pointed out by the finger of the future historian ! 
 Judging by Ins writings and his actions, we conclude that he is a 
 man of great self-confidence, zeal, and perseverance ; these qualities, 
 when combined with ability, judgment, and knowledge, form the 
 improvers of science, the master-spirits of their age, the benefactors 
 of their species ; but when combined, as they often are, with wrong- 
 headedness, and a heap of inaccurate and ill-digested knowledge, 
 they form very absurd, and often very mischievous men. Every age 
 affords examples of both ; the latter are not uncommonly mistaken 
 for the former ; but time corrects the blunder. 
 
 We are tired of refuting errors and exposing absurdities which 
 would require no refutation or exposure, if those who are to decide 
 were well acquainted with the facts of the question. We call on 
 our legislators, however, before they consent to abolish the system 
 of quarantine, to pause and reflect on the tremendous importance of 
 the stake ; to consider that these barriers were built up by our expe- 
 rienced ancestors, and that we have no experience who are about to
 
 A CONTAGIOUS DISEASE? 235 
 
 pull them down; that the experienced powers of the Mediterranean 
 behold with astonishment the opinions which have been broached in 
 England on the subject, and, in consccmence of the relaxations to 
 which our Government has already consented, have refused to admit 
 our vessels into their ports without a previous cniarantinc. We beg 
 them to remember how often, in their own families, they act on the 
 supposition of contagion, when the evidence amounts only to a pro- 
 bability; and we entreat them to legislate for the nation on the 
 same cautious principles as guide them in their own homes. 
 
 "We remember, a few years since, a newspaper story, with which 
 we will conclude. An old fellow, a chemist, appeared before the 
 Lord Mayor, begging leave to show, experimentally, that detonating- 
 balls were quite harmless, and drawing half a pound of gunpowder 
 out of his pocket, in which he meant to explode the balls, the Lord 
 Mayor exclaimed loudly against the experiment ; but at length, on 
 his earnest entreaty, and strong assurances, permitted him to try it 
 with a small quantity of powder. To the chemist's utter discomfi- 
 ture the powder exploded, on winch he protested that it ought not 
 to have done so. 
 
 If Parliament should be as yielding as the Lord Mayor, we shall 
 have the plague running over London, and Dr. M'Lean protesting 
 that it ought not to have spread, or, perhaps, supporting the sufferers 
 with the consolatory reflection that they are dying, not of a con- 
 tagious, but of a contaminative disease. 
 
 T11K KM). 
 
 PRINTED BY J. E. AULAKU, UA RT1IOLO.MIl W ClOSE.
 
 UNIVERSITY OF CALIFORNIA LIBRARY 
 
 Los Angeles 
 This book is DUE on the last date stamped below. 
 
 JUL 1 4 t98$ 
 m 2 4 Rflf 
 
 BlWB8E V&tco 
 
 ©SEP' 
 
 BiqBed jo 2978 
 
 BrOMED LIE). 
 
 2 WKS FROM RECEIPT 
 
 i MAY 1 % 1988 
 
 MAY 1 9 1988 
 RECD 
 
 Form L9-42m-8,'49(B5573)444 
 
 THE LIBRARY 
 UNIVERSITY OF CALIFORNIA 
 
 W SV3 A ■fcTZ-f T7IT T^rt