744

and send you the result of their experiments,1 remain, Sir, your constant reader andadmirer,

,TYRO.Aug. 31st, 1829.

PUERPERAL INFLAMMATION OF THE WOMB.

INFLAMMATION of the uterus, it is well

known, may occur either when the organ isin an unimpregnated state, or, in its puer-peral condition; the intensity of the diseasein each case varying according to circum.stances. As a general rule, however, theinflammation which attacks the womb after

child-birth, is the most acute and formidable,requiring for its treatment prompt and deci-sive antipblogistic means, whilst the diseasewhich affects the uterus in its simple state,is of a more chronic nature, and is removed

by comparatively less active treatment.

We believe there is no practical man whowill not concur in this opinion; it is,therefore, somewhat strange, that MasonGood* should state in an unqualified manner,that in puerperal inflammation of the womb,the symptoms are less acute than in simpleinflammation, and that " bleeding is to be

avoided." These reflections suggested them-selves to us on perusing the subjoined detailsof two cases ofhysteritis puerperalis, in thepresent number of the Medical and PhysicalJourrial, communicated to that publicationby Mr. Paxton, of Oxford." Mrs. B., aetat. 28 years, of a florid com-

plexion and sanguineous temperament, hadbeen married ten years, but had never beenpregnant till the present year. The usualtime of utero-gestation was passed withoutany troublesome sickness, or derangementof health. On the 21st of November, 1828,labour commenced ; the process went on

favourably and naturally, and at the end offour or five hours Mrs. B. gave birth to awell-formed female child. The placentawas expelled, with verv little assistance,in a quarter of an hour afterwards. Quiet-ness and composure were enjoined; but theinjunction was not complied with ; for thegratification of having become a mother afterthe lapse of an almost hopeless term of years,appeared to give rise to an excitation too

powerful for the due exercise of the vitalfunctions. In half an hour distressing symp-toms of hysteria came on, as screaming,

* Study of Medicine, vol. ii. p. 490.

sense of suffocation, pale cadaverous C9M’tenance, clammy sweats, and coldness ofthe extremities. On examination, there waifound considerable uterine discharge, and agreat sense of exhaustion followed.—Wineand water was given, and ammonia with 60drops of laudanum.

22d. The patient had a quiet night; butthis morning she complains of pain in theloins, and tenderness about the hypogastncregion. Passes water frequently, but iusmall quantities, and there is a very consi.derable lochial discharge. Pulse 125;tongue dry; thirst; surface hot and dry,and looks pallid. Calomel, gr. viij. statim,et haust. salin. quartis horis.

23d. Had copious alvine evacuations; lesspain, some sleep ; pulse 120. Pergat in usumedicamen. praescript. sine calomelane.

24th. Complains of headach; has hadchills, alternating with flushings of heat;acute and permanent pain in the same situ.ation as above described. When pressureis made, there is extreme tenderness of theabdomen, but no tension ; there are also

wandering pains over the whole body.Uterine haemorrhage continues.

25th. Haust. inf. rosae cum magn. sulph.3i. quartis horis. There is some abatementof the former symptoms. Large coagulawere expelled from the vagina during thenight. Haust. infus. rosae cum acid. sulph.dil. quartis horis. 01. ricini 3vi. statim.

28th. Up to this period no material changehas occurred. The pulse is small and fre-

quent ; tongue covered with a light brownfur on the back of it; temperature of theskin beyond the natural standard ; perpetualdesire to void the urine, which is scanty,deep coloured, and turbid. Lochial dis.

charge continues in considerable quantity.No milk has been secreted. Complexiénsallow. On some occasion the patient wasremoved from her bed, when syncope andclammy perspiration alarmed her attendants.She has no appetite, but is thirsty. There issome degree of fulness and uneasiness in theabdomen, but not amounting to pain, unlesspressure is made with the hand, which dis-covers the uterus to be thrice its unimpreg-nated size. Emp. canth. supra regionecuhypogast. applicaudum. Pergat in usu me.dicamen.December 3d. Some relief was procured’

the pains were very much diminished, and,on the whole, it may be said, that the trainof unpleasant symptoms and constitutionaldisturbance is subsiding. Pulse 10j; some.times small doses of ammon. subcarb. wereexhibited ; at others, effervescing medicineand occasional doses of ol. riciiii.

This state of things continued with littlevariation till the 8th, when marked rigours,sweats, and diarrhœa, suddenly, and cer-

tainly unexpectedly, supervened. Wine

745

and opiate confection were administered ;but the following morning (the 9th,) respi-ration became laborious, the sight dim, mindwandering, pulse scarcely perceptible ; pro-fuse colliquative perspirations bedewed thebody, and in the night the patient expired.

Sectio cadaveris.—The body was exa-

mined about twelve hours afterwards, inthe presence of Dr. Kidd. The liver, sto-mach, and intestines, exhibited no morbidaffection of any kind. There was no effusionor unhealthy appearance of the peritoneum.The disease was found to be limited to theuterus: this organ was five inches in diame-ter ; its peritoneal covering had some slightpencilling of vascularity; but its internalstructure had undergone very extensive

change. The whole inner surface was of adaik crimson and livid hue; the cervix wascompletely gangrenous, and gave forth a

highly offensive vapour.*CASE 2.—The second case occurred on

the 24th of May, 1829, on which day Mrs. H.fell in labour with her second child. A mid.wife attended her for fourteen hours; themembranes were ruptured, and very consi-derable haemorrhage took place, producinggreat faintness. A medical gentleman (Mr.Tomes) was therefore called in, who, veryproperly, immediately adopted an oppositeplan to that which had been hitherto pur-sued. Instead of warm stimulants, withwhich she had been plentifully supplied, heordered cold liquids, and sulphuric acid withinfusion of roses. This succeeded in sup-pressing the haemorrhage. The pains weretrifling. On examination, the hand of thechild was found to have fallen into the va.

gina. Mr. Tomes then requested my at-tendance. I advised the extremity to bereplaced, and the child to be turned; but,from the rigidity of the uterus, its powerfulcontraction, and from the large size of thechild, there was a delay of several hours be-fore this object could be accomplished. Thefeet were at length brought down, and thebody and head were then delivered without

Burns states, that " mortification is anextremely rare termination." Dr. Ley,(Medical Transactions of the College, vol. v.art. 30.) in describina the appearances ob-served in a fatal case of inflammation of thewomb, says, that " no appearance of mu-cous membrane remained ; the whole sur-face had assumed a gangrenous appearance,was extremely irregular, and of dark livid orgreenish liue, and these appearances wereaccompanied with considerable foetor." Sub-sequently, however, he states, that he wasnot convinced gangrene had absolutely- oc-curred, and refers the phenomena observed" to the effusion and putrefaction of lymphaud of blood in its aggregate state, effusedupon the surface of the uterus."—ED. L.

’difficulty. The placenta was not long de-tained. A sense of excessive fatigue andfaintness immediately succeeded, and a recurrence of hsemorrliage. Took tr. opii,m xl.

23th. The patient was very restless, sigh- ing, and experienced great pain in the backand hypogastric legion. Pulse 140 ; calo-mel, gr. x.; opii, gr. ij. statim. Haustetfervescens quartis boris.

26th. More comfortable ; pulse 110 ; butin the evening, chills and cold perspirationswere frequent, and the pain increased. Ca-lomel, gr. viij. ; opii, gr. ij. statim. Pergatin usu haust.

27th. The patient feels less pain, and hashad some sleep. Pergat.

28th. Passed a restless night, and the painhas returned with greater violence. Thereis a sense of exhaustion, fainting, anxiety,and general uneasiness : in particular, painover the uterus, which was increased on themost moderate pressure ; but there is noabdominal tension. Lochial discharge inconsiderable quantity. Applicentur hiru-dines xx.Somewhat relieved; but the circumscribed

swelling and tenderness at the lower part ofthe abdomen continue, and in the eveningcomplained of great pain and tendernessabout the os uteri, rigours or heats, depres-sion of spirits, ’ and general uneasiness.V.S. ad 3xxiv. Haust. efferves. cum ant.tart. gr. tertiis horis.The blood drawn exhibited marks of in-

flammatiou. The pain and sensibility, how-ever, was much diminished, and from thistime there may be stated to have been a rapidamendment until the 6th of June, when aslight attack of phlegmasia dolens super-vened, and protracted the cure for threeweeks longer; since which the patient hat)been free from complaints, and, indced,about her domestic occupations.The reflections I make on a comparison of

these cases are,ist. That copious depletion is the most

powerful means of subduing inflammatoryaction of the uterus.

2d. That uterine discharges have no effectin relieving that organ, when suffering underinflammation.

3d. That neither thefaintnfss experiencedby the patient, nor even uterine haemor-

rhage, or weakness of the pulse, should haveany weight on the mind of the practitioner,so as to prevent his carrying local or generalbloodletting to its requisite extent: for if

ithere is fever, with constant uterine andgeneral pain, this is the true criterion for

forming a judgment of the propriety of themeasure, and not any other comidt-ration., whatever.

-

746

ON THE PRECISE SEAT OF TIIE SMALL-POX

PUSTULE.

The following observations by Mr. GEORGEOAKLEY HMIING, surgeon, of Kentishtown,are also published in the same journal.IT has appeared to me that a distinction

may be made between the pustule of variolaand the vesicle of varicella, by observing thedistinct seat of these affections. From an

investigation,pursued with considerable care,I think [ have ascertained that the formerhas its seat in the sebaceous glands andmucous follicles, whilst the latter seems tobe merely subcuticular in general. Theexact seat of the variolous pustule seems tobe determined by observing the texturesmost apt to be affected by it, and the tex-tures excluded from it; the form of the

’pustule itse1f, its difference from that of thevesicle of varicella, and its similarity to thatof some other affections of the sebaceousglands. A still more direct proof of thispoint flows from minutely observing the

anatomy of the sebaceous glands and mu-cous follicles, and tracing that of the vario-lous pustule.The practical advantages of the inquiry

consist in its affording a source of diagnosis,and in its tendency, in this manner, to set-tle some disputes which still divide themedical profession, and to enable us betterto decide upon the real value of vaccination.It may be observed, that the variolous pus-tule is confined to the skin and mucousmembranes. After much diligent search, Ihave never been able to detect any thing atall resembling it in the serous membranes.I do not mean to say that there is, in no.case of variola, inflammation of a serousmembrane, but that I have not been able todetect any appearance of variolous pustule,or difference from that of common inflam-

mation. Then the circular, flat, and in-dented form of the variolous pustule differswidely from the hemispherical form of thevesicle of varicella : it is observed, too,from the hardness felt on an early examina-tion, that deeper seated parts are affected inthe former than in the latter disease. BeforeI proceed, I would observe that, althoughI have spoken of the variolous pustule asaffecting the follicles of the mucous mem-brane, such pustules are never perfect, thepresence of a cuticle being required to formthe perfect pustule. The variolous affec-tion of the mucous membrane assumes, first,the form of an inflamed point, then becomesan ulcer, and then passes into a state re-sembling that in alehthm. Wrisberg, Con-tumnius, and others, may therefore well havedisputed whether the perfect pustule of va-riola existed internally.

It is well known that the variolous pus-

tule Qccurs in every part of the sntface ofthe body. HaUer considered that the seha.ceous glands had not been demonstrated inevery part. Alorgagni bad seen them inthe back, neck, and other parts. Bichat

goes so far as to doubt the existence of thesebaceous glands; but his follower in thisinquiry, Beclard, distinctly affirms their ei-istence. Lastly, Chevalier says, that theyexist in every part of the cutaneous texture;and the last-named author has depositedpreparations in the Museum of the Collegeof Surgeons, showing the sebaceous glandsin the nose and chin of the infant. He con.tends that there are two sets of these glands,one more superficial than the other.The variolous affection is to be seen in

some part of the track of the mucous mem.brane, in almost every case of the disease,but in no single case in great number, Itis equally true, that the mucous folliclespervade the whole of these membranes.There are some parts of the mucous mem.branes, as on the tongue, the palate, andthe mouth generally, covered by a cuticleof sufficient thickness occasionally to allowof being distended by fluid effused under.neath, and, consequently, of the formationof a pustule. But, in most parts of themucous membranes, there is either no cuti-cle, or it is so thin as not to allow of dis.

tention by the subjacent effusion of fluid:in these, of course, no pustule can be form.

ed ; but we observe the mucous follicle en.larged by inflammation, covered by a layerof whitish matter, very much resemblingthat in aphthae, and sometimes ulcerated.Whether one or other of these appearancesbe found, will depend upon the different

periods of the disease at which the exami.nation of the mucous membranes takes

place. It is a curious fact that, throughoutthe mucous lining of the bowels, extending;from the stomach to the rectum, there is noportion of it where the mucous follicles areso frequently affected by small-pox as inthat of the appendix vermiformis, In reo

gard to any affection of a serous membrane,I must repeat, that I have never observedany thing either pustular or of the characterof the affection of the follicles of the mucousmembrane, which I have just described.The sebaceous glands, as is well known,

are small bodies, whose office is to secrete

a greasy matter, which is poured forth bytheir excretory ducts, and distributed overthe skin, and into each of these ducts tbecuticle dips. This organisation cannot bediscerned in the healthy state of the sebs.ceous glands; but, when they are diseased,itmay sometimes be seen even without a lens:they are very prone to diseases, of whichone form is called acne. It was the resem-blance that this diseased state of the seba.ceous glands bears to the little tumoun

747

htind in the early stage of small-pox, andthe striking similitude to a small-pox pustuleat a more advanced period, when an her-petic eruption about the chin extends overan enlarged sebaceous gland, conjoined to

other circumstances, which first led me tosuppose that the sebaceous glands and mu-cous follicles were the parts affected byvariola. Sir A. Cooper remarks, that sometumours arise from an enlargement of thesebaceous cysts, in consequence of theirorifices being obstructed; and he observes,that within the cyst there is a lining ofcuticle, which adheres to its interior, andseveral desquamations of the same sub-stance are found within the first lining."I am now attending a young woman who hase disease of these glands, and the orificesare so much enlarged that I can pass intothem a bristle. I applied a blister, and, bythis means removing the cuticle, had adrawing taken of the part, in which thisfact is illustrated. The sebaceous glandsand mucous follicles bear the strictest ana-logy to each other, both in their structureand functions, and consequently are apt tobe affected by the same diseases.

I now proceed to give an account of theappearances of the perfect variolous pustule:I would first observe, most particularly,that, although the indentation of the pus-tule of small-pox has generally been con-sidered by medical writers as one amongmany other circumstances by which wemay be enabled to distinguish it from

chicken-pox, it appears to me that, not

being acquainted with the cause of this verycurious circumstance, they have not attachedto it theimportancewhich it seems to demand.This indentation in the pustule can onlydepend upon the structure of the part affect -ed ; it is the natural formation of the cuticleat that part which produces the depressionm its centre.Dr. Armstrong says, " I have never seen

the central depression absent in small-pox,and, what is remaikable, I have never seenit present in chicken-pox.* My own prac-tice confirms this observation ; and I thinkthat most medical men must have observedthe uniformity of the central depression insmall.pox. The inference I would draw is,that small-pox, at all times, attacks the samestructure. At the earliest stages of theeruption of small-pox, it is generally firstseen in the hands and face, where smallreal spots indicate the inflamed state of thecutis. On these spots a small, round, hardtumour may be perceived by the touch, be-fore it becomes visible. In twenty-fourhours it is still more distinct; it gradually

‘ Dr. Armstrong is in the habit of show-ing, at his lectures, casts, which well ilIus-trate the central depression.-ED. L.

! changes its form until the third or fourth day, when it is perfectly circular, with aff attened top, in the centre of which an in-dentation may be perceived, resembling, ithas been remarked, " the impression madein the skin with the head of a large pin."The vesicle is then about the eighth part ofan inch in diameter ; it is of a cellular struc-ture, and filled with lymph, somewhat tur-bid, and finally purulent. By the fifth orsixth day, its size has augmented to twiceits former diameter. The central depressionis commonly evident on the second or thirdday in some of the pocks, where they arenumerous. Dr. Munro, in his Observationson the Small-pox, remarks, that " the cen-tral clear part of the pimple is evidentlydepressed on the fourth or fifth day : this

depression is not to be perceived in all thepimples in the same light ; but, by turningthe body, it can be seen in those vesicularpimples in which it had not been previouslyperceptible. This fact is generally over-

looked, and has often led to the denial of theexistence of the central depression when itwas present."

’, There may be cases in which the centraldepression is not perceived without muchdifficulty; but, if the pustule be carefullyexamined by a microscope, and in a properlight, it will be discovered ; it is most ma-nifest when the internal fluid is clear, and isessentially different from the depression inother eruptions, which exist only after theapex is encrusted. As the disease advances,a red ring shows itself round the circum-ference of the pustule, and becomes wideras it increases in size. There is a remark-able appearance of the pustule on the sixthor seventh day, which was pointed out tome by Dr. Marshall Hall : there is an ex-ternal ring of rose colour, in which is an-other ring of white, evidently rendered so bythe colour of the contained fluid; withinthis is a third ring, which is red, and hasan appearance as if the surface of the pus-tule was in contact with the flesh beneath ;and in the middle of this there is a portionwhich again looks white, but is dull and

cloudy ; these appearances I have constantlyobserved about the sixth or seventh day.After the seventh or eighth day, the pustuleloses its indented character, and becomesnearly spherical. If it be opened, it willbe found to contain pus ; and not only thesmall sebaceous gland, which was at first

merely inflamed and enlarged, has becomedisorganised, but all these small glands,within the circumference of the pustule,have partaken of this disorganisation, and aslough is formed nearly of the size of thebase of the pustule. A portion of coagula-ble lymph is thrown out around the slough,and this I am inclined to think is what Mr.Cruikshank supposed so be a membrane

748

situated between the rete mucosum andcutis, and which he has called the membraneof small-pox.Mr. Cruikshank describes this vascular

membrane as situated between the rete mu-cosum and cutis, and which he had injectedin the skin of persons who had died of the

small-pox. During the summer months hemacerated, in water, pieces of small-poxskin, which had been kept for some time inspirits, and he says 11 the cuticle and retemucosum were turned down, and, upon theeighth or ninth day, I found I could separatea vascular membrane from the cutis." Thereis little doubt but this was the vascular net-work described by Bichat, which Mr. Cruik-shank had injected, and, in consequence ofthe effusion of lymph which I have pre-viously described, lie was enabled to sepa-rate it in the form of a membrane.From the back of a patient who died of

the small-pox, I removed a portion of skincovered with pustules, which I macerated inwater eight or ten days. I succeeded in

removing the cuticle from the pustules;these still retaining their form, and beingcovered by another membrane. But, in thepresent doubtful state of our knowledge asto the existence of the rete mucosum in thewhite races, I found some difficulty in decid-ing whether this was the rete mucosum, oronly a layer of coagulable lymph effused atan early period of the formation of the pus.tule, and subsequently raised with the cuti.cle by the pus contained in the pustule.Dr. Armstrong has this preparation.Mr. Cruikshank found, that in the centre

of the pustule of small-pox, there was a

white substance, which he could not inject ; -,and this Mr. Hunter said was a sloug’hformed by the variolous inflammation. He

thought it was always to be found in thisdisease, and that it was a circumstance bywhich it might be distinguished. In mostcases it does exist, but 1 believe there aresome exceptions. Upon this subject, how-ever, I cannot speak decidedly, as I havenever had an opportunity of minutely exa-mining that kind of pustule. The cases towhich I allude are those of modified small-

pox, particularly as occurring after vdccina-tion. Here we have an inflammation of amore moderate kind, and partaking more ofthe adhesive character. Lymph is pouredout, which gives a peculiar hardness to thepustule, and, as the eruption subsides, a

small tubercle is left. The lymph, however,is again absorbed, and the hardness and

swelling are gradually removed. If these

pustules were examined at any period, 1 donot think the slough would be found. ;

The parts around the nipple, particularly ! in the female, seem so afford the best place Ifor the examination of the structure of the

small-pox pustule, as the sebaceous glands

’ there are more conspicuous than in most other parts of the body. In order to incM-

tigate it to the greatest advantage, it shouldbe done at an early period of the eruption,and before the disorganisation of the partstakes place.

If I have succeeded in showing thatvariola and varicella always attack differentstructures, I shall have established a factwhich will be useful in any further inves.tigation of this subject. If the seat of thesmall-pox be ascertained to be the sebaceousglands and mucous follicles, something notimmaterial is added to our knowledge of thedisease : there is a foundation laid ior futureinquiry.There are many other points of difference

between the variolous and varicellous affec-tions, which are known to those who haveconsidered this subject, and must not beoverlooked ; but I have been rather desirousto draw the attention to those differenceswhich prove that the two diseases attackdifferent structures.The minute anatomy of the parts affected

has been so neglected, that our knowledgeof the progress of the variolous pustule isbut imperfect; and this is a result of the

importance of that knowledge not beingthoroughly understood. The varicellous ve-sicle is hemispherical and inelastic; it is

easily broken, and being once opened it

empties itself entirely, and never fills again.The variolous pustule is circular and elastic,and if an opening be made into it and somematter taken from it, the pustule will never-theless soon be distended as fully as before ; and this is evidently a consequence of itscellular structure.

MIDDLESEX HOSPITAL AND LONDON UNI-

VERSITY.

To the Editor of THE LANCET.

SIR,—I read with much pleasure yourleading article on hospital fees, and the ex-orbitant price pupils are made to pay ior" walking the hospitals," (there could uothave been chosen a better name for It,) at

few of wiiich places are clinicallectures el’erdelivered. I sincerely hope that your effortsmay prove successful in restraimng the pick-pocket system ; but, alas, I fear it is too

deeply rooted for even your thunders to up-, set it.

Jt appears from a prospectus just issuedby the University of Loudon, th8t its me.

dical officers have determined it shall notbe said that their pupds do not enjoy thatbest mode of instruction, clinical lectures;and, accordingly, there is the following, at