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still retains it. The drawing, No. I., obligingly made by my friend Dr. Branson, shews very accurately a microscopic view of a portion of it magnified 250 diameters, which proves it to belong to the class of

o'clock at night and continuing till five or six o'clock
the following morning, when she became perfectly easy.
Her nights were wretched; her appetite bad; muscles
emaciated; and that peculiar discolouration of skin,
and painful and anxious expression of the face softbrous tumours.
commonly found in scirrhus uteri was
very remarkable in this lady. She
had no leucorrhoeal discharge, but the
bladder and rectum were irritated and
difficult to manage. I could only suc-
ceed in introducing (and that with
the greatest difficulty-the bymen being
unruptured) Salmon's speculum ani
into the vagina, but I managed, with
the aid of a good lamp, to clearly ascer-
tain the absence of the least increase
of size, form, or density of the cervix
uteri, and the os uteri was quite nor
mal. I assured her she was not suf-
fering from cancer, prescribed acetate
of morphia, iodine, and iron, which
soon relieved her acute sufferings, and
she returned home toj her friends at
some distance.

In July, 1846, I was sent for to
see her at her residence, and there
met her two medical attendants, who
had succeeded in convincing her she
was labouring under cancer of the
womb, and that she had not long to
live. She was greatly emaciated, con-
stantly bleeding from the uterus, her
nocturnal pains had become intolerable, and she
told me her life was a burden to her. I succeeded
in dilating the vagina with a sponge tent, introduced
with great difficulty Simpson's Speculum Vaginæ, and
through that his uterine sound, five inches and a half
into the uterus, which I examined from the abdomen
in front and through the rectum behind, and found
perfectly moveable. A deluge of blood followed this
examination, but I was quite satisfied the neck and
mouth of the uterus were not diseased. I assured
her she had no cancer; but that her disease con-
sisted of a tumour of some kind in the uterus. I
gradually dilated the vagina and os uteri by means
of sponge tents and Simpson's uterine dilators, until
I could see and feel the tumour in the uterus.
I then introduced the uterine sound, passed it all
round the uterus to ascertain the nature of the
tumour, and during that operation I accidentally
detached the tumour from the lining membrane,
and it came away with considerable hæmorrhage,
in one piece, weighing four ounces. The hæmor-
rhage ceased under the influence of ergot; the
nocturnal periodical pains became very much dimin-
ished, and I was in great hope my patient would
get well; but in the course of a few weeks the old
periodical pains and discharge returned; and on
a fresh examination with the speculum and uterine
sound, I discovered a new growth of tumour.

I am sorry I cannot shew this tumour, I sent it up to Professor Simpson, of Edinburgh, for the purpose of obtaining his opinion respecting the case, and he

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There being no pedicle to this tumour, I could not expect to detach it again advantageously; I therefore determined to try the effect of iodine internally and externally, in the form of tincture, balls, and injections, assisted by quinine and iron, and acetate of morphia, to relieve the pain. I have pursued this plan for four months; the result is she has less uneasiness of every description; her nights are good; her appetite, strength, and flesh have improved; and the tumour, as ascertained by the uterine sound, has decreased in size an inch and a half; the os and cervix uteri remain perfectly normal. She is now quite convinced that her disease is not cancer, and lives in hope that she may eventually be quite cured.

CASE II.

A delicate hysterical female, aged 35, married five years without ever having been pregnant, was attacked soon after marriage with severe burning, agonizing, and lancinating pains, referred to the neck of the womb, and extending from pubis to sacrum, thence down the thighs. These pains came on periodically every night about ten o'clock, and increased in intensity until about six in the morning. She was quite free from pain during the day. The pain on coition was excruci ating. She had very frequent hæmorrhage, and when this ceased, a sanious kind of matter, mixed with a fluid resembling pus in appearance, kept her constantly wet and uncomfortable; added to which the bladder and rectum were very irritable.

When she consulted me, in July, 1846, for what she

CASES OF NON-MALIGNANT TUMOURS OF THE UTERUS.

had been led to believe was cancer, she was emaciated, had a greenish sallow complexion, with that pceuliar appearance in the countenance indicating malignant disease. I examined the uterus by means of the speculum, found the os healthy, but the cervix elongated and rather narrow; the least touch with either my finger or the sound gave her great agony; I therefore desisted, and gave a cautious opinion. Iron, quinine, and morphia, with astringent and sedative injections, relieved the symptoms so much, that in October last I was enabled to introduce the uterine sound, which penetrated the uterus to three inches and a half, and I easily discovered by examination from the rectum and abdomen that the uterus was not attached to any other organ, but was, at its fundus, much larger than natural. I dilated the os uteri with Simpson's dilator, and then found a tumour apparently attached all round. I got hold of a bit of this with a pair of long forceps, cut it off, macerated it in spirit of turpentine, and examined a thin slice of it under the microscope, a specimen of which Dr. Branson has also kindly delineated for examination. (Drawing No. II.)

Finding this also was a fibrous substance of the same description as the first case, I resolved to let it alone, and try the effect of iodine internally and externally, by means of introducing the tincture into the uterus, injections, and balls. The result is, that by these means, aided by tonics and the cold shower-bath, the tumour has almost if not quite disappeared, and with it the whole of the distressing symptoms which were so similar to cancer as to have induced more than one practitioner of eminence to call the disease by that

name.

CASE III.

345

"A lady, aged 63, laboured under some obscure symptoms for more than two years, which induced her medical attendant to believe that she had some disease of the bladder. One day she was seized with sudden and profuse discharge of blood from the vagina, accompanied with sharp uterine pains, like those of incipient labour or miscarriage. I was then called to her, and informed by her surgeon that she had some disease of the womb, which he believed to be scirrhus. On examination I discovered that the os uteri was a little dilated, and very thin, with something protruding from the uterus, the nature of which could not at that time be correctly ascertained. She had long been suffering periodical pains in the region of the pelvis, I directed some ergot of rye, and on the following morning I found that the tumour had descended much lower. I passed Simpson's sound into the uterus, and carried it quite around it twice. Two hours after a large fibrous tumour came away, without pain, and the hemorrhage ceased; it was larger than a commonsized kidney, with an attachment about the size of a shilling, and it appeared to come away clearly

and entirely. All the former symptoms disappeared, and she rapidly improved. This amendment, however, did not last long; for about a month afterwards, periodical pains re-appeared about the region of the uterus, and some discharge. A most careful examination failed to detect any cause for these symptoms, which, although occasionally relieved, never subsided for any length of time. It is now more than three months since the tumour was removed; the pains are more severe, and generally occur every afternoon or evening, and resemble those of cancer in its early stage; the discharge, too, is more profuse and bloody, so that its effects are visible in the countenance and constitution. Her sleep and appetite are becoming impaired. I have repeatedly examined her with great care, but can detect nothing more than an enlarged, painful, and indurated state of the uterus, but I do not find any ulceration, or even thickening,

of the neck. Thinking there might be another growth, I dilated the os uteri with sponge tent, and examined that organ internally, without discovering any cause for the symptoms. She is generally free from pain until towards evening, when dreadful pain comes on. At first this did not happen every evening, but now she scarcely passes a day without much pain."

The only tumours growing from the internal membrane of the uterus described by authors, are soft and hard polypi, encephaloid, cauliflower excrescence, hæmatoma, scirrhus, and fibrous; the latter often

This case has been related to me by my friend Dr.running into osseous and calcareous tumours. The Toogood, of Torquay, which I will give in his own words.

symptoms and progress of these diseases are quite different from those I have described; and I have

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consulted the works of Dr. Montgomery, Dr. Davis, Dr. Lee, Dr. Churchill, Dr. Lever, Ingleby, Dr. Gooch, Dr. Ashwell, Dr. Marshall Hall, Dr. Henry Bennett, Boivin and Dugés, by Hemming, and Mr. Lee's Prize Essay, and can find no notice of a disease like the three cases detailed, all of which might be so easily mistaken for scirrhus and cancer, unless examined carefully by the aid of Simpson's speculum sound and dilator.

The first morbid change which takes place in scirrhus uteri is induration in and around the muciparous glands or vesicles, called by some ova Nabothi, which exist in great numbers in the cervix and margin of the os uteri. This induration is caused by the deposition of scirrhous or tuberculous matter, which thickens the parts, and gives them a greater volume, so that they feel unequal, bumpy, and knotty, like the ends of one's fingers drawn together; but in the cases described, no thickening or hardness can be either seen or felt. The severe pains are difficult to account for, unless the irritation and stretching of the neck of the uterus by the tumour can be considered sufficient; but even then, it is still more difficult to account for the absence of pain in the day time.

The periodical nature of the acute pain attending such fibrous tumours, which so nearly resembles that suffered in cases of cancer uteri, and the relief afforded by the treatment with iodine, will, I trust, be considered by the members of this Society, a sufficient apology for introducing the subject to their notice. Rotherham, March 4, 1847.

CASE OF PUERPERAL MANIA,

OCCURRING AT AN EARLY PERIOD OF UTERO-GESTATION, AND RELIEVED BY INDUCED ABORTION.

TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL.

SIR,

I propose from time to time to send you a few cases and observations copied from my note book, for publication in the Journal. Should you consider the present communication of sufficient value, you will oblige me by inserting it.

I am Sir, your obedient servant,

THOMAS SALTER, F.R.C.S.

Poole, May 20, 1847.

Puerperal Mania as its name implies, is unsoundness of mind occurring in the puerperal state, and most frequently from three to ten days after delivery, owing its origin to a peculiar irritation of the uterus derived from its previons impregnated condition. The peculiarity of the case about to be related, and to which it chiefly owes its interest, is the occurrence of mental disease antecedently to parturition, and at so early a period of gestation.

The various sympathetic derangements of the functions of the body resulting from uterine impregnation, in

ordinary cases, sufficiently attest the intimate connection subsisting between the womb and its appendages with the organs of organic life, and the frequent functional disturbance of the sensorium and the spinal system of nerves, as clearly manifest its influence on animal life. I am not aware that there is any case recorded similar to the one I am about to relate, but I know of no reason why such should not have happened; indeed Dr. Ramsbotham observes, that puerperal mania sometimes occurs during pregnancy; and it may be inferred from the introductory remarks of Dr. Gooch, to his chapter "On disorders of the mind in lying-in women," that he also was aware of the fact.

Puerperal convulsions mostly occur during labour, or, as in the case of puerperal mania, soon after delivery, but convulsions precisely similar are also some-,

times observed, (though rarely,) at different periods of utero-gestation. Some years since I had a patient who was thus affected in several of her pregnancies, commencing at an early period after impregnation, and who, in every instance, went on to her full time, and without any apparent injury to herself or child.. Puerperal mania and puerperal convulsions are kindred affections, and are essentially diseases of the nervous system, the primary morbid impression being exercised in both cases on the peripheral extremities of the uterine nerves. For the production of the former, the irritation is propagated to the sensorium; and for the latter, being conveyed through the excito-motory system of nerves to the spinal marrow and brain, induces the epileptic paroxysms,

CASE.

The subject of the following case is a lady of about thirty-one years of age, of delicate organization, fair and ruddy complexion, with dark hair and eyes, usually enjoying good health. She has been married three years and has been three times pregnant. In her first pregnancy a disordered state of the intellect commenced about the seventh month, and after continuing a fortnight, labour came on, and in a moderate time she was safely delivered of a female child, who is now living and in good health. She again proved pregnant, and this time the mental alienation showed itself about the termination of the sixth month, mani

festing the same symptoms as in the preceding attack— constant restlessness, almost total absence of sleep, and such a degree of violence of manner, as often to require four or five persons in constant attendanceupon her night and day. After continuing in this state for two or three weeks, it appeared to the medical gentleman under whose care she was, necessary to bring on labour, by rupturing the membranes and evacuating the liquor amnii. This was accordingly done and in five days she gave birth to a still-born child. The violent paroxysms of insanity which before threatened her life, two days after this event ceased, and she gradually recovered her former state of mind. Soon after her removal to this neighbourhood, from the north of England, her former place of residence, she became pregnant a third time, and on this occasion the unsoundness of mind showed itself shortly after she had passed the fourth month. From this period

CASE OF PUERPERAL MANIA.

347

my attendance commenced. The preceding account | found to be slightly opened, and the cervix seemed also I received from the lady's husband, whose intelligence and constant presence about her person, guarantee its

correctness.

I was bastily requested to visit this lady at two o'clock, a.m., March 5, 1844. I was informed that previously to going to bed she had manifested considerable irritability of mind; at the time of my visit she laboured under total mental alienation, and was constantly talking in an incoherent manner. I prescribed a sedative mixture, with æther and camphor, which appeared to have some quieting effect, but scarcely any sleep was obtained through the night. After this time she became more violent and unmanageable, requiring sometimes four or five persons to keep her in bed, incessantly talking, either religiously or quite the reverse; she also had occasional fits of screaming, so loud as to be heard by the neighbours living at a considerable distance from her own residence. She continued in this state, and without any sleep, day after day.

Saturday evening, five days from my first visit, (since which she has had no sleep,) there being no improvement, and no signs of abortion occurring, in order to ensure the safety of the patient, it appeared necessary to adopt the practice which had been so judiciously carried out in the previous pregnancy by her then medical attendant; but from the length of the cervix uteri, and its undeveloped condition at the period at which she bad now arrived, I felt that greater difficulties would present themselves in rupturing the membranes than on the occasion referred to. On making an examination for this purpose, the os uteri was found high up, and situated backwards towards the sacrum, and was therefore with difficulty reached; it was, moreover, so closed, as not to admit the point of the finger. The cervix was, as far as could be ascertained, of the usual length of that of the unimpregnated uterus. By passing the stilet of a catheter on the front part of the fore-finger of my left hand, whilst that member was in the vagina, and pressing against the os uteri, I made an attempt to puncture the membranes. Much difficulty was experienced in passing the stilet through the cervix, which, however, I once effected, but no fluid followed its withdrawal As I therefore did not succeed in my object, and fearing the cervix uteri might be injured by further trials, I desisted for the present from the purpose I had in view, and determined to make trial of the ergot of rye, in the hope by the influence of that drug to produce abortion. It was exhibited in the form of infusion, in proportion of three drachms of the powder to eight ounces of boiling water, giving one ounce of the infusion, with a drachm of the tincture, every two bours. From the violent and unmanageable condition of the patient not allowing it, the medicine was not given either as often or as regularly as could have been wished, and no sensible effect being produced by it, on Monday, the 11th, a scruple of the powdered ergot was added to each dose of the infusion.

Tuesday evening, March 12th. Another attempt was made to puncture the membranes, and which happily proved successful. On this occasion the os uteri was

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somewhat shortened, changes favouring the operation, and evidently produced by the use of ergot. From the state of the patient's mind it was difficult to ascertain whether or not there were any uterine pains. Remembering the difficulty experienced in my first essay, and the danger there appeared of injuring the cervix uteri, I, on this occasion, employed an instrument, (contrived by my son, Mr. S. J. A. Salter, now a student in the Medical School of King's College,) expressly with the view of avoiding the possibility of this accident. It consisted of a flexible gum male catheter, but of sufficient firmness to preserve its straight form, even when opposed to a moderatelyexisting body, having a perforation at its extreme point, just large enough to allow a common wire stilet to pass through.

The patient, lying on her left side, and near the edge of the bed, the catheter was introduced into the vagina with the right hand, and pushed forwards upon the anterior surface of the fore-finger of the left, and in this manner it readily entered the os uteri, and passed through the cervix; withdrawing the finger from the vagina and os uteri, the instrument was pressed forward until it met with steady resistance. The stilet was then introduced and passed on, making its exit at the opening prepared for it, when it was immediately found to have perforated the membranes. Renewed pressure being then made upon the catheter itself, that also entered the cavity of the amnion, and on withdrawing the stilet the liquor amnii flowed in a full and continuous stream, as urine is observed to do from a catheter introduced into a distended urinary bladder. The fluid collected amounted to about a pint and a half. Nothing could have been more successful than the use of this simple instrument, and I would venture to recommend its employment to my professional brethren, as equally adapted for the purpose for which it was had recourse to, as the ingenious cutting instrument contrived and recommended by Dr. Ramsbotham, which I did not happen to possess, and the use of which, in unskilful hands, might not altogether be unattended with danger, and be especially hazardous in cases where the cervix and os uteri are undeveloped, as in the present instance.

After the evacuation of the liquor amnii, the patient took one or two more doses of the ergot of rye, but as its previous exhibition had not occasioned any very decided uterine action, as evidenced by the absence of the usual pains, and the liquor amnii being so entirely evacuated, the further use of the medicine was not urged, in the confident belief that the ovum would be soon expelled by the natural efforts.

In the middle of the night of Thursday, the 14th, (nine days after the commencement of the mental derangement, and fifty hours subsequent to the puncturing of the membranes,) expulsive pains came on, and the delivery was accomplished at two o'clock on the morning of the 15th, being fifty-two hours after the rupture of the membranes and the discharge of the liquor amnii. In a very short time subsequent to this there was a manifest improvement in the state of the patient, and though still incoherent, and having

occasional paroxysms of violence, she became more quiet and manageable, and slept occasionally for a few hours. On the second day there were intervals of comparative soundness of mind. Since this period her improvement became gradual, and though slow, regularly progressive, and she is now, (April 5th,) in her usual health in every respect. She had, however, two or three violent paroxysms after her delivery, and frequently awoke from her sleep in a fright, screaming violently, and she, moreover, passed many nights without sleep; at such times, as well as previous to delivery, to procure rest, opiates were occasionally given, but they only appeared to answer the purpose once or twice, and from their heating and other effects, seemed to be rather injurious than otherwise.

During the whole progress of this case, the pulse was seldom more than 100 in a minute, and often not more than 80; the skin was cool, and there was upon the whole less disturbance of the functions than might a priori have been expected from the violence of the symptoms, and the long absence of sleep.

May 20th, 1847. This lady is now living, and in good health, but has aborted once without any unusual circumstance happening, the only time of her being pregnant since the above case occurred.

she came out of her cabin in two minutes, to tell me it had stopped the pain instantly. I requested her to re-apply it if necessary. The pain returned once when it again immediately and entirely relieved it. If so minute a quantity as is contained in the wine, could be attended with such good effects, I think much more might be expected from its use in the concentrated form of emetine.

Hospital Reports.

HÔPITAL DE LA PITIÉ, PARIS.

A CASE OF MENINGO-MYELITIS. (Communicated by SEPTIMUS LOWE, Esq., M.R.C.S.E.) History of the case; present attack; symptoms on admission; treatment; remarks.-Importance of a proper diagnosis from lesion of the brain; from a tumour or ramollissement, &c., of the spinal cord; from epilepsy, spinal irritation, &c.—Indications for

treatment.

M. B., a boy, aged 16, was admitted into the Hôpital de la Pitié, under Professor Piorry, April 21st, 1847. He is slightly made, rather short for his age, of lymphatic temperament, and fair complexion. He

IPECACUANHA IN THE BITES OF VENOMOUS appears to be very cheerful and intelligent, and

ANIMALS.

TO THE EDITOR OF THE PROVINCIAL MEDICAL AND SURGICAL JOURNAL.

SIR,

If you consider the following case likely to be useful on further inquiry, in the relief of venomous bites of reptiles and stings of insects, I wish you would publish it. I must own it made a great impression on my mind, and I should be glad if the profession generally

would try the remedy and publish the results if successful. I have never had another case, but many of my friends have found it useful in the sting of wasps. I remain, yours faithfully,

HENRY COLLET.

Worthing, June 12, 1827. Some years since the daughter of Templer, Esq., about eight years old, had her hand upon the companion ladders of the East India ship, Malcolm, when she suddenly felt it bitten by something which was not observed, but the two specks on her finger plainly showed the marks of a centipede's fangs, of which many of very considerable size had been caught. As surgeon of the ship I was called to her assistance, and found her in very great suffering, and after exhausting all the remedies usually considered useful,-oil, spirit, laudatum, ammonia, &c.,—I recollected having been informed by an old officer in a previous voyage, that the best cure for the bite of a rattlesnake was ipecacuanha. I fetched a bottle of wine of ipecacuanha from the chest, and gave it to the mother to apply locally, at the same time telling her that I had not the slightest faith in the remedy; but to my surprise and delight

answers questions with great perspicuity and accuracy. He states that for eight years he assisted his father to carry wood, and was constantly exposed to all kinds of weather. During the last year he has been a fringemaker, residing at Paris, working in the same room with several other persons, and sleeping alone in a small but well ventilated apartment. His food has generally been neither very abundant nor very wholesome. He was always rather weak and small for his age.

colds, but he never had an attack of epilepsy, convalHe has occasionally suffered from severe sions, or any serious illness, previous to the present

disease. About three or four days since he was purged considerably; the purging ceased yesterday. Last night he was suddenly seized with a burning tingling sensation in the right hand and right side of the head; he soon afterwards experienced cramp in the right fore-arm and hand, and towards morning the left arm and hand, as well as the inferior extremities, became painful and contracted; he found he could not close his hands, the fingers being rigid and partially flexed; he also states that he had considerable difficulty in forming his words, so that his utterance was somewhat impeded. He never lost consciousness in the least.

At present he appears perfectly sensible; the face. is quite natural; the pupils are sensible to light; he complains of great pain and burning in the head, especially on the right side, but he says it does not extend deeply; the thumbs and fingers, as well as the fore-arms, are rigid, contracted, and partially flexed, so that he cannot close his hands; he feels severe crampy pain in the hands and fore-arms, and a sensation of burning, tingling, and formication, in the right

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