Liquor of Hydriodate ef .4rsenic and Mercury. 199 the solid materials to the ~.-~th part, or less, should be held in solution in the liquor. This medicine is now used on the Continent, and in the United States. That its employment is rapidly extending is shown by the fact, that within the last two years and a half, about 300 pints of it have been sent out of my establishment alone, which is a vast quantity ef an article prescribed in minim doses. I shall feel obliged for such fnrthur communications as prac- titioners may choose to favour me with. It is by the plan of publishing such documents, that the real powers of this useful medicine will be ultimately developed and determined. 11, Clare.street, Dublin.

ART. VII.--On Chronic Inflammation of the Uterine dppen- doges, occurring after Parturition. By RrCaARV DoHEaTY, M. D., Honorary Member and Secretary of the Dublin Ob- stetrical Society, &c. [Read before that Society, 5th May, 1842.] 'I'H~ disease, 1 propose to myself the honour of bringing under your notice this evening, is one, which, in my opinion, has not received from obstetrical writers the distinct consideration it deserves; although from the obscurity of its early symptoms, the insidiousness of its progress, and the organic changes to which it may give rise, it behoves the midwifery practitioner to make himself well acquainted with its characteristics. It is a fact universally recognized, that after parturition the and its appendages are liable to inflammations of an acute and dangerous character. The symptoms of hysteritis, as it pre- sents itself after delivery, are too obvious in the generality of cases to escape notice, and it is of course well known to every one, whom I bare the pleasure of addressing, that the diseased action frequently extends to the ligamentous tissues and the . Thus if we see a patient, shortly after labour, seized with febrile symptoms, and complaining of pain in the hypo~s- 200 Dr. Doherty on Chronic Inflammation trium, where the uterus feels hard and tender to the touch, our suspicion is immediately excited, that some deviation from its natural condition has occurred. If tumefaction and tenderness at the same time manifest themselves in either lilac fossa, it is not difficult to surmise, that the has also partaken of the morbid alteration ; and if, in addition, the peritoneum become inflamed, we can readily believe the of the womb have not escaped unaffected, although it may be impossible to point out any indications which exclusively belong to the latter com- plication. With the well-marked symptoms which characterize these conditions, and the consequences they entail, if permitted to proceed unchecked, we are perfectly conversant. But the affec- tion, to which I would now beg to direct attention, is not of this prominent character. It is, on the contrary, stealthy in its nature, and usually makes its approaches so gradually, that for a long time the existence of any local malady may be unknown to the patient herself, who thus permits it to remain untreated week after week, until it has, perhaps, laid the foundation of organic changes, which it may be ultimately out of our power to remove. To this disease I have heard Dr. Kennedy, to whom I am in- debted for my knowledge of it (for I have in vain sought in books its accurate delineation),give the nameofsecondaryinflammation, by which he meant to imply the usually late period of'its occur- rence, and not that it must necessarily be preceded by a more acute, or other morbid process. It is not my intention to deny that the local changes which I am about to detail, may result from, or be, as it were, the remnant of a more intense degree of inflammation ; but the fact I wish to demonstrate is, that the appendages of the uterus are liable to become the seat of an in- flammation, but feebly announced by symptoms from the very first, and occurring after the period, during which the partu- rient female is usually considered obnoxious to such attacks. Tile history of these cases is generally as follows. The pa- tient has probably had an easy labour, and her progress been so favourable, we have ceased our attendance, or if an hospital pa- of the . 201 tient, she has been dismissed on the usual day, free from com- plaint. Convalescence proceeds uninterruptedly for some days, or even weeks ; but after exposure to cold, or some local source of irritation, she is seized with shivering, succeeded by hot skin and quick pulse, and a dull weight about the pelvis. After a few hours the feverishness disappears, and although some unea- siness still remains about the lower part of the abdomen, it is not sufficient to excite any apprehension in her mind ; and thus a considerable space of time may pass over. Febrile paroxysms however, recur at intervals, and at length becoming more fre- quent, and stiffness and pain being felt in moving tile leg of the affected side, she again applies to us for advice. We then find her pulse permanently accelerated, but soft, generally about 100 in the minute; her tongue foul; she com- plains of frequent rigors, returning, perhaps, at the same time every day ; she states, that when rising in the morning she is bathed in perspiration, that her health is declining, and she is unable to move one or both legs without pain and difficulty. She probably complains at the same time of a frequent desire to make water, and sometimes a tendency to diarrhoea. Such are the symptoms which will be detailed to us by an intelligent patient, but it should be remembered, the affection I speak of may exist for a long time, producing but little inconvenience, so that from many persons labouring under the malady, I have been unable to extract any history of its approach. When closely questioned, however, she points to one (more seldom to both) iliae fossa, as a source ot~ uneasiness, and placing our hand there, we perceive an unnatural fiflness, sensitive to pressure. On making a more accurate examination we are surprised to find the whole of the iliac region, particularly towards Poupart's , of a brawny hardness, with or without a prominent and more defined swell- ing, rather higher up, which, when it exists, is very tender to the touch. The question then arises, what is the nature of the disease we have here to treat ? There may be noticed, in the first place, an error, into which 202 Dr. Doherty on Chronic Inflammation

the medical attendant may be led, by proceeding hastily in his investigation. If the hand be placed hurriedly on tile abdo- men, and more particularly pressure made on it by the poinls of the fingers, the region, submitted to such contact may appear to tile touch hard and unyielding; although the resistance felt depends only on contraction of the abdominal muscles, which, in women of a nervous temperament, are very readily thrown into strong, and indeed involuntary action, during the agitation caused by our presence; and it is astonishing the force, with which pressure is repulsed under such circumstances. In making the examination, therefore, tact is requisite in more senses than one ; for not only is it necessary to be aware of the proper mode of manipulation, but we must also by our manner and words al- lay the apprehensions of our patient. While she lies Qn her back with her knees drawn up, she should be encouraged to permit us to make pressure (which should always be done with the palm of the hand), without puffing out her abdomen, or exert- ing herself, either by her respiration or in any other way, against us. In excitable females it is requisite to keep the hand in con- tact with the abdomen for two or three minutes, before we lean any weight upon it, until the parietes have become accustomed to its presence, and the spasmodic action of the muscular struc- ture has subsided. Then the palm may be pressed gently down- wards, and rolled backwards and forwards, until the existence or absence of any deep-seated turnout has been ascertained. I am induced to dwell upon these apparently simple precautions, from having frequently seen inattention to them cause tile patient a great deal of unnecessary pain, and lead to the formation of an incorrect diagnosis. If we have thus convinced ourselves of the presence of some unnatural tumefaetion, we have next to determine its exact seat and nature. A simple process is alone necessary to enable us to decide whether it is situated in the abdominal wall (premoni- tory of abscess), or in the structures more deeply placed. By di- recting the patient to lean on her hands and knees, if the turnout of the Uterine dppendages. 203 be within the belly, not only the skin but the whole thickness o{' muscular tissue can be freely moved over it, and will evidently appear unconnected with it. If then, it be the right iliae fossa that is engaged, we have next to determine, whether it may not depend on some of those affections, to which the c~ecum and the cellular membrane in its vicinity are liable. For this purpose the history of the case must be inquired into. If there be an accumulation of fa~ces in the caput coli,--a condition, which, though simple in its nature, we should remember may give rise in females to considerable constitutional disturbance,--we shall find, the bowels have not for some time past been satisfactorily emptied, colicky pains are felt through the abdomen, attended probably with vomiting, and the whole belly is full and tender, though more particularly so in the iliac fossa. The sudden re- lief, too, obtained on the expulsion offlatus~ and the effect of a large turpentine enema in diminishing the tumour, will aid us in the diagnosis. If inflammation have occurred in the cellular tissue, external to this intestine, an affection, to which the term typhlo-enterite has been applied, we shall find the history in this ease also point to disturbance of the abdominal functions, as an early feature in the complaint. The constitutional symp- toms, instead of a hectic type, present more the characters of low fever, and are much more urgent ; and on applying the fin- gers to the tumour, we are sensible of a crackling sensation, arising apparently fi'om the displacement of air beneath them. There is yet another disease, with which it may possibly be con- fbunded, namely, an abscess forming behind the iliae and psoas muscles. But here the patient will be much more careful to keep tlle limb flexed on the pelvis, and if the inflammation be at all active any attempt to extend it will produce intense pain; the standing posture can scarcely be endured, and striking tile foot against an obstacle gives rise to a great increase of suffering. The pain, too, is often referred to the knee, and in the whole of its symptoms it in many cases closely resembles disease of tile hip joint. In the chronie inflammation of the uterine appendages, 204 Dr. Doherty on Chronic Inflammation

on the contrary, although there is at least equal tension and hardness, and the patient lies with her leg drawn up, she is comparatively indifferent to her posture, and will readily ex- tend her limb at our request. The period, too, being subse- quent to labour or miscarriage will help us in drawing the dis- tinction. But the evidences, which most clearly distinguish this latter affection from all those I have enumerated, are obtainable by making an examination by the and rectum. On intro- ducing the finger into the former cavity, we find the hardness, so remarkable in the lilac fossa, has extended to the roof of the vagina, which is tender to the touch, and asjfirm and inelastic as a deal board ; a condition, which must immediately arrest our attention. Not the slightest impression can be made on it by our pressure, while we may also observe, that the uterus is bound down to the affected side, either throughout its whole extent, by which it suffers a lateral displacement, or only par- tially, so that the fundus is drawn in one direction, while the os tinc~e is turned in the opposite. Here then is evidence, it is the ligamentous attachments of the womb which have become infiltrated and thickened ; and beyond this the morbid changes may not have gone. But if the disease have existed for any length of time, the ovary will probably have become implicated, which will be evinced by more acute symptoms, and more severe pain, and by a prominent and defined turnout, continuous with, and above the deep-seated thickening, which along Poupart's ligament is gradually lost in the surrounding parts. This fact may be still more accurately ascertained by passing the finger up the rectum, when the swollen and generally painful tume- faction, produced by it, is easily felt. This latter mode of ex- amination is absolutely necessary to enable us to form a correct estimate of the extent of the disease. In this way the turnout may be grasped between the finger in the rectum, and the hand externally, and its situation thus correctly determined. Ttle leg of the affected side may also become implicated in the disease. of the Uterine Appendages. 205 The occasional pains, which shoot down in the course of the nerves increase into a general neuralgic tenderness of the whole limb, tu- mefaction commences about its upper portion, and ultimately all the symptoms of phlegmasia dolens are established. This affec- tion would in such cases, I conceive, be admitted to depend, pri- marily at least, on disturbance in the absorbent system, rather than on inflammation of the veins. I may remark, that it is not confined to tile puerperal state, as is commonly supposed, for I have seen it owe its origin to malignant disease of the ovary. The chronic inflammation of the uterine appendages, I have thus endeavoured to describe, may, as I have stated, be the re- sult of an imperfectly cured acute attack, announced by urgent symptoms within a short period after labour ; or as in the cases more particularly alluded to at present, it may make its obscure approach in patients convalescent from abortion, or parturition at the full term, several days or even weeks subsequently. In the latter form I think the general period is about the twelfth or fourteenth day, but I have seen instances, whose history indi- cated it to have commenced so late as the eighth week after delivery. I could bring forward several cases, which presented the characters I have detailed, but it may, perhaps, suffice to transcribe one, rendered still more interesting by presenting the curious feature of a sudden and exceedingly painful enlarge- ment of the ovary, evidently of inflammatory origin ; and I would observe, that the occasional supervention of similar attacks of an acute character is frequently met with during the progress of such cases. Margaret Graham, ~et. 26, the mother of one child, which had been born in the Dublin Lying-in Hospital a month pre- viously, was re-admitted on the 12th December, 1838 (during Dr. Kennedy's mastership), into the ward in that Institution ap- propriated to diseases of females. Her labour had been natural, and she had been discharged well on the ninth day. Four or five days after she had left the hospital, sickness of stomach and diarrhoea set in, and slight pains occurred in the lower part of voL xxm no. 65. 2 E 206 Dr. Doherty on Chronic Inflammation the abdomen. Within the last six days before re-admission she had occasional rigors, and the pain in the abdomen, particularly towards the right side, had considerably increased. She felt, too, great stiffness and pain when she attempted to walk, or even straighten her leg ; pulse was 100 and soft ; she slept generally till 4 o'clock in the morning, when she awoke bathed in perspira- tion; she had no difficulty in making water; her bowels had not been freed for the last two days. On examination great hardness and general tumefaction were detected in the right iliac region ; the roof of the vagina, as ascertained by the touch, was exceedingly resistant, and the uterus firmly bound down, so that the fundus was turned towards the right side, while the os was directed towards the left sacro-iliac synchondrosis. The plan of treatment adopted consisted in leeching, blistering, and the exhibition of Plummer's pill, and under it the iliac region became softer, and the vaginal roof seemed inclined to relax. Hydriodate of potash was then given, and iodine ointment ap- plied internally to the roof of the vagina, while counter-irritation was maintained without. Her recovery was interrupted by her leaving the house for a few days, ~nd shortly after her return, that is to say, on the 10th February, she had shivering during the night ; next day her pulse was quick ; there was considera- ble tenderness and tumefaction in the right iliac region, and the inability to stretch the leg was increased. During the night of the 12th the pain in the right iliac fossa became exceedingly severe, so as to make her seize hold of the bed post ; and on the subsequent morning the turnout was found to have greatly in- creased both in size and tenderness. It formed a swelling equal in dimensions to a foetal head ; it was regular on its surface, tense, but elastic. By means of an examination per rectum, it was ascertained to consist of the inflamed ovary. A dozerr and half of leeches were immediately applied, and she was immersed in a warm bath ; pills of Plummer's pill, James's powder, and opium given ; on the morning of the 16th the tumefaction had considerably abated, and the report on the 18th was, "turnout of the Uterine dppendages. 207 can barely be detected; no solid lumps came away, nor was there any reason to believe it to have depended on a f~eeal col- lection ; the pulse is quite quiet." From this period absorption appeared to proceed much more rapidly than before, and on the 10th of March she was dismissed with the pelvic tissues restored to their natural condition. In the foregoing example, notwithstanding the sudden and amazing enlargement of the ovary, perfect recovery followed the treatment adopted, and no local disorganization resulted ; and this is generally tile case when seen before any of the ill conse- quences I am about to relate has ensued. But in other instances, where the progress of the disease is uncontrolled, changes are wrought in the organs affected, or the adjacent structures, which give rise to symptoms of an immediately alarming nature, or lay the foundation for future mischief. Thus abscesses may form in the broad ligaments or ovaries, and escape either into the ca- vity of the abdomen, through the vaginal walls, or through the abdominal parietes, near Poupart's ligament ; or the irritation may even extend to the serous covering of the intestines, and establish a general peritonitis. But these consequences are much more liable to follow lhe acute form of the disease ; in- deed it is surprising how long the results of chronic inflamma- tion may remain effused into the uterine appendages, without running into any of the more serious consequences of inflamma- tion. Secondly, the may be rendered impervious, or its fimbriated extremity glued to an adjacent structure (con- ditions, which will necessarily be followed by sterility of the ge- nerative organs of that side) ; or if the calibre of the tube be only diminished, an ovum may at a subsequeiat time be arrested in its passage, and extra-uterine pregnancy produced. Thirdly, we have to fear, that the ovary, stimulated into activity by file disease, may remain, notwithstanding all our treatment, chroni- cally enlarged, and thus be subject to various displacements, or take on a still more morbid process, and become tile seat of ma- lignant disease. And fourthly, from the unnatural position in ~08 Dr. Doherty on Chronic Inflammation which the uterus is detained, future impregnation may be ren- dered impossible, or if conception do take place, the womb being firmly bound down and unable to expand, casts off'the ovum prematurely, and thus a succession of abortions may en- sue ; a fact to which particular attention has been drawn by Madam Boivin. With respect to prognosis, I think it may be favourable ; at least, I never saw a ease, amongst many, which came under my notice, resist the treatment I am about to detail, if seen before any of the ill conseqnenees mentioned had arisen. But their duration is very uncertain. Some yield speedily to our remedies, while others require several weeks for their cure. The treatment to be adopted should combine local depletion, coun- ter-irritation, and the use of mild mercurials. If the pain be severe, or the roof of the vagina exceedingly hard and ten- der, great benefit will be derived from the free application of leeches internally, by means of the speeuium, and from the use of cupping glasses externally; which measures should be re- sorted to, as often as a more acute attack interrupts the favoura- ble progress of our ease. We may then either cover the whole iliae region with one large blister, or what is better, apply a succession of smaller vesieatories ; for we should remember, our principal reliance must be placed on counter-irritation main- tained till the tissues regain their natural state. To aid in this favourable change we should resort to mercury in alterative doses, for instance small quantities of blue pill or Plummer's pill, which may be combined with hyoseyamus to allay the irritabi- lity that mostly prevails. After the mouth has been touched, we may commence with the hydriodate of potash, while we apply over the region of the tumour either its ointment, or that of the ioduret of lead. Under this management we shall at length observe the tumefaction subside, and the pliancy of the vaginal roof return. According as this restoration is aeeom-

Reeherches sur une des Causes de l'Avortement. Paris, 1828. of the Uterine Appendages. 209 plished the uterus may be perceived to rise, until it gradually resumes its natural position ; and thus, all the structures, as far, at least, as can be ascertained during life, will have regained their normal eonditlon. If in the progress of the disease, phlegmasia dolens shall have set in, of course, it will be neces- sary to combine with the foregoing treatment, those remedial measures which are in ordinary use in this complication.

AnT. VIII.--_.'/ Case of Femoral Aneurism, cured by Liga- ture of the external lliac Artery (with a Plate). By JOHN HOUSTON, M. D., M. R. I. A., Surgeon to the City of Dublin Hospital, Lecturer on Surgery at the School of Medicine, Park-street, &c., &c.

I AM indebted to my friend, Doctor George B. Russell, late Resident Surgeon of the City of Dublin Hospital, tbr the notes of the following case. A report of it was made to the Surgical Society of Ireland at the time of its occurrence ; but I have waited for some finality in the result, before giving it publicity in an authentic form. Alexander Byrne, ~etat. 26, admitted June 16th, 1840. By occupation he is a car-driver, and acknowledges to have been of intemperate habits, up to so late a period as four months back, when he became a member of the Temperance Society. He is a muscular, well-built man of middle stature, weather- beaten, and looking ten years older than he reports himself. He states that a year ago he observed a lump on the anterior and inner part of the left thigh. At that time it was ab()ut the size of a walnut, " beating" as strongly as at the time of ap- plying for advice. He has suffered very little from it, until within the last three or four months, when the anterior part of the leg felt numb, and both thigh and leg became subject to an aching pain, which was aggravated by his ordinary work, or by standing or lying on the affected limb ; latterly, his leg has be- come somewhat swollen.