I ; W£- '-■■J**- <& *%&umMmM '/ oof Surgeon General's Office AHfitfzyr ;\^r-o;(^OXO;C?Q.gQQl3uaaagQa 'M U //4T ft \ » > \ » Vv X^ V» \ ' » X \ . t x. \ , * V V & /y&^^?'^^y^£y. WOMAN: HER DISEASES AND REMEDIES. A SERIES OF LETTERS TO HIS CLASS. BY CHARLES D. MEIGS, M.D., PROFESSOR OP MIDWIFERY, AND THE DISEASES OF WOMEN AND CHILDREN, IN TnE JEFFERSON MEDICAL COLLEGE AT PHILADELPHIA; MEMBER OF TEE AMERICAN MEDICAL ASSOCIATION; OF TnE AMERICAN PHILOSOPHICAL SOCIETT, AND OF THE COUNCIL; VICE-PRESIDENT OF THE COLLEOE OF PHYSICIANS OF PHILADELPHIA; LATE ONE OF THE PHYSICIANS TO THE LYING-IN DEPARTMENT OF THE PENNSYLVANIA HOSPITAL; ft .ETC. ETC. THIRD EDITION, REVISED AND ENLARGED. PHILADELPHIA: BLANCHARD AND LEA. 1854. Entered according to the Act of Congress, in the year 1850, by LEA AND BLANCHARD, in the Office of the Clerk of the District Court of the United States in and for the Eastern District of Pennsylvania. PHILADELPHIA: T. K. AND P. Q. COLLINS, PRIJITERS. TO THE STUDENTS OF MY CLASS, IN THE SESSION OF 1846-7, THIS VOLUME IS RESPECTFULLY AND AFFECTIONATELY Betrtcateii, BY THEIR GRATEFUL FRIEND, THE AUTHOR. PREFACE TO THE THIRD EDITION. I am happy to offer to my class a Third Edition, much enlarged and carefully emended, of my Letters on the Diseases of Woman, and I avail myself of the occasion to return my sincere grateful acknowledg- ments to my professional brethren in general, by whose favor the work has succeeded so well. It will be found that I have not neglected this opportunity to render these Letters more worthy of regard than they were when first issued from the press; and I repeat that it is an anxious wish of my heart, that of placing on the shelves a useful and original American medical work. Should my life be spared to superintend yet another edition, I shall hope by that time to have rendered the style and language still less exceptionable. CHARLES D. MEIGS. 324 Walnut Street, May 1854. % AN INTRODUCTORY LETTER TO A FRIEND. Dear Sir : I send you a new Medical book, which I beg you to accept as a testimonial of my respect and affection. . I have not dedicated it -to , you, because it belongs to the Gentlemen to whom I addressed the Letters of which the volume consists. I shall be obliged to you if you will look at it, and tell me whether you think I have committed an unpardonable breach of the forms of our Science, in writing with such a freedom and abandon as you shall here find; for I might say with Juvenal— " Quicquid agunt homines, votum, timor, ira voluptas, Gaudia, discursus, nostri est farrago libelli." Dr. Forbes, in his farewell article, in the British and Foreign Medi- cal Review, tells us it is a lamentable truth that the eminent practi- tioners of England neither read nor buy medical books; and I fear a chief reason of it is to be found in the dulness and jargon which characterize so many medical writings. I am sure that, exclusive of such as treat of the Physiology of Man, many of them are very tiresome and disgusting; for the Doctors seem not to have heeded the lines of Horace, who says :— "Omne tulit punctum qui miscuit utile dulci, Lectorem delectando pariterque monendo." According to my poor ability, I have endeavored in these Letters, while telling the truth about our Science and Art, to avoid the dulness; and, in doing so, I have ever thought the honestest way for a man to speak is to speak what he thinks, in his own tone and manner, and not to come before the public under a false disguise. The young gentlemen who composed my Class were accustomed, all winter, to hear me say just whatever the occasion prompted me to say to them, without any reservation of mine, from distrust of them; for I went into the Lecture- room with my heart in my hand open before them, and it is in the same viii INTRODUCTORY LETTER TO A FRIEND. fashion that I have sent them these Letters. Indeed, when on the spur of an occasion I promised to write for them, I engaged to adopt the most familiar style, saying, "I will write in the same language I should address to any one of you, whom I might be instructing, in my library here at home." You will see that I have kept my promise. Whether such a mode of writing might prove agreeable to the brethren, so as to meet their approbation, remained to be seen. If I should fail in this attempt, I may still hope that some one else will in- vent a new and happier method than mine to get rid of our medical dulness, and our time-honored clergyableness. To judge of the medi- cal student of the present day, by comparing my own student-life with his, I cannot but think he must daily find the books as tedious and un- interesting as they used to be when you and I were young men like them. As to the doctrine and the precept of these Letters, I might well suppose I have a right, at this stage of my life, to be heard upon them— and having felt it an occasion of self-reproach that I could never find time, in the winter curriculum, to fulfil my duties as Lecturer on Dis- eases of Women and Children, I have taken occasion by speaking to my Class through the press to supply the deficiency. In doing so, I could not but stand before the public. Flaccus says "Scribendi recte, sapere est et principium et fons." You will be able to judge whether I have said that which is naught as to the diseases treated of herein. Certainly, I have had much oppor- tunity to see the things spoken of, and if the book turns out useless or disagreeable, mine is the fault. You, who have seen so much, may well become my competent and dispassionate judge. Let me tell you, though, my dear Hodge, that the whole of these 666 pages have been begun and finished since the month of May last. They, therefore, have no claim to the nonum prematur in annum merit; and I wish you to understand that I have been obliged to do the whole of the work in addition to my diurno-nocturnal task of visiting the sick. I cannot, under these circumstances, expect for it the same considera- tion as might be due to essays carefully revised and finished; and I have a just right to make this apology. But, shall people, who desire to make a contribution to the art that has absorbed their whole existence, refrain from doing so from a fear of offending in the matter of their manner? Would that be American- like? And shall everybody go out of the world making no sign? Beaufort was asked but to hold up his hand, but "he died, and made no sign." I wish you would make a sign for us; we all wish so. INTRODUCTORY LETTER TO A FRIEND. ix I have made this apology to you, because I look upon you as a chief representative of Medicine, on this topic, in the United States: and, as I desired to say a few words to the Brethren, in general, in addition to all I have said in these Letters to my Students, I trust that in say- ing these things to you, in whom they have confidence, I am, towards them, absolved as to apologies. As to my personal feelings towards you—did we not sit on the same benches at the lectures?—and have we not interchangeably assisted us with counsel and with dexterity, in our vocation these thirty years ?—What more! I pray God to prosper you long; and to allow the City, and the Country, to enjoy, for many years, the advantages of your skill, the honor of your well-earned reputation, and the benefit of your public instruction, as well as your private example as a minister of your phi- lanthropic calling. Farewell, dear doctor, and believe me very faith- fully Your affectionate friend, CHARLES D. MEIGS. November, 1847. To Hugh L. Hodge, M.D., Professor of Midwifery, and Diseases of Women and Children, in the University of Pennsylvania. CONTENTS. PAGE DEDICATION,........iii LETTER TO A FRIEND,.......vii LETTER I. Motives for writing, ....... 33—34 LETTER II. General remarks on conduct—The Doctor—Sir Thomas Browne's opinion of the practice of medicine, ....... 34—46 LETTER III. Sex—The ovum—Vitellus—The corpus luteum, .... 46—53 LETTER IV. The female—Her distinctive characteristics, .... 53—68 LETTER V. Sexual organs—Relaxed symphyses—Seton in pubal pains—Vulva—Labia puden- dorum—(Edema labiorum, ------ 69—79 LETTER VI. Wounds and laceration of the labia—Labial thrombus, - - - 79—84 LETTER VII. Ruptured labium—Ruptured labium and perineum—Uncured laceration of peri- neum with procidentia uteri—Labial cysts—Warts of the vulva—Dr. Brainerd's letter to J. F. Meigs—Pruritus of the vulva—Cicatrices, - - 84—95 Xll CONTENTS. LETTER VIII. PACE Nymphoe—Cohesion of the nymphoe, ----- 95—99 LETTER IX. Vagina—Its structure and relations—Absence of the vagina—Operation by Dr. Randolph for absence of vagina—Congenital narrowness of the vagina—Dila- tation of the vagina as a cure—Imperforation or atresia—Cases—Cohesion of vaginal walls after labor—Case of the same—Ulceration of the vagina—Vagi- nitis—Inversion of the vagina—Vaginal fistula—Vaginal rectocele—Vaginal enterocele—Vaginal cystocele—Double vagina, ... 99—129 LETTER X. Cohesion of labia and nymphoe—Ulcerated nymphoe—Excision of nymphoe, by Mauriceau, ------- 130—134 LETTER XI. Clitoris—Hermaphrodism—Free Martin—Nymphomania—Inversion of the blad- der—Mr. Crosse's case, ------ 134—142 LETTER XII. Displacements of the womb—Prolapsus uteri—Lamotte's account of it—Prolapsus, with abdominal neuralgia—Case — Levatores ani in prolapsus — Diagnosis — Carus's curve—Dr. J. H. Bennet—Causes of prolapsus—Pessaries—Gynoeciorum of Spach—Simulative prolapsus—Miss Helen Blanque's case, and dialogue with her,........142—180 LETTER XIII. Diagnostics of prolapsus — Bad training of girls — Quevenne's metallic iron— Powers of medicines—Dr. Cerise on neurosity, - - - 180—187 LETTER XIV. Pessaries—Mr. Joseph Warner and his instruments—Dr. Physick's pessarv— Suffita — Sachet— Sponge — Cork — Caoutchouc —Whalebone-ring—Blundell's pessary, -------- 187—199 LETTER XV. Prolapsus in the unmarried—Case—Immobility of the womb—Case—Cautions as to pessaries—Utero-abdominal supporters, ... 200__206 CONTENTS. xiii LETTER XVI. PAGE Retroversion of the womb—Wood-cut of retroversion—Dr. Amussat's pamphlet- William Hunter and Dr. Wall—Dialogue with a patient—Cases—Treatment- Chronic retroversion—Pregnancy as a cause of retroversion—Dr. Weir—Mr. Mayor's case—Instrument for the repositing of the womb, - 207 234 LETTER XVII. Anteversion of the womb—Flexion of the womb, - - - 234—241 LETTER XVIII. Inversion of the womb—Mr. Crosse, of Norwich, in England, - 241—255 LETTER XIX. Inflammation of the non-gravid womb, - 255—272 LETTER XX. Dr. Betton's case of inversion—Polypus of the womb—Dr. Safford Lee cited— Anne Rvder's case—Dialogue with a patient—A case of polypus—Adherent t ... - 272—289 polypus, - - - - - LETTER XXI. Polypus—Hasty diagnostics—Nascent polypus, - - - 289—293 LETTER XXII. Fibrous tumors of the womb—M. Serres's Anatomie Transcendente quoted, 294—306 LETTER XXIII. Cancer of the womb,......307—316 LETTER XXIV. Physometra—Tympanitis, - 316—324 Hydrometra—Hydatids, LETTER XXV. 324—327 xiv CONTENTS. LETTER XXVI. PAGE Ovarian diseases—Ovariotomy, - *■*' °^ LETTER XXVII. Diseases of the Fallopian tubes—Tubal pregnancy—Casei-Ovarian pregnancy— M. Pouchet's opinion, ------ 343—350 LETTER XXVIII. Puberty,........350-391 LETTER XXIX. The menstrua—Periods of eruption—Climatic influences—Nature—Causes—Ex- tract from Burdach—Germ-production in vegetables and in animals—Migration of animals, birds, and fishes, ----- 392—402 LETTER XXX. Periodicity of germ-production, or ovulation—Secretions—Prof. Huschke—Martin Barry and Gerber—Negrier, Gendrin, Lee, Bischoff, and Pouchet—M. Pouchet's Theorie Positive—Rapid evolution of a Graafian cell, - - 402—409 LETTER XXXI. Corpus luteum — Author's opinion — Opinion of authors, as HenlS, Carpenter, Huschke, Flourens, Velpeau, Jacquemier, Chailly, Bernhardt, Von Baer, Bis- choff, Coste—Experiments: constitution and usee of the corpus luteum, 409—419 LETTER XXXII. Menstrua—Brierre de Boismont's tables—Analysis of menstrual fluid—Roussel, 419—432 LETTER XXXIII. Emmenagogues, ...---- 433—440 LETTER XXXIV. Menorrhagia, ------- 441—450 LETTER XXXV. Dysmenorrhcea, .-....- 450—459 CONTENTS. XV LETTER XXXVI. PAGE Change of life,.......459-469 LETTER XXXVII. Hysteria,........469-484 LETTER XXXVIII. Disorders of pregnancy —Fecundation and conception —Early changes of the womb—Uterine intrusion—Ovum grows by vis insita—Sympathy with uterus in the mammary glands, the stomach, &c—Missing the return—Quickening —Rational signs and sensible signs—Some of the signs, as diseases of preg- nancy—Salivations and vomitings —Bruit desouffle uterin — Sounds of foetal heart__Dr. J. A. II. De Paul, of Paris, and his work on Auscultation—Early detection of foetal heari^Evory Kennedy and others—(Edema gravidarum— Constipation—Compression of the great vessels by womb—Duration of gesta- tion—Incipient phlebitis from varix, - - - - 485 51^ LETTER XXXIX. Disorders of pregnancy continued—Cost of pregnancy to the blood-membrane— Anaemia—A case—Palpitation—Endocarditis—Dropsy of chest—Sprain of the symphyses—Dr. Moreau's case detailed, ... 512—528 LETTER XL. Abortion—Dr. Merriman's table of duration of pregnancy—Causes of abortion- Take care of the pregnancy!—Hemorrhage—Prophylaxis, - 528—556 LETTER XLI. Lying-in diseases—Fainting after delivery—Concealed hemorrhage—Turn out the clots—Binder and compress—Keep the head down—Ergot —Opium—After- pains—Rheumatismus uteri—Neuralgia of womb and abdomen—Lochia—Dr. Lee of London—Asdrubali on bandaging the accouchee—Retention of urine- Medicines for the accouchee—Diet—Dies nondinoe—Vaccination of pregnant 556—583 women, - - - - Puerperal fever, LETTER XLII. .....583—631 xvi CONTENTS. LETTER XLIII. Phlegmasia-dolens, or crural phlebitis, LETTER XLIV. , • .-- - 637—649 Puerperal convulsions, r\c.r. 631—637 The female breast, LETTER XLV. 649—666 WOMAN: HER DISEASES AND REMEDIES. LETTER I. MOTIVES FOR WRITING. Gentlemen: When I took leave of you, at the close of the session of our Lectures of the last of February, 1847, I engaged to address to you a series of Letters, in which I should endeavor to lay before you my views upon some of the disorders of women; and you may remember that, on the same occasion, I requested each one of you to consider these letters as addressed to himself. I felt that I had not fully discharged the obligations of my professorship as relates to disquisitions upon the sexual maladies; and I explained to you that the time allowed for a course of lectures on obstetrics and diseases of women, a period of only four months, is too short to permit any one fully to describe all the diseases to which our females are liable. Notwithstanding I had taken advantage of every open occasion to describe the phenomena and treatment of the disorders and accidents of the various structures it was my province to demonstrate, still there was much, it was incumbent on me to say, which the shortness of your sojourn here would not allow me leisure to say to you. While I enjoyed the satisfaction of meeting you in the Lecture-room, I felt that my happiness was to be esteemed great, in the privilege I had of addressing so considerable a number of gentlemen, all patiently and politely receiving the instruction I was able to convey upon very im- portant points of a business which is related to some of the most deli- cate and hazardous periods of female existence. The labor of the task was always alleviated by the reflection that in endeavoring to do good I might hope to win, at the same time, your kind regards, and Lu- 3 3 34 GENERAL REMARKS ON CONDUCT. cretius allows this sentiment to be proper in admitting it as his own consolation, in the lines " Scd tua me virtus tamen et spcrata voluptas Suavis amicitise, qucmvis efferre laborcm Suadet." I need not repeat the assurances I gave at parting with you, that I was filled with painful emotions in bidding you farewell, for I could not be insensible to the goodness you had so steadily manifested towards me, nor to the admirable conduct of the whole class; a conduct which re- flects the highest credit upon them, as demonstrating their fine sense of what is due both to themselves and to their teachers—whom they highly distinguish and honor by such consistent and admirable deportment. To address these letters to you now, seems to renew our late delight- ful intercourse; and should I be permitted in the course of them to assist you, and strengthen your hands in your great mission of useful- ness and benevolence, I shall be thankful to Him by whose Providence I have been allowed, these now many years, to observe and contemplate the affections of which I am about to treat. Farewell. C. D. M. LETTER II. GENERAL REMARKS ON CONDUCT. Gentlemen: The relations between the sexes are of so delicate a character, that the duties of a medical practitioner are necessarily more difficult, when he comes to take charge of a patient laboring under any one of the great host of female complaints, than where he is called upon to treat the more general disorders, such as fevers, inflammations, the exanthemata, &c, to which the gentler, like the ruder sex is liable. So great, indeed, is the embarrassment arising from fastidiousness on the part either of the female herself, or of the practitioner, or both, that, I am persuaded, much of the ill success of treatment may be justly charged thereto. It is to be observed that a very current opinion exists as to the difficulty of effectually curing many of the diseases of women ; and it is as morti- fying as it is true, that we do often see the cases of these disorders going the whole round of the profession, in any village, town, or city, and falling, at last, into the hands of the quack ; either ending in some GENERAL REMARKS ON CONDUCT. 35 surprising cure, or leading the victim, by gradual lapses of health and strength, down to the grave, the last refuge of the incurable, or rather the uncured: I say uncured, for it is a clear and well-known truth, that many of these cases are, in their beginning, of light or trifling im- portance—cases where the constitution takes no part in affections of tissues or organs, and which, when slightly modified by disease, may long continue to be so without provoking any disturbance in the harmony of the other great organs; as, for example, those of the circulation, nutrition, respiration, and innervation. Yet, by neglecting such affec- tions in their rise, on the one hand, or by imprudently treating them by violent and disturbing therapeutical or hygienical methods on the other, the whole constitution may at last come into sympathy with the deranged member of it; and the health, the usefulness, and so, the happiness or life of the mismanaged and misinformed female, are sacrificed. All these evils of medical practice spring not, in the main, from any want of competency in medicines or in medical men, but from the delicacy of the relations existing between the sexes, of which I spoke; and, in a good degree also from want of information among the population in general, as to the import, meaning, and tendency of disorders, mani- fested by certain trains of symptoms. It is, perhaps, best, upon the whole, that this great degree of modesty should exist, even though it go to the extent of putting a bar to special researches without which no very clear and understandable notions can be obtained of the sexual disorders. I confess I am proud to say, that, in this country generally, and particularly in some parts of it, women prefer to suffer the extremity of danger and pain rather than waive those scruples of delicacy which prevent their maladies from being fully explored. I think this is an evidence of the presence of a fine morality in our society; but never- theless, it is true that a greater candor on the part of the patient, and a more resolute and careful inquiry on that of the practitioner, would scarcely fail to bring to light, in their early stages, the curable maladies, which, by faults on both sides, are now misunderstood, because concealed, and, consequently, mismanaged and rendered at last incurable. What in fact, is it, in the human body, that can become disordered so secretly as to elude the exploratory powers of a well-educated medical man, al- lowed to make the necessary inquiries; or what is the disorder that may not, in its forming stages, be made to yield to the prescriptions of a learned and wise physician ? Can anything be done to obviate the perpetuity of this evil—one that has existed for ages ? Is there any recourse by means of which 36 GENERAL REMARKS ON CONDUCT. the amount of suffering endured by women affected with peculiar com- plaints may be greatly lessened ? I am of opinion that the answer ought to be affirmative, and I believe that the fault is chargeable to us; and that our fault consists in the concealment within our own breasts of a great amount of communicable information which it is our duty to pour forth into the public mind, and which we should certainly diffuse, spread abroad and make vulgar or common but for our clerkly or clergyable pride. The doctors have an idea that their knowledge cannot be imparted to the world, and that it is better, in fact, that the world should not be possessed of such recondite information as theirs. The people, too, are in general afraid of doctors —distrust and eschew them, except when they cannot help themselves. I believe, that if any medical practitioner knows how to obtain the entire confidence of the class of persons who habitually consult him; if he be endowed with a clear perceptive power, a sound judgment, a real probity and a proper degree of intelligence, and a familiarity with the doctrines of a good medical school, he will, as far as to the extent of his particular sphere of action, be found capable of greatly lessen- ing the evils of which complaint is here made; and if these qualities are generally attached to physicians, then it is in their power to abate the evil throughout the population in general. Can there exist any reasonable doubt that the country is abundantly supplied with such well-informed physicians ; seeing that the land is filled with members of the profession who have enjoyed the best possi- ble opportunities of storing the mind with all the lines and precepts of medicine, delivered down through a succession of ages, continually pro- ductive of ameliorations in the doctrines and the arts of curing disease ? But such persons as these are worthy of the public confidence, both as to their morals and their understanding! They are, in general, worthy representatives of the style and character of the gentleman, and, there- fore, capable of attracting the confidence of such as are under suffering. I met, April 9th, 1847, with a case which shows how far the fastidious delicacy existing in the relation betwixt the sexes may be carried on the part of the physician. A lady, forty years of age, consulted me as to a painful menstruation she has had for twenty years. She experiences severe pain and disagreeable weight and pressure in the loins and hypo- gaster, and pain in the head for five or six entire days before each men- strual period ; all which symptoms disappear with the first gushings of the evacuation. She represents her health to be the same now as for twenty years past. Hence, I presume, there has occurred but little change in the physicial condition of the parts, else there would be some change in the sensations arising from the malady. She has been repeat- GENERAL REMARKS ON CONDUCT. 37 edly subjected to the taxis; but no one ever examined the os uteri with the speculum until to-day. Well, that examination reveals a certain state of the cervix and os uteri, and glands of Naboth, &c, which it was indispensable to know, in order to found a rational treatment. The delicacy existed, not on the part of the lady, but on that of the medical advisers; for I have her assurance that her sufferings, both bodily and mental, have been so great, that she should long ago have submitted to any means of even a probable cure; and was, indeed, always desirous to have everything done that was possible in her behalf. I doubt not this lady might have been cured long ago, had her malady been tho- roughly understood. I have mentioned this case to show how the physician may be in fault when he does not do his whole duty; for it is incumbent on him to leave nothing undone that may properly aid and comfort his patient. But let us return to our remarks upon the qualities that ought to dis- tinguish the medical man. I think that, in order to be a physician, one ought to enjoy strong perceptive faculties; he should be able to make nice discriminations— quickly perceiving the slightest shades of difference in all material forms, superficies, colors, weights, and resistance. The faculty of judging between the relations and differences of things should be of the primest quality; not sudden, hasty, and impatient in its operations, but slow, dispassionate, and attentive. The mind and heart of the practitioner ought to be the shrine of truth and probity: his mind should not deceive itself, and his heart should not suffer itself to be deceived and misled by any earthly temptation from the narrow and rugged way of duty and conscien- tiousness. His intelligence ought to be vast, as acquainted, very generally, with what is called knowledge and science by mankind. Particularly should he be fully informed as to the nature of the Life-force, as dis- played in the various tissues and organs of any living economy; not in that of man alone, but in the whole zoological series, as well as in the vegetable kingdom of nature. There ought to be no function of the economy, or of its parts, whose healthy rate he could not estimate, as well as all its deviations in sick- ness. But this is not all—he ought to be able to discern, not the signs only of maladies, but the tendencies of these maladies; as whether they possess a certain tendency towards recovery, or a tendency towards destruction; so as to enable him to say, as he does of a vaccine inocu- lation, let it alone, it requires no remedy, it carries the cure in its own nature, it will have disappeared, with all its phenomena, on the 38 GENERAL REMARKS ON CONDUCT. eighteenth day. Or, on the other hand, take care of that headache; she is pregnant, and near term; know that such a headache is but a step removed from an eclampsia, and that an eclampsia is often the penultimate phenomenon of life. Let that case alone—cure this one. Do you not perceive, young gentlemen, that such a physician is not of necessity a doser, a druggist; and that in a great moiety of the cases in which he is consulted, the patient will escape all physic and be cured by wise counsel—and likewise, that when therapeutical inter- ference is required, he will know what to do, what medicines are required, and when, and how much ? It is often dangerous to ask a physician the question, what shall we do ; because habit, custom, routinism, almost always compel him to say take—take. Let me persuade you to form early, the resolution to give only the physic and the counsel that may be really required in the case. If you will form and live up to such a resolution, you will early triumph over your difficulties. You will early learn, that a large variety of the com- plaints made to physicians are complaints of pains, of disabilities, of fevers that require for their removal only that the patient should know their nature, causes, and tendencies. The Homoeopaths treat multitudes of people by thus giving them not the least particle, but only the name, of a drug; and all those that recover under their guidance, give evi- dence of the great abundance of spontaneous cures. You ought to be familiar with the doctrines of a good Medical School; by which I mean, not the doctrines of the University of Penn- sylvania, or that of New York, or Maryland, or London, or Paris, nor the Jefferson College, but any school which has taught you a demonstra- tive anatomy, a real eclectic physiology, a sound and philosophical chemistry, &c. A school, in short, which has set before you, in full array, the results of man's achievements in medical investigation, experience, and art; leaving you, out of your own clear sound honest and capacious intellect, to become capable of saying, as to any case of disorder presented for your opinion, such is the malady, its tendencies are thus, or so, its treatment requires such and such methods. You should judge the case by the case, and by no other law or evidence. Be not methodists—on the contrary, be men of principles in medi- cine ; principles, which like the genii of the Persian fable, come at your bidding and do your bidding, for no one can be taught to cure diseases by a method. Method in medicine is beneath contempt; because, owing to the infinite variety and differences existing among the living molecules that are the subjects of the vital forces, there never were, nor can be, two absolutely similar cases. Each instance of disease is GENERAL REMARKS ON CONDUCT. 39 an integer, and should, in strictness, be so deemed, and studied, and understood, and managed upon a reference to it, and not to another integer. Old Paul Barbette, in speaking of that mysterious disease, the plague, says: "Deinde, quia licet omnium sseculorum pestilentias diligenter percurras, tam mutabilis semper fuerit, ut nullam omnino invenias, quae adamussim cum alia conveniet. Et hsec causa est, quare in curanda Peste praestiterit judicium tuum bene exercitatum sequi quam aliorum medicorum vestigiis insistere," &c. ; and this true saying is no truer of a plague than of a pleurisy, or a fever Manget. Pestis. It is true that the patient who is under care to-day may be like "him who died o' Wednesday," but is not Mm: hence, you perceive that I am no admirer of statistics, except for the Government, where statistical returns of Agriculture, Commerce, Manufactures, Crime, Population, &c, are useful to the statesman for making his assessments, his calcu- lations, and his levies. When I treat a case of pleurisy, I do not care how you treated your case of pleurisy ; I shall bleed my patient on account of his fever, pain, cough, dyspnoea, &c, and not because you bled your patient, who had similar symptoms, of the gravity of which I am no judge, not having been present to judge. So, if I treat a female with certain pain about the middle of the sacral bone, with dysuria, or retention of urine, &c, by methods calculated to take the strain off from her ligamenta rotunda, and thus cure her of retro- versio uteri, what is it to me that you adopted some other mode? That which interests me is, to be sure that a woman who has ligamenta rotunda not more than two inches and a half long, cannot have her womb turned topsy-turvy. That is the principle which I ought to apprehend, and I shall carry it out in my practice. Do you get some other principle, if you can, and come to prove my error by your statistics ; I should be strongly inclined to take after Mr. Dennis Bul- gruddery, in the play, who, if bothered with statistics, by his friend Bull, would have been apt to say, " To the divil I pitch you and your statistics, Mr. Bull!" If you had the statistical report of the weather at sunrise, for the last six thousand years, it could not tell you whether to-morrow morning will be clear or cloudy. Let a man, therefore, make himself so thoroughly learned in Medicine that he can detect the lesion of structure or function wherever it may hide, and then he is the sole judge of the action required in the case: not because twenty other cases were, but because this case is. But I stated that one great cause of unsuccess lies in the absence of information among the population generally. This absence of informa- tion is the fruitful source of Homoeopathy, Hydropathy, Thompsonian- ism, Panaceaism, and all the Catholicons, Infallible worm-destroying 40 GENERAL REMARKS ON CONDUCT. lozenges, Balms of Gilead, and that shocking absurdity—the Vegetable pill, which, like a sort of epidemic diarrhoea, has tormented the intes- tinal canal of thousands and tens of thousands of our far-seeing com- patriots, until the American population have become hardened in purga- tions, so that if Horace were here, he would not think the dura messorum ilia the toughest things in creation. It seems to me there must ever be found in human societies, a certain percentage of foolish people, who are born to be under the influence of quackery, or charlatanism of some sort. You must then expect, as long as you live, to suffer from the annoyance arising out of that class; and you need not expect to subvert or eradicate it when a new quackery breaks forth like Homoeopathy or Anaesthesia. You ought not to be alarmed about it, nor suppose that Physic is going to the dogs because of the hosts of the Quackdom. Horaco Walpole, in his letter to the Countess of Ossory, July 1, 1789, says of the madness of the French Revolution: "We have horse room and cart room for being as mad as we please. Loutherbourg, the painter, is turned an inspired physician, and has three thousand patients; his sovereign panacea is barley-water. I be- lieve it as efficacious as mesmerism. Baron Swedenborg's disciples multiply also; I am glad of it. The more religion and the more follies, the better; they inveigle proselytes from one another." Do you suppose, my dear young gentlemen, that if the community at large should be as well acquainted with physiology and therapeutics as you and I, the Ledger and the Gazette would occupy nearly one-half of their columns with those horrid descriptions and unblushing confessions of piles and itch, and other dreadful disorders, which the sufferers from them love to parade for the public gratification and edification, under their own signs manual in the newspapers ! You, who know the sceleton humanum, and the attitude of the uterus within the pelvis, do you think that Mrs. a. to x. should, out of a mis- sionary zeal, suffer her name to appear as one of the wonder-worked cures of a shameless procidentia, by what is, at our daily breakfast- table, brought up in the morning paper, to stare the ladies out of countenance, under the modest title, of a utero-abdominal supporter. Who wants to know, or who ought to know that the ladies have abdomens and wombs but us doctors ? When I was young, a woman had no legs even, but only feet, and possibly ankles; now, forsooth, they have Mfero-abdominal supporters, not in fact only, but in the very news- papers. They are, surely, not fit subjects for newspaper advertise- ments, nor would they be advertised but out of our own stupidity or remissness. GENERAL REMARKS ON CONDUCT. 41 I say, confidently, out of our remissness, and here are my reasons for saying so. We live in a land and an age of common schools and common sense. This is a country of general knowledge among the population. It is impossible that any system of science or art can stand in this country, flooded as it is with intellectual light, if sustained by any but real claims to the respect and confidence of the public. We doctors claim this confidence and respect; and we deserve it, doubtless; but we claim it imperiously and as a vested right, a right descended to us by in- heritance, from our avos et proavos, the founders of our order. But we ought to remember that our privileges, those we received in a com- mission proceeding from the Legislature, under the Great Seal of the Commonwealth, are not of the nature of the privilegium clericale, as the lawyers term it. There are too many persons in this country that can read and write, to allow us to claim a clergyable exemption from the general practice here of explaining one's self. What is the right, therefore, by which we assume, in the present day, to clothe all our proceedings in mystery, and to expect our patients to kneel down while we (not confess, but) cut them with bistouries and knives, or put arsenic and prussic acid down their gullets? They will not submit to our cle- rical manners; and they say, that if we will persist to hide our art under an impenetrable veil of mystery and jargon, they must remain incapable of discriminating betwixt the true physician and the quack- salver, since both agree upon one course, that of demanding an implicit faith and obedience without recourse to reasoning. When Meg Mer- rilies offered her Devil's broth to honest Dominie Sampson, and he feared to take the dose, what said the witch to him? She said what we doctors say to the sick lady or gentleman, " Gape, sinner, and swal- low !" Is not this representation a fair one? Even your early and noviciate experience must, we think, have furnished you the materials for judging whether I speak fairly or not. I say, then, it is our stupidity and our remissness that work evil to the people, redounding to our own hurt also; for there is no person, endowed with a good share of common sense, to whom we could not address, through that common sense, a reasonable and plain statement of the facts of his case, the probabilities as to its course, duration, and end; with an enumeration of the safest, most convenient, and certain processes for its cure. Imagine such a person, well-informed, and you have the idea of a patient the most docile, the most exact in thera- peutic and hygienic obedience; the most confiding in your skill, and the most grateful for your intervention in his behalf. Would that all our brethren in this land might adopt views like these. With their 42 GENERAL REMARKS ON CONDUCT. united force of intellect, character, beneficence, and social station, it would be but a short time ere the diminished head of charlatan- ism, under whatever disguise, would be found only to lift itself up among the most ignorant and abject portions of the population, in- stead of riding, as it does to-day, with chariots and with horsemen, a shame to the intelligence of the age, and a perpetual eye-sore to the lover of truth and contemner of every species of imposture. Let us explain ourselves then to the people. I hope it will not be impertinent in me to say that I have en- joyed a large share of professional business for some years past, and that, in the main, I have had reason to suppose I received very un- bounded confidence, and a general obedience to my medical directions, from those persons and families who called me. This good fortune I have long attributed, in a considerable measure, to the entire frankness of my explanations as to any diagnostic, prognostic, therapeutic, and hygienic views in my cases; as well as the pathology of them. I should have been a less fortunate physician if I had made more of a mystery of my rhubarb and magnesia; my senna and my salts; my antimonial wine, and my lancet. Some of the brethren, chiefly I presume those who have not very clear and concise views of their own on medical topics, are bitterly op- posed to all such explanation, on the ground that the principles of our science are far too recondite for the vulgar, who are not able to appre- ciate either them or the facts on which they rest. What a set of snobs ! I have occasionally met with difficulties in consultations from the oppo- sition of brethren to my desire to let the patient fully into my opinions. If a man really have any opinions, that are honest and clear, and well founded, do you know why he should conceal them? I profess to believe that where a physician forms perfectly transparent views of his cases, there is no need for the powdered wig and the gold-headed cane, the mysterious nod, and all the apparatus of deception that we might look for rather in old Felix Plater, or Horace Augenius, than in a modern physician, who is or rather who ought to be a modern gentleman and man of honor; and as such, above all false pretences—open, candid, and manly. Now I sincerely think that where you may hereafter desire to effect a cure, yet meet with obstruction through the timidity, the doubts, or apprehensions of the patient, you will only have to speak common sense, and to take out your pencil, and on a sheet of paper make a few well- sketched diagrams of parts, organs, and relations of parts and organs, in order to bring the recusant back to a truer and firmer faith than be- fore, by convincing bis judgment and winning his inclination. Yea, GENERAL REMARKS ON CONDUCT. 43 verily, you shall sustain the fainting hope and the dying faith of the sick girl, for days and for weeks, and through months of pain, if you speak the truth, and explain the truth; if you show the hope and have the hope; if you claim the power, and really possess it. But if you have not the confidence of your patients, it is because you either do not merit it by your science, your skill, and your temper ; or because, possessing all these, you are destitute of, what I beg you to ex- cuse me for calling in a grave book by a slight term, gumption. Depend upon it, my dear young gentlemen, there are plenty of people, " plenty as blackberries," who seem very learned and very shining except when you come to a rub with them, but who lose all their shining qualities because they have not and cannot take a real polish. They are covered only by a varnish. The celebrated Dr. Clarke, of London, from whose lectures that capital little midwifery book, called the London Practice of Midwifery, was pirated, says, somewhere in its pages, that one Doctor, by his good sense, shall retain the entire confidence of the woman in labor through the most painful protractedness of labor, while another would lose her confidence, in a very short time of hope deferred; and that, not because he hath not ability as a prescriber equal to the other, but from some fault of manner, expression, or conversation. If you would be learned men, it is well; but it is better to be wise men. A man maybe wise without being learned; but it is not un- common to be learned and yet to be a perfect ass in all that relates to what I might term administration, or action. Let your light, therefore, shine among men : set it on a hill, and do not conceal it under a bushel of gawkeyness, or some stupid conceit of your personal dignity; or, what is still more asinine, the dignity of your calling. Dignity is you, not physic, nor the practice thereof. Did you never hear that " Worth makes the man, the want of it the fellow, And all the rest is leather and prunella ?" I have seen dignified shoemakers, carters, butchers, and even a very dignified tailor, and I have known philosophers and very learned men without the least dignity. Believe me, there is true dignity in great virtue, great information, and great power to diffuse, apply, and make that information useful to our fellow-men. Such is the dignity you should strive to attain. Such is the dignity of the scholar. Lie is not the scholar who knows most, but rather he in whom scholarship begets the fruits of wisdom both as to conversation and conduct. That wonderful old man, Virey, says: "La presence, l'attouchement ou les parolles d'un homme tres-eminent par son caractere moral, ou par 44 GENERAL REMARKS ON CONDUCT. la sublimite" de son esprit ou par l'opinion de sa dignitd, influent sin- guli&rement sur les ames inferieures et sont capables de guerir les corps." (L'art de Perfect. VHomme, ii. 22.) If I could give you the best piece of advice in my power, I think I should give you this advice ; namely, in all your dealings hereafter as physicians, and in all your life-doings, strive, first, to increase the boundaries of your knowledge; and, second, to make that knowledge as vulgar, as popular as possible. Be a reformer in this particular, and you will, should you succeed, become the real founder of a Sect in Medi- cine, and that sect you may baptize as the lroung Physic that Dr. Forbes advocates. That will be the true young physic, which succeeds in bringing down Old Physic to the level of this common sense age. I say again, therefore, wherever you place yourself, be sure to have no concealment, no mystery, no pretence; but endeavor, in the clearest manner, not pragmatically to assert, but clearly to show your claims to superior power in that great utilitarian avocation of curing the sick and the wounded ; an avocation which is almost, I say it with reverence, next in goodness to the mission of Christ, who went about clothed with power and authority—(tytipilv -tovc. rsxpovs xo.1 £uortoisiv.} In order fully to discharge the duties of this great mission, is it not indispensable that you should prepare yourselves for its offices by suitable preparation of the mind and person ? Of the mind, by arming it with knowledge and wisdom ; with prudence and patience ; with firmness to encounter all vexation and responsibility; with charity and liberality, and with all that armature of the soul that alone can render men worthy to be called eksv9epol} or freemen, for none are so but those whose condi- tion has raised them above the grossness and sensuality of the corporeal nature, rendering the body the servant and the minister, not the tyrant of the soul and the heart; not as humbling the intellect, but adorning it with noble sentiments. It is difficult to say how a man, in forming his manners, should pro- ceed. Indeed, there is, probably, no art so great to form the manners as that which teaches us to keep the temper and the desires of the soul within the just bounds by which they are restrained among all true followers of the Christ. To be a true and accomplished gentleman, one should " do justly, love mercy, and walk humbly before God." Any person, under such guidance, cannot fail to have manners acceptable in all forms and ranks of society, wherever business may lead him. Such a person will have his own manners, and not be a servile imitator of other men's style—and this is far better; for where a man is seen to represent himself, and not some other person, he will surely be trusted GENERAL REMARKS ON CONDUCT. 45 and respected because he preserves his own identity, and so is never to be likened to a two-faced Janus. A special regard to one's personal appearance is also a very indis- pensable means of success, not in making money, but in curing the sick. The sick are affected by the presence of the physician. A man well dressed, of good manners, of agreeable conversation, neither too grave nor too gay, would, cseteris paribus, inspire more confidence, in- fuse larger courage, longer patience, and greater hope, and therein succeed more surely in curing his patient, than another of equal infor- mation on medical science, but careless and negligent of his behavior and appearance, vulgar and rude in his conversation and manners. Sick people think that the physician should be a wise and a learned person, or a scholar. They know that Medicine is Scholarship, and a brute never can be really a scholar, who, as I said already, is a gentleman. Let every scholar, therefore, become really a freeman of the republic of letters, not a servant or slave. Let him be assured that St. Augustin spoke the truth in saying quod scimus debemus rationi, quod credimus auctoritati. Be ye therefore men that know, and not merely people that believe of a doctrine whether it be good or bad, true or false. I cannot advise that you always should carry about with you an air, and, indeed, a habit of boasting, and an appearance of self-sufficiency, which, wherever they are observed, generally are taken to be signs of weakness. But that which you do know, I would have you conscious of knowing, so that you may be enabled to speak with due boldness and decision on all proper occasions. What you do know you ought to know well; but you should not forget that your training and education, that have made you familiar with many deep things in science, can not pre- vent you from being troubled with professional opinions by non-profes- sional people. Despise them not; remembering that one man can not know all things even in his own art—and that even if he could, the remark of Mirabeau is a good one, that " To succeed in the world it is necessary to submit to be taught many things which you understand, by persons who know nothing about them." But, I fear I am uselessly consuming your time and exhausting your patience. I shall close this letter, therefore, by recommending you to observe the rules of conduct laid down by your professor of the Insti- tutes on Commencement-day. Should you remember and follow out the plan he then pointed out, you will become what I desire ardently that you should become, useful and successful in your calling, which will redound not only to your own honor and profit, but to the credit of your Alma Mater. Before I close this letter, pray allow me to cite for your perusal a 46 SEX. passage from Sir Thomas Browne's Religio Medici, p. 139, who, if you imitate him in the sentiments and conduct here pointed out, will be your sufficient model. " I feel not in me," says Sir Thomas Browne, " those sordid and unchristian desires of my profession ; I do not secretly implore and wish for plagues, rejoice at famines, revolve ephemerides and almanacks, in expectation of malignant aspects, fatal conjunctions and eclipses : I rejoice not at unwholesome springs, or unseasonable winters ; my prayer goes with the husbandman's ; I desire everything in its proper season, that neither men nor the times be put out of temper. Let me be sick myself, if sometimes the malady of my patient be not a disease unto me. I desire rather to cure his infirmities than my own necessities : where I do him no good, methinks it is scarce honest gain ; though I confess it is but the worthy salary of our well-intended endeavors. I am not only ashamed, but heartily sorry, that besides death there arc diseases incurable ; yet not for my own sake, or that they be beyond my art, but for the general cause and sake of humanity, whose common cause I apprehend as mine own." Farewell. C. D. M. LETTER III. SEX. Gentlemen: You may remember that in lectures at the college, I frequently repeated that the ovary of the female gives to her the sexual character, and that as the interior and active tissue of the ovary, is the part which Ch. Ernest von Baer calls the lager or stroma, so that very stroma itself is Sex. You. might, perhaps, at.first hearing this dogma, feel disposed to reject it as too concise an expression of the multitudinous and diver- sified characteristics of the sexual nature—but I hope a careful exami- nation of the matter may induce you to coincide with me in opinion. The sexual office is designed to reproduce the material forms and faculties of a genus or species; and this is not done save by the pro- duction of a germ, which at least in all the Zoological series, is found within an ovum, which, in plain English, is an egg. Omne vivum ex ovo is a true saying. An ovum then is an egg—which is not to be considered as a germ, but SEX. 47 as a thing containing a germ, and also the material or pabulum for the early stages of the development of that germ. An egg is a yelk-ball—which in some instances is invested with a quantity of albumen or white, and in some cases is not accompanied with any material of that sort. A yelk-ball is a vitellus—and consists of a multitude of corpuscles and granules and punctiform bodies with small globules of oil swimming in a clear colorless fluid, all inclosed by a delicate anhistous membrane, called the vitellary membrane. In most cases, yelk matter is of a yellow hue; in some it is red or greenish, &c. If you break open a yelk, whether of the humming-bird or the ostrich, of the elephant or the mare, the rabbit or the earthworm, the shad, the minnow, or the whale, you will find it to consist of corpuscles, granules, and puncta, with oil globules and a clear fluid. If the egg has not been previously subjected to fecundation, as it could not be while remaining in the ovary, there will be found within it at the centre of the ball, or near the inner surface of the vitellary mem- brane, a smaller spherule of a beautiful transparency, and which is de- nominated the germinal vesicle—within which, and adhering to the wall of the vesicle, are a number of very minute microscopic granules, which by Rudolph Wagner, of Berlin, by whom they were discovered, are called the macula germinativa or germinal spot—so that an egg is, 1„ a vitellus; 2, a germinal vesicle contained within a vitellus; 3, a germinal spot lodged upon the inner wall of the germinal vesicle. It is to be believed that the germinal spot is the true germ-point, or germ itself, and that all the other constituents of the ovum are placed round about it, in order that by its changing and formative power, its metabolic and plastic force, it may convert their elements into its own corporeal elements, evolving out of them the rudiments of its own organs, as brain, veins, heart, blood, &c. &c. Such an ovum, after having acquired sufficient organic form and force, to make, its mesen- teric attachment to the living parts of the womb, is ready to be con- ceived. Conception is the formation of that mesenteric attachment, and nothing more nor nothing less; for conception is the fixation of the fecundated germ. Nature, all whose operations are preordained, as being guided and limited by the law of God, has provided fully and most liberally for the production of germs, and thereby secured the perpetuity of her kinds. She has, in order for this germ production, adopted various methods of arrangement. In certain animals she has devolved the germ-producing and the fecundating powers upon the same creature—in others, she has 48 SEX. provided two independent forms of being for the carrying on of the office. In the lower orders of beings, as the earthworm, for example, both the germiferous and the fecundative attributes are comprised within the same individual body. So that the creature can fecundate its own female constitution by the act of its male constitution; and this simple but effectual mode of keeping up the genus or species is admirably adapted to the inactive and aperceptive nature of the being itself. In higher forms, two separate individuals are provided, one endowed with the male, or fecundating nature, and the other with the female, or germinating nature. " Male and female created he them," unto the end that they might increase and multiply, and fill the earth with sen- tient beings, wonderfully endowed with life-faculties, and therefore with the means of enjoyment, in other words, of happiness. To procure happiness and establish it, must be regarded as one of the highest attributes of Divine power and beneficence. The important, the indispensable ovum, could not be left without protection—nor could it be developed without a machinery. The ovum is, therefore, protected within an ovisac, or capsule, which is what is called a Graafian vesicle, or Graafian follicle, or Graafian cell, from Regnier de Graaf, a Dutch physician, who, in his Treatise de Mulierum Organis Gcnerationi Inservientibus, published in 1672, gave the first clear account of those small pellucid vesicles that you have so often seen in the ovaries I exhibited to you. A Graafian vesicle consists of a double-coated capsule, of which the outer one lies in contact with the stroma, and contains the inner one within its own sphere; not loose and unattached, but connected to it by means probably of a very delicate laminated cellular tela. This interposed and connecting cellular tela may become filled with secretions; and as the outer one is, like a mineral in its gangue, pressed against the stroma, it is clear that any interstitial deposit must have two contrary results, one to enlarge the outer concentric and throw it further back against the stroma, displacing and distending it; the other to press the ovisac inwards towards its contents to compress them, and so render the inner aspect of the ovisac uneven, wrinkled, or convoluted • and, in fact, I have shown you on several occasions both these different results. I pray you call to mind, not only the human ovaries in which I showed you the convoluted or wrinkled appearance of the inner aspect of the ovisac, but the more striking samples of the same effect in the ovary of the sheep and the cow. In this latter case, the interstitial deposit was so enormous that the outer coat of the ovisac had grown to SEX. 49 a size nearly equal to half the mass of the whole ovary, and was of an orange hue, derived from the deposit of a great quantity of vitellary matter betwixt the two laminae; the outer one being greatly expanded or extended, and the inner one being crimped, convoluted, or wrinkled. This great orange-colored mass was the corpus luteum. Before the corpus luteum had begun to be formed, the ovary had been occupied in furnishing vitellary matter for the construction of the yelk-ball; but that ball, having become complete in all its parts, and incapable of any further accretion, as contrary to its generic law, the ovarian stroma, whose office it is to produce germs and vitellus, could not at once withhold its villiferous power, and the deposit went on upon the outside of the true ovisac after the completion of the vitellary ball. Hence, you perceive that within a perfectly mature Graafian follicle there is a yelk-ball, with its germinal vesicle and its germinal spot inside of it; some fluid of the ovisac filled with granules; and on the outer surface of the ovisac, between it and the external capsule or coat, a yellow deposit, which begins to appear there about the time when the yelk is quite ripe, and continues to augment in quantity for some time after the yelk has been discharged. Let me repeat, that this yellow body is the famous corpus luteum, and that such a yellow mass is deposited with the maturation and discharge of every yelk. Some- times, perhaps in pregnancy, the corpus luteum is larger than at other times, but whether large or small, it is a real corpus luteum; for there are not, as some writers pretend, true and false, but only true corpora lutea. But this gradual evolution of the luteal deposit has the effect of lifting the germ, with its vesicle and its yelk-ball, nearer and nearer to the superficies of the stroma: to press outwards the tunica albuginea; and, finally, to press it so forcibly that absorption commences at the weakest and most distended point of its surface, until, a pore being formed, the yelk and the fluid about it escape from their imprisonment in the ovisac, and either fall into the belly, or are received within the infundibular orifice of the oviduct, which you call Fallopian tube, which conveys the egg to the womb. Its mesenteric attachment to the womb, as I before said, constitutes a conception, which pregnancy follows. I have made the foregoing observations in order to fortify my asser- tion, that for the female stroma is sex. But you will find, if you will read the good authors, that this is not my doctrine. It is the doctrine of the highest authorities. The British and Foreign Medico-Ohirurgical Review for Jan. 1849, ridicules me for saying that stroma is sex. I have not that vainglorious 4 50 SEX. pride that can lead me to suppose that truth is mine. Truth is God's, and his alone. Truth belongs to no mortal: he may only see it and feel conscious of it. I am conscious that I speak the truth when I say that stroma is the sexual concrete, and that it alone is so, as alone being a vitelliferous organ. " La difference sexuelle ne repose done pas sur une polarisation complete, sur une scission en deux facteurs qui s'excluent l'un et I'autre; I'ovaire reste, jusqu'a un certain point, la chose primordiale, indifferente, procreatrice de son propre fonds, et il n'y a antagonisme de polarite* entre lui et le testicale qu'en dgard a l'achevement de ses produits, par consequence de rintensite* de ses forces." {Burdach, i. 360.) Do you think that if a creature should be born with the external genitalia perfectly well formed, with a perfect uterus, and vagina, and tubes, but without any trace of ovarium, such a creature could be a female ? Or, if she should have two perfect ovaria, and be born with- out womb, or vagina, or external organs, would she be anything else than female ? I am sure you will agree with me that she would not, in the former case, be female, and that, in the latter, she would be truly female—because, though unhappily deprived of any gestative organ, or organ of copulation, she is endowed with the germiferous through her vitelliferous faculty, which resides essentially and exclu- sively in the substance called stroma. No germ could she evolve in the spleen or liver, in the kidney or brain, in the heart or lungs, nor, indeed, anywhere save in the stroma, which is the true sexual concrete, and is, therefore, itself sex. Liver, heart, brain, lung, nor digestive canal, is not sex, but stroma is sex for the female—nothing else is sex. Oken says: "Already in the course of the heavenly bodies has the highest act of the animal, that of copulation, been preindicated or por- trayed. The creation of the universe or world is itself nothing but an act of impregnation. The sex is prognosticated from the beginning, and pursues its course like a holy and conservative bond throughout the whole of nature," &c. (Oken, Physio.-Philosophy, 398.) But, after all, what is sex? Methinks you ask the question, which is a very difficult one. Perhaps I should best answer it in a few words, by saying it is reproductive power, whether male power or female power. It is a matter of indifference whether the philologists derive the word from secus, aliter, otherwise, after another manner; or from secare, to cut, to divide one from another. We have, in physic, less to do with philology than with facts. I think that we are hitherto unacquainted with any facts that give convincing proof of a sexual nature in the germ. There is an embryo- nal stage of life in which it is utterly impossible to determine the sex SEX. 51 of the embryo; and it is not known whether the female embryo pro- ceeds from a germ originally female, or whether the germ, being in its inchoate state, neither male nor female, assumes the female nature in the progress of its evolution, or takes on the nature of the male at some certain stage and under some law as yet unknown to us. It is very certain, however, that for the human race, the proportion of the sexes, as to their number on the globe, is maintained from age to age. The law that ordains this equable rate of production, operates so as to bring into the world about 104 males to 100 females; a pro- portion which keeps the sexes nearly equal in number; it being pro- bable that the temperament and exposure of the male render him more liable to premature death than the female, on which account the excess of male production is ordained. If we refer to what is known to be true as to the non-sexual nature of the larva of the bee, hereafter to be mentioned, we may find arguments for the opinion that the germ, originally, is non-sexual, but becomes male or female under some unknown law of development, in its earliest embryonal life. If such a sentiment may be rightfully entertained, you will, perhaps, agree with me that sex is something superimposed upon the mere living nature of a creature; and you will more readily admit of it if you con- template two children, one male and the other female, of the same stature, weight, and temperament, born at the same hour, and brought up at the same breast. You cannot report to the mother of what sex they be, without referring to the pelvic extremity of the trunk. They are pleased with the same rattle, tickled with the same straw. They play at the same toys, and are alike in moral and physical attributes, until the sexual endowment comes to be granted to them. Upon that instant they divaricate; their whole physical and intellectual, and moral forces become different, and they pursue, so to speak, a separate walk of life, until the exhaustion of the sexual attribute, in the one and in the other, causes their paths to converge again, until they are seen sleeping uthegither at the fit" of the hill of life, over which they had toiled in distinct tracks from the puberic until the critical age. What can be more like an old woman than an old man ? or what can be more like a girl than a perfectly ingenuous boy? Where is the likeness be- tween men and women? Is it not true, then, that the sexual nature is something superadded to the mere living or corporeal nature, which, on being taken away, reduces the sexual individuals back again to their original sameness of life-nature? Is not sexuality a complement? You have heard, I presume, of a circumstance that may tend to 52 SEX. illustrate this idea, in the history of the honey-bee. The community requires a queen—which means a vitelliferous, and so a germifcrous creature—and it also requires a considerable number of drones—males, or fecundating members of the society, which being provided for the hive, nothing more is wanting but a sufficient number of mules, work- ing bees, or creatures capable, first of enjoyment, and second, of providing for the conservation of the species by collecting food—1, for the germiferous; 2, for the fecundating; and 3, for the laboring part of the species. Now all these males and workers are alike while in the ovular state; but if the males die, by some epidemic, a battle or accident, the community know how to convert the larvae into males by administering to them certain sorts of food, or else leave them mere worker-mules, by withholding that kind of aliment. So that, in fact, you discover here that the mere corporeal life of the larva possesses no sexual nature, and that a sexual nature may be superadded by a certain economy of the hive, an economy that can cause the ovum so to develop itself as to become fitly provided with the fecundating apparatus and material, or to become drone bee or germiferous bee. When a queen dies, after having deposited many thousand eggs in the mule-bee cells, the alarm and confusion in the hive are very extraordinary; but it sub- sides after the tumult of the first excitement, and the mules or workers select some one egg, for which they enlarge the cell by converting three common ones into a single royal cell. By feeding the grub with an aliment called royal jelly, they cause it to pass into the female state, and thus the lost queen is succeeded by a queen produced from the egg of a mule or worker-bee; an egg that could only have developed a non- sexual creature but for the special influences brought to bear upon it from a state necessity. I ask you again, if this be true, whether it does not show that the sexual nature is, not an original nature, but a nature superimposed upon a mere animal or living nature. And, if true of the bee, does not that truth, established, likewise establish the law for all possible animal and even vegetable existences? M. G. Cuvier, in the Regne Animal, vol. vi. 314, is of opinion that the mule bee is but an undeveloped female; but even this view confirms the one I have taken above, for what is an undeveloped female ? I see not how a better proof, or at least illustration, could be given of my idea that the sexual nature is a climax. A culminating life-force evolves it. It ought not to excite our astonishment that the female sexual nature gives to the physical intellectual and moral attributes a bias different from that of the male. The sexual organs in woman are different—they are subject to fluctuations as to the tide of life within them that those of the SEXUAL PECULIARITIES. 53 male are by no means exposed to. Women are always about to men- struate or menstruating, or ceasing to menstruate : the womb is gravid or going to become so, or it is recovering from the parturient state: these organs have never an even steady tenor of life. These organs require a different and more complex system of innervations, more expensive to the nerve-centres than those of the male ; more delicate, sensitive, im- pressible than his. Here are circumstances, then, implying a dependency and physical debility as compared with him ; a reliance upon and a trusting to his power : and, in fact, all the peculiarities that mark her as a creature of the feminine and gentle sex. I shall in my next letter occupy your atttention with some re- marks on the distinctive characteristics of woman, to which I shall beg to invite your attention, not with a view that you may learn of me what those distinctive characteristics are—for a volume would not suffice fully to relate them—but that I may, perhaps, be able to turn your attention in that direction, in the hope that your young and vigorous strength may be incited to a more consistent and energetic pursuit of whatever literature and science ought to be garnered up by a physician, as the ornaments and aids of his career of usefulness and dignity. Farewell. C. D. M. LETTER IV. SEXUAL PECULIARITIES. Gentlemen: Before I proceed to the consideration of the topics that are to engage our attention in the main, I wish in this letter to say some words to you on the Distinctive Characteristics of the Woman —or rather, I should say, on some few of those characteristics—for to describe them all would require rather a series of letters than a single discourse. I shall, therefore, in the present letter, only attempt to indicate a few points of contrast betwixt the male and female, with a view to turn your attention that way. I could readily fill a volume upon the different texts that I am about to present to your considera- tion. It is proper that I should fulfil this design, because I have long thought, as I now do, that without some preliminary thoughts and reflections in this direction, you might be less fully prepared to receive proper views of the disorders to which the woman is subject, and which it behooves 54 SEXUAL PECULIARITIES. you as medical men to acquire ; and less capable than you should be to appreciate those modifications of therapeutical indication and process that are demanded by the moral, intellectual, and physical qualities of the female ; for her mere human or generic nature is modified by her sexual or female nature to such a degree, that as to certain of the great crises of her life she demands a treatment adapted to the very specialties of her own constitution, as a moral, a sexual, germiferous, gestative, or parturient creature. I do not suppose you could acquire just views on these points in the dissecting-room, or the theatre of anatomy alone. Nor can I give them to you here in one letter, for the time is too short. There, it is true, you might explore the items of her physical structure, in order to com- pare them with those of the hardier sex. You might there learn that though she be a part of mankind, more truly a Zygozoaire than those of M. de Blainville's classification, she yet differs from men in her stature, which is lower; in her weight, which is less ; in her form, which is more gracile and beautiful ; in her reproductive organs, that are peculiar to her ; and in her intellectual and moral perceptivity and forces, which are feminine as her organs are. Beyond all these, you shall have to explore the history of those won- derful functions and destinies which her sexual nature enables her to fulfil, and the strange and secret influences which her organs, by their nervous constitution, and their functions, by their relation to her whole life-force, whether in sickness or health, are capable of exerting, not on the body alone, but on the heart, the mind, and the very soul of woman. The medical practitioner has, then, much to study, as to the female, that is not purely medical—but psychological and moral rather : such researches will be a future obligation lying heavily upon you, upon all of you. Every well-educated medical man ought to know something more of woman than is contained in the volumes of a medical library. Her history and literature, in all ages and countries, ought to be gathered as the garlands with which to adorn his scholarly career as a physician ; but these insignia of his power he can only gather by the careful and tasteful study of his subject among the rich stores of learning that are garnered in the belles-lettres collections, whether archaiological, mediae- val, or modern. The medical man, surely, of all men, ought to be best able to appre- ciate the influence of the sex in the social state; because, more than other men, he is by his vocation in habits of closer observation of those influences that bind together the members of families that compose the SEXUAL PECULIARITIES. 55 social compact. He more clearly than others can recognize the power of woman in the family—and thus in all society, which he sees to be moulded and controlled by the gentler sex. But for the power of that female influence, which one of you would doubt the rapid relapse of society into the violence and chaos of the earliest barbarism? Are you not aware that the elegance and the polish of the Christian nations are due to the presence of the Sex in society—not in the Zenana ! Do you not perceive that Music, Poetry, Painting, all the arts of ele- gance : Luxury, Fashion, (that potent spell!) are of her, and through her, and to her ? Versailles and Marli, and the Trianons, had never been built for men. The loom blends and sets forth the dyes that add richer reflections to her bloom; the wheel flies for polishing the diamond that is to flash in impotent rivalry above woman's eyes ; sea and land are ransacked of their treasures for her ; and the very air yields its egrets, and marabouts, and paradise-birds, that their plumes may add piquancy to her style, and grace to her gesture. Even literature and the sciences are in a good measure due to her patronage and approba- tion, which is the motive power to all manly endeavor. This is true, since, but for her approving smile, and her rewarding caress, what is there should stir man from the sole, the dire, the unremitted compulsion to act that he may live ? With woman for his companion, man acts not only that he may live, but that he may live like a Christian, and like a Gentleman. Dr. Johnson says, that " to be happy at home is the ulti- mate result of all ambition, the end to which every enterprise and labor tends, and of which every desire prompts the prosecution." " Blest as the immortal Gods is he, The youth who fondly sits by thee, And hears and sees thee all the while, Softly speak, and sweetly smile!" The great stage of the world, we are informed by the inspired writers, was prepared as the scene of a grand moral drama. The earth and all that it inherit is for man, his use, his delight, his trial I But, this mankind—this genus man—is an imperishable unit that commenced at the beginning, and touches the middle and the end of time. It is a vast wave rolling down the tide of time, ever rolling, ever descending. Its spray and its foam are lost in the sands, or melted in the air, as the fragments of mortality are broken off and swallowed up in the grave ; but the wave is unbroken ; it grows as it goes; the great majestic wave rolls onward, onward forever—perdurable ; and shall not be swallowed up till the last trump shall sound, and the last end be come. The sun himself, they say, "grows dim with years," but the unit, the Genus man springs ever fresh in immortal youth and vigor, like Antaeus of 56 SEXUAL PECULIARITIES. old, foreshowing the immortality of that spiritual part to which Adrian the pagan addressed his speech, as it was leaving the imperial possessor a mere dust-fragment of the vast, ever living unit man. Animula vagula blandula Hospes comesque corporis Quae nunc, abibis, in loca! Pallidula, rigida nudula, Nee ut soles, dabis jocos. Ael. Spaetianus.—Adrian. Cxsar. It is strange to think on the power of the race; and yet from what low beginnings ! even from the germiferous tissue of the female ! It is from her stroma that issues the generic as well as the genetic force ! What a wondrous law is that of species! what a constant power is that which maintains each genus and species pure and unalloyed as when it issued from the Creator's hand ! So strange, so powerful is it, that each of them is set, as it were, within a magic circle, out of whose charmed round it can never stray; so that no wild and horrid passion, no brutal lust, no insane desire can break, much less change or abrogate the law that set forth the primordial models, " each after his kind," of the species of the globe. For, notwithstanding the countless myriads of generations that from the remotest ages have reproduced individuals more numerous than the sands of the shore, or the stars in the firma- ment, each blade of grass, still obedient to its generic law, imitates exactly its primitive pattern ; and every elephant or worm; every eagle that soars to the sun, or sparrow that chirps in the hedge ; every man, and every woman go steadily, like the current of a river, down Time's flowing stream, ever ending, ever beginning, always changing, yet immutably the same ! I repeat it, the generic power is launched from the ovarian stroma, which is the sole animal concrete that is capable of producing reproductive matter. Yelk matter is germinal or generic matter ; I should rather say reproductive matter. The male tissues are nowhere endowed with the power of this yelk production, and the sole elaboration of the stroma of ovaries is germ-elaboration. See, then, in this unobvious, apparently vile lump of animal texture within the inner court of the temple of the body, the very ark that contains the law which keeps the genera and spe- cies unmixed from age to age. How can you study this subject sufficiently ? But let us pass to other views. Let us go to look upon woman in the phases of her. intellectual nature. If we scan her position amidst the ornate sites of a Christian civilization, it is easy to perceive that her intellectual force is different from that of her master and lord. I say her master and lord; and it is true to say so, since even in that SEXUAL PECULIARITIES. 57 society she is still in a manner in bonds, and the manacles of custom, of politics, or of bienseance, not yet struck from her hands. She has nowhere been admitted to the political rights, franchises, and powers that man arrogates to men alone. The Crown, when it rests on the brow of a woman, is always a political accident, grievous and deprecated ; and even then, where woman reigns, man governs. The great administrative faculties are not hers. She plans no su- blime campaigns, nor leads armies to battle, or fleets to victory. The Forum is no theatre for her silver voice, full of tenderness and sensi- bility. She discerns not the courses of the planets. Orion with his belt, and Arcturus with his suns are naught to her but pretty baubles set up in the sky. She guides no ship through night and tempest across the trackless sea to some far off haven half round the world. She com- poses no Iliad, no iEneid. The strength of Milton's poetic vision was far beyond her fine and delicate perceptions: she would have been affrighted at the idea of that fiery sea on whose flaming billows Satan, " With head uplift above the waves, and eyes That sparkling blazed------------ extended long and large, Lay floating many a rood: in bulk as huge As whom the fables name of monstrous size ; ------------or that sea-beast Leviathan, which God of all his works Created hugest that swim the ocean stream." Do you think that a woman, who can produce a race and modify the whole fabric of society, could have developed, in the tender soil of her intellect, the strong idea of a Hamlet, or a Macbeth? Could her voice, like the accents of Hortensius, or Tully, or Chatham's, or Burke's, command the bent ear of a listening senate, or move like leaves whirled in a tornado, the agitated masses of a people tossed in the tempest of its vehemence : or like a gentle west wind, soothe and caftn them down again by the influences of its reasoning and prayerful suasion ? " Ille regit dictis animos, et pectora mulcet." iENEID, I. Such is not woman's province, nature, power, nor mission. She reigns in the heart; her seat and throne are by the hearth-stone. The house- hold altar is her place of worship and service. The Forum is too angry for her. The Curia is too grave and high, and the Commitia too bois- terous and rude. Home is her place, except when, like the star of day, she deigns to issue forth to the world, to exhibit her beauty and her grace, and scatter her smiles upon all that are worthy to receive so rich a boon—and then she goes back to her home, like as the sun sinks in 58 SEXUAL PECULIARITIES. the west, and the memory of her presence is like the soft twilight that lingers long behind a bright departed day. Her voice is not for brawling. Its tender tones are for soothings and caressings. The sweetest lute is in her vocal organs ; and with its music she stifles the passion, assuages the rage of her master, and re- duces .back to the gentlest flowing, the furious tide that boils in his veins. It is by the mere contrast of her gentleness, her docility, her submissiveness and patience, that she makes herself the queen and the arbitress of the fate of whom she loves, and whose best rewards for the pains, hazards, and toils of existence, are ever to be found within the narrow circle of her domestic reign. It is true that we meet in the pages of History and Biography the relations of strange phenomena in the lives and actions of certain women. There are Julias and Messalinas, that are monsters. Frede- gonde and Brunehaut terrify us by their atrocities. There is even somewhat questionable in the nature of such ladies as Elizabeth, or Mary of Medici. We have male powers in a Dacier and a Stae'l. We find the gentle and feminine Hemans sometimes bursting forth with a wild, impetuous, and martial enthusiasm. Yet these are exceptions, and not rules; exceptions that fill us with surprise, as of things out of or beyond the common course of nature. Among the wonderful exceptions of power in women, there is perhaps none on record so extraordinary as that of the actress Rachel. The power of that woman's eloquence seems superhuman, and I much doubt whether the most splendid orators of antiquity, or the most powerful senators of modern times, could vie with the potent and spell-weaving accents and gestures of that extraordinary creature. A word, a look, a sign, a pleno rotundoque ore effusion of thoughts that breathed and words that burned, overbore me that I could no longer look at her face and figure, but compelled me to avert my eyes from the intolerable blaze of genius that flashed like a glory all about the pretended daughter of Virginius. Although I believe that Rachel is the most eloquent human being that has lived, she is mainly so in the use of others' thoughts and others' words. As to her own power of imagination, reasoning or judgment, I presume they are those of a play actress. The bibliographical lists are full of the prettinesses of the ladies.— No Mecanique Celeste—no Principia—no Treatise de Senectute—no Annals of Tacitus belong to them; but Canzonetti, Fairy tales, Stories of the heart, Mysteries of Udolpho, and Coelebs in Search of a Wife. Such are their works. So that it is easy, by a slight glance at history, and by the facts that surround us, to conclude that the intellectual and SEXUAL PECULIARITIES. 59 moral force of the female are different from those of the stronger or ruder sex. Who could imagine such an intellectual fairy as Felicia Hemans join- ing a charging squadron of crusading chivalry, knee to knee with God- frey de Bouillon or Cceur de Lion, and glorying in the commingling of the spears! Yet, though timid herself, her very tenderness gives her the keenest perception of the nature of courage, and the deepest sym- pathy with the feelings of her gallant knight. See, gentlemen, in the following lines by Mrs. Hemans, her touching sympathy with a captive Crusader in some lofty Pagan tower, perched above a deep craggy waddy in Palestine. Worn and wearied with a long and lone captivity, his valiant heart, though broken, still pants, in its solitude and hopelessness, for the free- dom and action of the field. Suddenly he starts at the wild scream of a bugle, which rises to the topmost height of his lonely tower, pene- trates its embattled walls, and thrills in every fibre as he listens. 'Twas a trumpet's pealing sound! And the Knight look'd down from the Paynim tower As a Christian host, in its pride and power, Through the pass beneath him wound. Cease awhile, Clarion—Clarion loud and shrill— Cease; let them hear the Captive's voice. —Be still, be still! I knew 'twas a trumpet's note; And I see my brethren's lances gleam, And their pennons wave by the mountain stream, And their plumes on the glad wind float. Cease awhile, &c. I am here in my heavy chain! And I look on the torrent sweeping by, And an eagle rushing to the sky, And a host to its battle plain! Cease awhile, &c. Must I pine in my fetters here, With the wild wave's foam, And the free bird's flight, And the tall spears glancing in my sight, And the trumpet in my ear ? Cease awhile, Clarion, &c. &c. Now, for my part, I cannot but see in these verses of that most sweet poetess, proofs of her liveliest sensibility to both the nature and the intenseness of those male passions, which, however they may be fitted to enkindle her admiration, and enslave her heart, as forming a perfect antithesis to her own gentle nature, would, as existing in her own breast, 60 SEXUAL PECULIARITIES. demoralize and deform it. The military pennons and plumes floating on the glad wind, and the tall spears glancing in her mental sight, are not for her to wear or wield. But she may well glory in the hero who is both able to wear and to wield them. As to the more strictly moral attributes and propensities of the female, what are the facts ? Is not her heart, in general the seat of tenderer and gentler emotions than those of her mate ? Her susceptible soul is acutely alive to the human charities and trembling sympathies that spring spontaneously in the delicate moral perceptions and physical innervations of her feminine constitution. She cannot unmoved look on scenes of woe. She melts at the spectacle of human distress—a maiden sheltering a wounded dove in her bosom is an eidolon of the sex. Mungo Park in the Sahara, and Ledyard among the wildest Sa- moiedes, always received good, and not evil entreaty at the hands of women, whose husbands had hearts like the nether millstone. Notwithstanding the poet has characterized her as being, " in our hours of ease, Uncertain, coy, and hard to please, And variable as the shade By the light trembling aspen made," she is faithful and true. She follows the fortunes of her mate, who has gained her affections. Yea, she adheres to the promise at the altar, which was for better for worse, for richer for poorer, in sickness and health—even unto death; so that the same rhymer apostrophizes her with " When pain and anguish wring the brow, A ministering angel thou !" What a beautiful picture is that engraving of the "Intemperate," which you see everywhere in the print-shops! What touching, what immortal fidelity is depicted by the artist in the face of that woman! A face beautiful in its expression of resignation, and of pride in her own faithfulness and truthfulness, as she bears on her bosom the youngest child, while she leads a sick boy by the hand, and is clutched by a timid older girl, all of them barefooted, houseless, hopeless, home- less, for they leave behind in the distance the pretty cottage where they were born, to pursue, along a rugged way, the uncertain, drunken foot- steps of the husband and the father, who leads them miserable far away, deserting the homestead she had brought as her dower, in that blessed morn when in the village church she gave herself away for him. Now here is her reward ! But she will cling to him until the death of the SEXUAL PECULIARITIES. 61 drunkard shall have broken the bond; and after that, go weep on his discreditable grave, and forgive him too. Such pictures are from life. There are thousands of such. The female is naturally prone to be religious. Hers is a pious mind. Her confiding nature leads her more readily than men to accept the proffered grace of the Gospel. If an undevout astronomer is mad, what shall we say of an irreligious woman ? See how the temples of the Christian worship are filled with women. They flock thither with their young children, and endeavor to implant in their souls the seeds of virtue and piety, to be reared in that pure soil and by their watchful nurture, into plants that shall blossom like the immortal amaranth among the stars. See, then, what and how great is the influence that women exert on the morals of society, of whole nations, of the whole world! Wherever there is a true civilization, woman reigns in society. It is not until she comes to sit beside him, in view of all the people, that man ceases to be barbarous, or semi-barbarous, and cruel, and ignorant. She spreads abroad the light of civilization and improvement as soon as she issues from the prison of the Harem or Zenana, to live with him in the world. Who made us human ? Whose were the hands that led us to kneel down, and whose the lips that taught our infant voices the earliest invocations to Heaven ? Is it not so, that after the world and fortune have done their best, or their worst by us, we, in late years, and early, forget not those pious mothers, who so steadfastly strove to bias our young minds in favor of whatsoever is true, whatsoever is pure, whatsoever is of good report!! How can we forget the rewards we received at her hands for all our good, and her gentle, and sometimes tearful reprovings of our evil inclinations and practices ? She was not only our teacher and pattern, but our companion and playfellow, for, of a truth, she was of a childlike temper—and that was the secret of the bond that united us to her so long and so closely. Hear what an eloquent Frenchman says of her :— " Source feconde et sacre"e de la vie, la mere est la creature la plus respectable de la nature ; c'est d'elle que decoulent les generations sur la terre; c'est Eve ou l'etre vivi- fiant, qui nous rechauffe dans son sein, qui nous allaite de ses mammelles, nous re- cueille entre ses bras et protege notre enfance dans le giron de son inepuisable tendresse. Femme ! mere ! honneur de la creation ! quels hommages eternels ne vous sont pas dus dans tout l'univers ?" Viket.—La Femme. The male is less versatile than the woman. His mission is more adventurous and dangerous. He enters on the path of ambition, that dark and dangerous, or broad and shining road. He pursues the devious track of politics with a resolute will; reach- 62 SEXUAL PECULIARITIES. mg ever onwards to the possession of fame and patronage, and rank and wealth, and power. She sits at home to adorn the tent or the cottage with wreaths of flowers, or to guide the tendrils that give shade to his bower. She plies the busy loom—and the sweet sounds of her singing—how often have I listened as they accompany the hum and buzz of her wheel, as she gracefully advances and retires by turns, forming the threads about to be woven into garments for her husband or child ! Her nimble fingers, all day long, ply the shining needle, to fashion the robe for her spouse —or to arrange the more elegant embellishments of her person, that may engage his admiration, and augment the flame of his love. For woman, man's love is the moving spring of all her actions. This is at the foundation even of her vanity. Lais herself is said to have sacri- ficed even her rage for wealth, at times, to the gratification of her vanity; and though the lioness tearing a ram to pieces, which was sculp- tured upon her tomb, was the emblem of her insatiable avarice, yet Lais lived more for love than for gain. What say you of the fortitude of woman ? She bears the evils of life without repining or complaining against the providence of God. Is she evil entreated, prevented, injured? That which sets a man on fire with an insane rage, kindles in her bosom, perhaps, only a virtuous feel- ing of indignation. She bears the greatest crosses. How beautifully does Shakspeare say so in the words, " She never told her love, But let Concealment, like a worm i' the bud, Feed on her damask cheek; And sate, like Patience on a monument, Smiling at grief." She dies a willing martyr for religion, for country—for her children. Who can number the Lucretias and Portias? How many are like unto the charming Roland? Think of the calm features of Charlotte Corday! Did you read of the deeds and the death of La Pucelle? Women possess a peculiar trait—modesty, which is one of the most charming of their attributes; springing probably from their natural timidity and sense of dependence, of which it is the ideal in expression. All rude, boisterous, and immodest speech or action unsexes and dis- graces woman. Hence, modesty is one of the strongest of her attrac- tions ; and she sometimes, perhaps, affects to possess it for the purpose of riveting her chains on the conqueror man. How sweetly Virgil says so in his Malo me Galatea petit, lasciva puella, Et fugit ad salices et se cupit ante videri. SEXUAL PECULIARITIES. 63 The attribute of modesty certainly lends the most powerful aid to the other charms of a woman. It is one of the qualities given to her in order to be a strong fence for her children, for it binds her to the domestic altar—her children could not but endure damage and loss, should she leave them at home to plunge into the torrent of public affairs, or mingle freely with the distracting world! Her modesty, gentleness, and timid- ity, assimilate her to the characters of children, whose best playfellow, nurse, and instructress she is. Come out from the world, and be sepa- rate from it, is peculiarly a command for her. There is in the Museo Pio-Clementino, at Rome, an antique statue, which the learned Visconti asserts to be a statue of Modesty, and which, as I am informed, is among the most beautiful of the works of ancient art now remaining in the world. It is completely clothed from head to foot, and veiled. It seems to me that such a work is proof enough of the ancient admiration of the quality in question; for the artist who could produce, and the people who could appreciate, such an exquisite specimen of taste and right feeling, must have had a keen per- ception of the charm. By her physical form and proportion, she is still more trenchantly divided from the male. Look at two statues, male and female. Take the Venus de Medici as the consummate exposition—the very eidolon of the female form, just as Praxiteles in the greatest verve, fervor, and enthusiasm of his genius, and he alone of all mankind, could conceive the idea of the Queen of the Loves. Compare her with the Apollo of the Belvidere—she has a head almost too small for intellect, but just big enough for love. His mag- nificent forehead, calm as heaven, and almost as high as it, rises above those eyes that are following the shaft he has sped with his clanging silver bow. " The front of Jove himself, An eye like Mars, to threaten and command; A station, like a feathered Mercury, new-lighted on Some heaven-kissing hill." Her thorax seems built as the sanctuary of that beautiful bosom, whence is destined to flow the sweet nutriment of the winged boy. Man's vast chest is for breathing, for eloquence and command. From its capacious stores of oxygen he draws the elements of the most strenuous, the most protracted exertions. He breathes deep, that he may ascend the highest hills and the sharpest crags in pursuit of his game or his prey, and that his loud harmonious voice may command his armies in the midst of the conflict, or sway the forum with its tones. 64 SEXUAL PECULIARITIES. Like Virgil's wild horse, he is equal to the longest career—nothing can stay him in his race. " Xon Scopuli, rupesque cavir, atque objccta retardant Flumina, conreptos unda torquentia montes."—Georo. III. See his loins how they are narrowed down, as they approach the hips, that he may balance himself, as it were, on the point of an inverted cone, ready for the promptest motion. His pelvis contains no variable organs, requiring ample space for extraordinary developments ; but its depth and solidity afford origin and insertion to the powerful muscles, by whose immense strength he can act well in the wild, rude, and ad- venturous life to which he is ordained. The cone, on the other hand, is reversed in the female. The apex is above, and the base is at the hips. It is within that bony cell that are hidden those miraculous organs that out of nothing can evolve the wondrous work of reproduction. The pelvis is broad and shallow, light in substance, its excavation ample, and its pubic arch round or Roman; while his is Gothic or lanceolate. From under this arch a child could not go; the other gives it easy utterance. His organisms are permanent —hers are mutable. The uterus—no bigger than a thumb—comes in gestation to be twelve inches high and nine in width. Its invisible vessels and nerves come to be great cords and tubes, and its uncog- noscible muscles acquire a force to rend itself in pieces in its rage, or, what seems still more miraculous, to expel a full-grown infant from its cavity, against the enormous resistance of flesh and bone. She is a germiparous and vitelliferous creature. She—the female—possesses that strange compound or concrete which you call stroma, ovarian stroma, of which I already have spoken, but must again speak. Now, that stroma lives by the blood it receives out of a common endangium, and yet it has a nerve which enables it to convert that blood into vitellus or yelk. The perpetuation of races and germs depends on the elimination of that matter. There is no animal germ without it—so that an organ so small, so unobvious, is endowed with the vast respon- sibility of keeping up the living scheme of the world—with its moralities —its lives—its actions—its trial—which, were it to cease, there would be left no flowers to bloom, no insects to sport in the evening beam, no choral song of birds, no lowing of cattle, no bleating of flocks, nor voices of men to thank and praise and acknowledge the Author of every good and every perfect gift. Think, gentlemen, of such great power—and ask your own judg- ments whether such an organ can be of little influence in the constitu- tion of the woman ; whether she was not made in order that it should SEXUAL PECULIARITIES. 65 be made, and whether it may not on occasion become a disturbing radiator in her economy, and how much. You will answer yes, if you know that her ovary is her sex—and that she is peculiar because of, and in order that she might have this great, this dominant organ planted within the recesses of her body. Men cannot suffer the same pains as women. What do you call the pain of parturition ? There is no name for it but Agony. Why does she love her child more than its father does ? Why, he grew to her ! He was perhaps an acinus cast out of her stroma, and after drawing his blood from her own blood, he drank life at the living well of her bosom, and character from her monitions and example. What were Cornelia's jewels ! Who was Washington's mother! What do we owe her ?—life, peace, liberty, social order. She built up this great frame of society in civilization. It is to her we are in- debted for our "Placidam sub libertate quietcm." Christianity is propagated by her domestic influence. The loom is her work, and the tapestried walls are of her imagining. Were it not for her, we were this day clothed in sheep skins and goat skins, and should lie down in dens and caves. It is for her that the looms of Cash- mere, the silks of China, the gauzes of Hindustan, the mousselines of Lyons, the laces of Belgium and England are formed ; the carpets of Ispahan and Dresden, Cornelius's blazing chandelier, all the riches dis- played by Levy and Bailey are for her. Everything that man is and hath, except his brute force and brutal inclinations, are of her and for her. See her gliding down the Cydnus in her stately barge, with its silken sails and costly equipage, and the great Triumvir at her feet, who deemed the world well lost for her love, and gave up the world to lie there. Look at her in the regal halls of Windsor, waving her golden sceptre around the globe, over dominions of hers, on which the sun is never at once set for all. Drive her and all her sex out into the primitive rude- ness of her nature, and leave man alone, and what should move him afterwards to do more than is done by the lions and tigers, who follow their instinct, and who are less cruel than he by nature, since he reasons in his evil, while they are only instinctively monstrous ! Study the nature of woman, young gentlemen, follow out all the psychological and physical transformations which her sex produces. What is her erotic state? what the Protean manifestations of the Life- force developed by a reproductive irritation which you call Hysteria. 5 66 SEXUAL PECULIARITIES. Take Martin Barry's microscope, and Bischoff's History of Develop- ment, and study the myriad germ points that are buried in the depths of her stroma. I shall soon place in your hands the key that unlocks all the secret details of her mensual phenomena, and not hers only, but the ovula- tions of all that reproduce, both in the animal and vegetable kingdoms of nature. It were an endless task to undertake the portraiture of all the characteristics of the sex, as exhibited in their intellectual and moral aspects. I have made the foregoing slight indications of them, with the pur- pose of turning your thoughts in that direction; for I believe the con- templation of such subjects is extremely useful to the practitioner of physic, and especially so to those that may design to engage themselves in business connected with the obstetric science and art. I shall not deem it necessary now to do more than merely hint at the potent influ- ence which must be exerted upon the pathological tendencies and states of the female, by the constitution of her organs, and, indeed, by the more delicate, gracile, and impressionable nature of her whole economy. I say I shall merely hint at the subject in this letter; for as much as the whole series is relative.to these effects, I shall treat of them herein in extenso. Appreciating as I do, at the highest possible rate, the influence of the gentler sex upon the character and action of the male, I cannot but see in that influence the cause of the major part of the happiness now enjoyed by mankind in civilized, or to speak more exactly, in Christian lands. It is true, that during the great glory of the Roman empire, manners, luxury, pomp, had attained to a high perfection; but it is equally true that the social and domestic position of the woman was even there elevated, although not to a station so coequal as that to which she has attained in our own age. Petulanter facimus, si matrem- familids, secus, quam matronarum sanctitas postulat, nominamus—is the saying of Cicero. When, upon the dismemberment of the Roman empire, and the darkness that was consequent to the descent of the barbarians into western and southern Europe, society seemed to have lost all its security ; and when brute personal force appeared to be at the founda- tion of all administration, as well as of all domestic security, the sex came forth again, and by troubadour and knight, whom she created and moved, woman brought her humanizing hand to bear upon and recom- pose the shattered frame of society. The virelay and the tale of the troubadour, and the scarf and the triumph of the knight, were worth- SEXUAL PECULIARITIES. 67 less but as sanctioned by her smile of approbation. The Tales of Boccaccio, the old Romances, the illuminated missals and hours, led by degrees to the search for a higher literature and a truer learning ; so that, at the breaking forth of the love of letters in Europe, the way was already prepared for their reception and just appreciation. Educa- tion, decency, what is understood by good breeding, laws of society— all these take much of their complexion and most of their beneficence from the sex, who thus, while disfranchised, as it were, by the political constitution of the world, are yet, in fact, the secret promoters and moving power by which it is made both progressive and improving. In speaking thus of the influence of women on society, I do not wish to disparage that of religion, of which they are justly to be viewed as the best promoters; nor would I lessen the sense of gratitude due to the wise philosophers, the good legislators, the ardent philanthropists, to whom we owe an impayable debt of reverence and praise. I am far from desiring to look on woman as the race—I contend that though she is unlike man in her fleshly nature, and different from him in her intel- lectual nature, yet she is a great and predominant Force in the world; physically weaker, yet not less noble; restrained of power, jet the cause and reward of his efforts—requiring his protection, his homage, his love, yet repaying him in the perpetual provocation she offers to noble endeavor; more than compensating him for her support, by the rearing of his offspring, and by the humanizing, softening, meliorating influence which she carries into his public as well as his domestic life. As for her beauty—in what words should we attempt to describe its enchantments ? It overpowers the imagination, which in vain seeks fitting objects with which to compare it. In great female beauty thero is something almost holy—it compels love, respect—even reverence. "I saw her coral lips to move, And with her breath she did perfume the air; Sacred and sweet was all I saw in her." Lucentio. In ruder times than now, female beauty exercised its sovereign do- minion in the heart, and touched and fired the imagination. Take the following verses from the famous Roman de la Rose, which, even in its quaint expressions, reveals the humanizing power of woman's beauty. Le Guyschet, qui etoit de charme, Me ouvrit une pucellette Qui assez etoit cointe et nette; Cheveulx eut blons comme ung bassin, La chair plus tendre que ung poussin, Front reluisant, sourcils voultis ; L'entr ceiul si n'etoit pas petis, 68 SEXUAL PECULIARITIES. Ains fut asscz grans par mesure ; Le nes eut bien faict a droicture ; Les yeulx eut vers comme faulcons, Pour faire envie a tous horns ; Doulce alaine eut et savour£e, La face blanche et coulouree, La bouche petite et grossette, Et au menton une fossette ; Le col fut de bonne moyson, Gros assez et long par raison, Si n'avoit tache ne malan: N'y eut jusqu'en Hierusalem Femme qui si beau col portast, Poly estoit semblant au tast; La gorge avoit aussi blanche Comme est la noif dessus la branche Quant il a freschement neige: Si eut le corps bel et renge; Ne convenoit en nulle terre Nulle plus beau corps de femme querre. Le Roman de la Rose, p. 97. But, alas gentlemen, why should I have attempted a theme too great for a volume, and far beyond my abilities ? You see how I have failed. It requires the eloquence of a Roussel, and the learning and enthusiasm of a Virey, to present even a sketch of a topic so vast, so interesting, so closely related to whatever may be called happiness, whether domestic, or social, or political. I hope you will study this subject better than I have done, or can do. I do not believe in a physician who knows only calomel and rhubarb. I would have you fill your souls with knowledge; I would have you bathe in it as in an ocean. Were I young again, and could I appre- ciate as I now in some degree begin to do, the beauties of learning I would not cast away, as I have done, a half century of time, but I would grow pale by the reflection of the midnight lamp, and I would never be satiated until my soul were satisfied with the fulness of know- ledge. For what are we in the general but erring and curious inquir- ers? and, does not the most highly cultivated intelligence to be found among men leave them at last, even the most gifted among them blind groping, feeble worms of the dust? What should be our motto and our cry, from the lowness of the human nature in which we lie grovel- ling?—Excelsior! Excelsior! C. D. M. SEXUAL ORGANS. 69 LETTER V. SEXUAL ORGANS. Gentlemen: In my Letters, I have set before you some general ideas as to the nature of sex in the female; and have also pointed out some of the more distinctive characteristics of that best half of our race. In this letter, I shall speak to you of the reproductive organs; begging you to accompany me in the disagreeable task of this investi- gation with minds purified by the love of truth, and with that decent self-respect which ought to guard every physician when he comes, as a part of his professional obligations, to study this department of ana- tomy; a department he cannot omit to learn without leaving himself incompetent to the safe discharge of many important medical and chi- rurgical duties; and which he cannot study without feeling that he is engaged in inquiries that ought not to be exposed to the public gaze. Instead of treating in this letter of the private parts in question, I might perhaps as well have referred you to the anatomical treatises already published; but, by so doing, I feel that I should leave this volume less complete than it ought to be; hence I enter on this subject with reluctance. It is in itself, perhaps, to be regarded as obscene; and to show what outsiders think of such things, let me say that in a recent report of testimony given before one of our courts of justice, where a person was in question for having published an obscene book, pretending to be a medical work, a witness characterized it as " fit to be seen only in a Doctor's shop." Let us take a lesson from this undesigned reproof of the medical faculty; and while we acknowledge that our ministry calls upon us to know all that can be learned as to the anatomy and physiology of the reproductive organs, let us admit also that it behooves us, out of a feel- ing of self-respect and respect to our calling, to treat these subjects with all decency, and with a just deference to our friends not of the profession; who, having no motives to acquire the knowledge we are compelled to obtain, must not be offended by any unavoidable indelicacy of expression in our writings. Such persons being as to us entirely strangers, ought not to suffer themselves to pry into those esoteric teachings of the medical profession, which it is better for them not to 70 SEXUAL ORGANS. learn than to know. If they look into our books and blush, they arc like eaves-droppers, who generally hear no good of themselves. Good old Thomas Raynald, in the Woman's Booke, or Byrthe of Mankynde, speaking in the prologue, of non-professional and impertinent people who may "chance" to get possession of it, quaintly says:— •' The which thing when they shall do, here shall they heare of me, that they be in theyr doinges, neyther honest, good ne godly, but speakyng unreverently, contemptuously and untymely of such thinges, they do great injury, dishonour, and contumely to nature: For he that declareth any thyng in man or woman, privie or apart, talkyng and re- hearsing it in reproche derision or confusion of his even Christen, can not be excused of mortalle and deadly sinne, for so muche as contume- liously he ashameth and confoundeth his even Christen, wherewith he bryngeth hym out of pacience, worrying hym to yre and vengeaunce, in rehearsyng of such thynges and after suche sort, as he knoeth shoulde agrieve and vexe his mynde; wherefore for suche dedes he shall not be accounted of the number of honest and sage persons, but of the light and lewde." As for us, let us remember that the President of the Board of Trustees, who, in the name, and by authority of the State of Pennsyl- vania, admitted you to the rank and quality of Doctors in Medicine, declared you vested with the powers exercendi, docendi et scribendi, ubi rite vocatifueriiis; and that this commission allows you a great privilege of discussion; which being needful in our art and for the security of the people, is decent and proper in our hands, but vile and contra bonos mores in the hands of other people. Fantoni, as cited by Dr. Asdru- bali, in the Trattato G-enerale di Ostetricia, &c, p. 68, t. 1., says, " Honesta quantum potero, muliebria, examinando ; honeste, inquam si potero ; nam fieri vix posse puto, ut honestis apellationibus res vulgo obscsenas designamus, quae facile pudicas aures offendent. Sed vobis nullus sit pudor integris auribus ea excipere quae divina sapientia creare non erubuit," &c. The reproductive organs of the female are external and internal ; the former being situated upon the outer face of the pelvis, and the latter concealed within its bony cavity. A sense of modesty induced the ancients to give the denomination of pudenda to the external or visible privities of the female; and this word, which is a plural noun, applies to the whole of the external genitalia. The pudenda, therefore, comprise the mons veneris; the labia externa also called labia majora; the labia interna or minora, called also nymphae ; the clitoris ; the praeputium clitoridis ; the vestibulum • the SEXUAL ORGANS. 71 os magnum ; the carunculae; the hymen; the fossa navicularis; the meatus, the fourchette, and the perineum. The internal genitals are the vagina, or vulvo-uterine canal, as the Frenchmen call it; the uterus, or womb; the Fallopian tubes; the ovaries; the round ligaments, the broad ligaments, and the utero-sacral liga- ments. The word vulva applies to the sexual fissure, rima, or sulcus, that is observed between the two opposite labia majora. Now, as to the mons veneris {le Penil), it is an elevated portion of skin, that is lifted above the general level of the lower part of the belly, partly because it is on the share-bone or os pubis, which projects above the general line or level, and partly because it is underlaid by a con- siderable quantity of adipose tissue distended with fat or oil. This part of the skin is of a darker color than that which is above and about it, for it contains a portion of pigmentary membrane that deposits on the exterior surface of its corpus mucosum the same sort of dark matter as is known to color the axilla, the aureole of the mamma, ' the perineum &c. It is also covered abundantly with hair, which begins to make its appearance under the critical efforts of the constitution when those efforts are being employed to convert the creature from childhood to puberty;—or, in other words, when she is about obtaining such a degree of development as may consist with the power of germ- production. It is not unworthy of your observation, that when the power of germ-production is lost at the change of life, that of producing the pudendal hair is diminished very sensibly, and in old age, not unfre- quently to the extent of a complete depilation. Women also, who from feebler health cease to bear children, as they advance in age, but who have not wholly lost the faculty of germ-pro- duction, often find that the pudendal hairs are lessened in abundance during the suspension of the childbearing faculty ; and that the quan- tity is greatly increased as soon as they find themselves again pregnant after many years have passed since any former gestation of theirs. This I have learned from several cases observed and inquired of in my clinical experience, for I have many times had charge of labors in women, who being as it is called getting old and not bearing children for eight, ten, or twelve years, were yet afterwards surprised and vexed to find themselves so wonderfully young again. As to the disorders to which the structure called the mons veneris is liable, you will be sensible that they must be of the nature of the spe- cific, the exanthematic, and the phlegmonous inflammations, or contusions and wounds; and that such affections have not and can not have any special relation to what is properly called midwifery. Perhaps, indeed, 72 SEXUAL ORGANS. we may except some rare samples of pain, neuralgia or inflammation of these textures connected with strains, or violence done to the sym- physis pubis, either by the protracted influence of continued pressure and weight on the pubes by a heavy womb ; or by injurious tension and even disruption of the symphysis or of the bone, during the transit of an overgrown foetus or in a badly managed forceps operation. Where great violence is unhappily done to the bony structures either by the power of the womb, in its expulsive efforts, forcing too large a child through too small a pelvis ; or where, by the additional power of the forceps, such a child is drawn through such a pelvis, the articulation of the pubis, which lies underneath the mons veneris, becomes so strained as to inflame after the labor is over: or the bone itself may be even broken asunder, as in some instances related by Madame Lachapelle in her admirable Treatise on Midwifery. In any such cases, where pain is felt in the lower part of the mons, as I have heard many persons complain, it appears obvious that the same chirurgical treatment ought to be adopted as is known to be most suitable to the articular maladies in general. Professor Miitter has doubtless taught you that in the treatment of articular imflammations, rest is of the greatest importance ; and that in the movable joints, when inflamed, a splint is the first and greatest of remedies. Hence, in the instances where your patients after childbirth shall complain of pain in the mons in walking or in turning in bed, you ought to direct your attention to the condition of the symphysis or joint of the pubis. I have met with many instances wherein the ligaments that bind the ossa pubis together have become so relaxed, under the infiltrative in- fluences of pressure and tension continually exerted by the gravid womb, as to allow of a very perceptible play of the opposite ends of the ossa pubis upon one another; the right pubis moving upwards when the woman stood upon the right foot, and the left one rising above its fellow again as she stood upon the left foot. In those women who do suffer from this relaxation, you must understand that they complain of it for weeks be- fore the child is born, and should therefore refer the accident not to the labor, but, as I said, to the infiltrative tendency that results from weight, distension, and an excess of sanguine affluxion towards the pelvis. I leave you to imagine the pain, the discomfort, the uncertainty and the feebleness of gait, attending such a considerable or even any motion of this important joint. You fully know that the pubal bones cannot pass and repass each other without, in some degree, disturbing the repose of the sacro-iliac junctions; and I have shown you what sort of a cartilage that is, that we used to study under the denomination of the auricular cartilao-e of the sacrum and ileum. A cartilage so firm and resisting as that, could SEXUAL ORGANS. 73 not become the subject of motion without the greatest inconvenience. It could not be treated by means of internal medicines ; nor could any counter-irritants, liniments, lotions, or plasters, or ointments, have a very useful effect in the treatment. Hence, you perceive, my friends, that, for treating your patient com- plaining of such movableness of the joint, there is but one chirurgical principle; and that is, the joint must be allowed or compelled to rest. She must not make it move by walking about—for she can never trans- fer the weight of her body from one foot to the other, without transfer- ring it from one acetabulum to the other; and you remember that the pubis owns one-fifth of the acetabulum, and you ought to know that an inflamed joint is nearly as unapt to be cured while motion is allowed in it as a broken bone; they equally demand the use of the splint. This is the treatment for disordered joints, suggested and used for half a century by our illustrous compatriot, Dr. Physick. In Europe, it is becoming understood, within a few years past. I have tried various bandages, springs, and compresses, to relieve certain of my patients thus affected; but such bandages are intolerable, because they cannot be kept in adjustment. Some women have soon spontaneously recovered by means of rest, which permits the joint again to become firm ; while others have continued to suffer more or less through successive pregnancies.—Rest is the cure. I will not say, that where the disturbance of the joint has caused an attack of inflammatory congestion in the parts, rest alone is indicated— for, in such a state of things, the patient might very reasonably expect that you should seek to relieve her, further, by means of leeches; by counter-irritant applications ; by stupes and cataplasms, and by anodyne liniments; for the selection of which remedies in particular, 1 must refer you to the indications of the special case and time—as well as to your memory, of what Professor Mutter has counselled on such topics. These remedies are, however, not dependable.—Rest is the cure. I hope you will come to the conclusion, that wherever the symphyses of the pelvis are found loose and relaxed after gestation, that effect has been, as a general rule, produced by a maladive condition. I am fully of Dr. Dewees's opinion on this point, and he used to scout at the notion of the bones naturally yielding in order to let the child escape more easily. Dr. Moreau, of Paris, whose work on midwifery is in the hands of many of you, seems to think that the relaxation of the ligaments of the pelvis is not an unusual or unheathful occurrence; his remarks on the subject are at page 46, torn. i. I should be glad if you would read at- tentively his relation of a case at page 47, as well as a most interesting 74 SEXUAL ORGANS. one at page 51. The perusal of them would serve to show you how to act under similar circumstances. My own experience has not given me any opportunity to observe such great disorders as he describes in his patients. When I was in the city of Brussels, in the month of June, 1845, I paid a visit to the magnificent Hospital of St. John, in that city. The medical officer on duty that day was Dr. Grauiex, whose name is pro- nounced Gro. While accompanying him through the wards, and ob- serving his methods of diagnosis, and of therapeutical direction, we ar- rived at the bedside of a very fine-looking young woman, about 22 years of age, who did not look at all as if in bad health. I found she had been for a considerable length of time under treatment for a catarrhus vesicae, and that she had made no progress towards a cure. The frequent mic- turition was painful and annoying. Dr. Grauiex, after carefully ex- amining the region of the bladder by palpation, took out a seton-needle already armed, and in a moment he passed a very long seton from side to side, near the upper edge or limit of the mons veneris, to the great chagrin and vexation of the young girl. But Dr. Grauiex was master in the case, and she was obliged to submit. I told him it was the first example I had seen of such a treatment of the troublesome disorder in question, when he rejoined that he regarded it as the most efficacious he had known; and that he had learned it at Paris, in the service of the illustrious surgeon, the Baron Dupuytren. Dr. Grauiex seemed to me to feel quite sure that his operation would cure the patient; but, as I very soon afterwards left the city, I am not able to state the result. I should think, from the opportunity I had of seeing Dr. Grauiex, and conversing with him, that his opinions on any chirurgical or medical subject are deserving of great respect. I have related this case, not only in order that you may, if occasion should arise in your practice, resort to it for the treatment of some of the more rebellious forms of cystic irritation and inflammation, as well perhaps as for that of certain conditions of uterine function that do not yield to gentler modes; but because, I suppose, that where the symphysis pubis may have been injured in gestation or labor, leavino- a chronical inflammatory state of the junction, you could hardly adopt a safer or surer remedy than this of Dr. Grauiex. It may seem out of place in this letter, but I trust, that whether apropos or not, you will find it apropos in the chronic maladies of the parts crowned by the mons veneris, and this is the reason why I make the suggestion in this place. It is true that I have not employed such a treatment in any case of chronic pain dependent on this forcing of the symphysis. I have in vain proposed it to a lady under my care, who would not accept SEXUAL ORGANS. 75 of the proposition on account of her natural timidity, as well as from the disagreeableness of an issue in such a locality. I am not aware that the seton has been thus employed in this quarter by any of my friends. Let us now proceed with our inquiries as to the other portions of the pudenda; and we shall find that the next in order is the part called the labia, the labia externa, or labia majora. They are called by Felix Plater, in his Treatise de Partibus Mulierum Generationi Dicatis, by the name of Oolles, seu monticuli. The Greeks called them £the fundus and corpus uteri, because we can- not only judge of them by the Touch, with one or two fingers, but we can judge of their varieties by the eye, which sees them plainly at the bottom of the metroscope or speculum uteri. The two senses of sight and touch, when their combined results come to be presented to our judgment, are little likely to deceive or mislead us; and so we may, as I above remarked, possess ourselves of highly certain information in such disorders ; and we ought to have the privilege to make such re- searches for the benefit of the patient, even if we set aside the honor of the science, which is more promoted by accuracy of knowledge and success in treatment than by any other measure. If we are not per- mitted to make up a clear opinion, we may always enjoy the privilege of declining to take charge of the treatment. A woman shall come to you to complain of pains in the pelvis, drag- ging, heat, burning, pruritus, leucorrhoea, frequent returns of slight show, anticipation of the catamenial return, excessive menstrual dis- charges, pain in coitu, &c. &c. What can be the cause of all this dis- tress ? Is it rheumatism of the womb ? is it ulceration of the lip of the os tincae ? is it mere hyperaemia of the vaginal cervix and os, mani- fested in swelling and great redness of the parts seen in the metroscope? 264 INFLAMMATION OF THE NON-GRAVID WOMB. is it follicular disease of the lips of the os, or of the canal of the cer- vix ? is it syphilitic ulceration ? These are questions you must answer before you enter upon the cure. If it be rheumatism, it will coincide with symptoms of a rheumatic kind elsewhere. Perhaps it will be found to be a lingering remainder of articular or muscular rheumatism, that has long tormented the patient, or it coincides with neuralgia of the head or neck, or it is chiefly distressing in cold damp weather, or in seasons when the weather is most variable. Certainly, there is reason to believe that the parts contained within the female pelvis are prone to be attacked with rheu- matism, and such attacks are incited or provoked by the incautious use of cold water, by damp cold feet, by improvidence in regard to dress, shoes, &c. &c. If a woman complain to you of great pain in the pelvis, supposed by her to be uterine pain, and you cannot make out the existence of any deviation of place or direction in the organ, if the surgical cervix be not indurated, nor the os uteri inflamed or ulcerated, I think you will have a motive to regard the case as one of the samples of rheu- matism of the womb ; and in that decision you will be confirmed, if you discover neither rectum pouches nor hemorrhoidal tumors, but much sphincterismus and painfulness in the action of the levatores and sphincter ani muscles. Such a rheumatic state of the womb is not necessarily attended with a febrile train; yet, when it is violent, you may well expect to find a disturbed pulse, and all the constitutional accompaniments of such disturbance. Rheumatic affections of the uterus are very often allied to painful states of the muscular and fibrous parts within the pelvis, and by symptomatic aching of the thighs, resembling cases of sciatica. In these instances, it is not rare to meet with persons who suffer the great- est distress from sphincterismus, or spasm, or cramp of the sphincter muscles, both of the rectum and vagina, as I have above said. This cramp, I have had reason to suppose, in certain of my patients, has also extended to the levator muscles. The habitual state of condensa- tion of these various muscular fibres comes, after the lapse of several months, to take away, in a good measure, their power of relaxation, and thus compels the sufferer to make violent efforts of defecation whenever the bowels are to be moved. It may well be supposed that, when the feces become dry and hard in those who are costive, each alvine operation is attended and followed by insufferable distress ; I have found many persons compelled to lie down for several hours after INFLAMMATION OF THE NON-GRAVID WOMB. 265 each evacuation ; the pain, occasioned by the resistance of the distem- pered muscles, being too great to allow of their sitting up. Such a state of the sphincter may be known to exist by any attempt to pass the index finger within the rectum. In such an attempt, it will be found not only highly painful to the patient, but very difficult to make the finger overcome the spasm of .the muscle, which, after the in- troduction, will be found to compress the finger with great force. This state of things is often miscalled piles, fissure, rectum pouches, or womb disease, the sufferer being treated accordingly, and in vain. I hope that when you are called to see such patients, you will be sure to examine carefully as to the possible and probable causes of the pain; and if you should come to the conclusion that the case is one of sphincterismus, that you will adopt a sensible method of cure. You know, I suppose, that the surgeon may, by a cautious and dex- terous method of operating, be able to introduce the whole hand within the rectum of an adult, and if so, then you know that the sphincter ani muscle will admit of having its circle of fibres greatly enlarged. In ordinary defecation with moulded stools, the circle of fibres is for some persons greatly expanded. But in instances of violent and chronic sphincterismus, the circle, as I before said, cannot be expanded so as to equal the diameter of the index finger, or even of a catheter without pain and difficulty; and that because, through long use and custom and disease, the muscle has lost great part of its relaxability. Read what Mr. Hunter says on a power of relaxation. What will you do in such a case ? Will you take a tenotomy knife, and with it divide the sphincter ? This would cure the constriction for a moment,.or for a few hours, perhaps, but it would return with the healing of the wound. For my part, I believe I have always succeeded in curing my patients, thus affected, by the use of the conical gilt bougie that I have described in this volume; and I advise you to allow your patient to begin, with a bougie of the lowest size, to dilate the ruined muscle. Let the dilata- tions be repeated daily, proceeding by gentle degrees in the use of the bougies, from small to great, until, at last, the largest one of the series can be passed through the sphincter with facility and without pain. This wiU certainly be the case in a few days or in a few weeks, and at the end of the treatment, the muscular fibres of the sphincter will have been restored to their normal dimensions, or, in other words, the sphincter, recovering its relaxability, will have laid aside its habitual state of cramp or spasm. You ought to know that this sphincterismus, of which I am speaking, is a very common disease among women, as well as in men, and even in 266 INFLAMMATION OF THE NON-GRAVID WOMB. little children, among whom I have seen it when the children have not been more than three or four years old. In such little patients, every attempt to evacuate the rectum is attended with cries ; and so great is the reluctance of the sufferer to encounter the oft-repeated pain, that he refuses to go on the pierced chair in order to the stool. I have met with it in young virgins, in married women of twenty-five or thirty years of age, and in persons of sixty and upwards. I assure you the disorder is intolerably painful, and that it may continue for years to agonize the patient with every diurnal evacuation, and afflict her, in the intervals, with a sense of soreness and pain that at length undermines her whole health. It is very certain that a muscle that is not extended by means of a power extrinsic, will exert its intrinsic force of contraction, and con- tinue to do so until it shall at length wholly lose its extensibility, and this is the case in the malady under consideration. In this chronic sphincterismus, the extensibility of the sphinctorian fibres is lost, and the indication of cure is to restore that lost extensibility to the ruined muscle. The natural powers cannot do it. The muscle has assumed a condition analogous to that acquired by the sterno-cleido-mastoid in wry-neck, or that of certain muscles of the leg in varus or valgus. Those faulty muscles may be cured by stretching them with instru- ments and bandages, and the sphincterismus may in like manner be cured by stretching the sphincter-fibres or expanding the ring by means of the gilt bougie. The sphincter ani ought, in health, to be capable of becoming a ring or circle an inch and a half in diameter, or four and a half in circumference, without causing the individual to feel much pain. In sphincterismus, it is very painful to dilate it so much as to equal a circumference of one quarter inch. Suppose, in such a case, you could by your art succeed in dilating the ring to a circumference of four and a half inches ! do you not per- ceive that you would thereby cure the sphincterismus ? The muscle would, in that event, have been restored to its pristine diameter, and a little attention to the duty of putting it fully in extension once a day, once a week, or once a month, would confirm the cure. To treat such a case, your duty will be first to clear up the diagnosis of it—to make sure that the patient, if a female, is not laboring under some supposed disease of the womb, and to explain the principles of the disease and of its cure. You should provide yourself with a few gilt bougies, each about four inches long, the smaller sliding into the larger, the smallest being about half an inch and the largest fully one inch and a half in diameter, with two intermediate sizes, sliding, and easily fitting into the sizes next above them. INFLAMMATION OF THE NON-GRAVID WOMB. 267 Let the patient be placed upon her side, covered with a sheet, near the foot of the bed—the knees being drawn up. The smallest bougie being used 'first, should be dipped in oil and passed as far upwards within the grasp of the sphincter as it may go without giving too much pain. It should be left in sitil about two or three minutes—and the operation should be repeated once a day, using always only a very gentle force, lest the too rapid overcoming of the contraction should, by contusing or overstraining the muscle, cause it to inflame, and thus com- pel you to desist from prosecuting the cure. I findvthat some of my surgical friends are disposed to think, in dilat- ing strictures, that the distending catheter or bougie ought to be left a long time within the stricture. I have not found it so. On the con- trary, in dilating the most perverse stricture of the urethra, I never leave the bougie in situ more than one or two minutes—finding that what I have gained to-day is preserved for to-morrow—and that I can readily pass, at the next operation, a larger bougie than that used in the antecedent one. I am very well satisfied to have had this opportunity of laying before you my views on the cases of sphincterismus, both as to the signs, nature, and treatment of that disorder; a disorder that is very commonly over- looked, even by most experienced physicians, and almost sure to be misunderstood by the early practitioner. I shall now proceed to say something on the more special subject of the disorders of the surgical cervix, or that part of the neck of the womb that projects downwards into the tube of the vagina. It is called the surgical cervix, or the vaginal cervix, in order to distinguish it from that part of the cervix that is above or beyond the reflection of the vaginal mucous membrane. A medical practitioner much conversant with the nature and .signs of disorders of the reproductive organs is a person who has acquired a most familiar knowledge of the form, size, and resistance of that portion of the womb that can be reached by the Touch. In fact, such a person is one who has formed an intellectual ideal of the organ or parts to be examined; and that ideal which exists ever at hand and perfect in his understanding, serves as an absolute, perfect standard, or scale by which he is enabled to judge and measure every real specimen that is sub- mitted to his opinion on the case. A man ignorant of the structure or functions of such parts, might in vain explore them with a view to determine their condition as relative to health or disease. Wherefore, I advise you to form for yourselves perfect Ideal Models or standards by which to judge and with which you are to compare every deviation of form, volume, resistance, tint, sensi- bility, and function; for it is only by so doing, that you can rely upon 268 INFLAMMATION OF THE NON-GRAVID WOMB. your professional ability to say of this or that—it is wrong, or it is right, and that the deviation is thus or so, and not otherwise. One who has thus accomplished himself knows all about the matter. He knows, upon making such Taxis, that the os uteri is too large, or that it is too small—that the lips of the os are too thick or too thin—that the mem- branous surface is too rough—that it has a succulent or soft granulated feel, that it is sensitive beyond measure, that it bleeds from a Touch, &c, &c, which leads to the inference that it is turgid with excessive cir- culation, or even affected with a soft surface of ulceration. The same adept physician will, by a graduated pressure with the point of the index finger, determine the degree of sensibility of the surgical cervix. " Does that hurt you?" and he presses the os—and the anterior, the posterior, and both the lateral aspects of the neck of the womb. If she cries out with a sudden pang thus produced, he knows that such pain is one of the unmistakable signs of an inflammation established there—for he knows that, of the four things, tumor, color, rubor, dolor, the latter, or pain, is one of the most pathognomonic. The same act of Touching informs him of the position of the womb; for he knows that, if the os tincae is too near to the symphysis, there is a deviation, or dislocation of the organ, and how much. Lastly, the moisture or dryness, the heat or coolness of the internal textures, as well as stains upon the napkin used to cleanse the hand, reveals import- ant items in the diagnostic he seeks to establish. I am convinced that a very experienced or erudite Touch—a Tactus eruditus—can often report to the practitioner's intelligence all that he shall require to know of the case. Yet, when that same Touch leaves him in doubt, let him settle the question by referring to the report of a rrfetrosc^pic investigation. That alone can yield a clear information as to the hue or tint of the affected parts, and aid him to fix with precision the therapeutical or chirurgical indications. I advise you not to make use of an artificial light in your metroscopic operations. It is to the last degree humiliating to the patient to be examined with a candle; and I never see a Doctor so engaged without thinking of the woman in the Testament who had lost a penny, which she searched the whole house for, having first lighted a candle; and I fe,el a propensity to ask : " Do you see the penny ?" Try to find a clear light from the sky, and a north light is the best. The bed should be three or four yards distant from the window that admits your light. The patient is on her back, with her head, not her shoulders, on a pillow, and a thickly folded sheet under her sacrum, to prevent her from sinking too low in the bed. This sheet should be very near the bed's edge, leaving space on which conveniently to rest her INFLAMMATION OF THE NON-GRAVID WOMB. 269 feet, the knees being completely flexed. Before she lies down let a sheet be thrown over her, the margin resting on the floor so as to cover her whole person. Sitting in front of the patient, adjust the Recamier speculum beyond the grasp of the sphincter, and then, withdrawing the guide, wrap the lower edge of the sheet around the outer portion of the speculum, care- fully covering her person and even her slippers, so as to leave no part of her body exposed. This I conceive is the least flagrant performance of a flagrant act—an act inexcusable save under the duresse of a con- viction that it is needful for the safety of the sick woman. Having thus protected the patient from view, you can, by rotating the tube on its axis, and by movements of circumduction of the upper or bevelled extremity, at length catch the cervix in the aperture and bring it into full view. In cases where the fundus leans very much forward, the os tincae is proportionally directed backwards, and the uterus and vagina meet at an acute angle. When this happens it is a very difficult thing to engage the vaginal neck in the open end of the metroscope. The projecting long lip of the bevelled speculum enables you, however, to catch the os uteri and raise it upwards far more readily than any other other instrument that I am acquainted with. When you have properly engaged it you can inspect the part at your leisure. The great variety of appearances in different cases, thus disclosed, shows how important it is for the cure, to be able to appreciate them, and adapt the means of cure to the end. When you find the whole cervix uteri much swollen and red, the inner aspect of one or both lips of the os red as a raspberry—or studded all over with clumsy points like minute red currants; when you find the epithelium gone, and the superficies it has abandoned bleeding at the touch of the bit of sponge held in your speculum forceps—the orifice of the canal of the neck streaming with mucus resembling white of egg— the mouth of the womb gaping wide enough to admit the end of your finger—what shall you say ? You can say nothing else than that here is an inflammation to be cured—and how cured ? Drop four or five Swedish leeches into the open end of the speculum, and push them down to the bottom with a bit of sponge large enough to keep them from coming out again. In one or two minutes, they will begin to bleed the engorged capillaries, and four such leeches will make four punctures, which from first to last will discharge four to six ounces of blood—and that is enough—for, as the uterus weighs only two and a half to three ounces, six ounces are equal to twice the weight of the whole organ. You ought to use the foreign sort of leeches, because our American 270 INFLAMMATION OF THE NON-GRAVID WOMB. leech does not draw so much—and you understand that it is very desir- able to get the greatest quantity from the smallest number of punctures. It is not a matter of indifference whether you make one or twenty punctures in the inflamed cervix—for there are certain forms of these inflammations wherein these leech-bites heal very reluctantly, and tend to convert themselves into ulcers. Nitrate of silver, when applied to inflamed tissues—I mean when discreetly applied—has, in the highest degree, an antiphlogistic influ- ence upon them; and it often happens that two or three contacts of the crayon of caustic completely cure an inflammation of the most chronic character. Such contacts with the caustic pencil ought not to be daily repeated, since the too frequently renewed operation is more likely to be hurtful than advantageous. Make for yourselves, here, an absolute ideal of the operation you are about to perform. It is not enough to consider that nitrate of silver is a remedy for these disorders; for to say so, in vague general terms, is to say what is not true; for if you take a bit of fused nitrate in a port-caustic and hold it for a short time against a moist living tissue, it will dissolve or destroy it. You see then that you can if you please make a destructive contact with the pencil. But you by no means desire to destroy any portion of the tissue. A^ain, if you make so sudden and short-lived a contact as you could do, by barely touching the surface for an instant of time, such a touch would be indifferent and of none effect. You see, then, that you can make either destructive or indifferent contacts ; neither of these do you desire ; but what you seek to do is to make an antiphlogistic contact, and it is beyond question that you can so use the pencil as to procure from it the most marvellous antiphlogistic operation. Such contacts are in the highest degree curative; they act, I suppose by a contra-stim- ulant power that, by establishing another and non-injurious vital status, expels or becomes substituted for the other or morbid action. There- fore before you proceed, reflect a moment, and carefully determine what it is you are about to do, whether you are going to make a de- structive, an indifferent or an antiphlogistic application of the nitrate crayon. How often should the cauterization be made ? That is the question. I have seen a patient to-day. who told me that she had been under a very long course of treatment by cauterizations of the os uteri, which were repeated by the surgeon every other day. Judge ye, if this was not an imprudent and abusive use of a good remedy. Suppose you should apply a crayon of caustic every other day for several consecutive weeks to the os uteri of a perfectly healthy woman. Would not she soon be affected with a distressing inflammation of the part ? Do you INFLAMMATION OF THE NON-GRAVID WOMB. 271 answer, yes ? Then let that answer govern you in regard to the ad- ministration for persons who are sick. In case you are using the caustic to cure an ulcer, to cut down a vege- tating mass of granulations, to root out a vasculo-cellular polyp as big as a nut, you may cauterize it daily, for your object will be to get a new and healthy surface; but, having got at that new and healthy surface, your game will be gently to stimulate, and not violently to inflame the textures that you are desiring to heal. You should, in good time, cease from cauterizing it altogether. You should remember, that, in the course of the treatment, the nervous sensibility of the part undergoes changes as the cure goes on ; and that a dose of the caustic suitable on the first, would be too weak or too strong on the tenth of the month. Do you ask how are we to judge, and how decide as to the strength of the application ? There is no other way than to try to judge—to acquire the habit by Touch, or by inspection, of determining what force of the agent is requisite for the special case. "Judge in your wisdom and awake your senses, that you may the better judge ;"—learn not to be mere routineers—mise- rable machines in the hands of the authorities. Kick the authorities out of doors, and be yourselves authority for yourselves. This is the way to show yourselves free and independent, and it is the only way ; for, if you think yea or nay because Hippocrates or Sydenham thought so, you are their slave, their vassal. Venerate those good and great men—they are worthy of veneration; but, though masters in one sense, yet are they not my master—nor your master. You will meet with many cases of engorged and inflamed cervix, that will not get well until you cure the constitution—because many of them are merely local results of constitutional disorders. Constitutional disorders, did I say ? What is a constitutional disorder ? In my opinion, a constitutional disorder is synonymous with a nervous dis- order—a disorder of the nervous mass. That nervous mass is the creature. If it, if the creature be sick, the dependencies of it are liable to fall into morbid states. Many of the uterine maladies are mere expressions of a feebleness or of a dyscrasy of the nervous mass; and most of such cases are dependent upon debility of that mass. The means of redintegrating a debilitated nervous system consist chiefly in prudent alimentation, and in the use of corroborants, as iron, wine, vegetable bitters, air, and judicious exercise. All cases of womb dis- ease, therefore, are not to be best treated by sending the woman to bed for months together; on the contrary, some of them admit, and even demand a treatment by exercise, and by all the - arts we possess for the augmentation of the ratio of the solid constituents of the 272 POLYPUS UTERI. blood, and the reduction of the figure for the watery element of it. It boots not that I should here repeat the commendations, already reite- rated in this volume, of the metallic iron of Mr. Quevenne. Indeed, since my first publication on that subject, the iron by hydrogen has been so popularized, that it is in general use by the profession of this country. Let your patient use the iron then in two grain doses, to be taken on a full stomach. Let her breakfast on wine and water, with bread and meat or eggs; and give her a full dinner of meat and vege- tables, with her wine and water to wash it down withal. I must warn you not to be discouraged by the slow process of some of the cures—never tire of acting reasonably. You may pause in order to consider whether your treatment is really doing good or no ; and whether you ought not from time to time to change your agents— whether a few leeches, well timed, might not assist in the subduction of the uterine hyperaemia—whether you ought not to allow a velvety sponge as big as a walnut, imbibed full of a solution of extract of co- nium, or of belladonna, or morphia, to lie in contact with the cervix for a few hours daily, or every other day. You should consider the probable usefulness for the patient of a cupping or a blister on the sacrum or the hypogastrium, or a seton above the symphysis pubis. Think whether a dose of compound powder of jalap, taken thrice a week, might not dislodge the intra-pelvic irritations of your patient. Think on the power of the warm-bath, the sitz-bath, the emollient enema, and the nightly use of an anodyne enema, as remedies. Think whether the engorgement and the pain may not depend upon a deviation or a prolapse of the organ, and whether the true remedy is not to be found in some form of the pessary. C. D. M. LETTER XX. POLYPUS UTERI. Gentlemen: Let us now proceed to make some inquiries concern- ing polypus of the womb; and, I ask, is it not obvious that all the tissues of a living body are ever undergoing a perpetual accretion and waste; that the perfect balance between this deposit and absorption maintains all the organs and the parts, and the whole body in one even tenor of health, of weight, and dimensions, for months and years of POLYPUS UTERI. 273 time ; and that the loss of such a balance or equableness in the waste and deposit changes the weight and dimensions as well as the health of the body, or of any of the parts or organs of it ? But when the accretions of a part become excessive, then we have either a hyper- trophy or a tumor. We cannot have a tumor nor a hypertrophy of the whole body, unless you please to regard King David's antagonist the son of Anak, as a mere hypertrophied man ! It is one of the standing miracles of nature, that the bodies of crea- tures are maintained at one even tenor, not only through the lifetime of the particular individual, but from age to age. Thus, a single her- ring shall develop three hundred thousand eggs, from each of which shall be evolved a herring, whose weight in no instance, perhaps, in the countless myriads of that tribe, will ever be found to exceed by one hundred per cent, the weight of a perfect fish of its genus Clupea. On the other hand, an army of wild pigeons so numerous as to darken the air for days and days of its migratory flight will not contain a single pigeon as large as the barn-door fowl; because each genus of creatures, by its miraculous generic law, is limited to a certain stature, weight, and dimensions. The same thing is true of the vegetable tribes. You shall never expect to see an arbutus rival the forest oak, nor a violet to grow on the branches of a trunk as tall as the plane-tree. You wonder not, nor become amazed at this miraculous order ; but you and all your county would turn out in crowds to see an ear of Indian corn growing on a wheat stalk, or a magnolia grandiflora blossoming on the tender vine of a cucumber. You are, therefore, not surprised at the daily miracle set before your eyes in the order and regularity of Nature's operations; but you are startled, and lift up your hands in a gesture of wonderment, when she errs, and in her errors gives rise to some unnatural form or conjunction; you think of a " Saeculum Pyrrhse, nova monstra qusestae." Do you not perceive reasons to be far more surprised, when you observe that men and women too are found to live out their threescore years and ten, and even longer, without having experienced, during their whole life, a single deviation from the natural forms and weights of their organs, or of their external configuration ? There can never be deposited in an organ any atom or moleculum of its constituent tissue, but by an act of a bloodvessel, which puts it down in its place, and puts down the true physical elements in the right place. But the bloodvessel that carries and deposits the molecule can only deposit it under the indicating and controlling force of the accom- 18 274 POLYPUS UTERI. panying nerve. You are very well aware that each organ has its own nutritious artery to convey to it the materials for its daily accretion; that it has its lymphatic absorbent, to remove the daily detritus of the life of the organ ; and also its generic nerve, which indicates and con- trols, by its force, the kind, as well as the amount of the daily deposit, and the kind and amount of the daily absorption. You do not doubt, if the generic nerve becomes compressed, or is tied or cut off, or softened, that the organ will waste away, or become atro- phied, however sound and perfect the artery may remain; or, if too energetic in its indication and compulsion of the daily deposit, that the organ may become inflamed or hypertrophied, from a faulty rate of action of the generic nerve. In the womb, for example, the daily detritus and accretions of life will maintain the form, consistence, and weight of that body in one even tenor, for a lifetime, if it continue obedient to the generic law of its development—for that law which tends to keep it always two inches long, and of the weight of two ounces, and of a certain form, is as truly a generic law for the womb as is the law that determines the genus Bos, or Equus for those genera. But, if it disobey its generic law ! What then ? Now, in the code of morals—the Decalogue—we have plainly set down for our guidance certain rules or laws of action, to be obedient to which, or to be disobedient to which, constitutes us good or bad men, righteous or sinners. So, in the physical nature of living beings, there is a law which they ought to obey, and be bound by; if they disobey! if they fail to be governed by the provisions ordained for their just maintenance! then they may be likened to sinners against the moral law. They, in fact, do sin, rebel against or contemn the law ordained for their govern- ment, their protection, and security. In this physical disobedience, I can perceive a close analogy with moral disobedience. In each, it is the first step that is fatal—c'est le premier pas qui couie. In the moral law, the first sin, or corruption, leads to still renewed wickedness, until the whole moral constitution of the man is subverted, changed, and ruined, and becomes a mass of moral pollution. So, in the physical or organic sin; the first error is followed by the second, until the entire constitution of the organ is subverted and ruined so completely so com- pletely changed, that the most expert anatomist can no longer detect its old familiar features in the depraved and heterologue mass that lies under his scalpel or is scanned by means of his doublet. In the hopeless wreck of the moral creature, brought about by vicious indulgence, the voice of conscience is raised in vain, the appeal of reason POLYPUS UTERI. 275 is powerless; the invitation of the minister of the Gospel is like the idle wind, and suasion and argument equally fail to recall him to the path of duty and safety. Just so is it in the physical sin of the organs; when they have fairly broken the generic law, they continue free from all future bonds, and go, like the idle wind, where they list, and no one knows whither. It is in vain that you apply the restraints of your hygienic and therapeutic forces. The heterologue mass has no generic law, and the cry of the rest of the organs that suffer for its rebellion, like the cry of society against the breaker of the common law and the contemner of the statute, is raised for ears that are deaf. Such an organ is become like a wild1 horse in a boundless plain, that scorns the caress; and, fleeter than the winds, will not bend his neck to the accus- tomed rein. I have been led into these reflections by having witnessed to-day, June 10th, the dissection of a preparation brought into the city by two medical gentlemen from a distant county. Prof. Horner made the ex- amination. The whole mass weighed thirty pounds, and consisted of a womb, very much thinned and attenuated, which, upon being laid open by an incision from the fundus to the os uteri, disclosed a solid tumor, whose weight could not have been less than twenty-nine pounds avoir- dupois. This solid mass was a fibrous polypus, springing apparently from the side, not the fundus of the uterus; and attached here and there by strong exudation or accidental attachments—the results of pressure and inflammation long endured. Now, this vast mass probably sprung, at the beginning, from the very slightest aberration of the development force. The offence was small, and then became greater, until, in the end, you see how " rank" it was. What therapeutical power could you bring to bear as a control upon such a heterologue mass as this polypus of twenty-nine pounds avoirdupois; a polypus whose sole connection with the living constitu- tion of the poor victim it destroyed may have been by a root, neck, or pedicle, not bigger than your thumb ? Don't you see what a physical sinner it was, and how small was its first offence? It had broken its generic law, and you perceive the end. Let us take good heed that, in our small and venial offences, we do not at last come to say with the king— " Oh, my offence is rank; it smells to heaven!" This parallel between the moral and physical states of disobedience to the laws that ought to govern both, I have run in order that I might haply impress your minds, and my own also, with clearer perceptions of what we have to hope, and what we have to fear and do in the con- 276 POLYPUS UTERI. duct of those maladies that are, in the strictest sense of the term, chirurgical. I also wish that the analogy I have set forth may not be without some advantage in its moral, since from it we may lay to heart the equal necessity, in morals and physics, of opposing the very begin- nings of evil.; and since we ought, like Jacques in the forest, to be able to find " sermons in stones, books in the running brooks, and good in everything." But let us leave moralizing, and return to our physic; all the cavities of the living body, as the cavity of the nostrils, the ventricles of the brain, the womb, and even some of the solid parts, are liable to become the seats of excrescence or growths, some* of which take the name of polypus, which is a tumor growing by a narrow neck, or root, out of any superficies, and extending itself in length and breadth to an extent limited only by the duration of the life of the patient, and by accidental strangulation, or death taking place in the tumor itself. Such a tumor is a polypus, which may be either hard or soft, being called in the former case a fibrous, and in the latter a cellular or cell- ulo-vascular polypus. Such a tumor possesses a low organic life. It has a scarcely traceable interior circulation, while its superficial circu- lation is in many cases active enough to give rise to profuse hemorrhage: without some internal circulation, it would be subject to decomposition; without an active superficial circulation, it would not grow. Its growth is supposed to be peripheral. A polypus of the womb is far from being a rare chirurgical malady. A polypus growing from the interior of the uterus may be supposed to be, in its earliest state, a small excrescence like a papula, which, rising higher and becoming broader at the base for a certain space of time, ceases at length to grow at the base in breadth, but elongates itself, spreads out into an utero-morphous mass, filling the cavity of the organ more and more as it grows larger and larger, sometimes distending the uterus enormously, as in the instance above mentioned, and in other instances pressing itself into the canal of the cervix uteri, and so dilat- ing it as to find its way at last through the os tincae, whence it slowly advances into the vagina, then expanding in a lateral direction, so as at length greatly to distend that organ, and at last, when sufficiently grown, emerging from the genitalia in form like a pear. A polypus, then, is a tumor either fibrous or cellular—that is, either hard or soft; springing by a narrow neck or stalk from the womb, and increasing in size daily, so as to distend and fill up the womb to a con- siderable size: or, otherwise, it may dilate the neck and mouth of the womb, so as soon to come forth into the vagina, or even to project beyond the ostium vaginae. POLYPUS UTERI. 277 A polypus will not, in all cases, come out of the womb; especially will it not come forth to disclose its true nature in those cases where accidental adhesions have taken place between it and the womb. In such a case of adhesions, it would be in vain that the womb should make efforts to cast out the incumbrance; no pain nor contraction could get it forth from a cavity to which it has become attached in conse- quence of adhesive inflammation. In all cases, however, where the sole connection of the polypus and womb is to be found at the root or neck of the polypus we have reason to expect, in the long run, that the uterus will become irritated into contractile or labor-pains, and cast it out just as it does cast out a dead ovum or embryo that has perished in the early months of pregnancy. It is very possible that the earliest beginnings of a uterine polypus may consist merely in hypertrophy of some superficial layer of the womb, or else in a hypertrophy of some area of its tubular mucous mem- brane only, and that the tumor, in this sense, is either a part, and a real part of the womb itself, a fibroid partaking of the true nature of the uterine tissue: or, if it consist of altered mucous lamina only, it will be soft, or cellular—but, whether the growth proceeds in such a way as to make it come to be either a fibrous or a cellular polypus, it cannot be supposed that it will go very far before the new accretion will become really heterologue, and thus give rise to a mass growing from the uterine surface, nourished by branches of the uterine or spermatic artery, yet retaining, in its histological character, no true features of the womb from whence it derived its origin. I have met with instances of enor- mous enlargement and malignant degeneration of the whole inner or lining membrane or mucous lamina of the womb. Such a tumor has no generical limit; it is not a part of the natural body, though it is attached to, and derived from it; it might grow to the weight of a ton, could it be supposed to continue in the reception of its pabulum from the uterine branches to which it owes its existence. It has no generic delimitary term; and it can have none; seeing that it carries with it no special absorbing apparatus to counteract the accre- tion power which it receives from the vessel that makes the deposit and from its nerve. It is probable, as I before said, that most of the in- crease which it receives is derived from the exterior surface of the tumor, which, even in the most enormous tumors of the womb, it is said, may be successfully injected upon the more superficial portions. Dr. Th. Safford Lee tells you, at page 8 of his book on Tumors of the Uterus, that an injection may be made to penetrate " the morbid mass," and that 2268, 2270, and 2266, in Guy's Hospital, are cases in which the injection has been made; but surely, Dr. L. would not 278 POLYPUS UTERI. suppose that such a tumor as he has beautifully figured in Fig. 2 of his plate could possibly be injected by the anatomist; at least not the whole of it. Such a tumor carries with it, in its augmentation, delicate prolonga- tions of the arterioles and capillaries, from which it draws the material of its daily accretions. It probably also carries with it a certain amount or form of nerve fibrils, without the presence of which it would be subject to putrefaction; but those nerve fibrils may reasonably be deemed to be imperfect in their action, and as serving merely to retain the growing mass in vital relation to the body of the woman, yet unable to restrain and modify the accretions as they can and do in healthy normal function of the development forces. I deem that there cannot be truly any life where there is no cerebral or nerve matter; but I can well conceive that, in the case of the most extreme deviations as to form, magnitude, and consistence of organs or parts, by their conver- sion into tumors, there must accompany them portions of nerve matter, deriving a source from the nervous system of the patients, yet so im- perfectly connected with it by constitution or power as to lose the faculty of controlling the development of such said organs or parts. Certainly, wherever there runs a bloodvessel, there must be an ac- companying nerve; for a vessel is ever accompanied, and as it were sheathed in a nerve-plexus. If this view of the case be just, it would be idle to attempt to modify or control the growth of such a tumor, by means of drugs and medi- cines administered internally; since, however powerfully such drugs and medicines might be able to modify the actions of the woman's con- stitution under its natural physiological laws, they could not reach in their influence, nor in any degree control the accretion forces employed in the production of the polypus; which, being heterologue, will not, neither indeed can, come under obedience to the specific or generic physiological law of the woman's life; a law with which it has no longer any lot or part, beyond that of living as long as she lives, preying as a parasite upon her materials, and sending back no answering organic influences to serve in maintaining that beautiful harmony of the or- ganisms whose concert of action is life. Such a growth is not a part or parcel of the economy; it is not like one of the members of a family or a flock, but is like a stranger or a thief and a robber, that has entered in by guile or by violence, to dwell among them and to disturb and de- stroy them. Hence you see that such tumors are to be treated chirurgically and not medically. They may be extirpated, they cannot be cured. Save POLYPUS UTERI. 279 yourselves and your patients, therefore, the trouble and loss of using physic or drugs. In a womb that becomes the seat of a polypus, it is natural to expect the signs of uterine irritation. Therefore, as soon as the excrescence begins to acquire a certain volume, and to press upon and distend the cavity of the organ, we may expect to find the fruits of such irritation in diseased sensations, as pain, weight, tension, modification of the menstrua, white and sanguine discharges, &c. It is true that we shall not be able, in the early stages, to make the diagnosis of such a tumor, because, when it inhabits the cavity of the womb, and expands that portion of the organ only, it may not in the least degree change the form and dimensions or resistance of the cervix. We have no art and no skill, under such a state of things, to pronounce confidently as to the existence of a tumor; though we may be induced to infer it from the total absence of signs of other malady. It is inaccessible to our touch or sense. A woman, otherwise in good health, shall, at irregular periods, be attacked with uterine hemorrhage, whether moderate or violent, and when you come to make your diagnosis you can by no means discover that there is any inflammation, ulceration, deviation, hypertrophy, ple- thora, &c, on which to rely as sufficient cause for the irregular and alarming attacks of flooding. You are fully resolved that it is not a menstrual hemorrhage, for the causes of menstruation are not so irregular in their operation as to allow you to call it mensual hemorrhage ; what course will you take to clear up the difficulty? I see not what other recourse there is than that of accusing a polypus of the womb. The womb-sound or womb-probe will not, I think, throw any very clear light upon the case for you. The vaginal taxis and the hypogastric exploration cannot clear up your difficulty, if the polyp be yet a very small one. It is a process of ratiocination that leads you to the one and only possible conclusion. The case is one of a polypus, because it could be nothing else. I have not been afraid to make such a diagnosis. I had for ten years the care of a female, who, at the age of about thirty years, was repeatedly attacked with the most alarming uterine hemorrhage, accom- panied with severe pelvic and hypogastric pains. I do not suppose I have ever met with more violent hemorrhages of the womb than in the person alluded to. It seemed scarcely credible that she could survive the attacks. She was very thin, and feeble, and pale, and rachitic. I never could detect any augmentation of the size of the fundus and body of the womb by the Touch, or by external palpation, and yet so free was she from all the symptoms of other disorders of the interior of the 280 POLYPUS UTERI. womb that I ventured to tell her she had polypus, which at some future day would surely disclose itself. I was called, in the course of consecutive years, many times to this person, on account of the frightful hemorrhage and pain with which she was attacked ; and I repeatedly explored the case by the vaginal and rectal Touch, and the hypogastric palpation. I could never detect any certain physical signs of the malady, but rested convinced that a polypus was concealed within the womb. At length, amidst the severest pelvic pain and a great flooding, the polypus was expelled into the vagina, and I removed it with Dr. Gooch's double canula. After which, she had no more return of the hemorrhage. But she died, two years later, with pulmonary consumption, connected with a distressing rachitis, and precipitated, I suppose, by the extreme debility brought on by ten years of repeated hemorrhages. Life had become a burden to her, and she died with a countenance beaming with smiles, as she faintly repeated, in broken and scarce audible whispers, the beautiful verses— Vital spark of heavenly flame ! Quit, oh ! quit this mortal frame ; Trembling, hoping, lingering, flying; Oh, the pain, the bliss of dying! Cease, fond nature, cease thy strife, And let me languish into life! Do you ask me why, in a Letter on Diseases of Women, I cite these mal-a-propos memoranda of a death-bed; and which have nothing to do with our subject ? I answer that my Letters are about women, as well as their diseases and remedies. I would not forego this opportu- nity connected with her case, to make mention of one unknown, hum- ble, truly pious, whose gracious manners, whose noble sentiments and heaven-tempered spirit, as well as her willing submission to an inevita- ble and painful fate, filled me with admiration of the characteristics of woman. I have seen a man die with the dignity of a Christian and a gentleman ; none but a woman could die with such gentle and feminine grace and beauty as poor Anne Ryder. In her, her nature was wholly unchanged until the last dull clogs of her mortality were already cast off. There is nothing so difficult, my dear young friends, as to become a physician from the reading of mere descriptions of disease in the books. To read those descriptions is well, nay, indispensable. But to understand them, one must see the cases, and compare them with the book descrip- tion. I can hardly flatter myself that I shall be peculiarly successful in teaching you how to discriminate between the different maladies that are often characterized by the same outward signs. Let me hope, how- POLYPUS UTERI. 281 ever, that I can describe a case and a conversation that I had some time ago with a patient; and we shall see whether I can give you a clearer view than you now have, of the method of proceeding, and of the ra- tionale of an opinion, that you may readily form without greatly vexing your patient. Notwithstanding some of the critics who honored the first edition of these letters with their notice have rated me severely for introducing these dialogues, I hope you will not disapprove of them. I desire only to make my meaning plain to you who are young and inexperienced. Hence I am willing to bear the reproach of the literary martinets, if, by so doing, I can make you understand these mysteries, which I fear some of the reviewers themselves have no very clear notions of. I wish you to look in with me upon a patient of mine, and hear me talk to her, and judge why I ask her certain questions, and conceive what inferences I deduce from her answers. I am going to tell you a true story ; why should I not tell it in my own way ? I am sure a writer should use his own manner, and not that of another, if he should be truly desirous to set before his reader any statement of facts or argu- ment. Here is my story, and it is a true one. The person in question was a very tall, slender woman, a widow, who lived in Sugar Alley, near Seventh Street; she may have been some thirty-eight years of age, and had children. When I went to her chamber, she sat at an open window sewing the leather binding on a truss, which was her trade or occupation. The room was about fifteen feet square; and I seated myself near the door, while she sat at the window, say fifteen or sixteen feet off. She was a stranger to me, and I said, " You wished to see me as to your health ?" " Yes, doctor, I have been long sick, and knowing that you attend many women, I was in hopes you could tell me what's the matter." " Why, you look very pale ; too pale and weak to work, I should say. Pray, how long have you been so ?" " Oh, a long time, sir." " What makes you so pale, though ?" " I am all the time unwell." " I should think so. How long have you been unwell ?" " Six years and a half." " Six years and a half! Do you mean really to say six years and a half?" " Yes, sir. I have not been free from my courses for six years and a half?" " What! not one day ?" 282 POLYPUS UTERI. "No ; not one day." " Tell me ; are you serious when you say that for six years and a half you have not been a single day without an issue of blood ?" " Yes, sir, perfectly serious ; I have not passed a day without a show, and sometimes a flooding, for six years and a half.'' " But that is enormous ; yet to look at your face and hands, and to see how pale you are, one might well believe it." " It is perfectly true." " Have you any pain ?" "No, only weakness." " No pain in your back, nor in the lower part of the bowels, nor thighs ?" " Not the least; only weak." " No offensive discharge ?" " No, sir." " No burning sensation, no shooting pain within, and between the two hips ?" " Not the least." " Are you much unwell still ?" " Sometimes very much—sometimes not much—but I'm never with- out it." " Any trouble about making water ?" "No, sir." " No pain at the stool ? no difficulty ?" "Never." " And you have no offensive discharges ?" "None." " Then you have a polypus of the womb." " What is that ?" " It is a tumor, or lump that grows in the womb ; it has a narrow neck, which lets it hang out of the womb into the passage; it has bloodvessels, that always bleed." " What causes it ?" " I'm sure I don't know. Nobody knows ; it comes without any ascertainable cause; it comes in women who bear children, and in those that have never had any, as well as in unmarried women." " What can be done for it ?" " It can be removed with a ligature; that is, by tying a string round its neck, whereupon it will fall off, and then you will bleed no more * but, if you do not lose your blood, you will grow strong and healthy again." " But I cannot let you do it." POLYPUS UTERI. 283 " You ought to have it done; at least, you ought to have it examined, for, though I am very sure of finding the polypus, I have never yet had any sensible sign of it. I only judge it to be there." " I cannot." "Very well, madam. You have bled six years and a half; you are greatly reduced; your blood is thin as water, and if you go on much longer, there is fear you will have a dropsy, and then lose your life. Would that be wise, or foolish ?" " I can't help it; I cannot think of being examined." " Very well; it is your affair, not mine. I have no other advice for the present than that you should carefully revolve the prospect before you, and, if you should change your mind, you can let me know if you should desire to see me." And so I left her. to her reflections. On the next day she begged me to return. I went to her, taking my Gooch's canula with me, and found a soft polypus', large as an egg, on the neck of which I threw Gooch's ligature, and the tumor fell off in less than twenty-four hours; after which she had no more hemorrhage, but recovered her health and strength. Now the above is, I think, very near literally the conversation I had with Mrs.----, and since you have read it, I ask you what other opinion I could possibly take up as to her case ? She had no pain ; therefore she could have no carcinoma: she had no disagreeable odor of the discharge ; a fortiori, she could not have cancer; she had been unwell six years and a half without a day's in- termission ; but that was not the character of a menorrhagia. A woman can menstruate only as she ovulates. If she bleeds for weeks in succes- sion, it must be from other than her ovulating force. It must be that she has some insensible tumor that will bleed always, and yet never give her any pain ; what insensible tumor ? There is none other than polypus uteri. Had I not, therefore, a just ground to make the infer- ential diagnosis of polypus uteri, and to indicate the proper treatment. What a shameful mistake to have said—it is change of life—it is weakness—it is irritation—menorrhagia—it is this, or it is that, and so compel the woman to swallow drugs, usque ad nauseam, and at last find one's diagnosis proved erroneous to the discredit of Medicine, which is always discredited by the mistakes of physicians. Sixteen years after the events above related, this same woman came into my office. I did not know her, she was very stout and robust. She came to pay me for my service to her ; and having recalled to my mind the circumstances of her case, and saying she was now in easy circum- stances, she had come to give me a fee I had never solicited. She had 284 POLYPUS UTERI. never experienced the slightest inconvenience from her disorder, from the time I removed the tumor. She gave me a proper fee, which I willingly accepted, because she had more pleasure in tendering, than I in receiving the testimony, the honorarium. A polypus of the womb, I have said, cannot come out from its nidus, provided it have become attached at various points to the uterine walls, by inflammatory adhesion. You are not to be surprised that such ad- hesions do occur, for as the superficies of the polypus is quite vascular, and covered by a smooth membrane, which is probably of the nature of mucous membrane, adhesions would be very likely to ensue upon the escape of exudation particles from the uterine, or from the polypous surface. I have no hope to offer for such cases. It seems to me in vain that any one should attempt to extirpate, and I have no faith in the curative power of drugs for them. I am unable to state what is the difference of the causes that on the one hand produce fibrous, and on the other cellular, or soft polypus. I believe they are equally curable by the ligature; at least, I have not met with any instance in which, after the removal by the ligature, the tumor has again proved troublesome by renewed development from the root; which is not a little wonderful, seeing that, whenever we destroy one by the ligature, we must leave the base or root from which spring all the vessels and other apparatus concerned in the nutrition and develop- ment of the tumor ; and that might well grow again. I have met with no case in which I could accuse the polypus of ma- lignant degeneration, except one that I saw in the Lying-in ward of the Penna. Hospital; and that, perhaps, was not a true polypus in its origin. It was the case of a stout, short woman, about fifty years of age, who had long had putrid sanious discharge from the womb, and in whom, after a long time, the os uteri opened sufficiently to admit of the introduction of two fingers, by which a mass occupying the cavity of the organ could be felt. I in vain attempted to pass an instrument containing a ligature, and was obliged at length to break the mass with the fingers, by means of which I got away a large handful of hetero- logue material, half fibrous, half cerebriform, to the considerable relief of the patient, who at subsequent times was relieved, in the same way, of considerable portions of the same kind, as the contractions of the womb forced them down within the reach of the fingers. But, although a considerable quantity of it was brought away, the production of it continued. The woman left the ward at length a good deal relieved, as it was thought; but it proved otherwise in the end. Her sufferings be- POLYPUS UTERI. 285 came very great, with all the marks of malignant degeneration of the uterus. I know that Dr. Dewees attended a lady here, many years ago, af- fected with polypus uteri; he removed the polypus, as he informed me, and unmasked a cancer of the cervix, which soon afterwards destroyed the patient. You will find, in your studies, that it is conceded the presence of a uterine polypus may lead to malignant disease of the womb. The same thing happens in polypus of the nose, or antrum. The distending pres- sure of the tumor alters all the tissues that are in contact with it. The same might be true of the uterus and vagina. There are various instruments for putting the ligature on the neck of a polypus. I prefer Gooch's to all of them; and I think the ligature is to be pre- ferred to all other modes of extirpation. It is not in every case to be effected without hemorrhage. I know of two cases here in which' the hemorrhage was terrible; but there is less danger from hemorrhage by this process than by that of twisting or avulsion of the tumor. Whenever you are called to a case of polypus uteri, in which the neck of the tumor can be secured by a ligature, it will be your duty to put it on. You might be able to put it on in certain of the eases even where the tumor is still contained wholly in the womb; but, in order to such a great success, it will be indispensable that the os and cervix uteri shall be both dilated and dilatable; and the polypus ought not to be a very large one. Where the polypus is of vast size, an instrument used to conduct the ligature upon its neck should be so curved as to fit the convexity of the tumor, and the coincident concavity of the womb. It must be a very difficult task to arrange the curve in a proper way; and if it be not so arranged, the pressure of the instrument could not but be very dangerous; since the inner wall of the uterus is ill calculated to suffer the forcible contact of any foreign body long continued. Upon the whole, then, I am disposed to advise you, where the polypus is still within the uterine cavity, to wait until it is forced into the vagina, where there is little difficulty, and perhaps no danger, attending the operation of tying it. Dr. Lee, On Tumors of the Uterus, p. 69, says, in speaking of the treatment of polypus: "Supposing it to be placed within the cavity of the uterus, and the os uteri closed, it would be folly to attempt its re- moval ; we must suppress the bleedings by plugging the vagina, rest, an elevated position of the pelvis, and local cold, with some refrigerant drink." I am glad to be able to quote so sensible a writer in behalf of so sen- 286 POLYPUS UTERI. sible an injunction: for there are cases of persevering endeavors to ex- tract large polypi from the womb, that bespeak more obstinacy than prudence on the part of the practitioner. Indeed, some of these opera- tions are rather to be regarded as professional assassinations than proper surgical proceedings. The rule is a good one, not to attempt the extraction until the tumor has passed—partially or quite completely into the vagina. I do not mean by this to say it is not to be done until the whole tumor has come down, but only that we should wait until it is so far descended that the uterine cavity which still contains a part of the mass shall have become a cylindrical, and not a globular or pyriform cavity; whenever it has become cylindrical, which will be the case where the major part of the polypus is pushed out, no objection can exist against the casting of the ligature upon it. To adjust the ligature upon the polypus even in the vagina is often a vexatious and difficult task. Take patience for the work, and be not in a hurry to get it done. If the vaginal walls are tense, you will require some time. Let the patient lie upon her back; the hips to the very edge of the bed; the feet resting on the backs of two chairs, well separated. Let the Gooch canula be of a good length—most of them are incon- veniently short. See that the ligature is long enough not to annoy you with the rings interfering with your hands. See that the ligature be well oiled, so that it may run freely; strong enough not to cut or break; and small enough to move freely in the canula. Arrange the canulae so as to have them parallel in the right hand; introduce them, parallel, to the greatest depth; and then, taking one in the left hand, while the other is held in the right, carry either the rio-ht or the left hand one round the tumor, until you bring it parallel a^ain with its fellow. In this way, you will have cast the ligature round the neck of the tumor; next, you are to slip the canulae each into its ring at the end of the staff, and slide that ring to the top, securing the foot of each canula in its cannon. If great care be not taken in doing this, the ligature will be apt to fall off. You will know whether you have succeeded, upon gradually tightening the cord. If it has taken proper hold, it will pull the polypus downwards when you draw with it. Take great care to slide the ends up as far as possible, so as to get as much as you can of the base or neck of the tumor in the loop, and then draw it as tight as possible, so as effectually to strangulate the mass. If the polypus be a cellular one, you may expect it to fall off in twenty-four or forty-eight hours; if it be a hard fibrous one, it some- times requires seven or eight days to cut it through. POLYPUS UTERI. 287 The woman ought to be put to bed, and commanded to keep her bed, until the canula comes away. Once a day, the ligature should be tightened, as the compression is lessened by the daily shrinking of the mass. As soon as the mass dies, a most foul and offensive discharge comes on, which requires all the cares of cleanliness. Sometimes, when the apartment is warm, copious injections of soap and water should be made with a syringe having a gum elastic tube adapted to the metallic fistula. If the polypus is very large, you can pull it away with a Muzeux forceps, or with a sharp crotchet, or even with the obstetric forceps. In some cases, the tumor has been so large as to require to be divided before it could be got away, by a polypotomy operation, as one might call it. The extirpation of a uterine polypus is a very beneficent operation, as it relieves the patient from wasting hemorrhage, and from mental anxiety and physical pain: she soon recovers her health and spirits, and is in general grateful for the relief, as much so, probably, as for any surgical operation whatever; but you cannot always do the opera- tion. For example—some months ago, a lady came to me from New Jersey. She had been for some years laboring under a uterine disease, accompanied with violent and exhausting floodings. Upon arriving here, she was wholly unable to walk or to sit up in her chair. I dis- covered a hard polypus, whose apex was lying just within the os uteri, which was a circular opening as large as a half dollar. This os uteri was pretty low down in the pelvis; it was very hard, and completely undilatable. The fundus uteri was half-way up to the umbilicus, and the uterus hard and solid, so as to allow me to trace its outlines very clearly in my hypogastric palpation. I assure you I have rarely met with a more extreme case of anaemia than in this person. This anaemia was evinced not only in the pallor of her surface and its flabbiness, and in her irregular breathing, the frequent palpitation of the heart, and the anaemical throb of her pulses, but in the state of all her innerva- tions, which were most miserable, indeed, except when lying profoundly still in a low recumbency. After a few days of refreshment from the journey, I attempted to do what I thought I should fail to do; namely, to get a ligature on the tumor. But I soon found how vain was such an attempt, for I never found the uterus a moment relaxed, nor to open beyond the size of half a dollar. My attempt caused an attack of hemorrhage to come on, that I was glad to suppress by cold, by rest, and by opium. I kept her here many months, in hopes of seeing the uterus enter into powerful contractions to throw off the morbid mass. I gave her 288 POLYPUS UTERI. large doses of ergot. I thought the ergotism that was produced might expel the polypus, but I was disappointed, and subsequently had reason to believe the tumor had formed strong attachments to the inside of the uterine walls, so low down that I could reach them with my finger, but could not break them up. During her residence here, I thought to see her bleed to death before my eyes; her life was hardly saved by the tampon, so perverse was the hemorrhage. At length I sent her home, with directions as to her health, and a request to be informed if the tumor should descend into the vagina. It could never descend into the vagina, if the adhesions I supposed to exist were truly there. This lady died within a few months. She returned to Philadelphia and employed a medical gentleman to take charge of the case. He performed an operation, I know not what, and she died within a few days after it, before the ligature had come off. I have mentioned this case to you, in order to show you, in the first place, that I could by no means cause that os uteri to dilate; neither by manipulations nor by force of the ergotic spasm; and in the second place, and chiefly, in order that I might tell you what happened in the course of my treatment of it. It is this: she came here most deplora- bly anaemical. She continued here many months, during which time she always had some show, and suffered several severe floodings, one of which, as I have stated, was wellnigh fatal. But, except when reduced by copious floodings, she was raised, I was going to say, as by magic, into a state of ruddy health, by the daily use of Quenesville's metallic iron, in doses of two grains after each daily meal. I pray you do not accuse me of being credulous, and as arguing a propter hoc, in a post hoc case. The phenomena were so striking and so sudden as to convince any one that they ought to be attributed to the power of that article over the blood-membrane, the membrana vasorum communis. The greatest waste of her blood was followed by a rapid reproduction of it under the tonic power of the article. Do not say that it was her constitutional force that restored her; since, for years, she had been pale, palpitating, and exsanguious; whereas, under the use of the remedy, she rapidly regained all she had lost by the attacks. At all events, I pray you, when such a case shall present itself, and where you cannot get the offending tumor away, I pray you to test the power of microscopic particles of iron over the blood-making faculty which as I have so oft repeated in your ears, I suppose to reside essentially in the endangium, a tissue which I deem to be as obedient to the thera- peutical influences of iron as the alimentary canal is to rhubarb or the uterus to secale cornutum. You see I speak very confidently on this POLYPUS UTERI. 289 topic. I confess, men suffer themselves to be readily deceived by what they deem experience. But, at least, I conceive that my experience warrants me in this confident belief, a confidence which, while it is con- firmed by my diurnal observations, is also enforced by the authority of such a writer as Raciborski, not to mention numerous authorities who give opinions, if not so approving as mine, yet at least such as to recommend the medicine to your careful study, as to its therapeutical powers. Upon reviewing this letter, I find that I have been less exact, and less full in my account of polypus, than I intended to be. I shall not rewrite it, at least for the present; in fact, the question as to polypus resolves itself principally into this : viz. to discover it, and to remove it by the ligature. That is to say, to remove it when you can, not when you cannot; but you cannot, in cases where it is shut up or adhe- rent within a contracted womb. Physic and drugs are useless in the view of counteracting or retarding the growth of such tumors. Physic cannot hurt the polypus; but it can and will hurt the patient. If, however, the patient bleeds too much, you must check or repress the flow. If the polypus is offensive, you must give such directions as may keep it free from that odious quality. If it gives pain, you must lessen the pain. I do not think you will get any advantage from caustics or cauteries; whenever such things are applicable, the ligature is applica- ble, and that will eradicate the evil. I beg you to receive this letter, im- perfect as it is, with the assurances of that respectful regard with which I am yours, very faithfully, C. D. M. LETTER XXI. Gentlemen: In my last letter, which, as you may remember, I begged you to receive, notwithstanding I had prepared it with less care than I ought, but which I concluded to send you, notwithstanding my dissatisfaction with it, I did not say anything as to those polypes that arise from the lip of the os uteri, from the canal of the cervix, or from the surface of the vagina itself; nor, indeed, can I think it very much a matter of consequence to say anything of this sort of cases; forasmuch as, the chirurgical nature and quality of these tumors being once esta- blished, nothing remains except that I should apply the proper remedy, to wit, the ligature. This task is comparatively easy in these cases of 19 290 POLYPUS UTERI. polypus, because they are readily accessible, and may be subjected to strangulation upon their detection. Allow me, however, to put you upon your guard against a mistake that you would be liable to fall into in certain of these cases. I mean the instances in which the polypus is so small that you can with diffi- culty detect it by the touch; and are even liable to mistake it when you do touch it, for a coagulum. I have seen one of these excrescences not so big as a grain of corn, and I lately removed one, not much larger than a grain of corn, for a patient who had suffered a constant wasting hemorrhage from it for more than a year; to so great a degree, indeed, that she was rendered thoroughly anaemical by it, and suffered all the miserable effects of an anaemical innervation. I confess, I was surprised myself upon discovering the polypus to be so very small; having expected to find one as large as a small pear at least. I was in doubt for a while whether so great a waste could have depended on the effusion of blood from so small an excrescence; but when I had taken it off, the waste immediately ceased, and the lady recovered her health and strength; from which, I imagine, I have good reason to believe that the hemorrhage did, indeed, proceed from the polypus. I have cured several women, by means of the acid nitrate of mercury, of polyps springing from the os tincae, and which were so small as not to be detected, save by inspection with the speculum uteri. You may refer to my account and drawings of such cases in my treatise on the acute and chronic diseases of the cervix uteri. Pray, then, remember, that when you have perverse hemorrhages of the womb, not justly attributable to a menorrhagic cause, or to a large polypus, you may, perhaps, by careful exploration by the touch, or by the speculum uteri, make a good diagnostic so as to enable you to cure the patient, whom you could not cure should you happen to overlook the true organic cause of the trouble. I am afraid that I may in my letters, now and then, lead you into the error of jumping at a conclusion. You ought never to do that: you ought to arrive at all your conclusions in medicine by a regular process of perception and of reasoning. Let me tell you a story about leaping at conclusions, which may serve better to put you on your guard than ten pages of mere homily about prudence and cautious- ness. ' A gentleman here, for whose medical judgment and chirurgical skill I have the very highest respect, called on me some time ago to request I would assist at the removal of a polypus uteri, for which he proposed POLYPUS UTERI. 291 to operate the next.morning. He said, the polypus was already par- tially descended into the vagina; but the patient had been much an- noyed by it, both as giving pain and causing the loss of a good deal of blood. He had carefully made out the diagnostic of the case, and would be provided with a Gooch canula for adjusting the ligature. Upon reaching the rendezvous next day, I found a good many of the lady's friends assembled on account of the operation ; and of course no little anxiety was visible in their inquiring faces; for, notwithstanding such an operation is a trifling matter in fact, the women will not so deem of it. My good friend informed me he had repeated his diagnosis, which was satisfactory; whereupon I was requested to examine the tumor, in order to found my own opinion. When we had retired to another apartment, I said— " Are you sure, my dear doctor, that your diagnosis is correct in the case ?" " Oh yes, certainly; I made it very carefully." "I am afraid you have made a mistake." "How?" " Why, I do not take it to be certainly a polypus." " What do you take it to be, then ?" " I think it is a compressed ovum that she has been long casting off, and that is now ready to come away from the canal of the cervix." " Oh no, sir, not at all; I assure you I have most carefully exam- ined it, and I am sure it is a polypus. Did you not observe its pear- shape, its smooth and polished surface, its resistance ? It is clearly a polypus uteri." " Certainly I do not like to differ from you in opinion on the case. I may be mistaken myself; but I shall be greatly obliged if you will do me the favor to repeat your examination, carefully noting the diagnostic differences of polypus, and the case I supposed. I am far from pre- suming on my own judgment, but I must doubt you will come to my way of thinking as to this matter." So he went to the patient's room, and soon came back, assuring me, most confidently, that I had been mistaken, and that the case was a case of polypus uteri, pointing out to me all the infallible signs*vf that diagnostic. " Very well, doctor ; it may be that I have made a strange mistake : but you know that a man's perceptions are his perceptions, and they are what he is to go by. I hope you will allow me, before the opera- tion is performed, to correct myself by a new exploration." " Oh, certainly, I wish that you should do so, for I am quite sure you will find it as I haye said." 292 POLYPUS UTERI. We went to the chamber; I passed the right index finger along the tumor into the canal of the cervix, which was considerably dilated by the ovum, and, having carried it as high up as I could, I bent the last joint, indented the mass with the finger-nail so as to make it serve as a crotchet, and then exhorting the woman urgently to bear down—to strain—hard ! harder ! the dead ovum slipped into my palm. I called for a basin of water to put it in, and, taking it to the win- dow, I showed him the dead compressed ovum, of the nature of which the chorion and amnion were the irrefragable evidences. " What is it, doctor ?" " It is an ovum." " I told you so." " Yes, but it is very strange ! Do you know that I have attended a thousand labors ? How could I make such a mistake !" Now, do you, my friends, ask why I make all this detail of so simple an affair ? All medical practice is a simple affair : it only requires, first, that you should be well informed as to the nature of your duties : and, second, that you should reflect upon those duties in order to per- ceive what they be. The gentleman in question is a man of talents, very superior to hundreds or thousands of our brethren. But you see what a mistake ! I make all this detail, in hopes of warning you not to frighten a whole household by discovering that the mother of it has a polypus uteri, when she has no such thing. In fact, I make it to prevent you from jumping at a conclusion. How jump at a conclusion, say you ? Why ! certainly my friend did so ; and in this way. " The woman bleeds. She has a polypoid mass in the vagina, with certain uneasiness and pain ; ergo, it is polypus, ergo, it must be extirpated." He ought to have reasoned differently. He should have said: " The woman bleeds ; she has bled not many days; she has young children; she is a breeding woman ; she has a polypoid mass in the cervix and vagina; but a polypus requires a long time for its development; ergo, though polypoid, this mass is not polypous ; it is an ovum, compressed, and which is grasped by the cervix; I shall pick it away with my finger; and when it is done, I shall say, ' You are well, now, madam ; the mis- carriage is over, for I have the whole product of the pregnancy in my hand.' " I have no further remarks to make upon the subject of concluding too suddenly an opinion on such a case. If you will perpend the cir- cumstances I have just related, the facts, for they are facts, ought to serve to arouse your attention; but, if you will be really attentive to the business before you, how can you fail to make just and right con- clusions ? POLYPUS UTERI. 293 Let me relate another case to you, which is that of a lady about six- and-twenty years of age, the mother of a child about two years old. Having for some time complained of pain apparently situated in the womb, and of vaginal discharge, and aching of the loins, and, indeed, of the pelvis generally, with increasing general debility, she was pre- vailed on to submit to an examination by the Touch. The os tincae was low down in the pelvis, and painfully sensitive; but I could not discover any marks of swelling of the vaginal cervix, nor of engorge- ment of the whole uterus. By means of the speculum, I found that the os uteri as to the left half of its anterior lip was red, injected—the venules and arterioles being visibly enlarged. The color was that of the brightest and healthi- est lip of a young person. The rest of the os tincae was of the natural pale whitish hue. I advised rest; recumbency during part of the day, and all night; a regulated diet; and, as for the local turgescence, I treated it with con- tacts of the nitrate of silver pencil. But I did not make any progress towards a cure. As soon as the effect of the caustic was done away, the redness was found to be more intense, and occupying a larger base. The substance of the inner aspect of the said lip, and as far up the canal of the cervix as I could trace it by sight, was red and swollen, and vascular. This vascularity augmented, and the mass became a small tumor, which began to hang outside of the os uteri, so that I could lift it, and move it about from side to side, and up and down, with the points of the speculum forceps ; and, in short, it had converted itself by degrees into a cellulo-vascular polypus; very small, it is true, but a real polypus. I cut it down to the level of the surface from which it sprung, with acid nitrate of mercury; but it sprung again, and again I cauterized it; and so for several repetitions, until at last the tendency of the part to develop a polypus was abolished, and now I consider the patient as cured. Have I not cured this patient of a nascent cellulo-vascular polypus of the os uteri ? I believe that I have, and the case is on that account rare, and worthy of your attention. The little tumor always carried with it an epithelial covering, which was so tender that, on some occa- sions, it would give way and bleed, upon being touched very gently with a plumasseau of lint. Perhaps some of you may think it was a mere vivace that I cured ; but I cannot but suppose that, had I left it alone, it would soon have become a bleeding polypus, like the small one that I mentioned in a former part of this letter, and which caused so long and exhausting a hemorrhage from the lady. I am, &c. C. D. M. 294 POLYPUS UTERI. LETTER XXII. Gentlemen: I showed you, on several different occasions last winter, samples of uteri containing one or more hard nodular-looking tumors; and also specimens, in which the entire mass of the womb had, by disease, been converted into a tumor. You may remember that of the smaller tumors, some rose to a considerable height above the general level of the peritoneal surface; some of them being mere knots, and others having the appearance of being attached by necks or peduncles to the superficies of the organ, from whence, and through a faulty ope- ration of whose development force, they had sprung. You shall find cases in which a womb shall be covered all over with such botryoidal prominences. They are to be met with as large as a child's head, and of every intermediate size, down to that of a filbert or a pea. They are, doubtless, all of them polypes, and they differ from the other sort, of which we have been before speaking, only in this, that they grow in a direction towards the serous, instead of in a direction towards the mucous paries of the uterus, being essentially affections of the fibrous lamina of the womb, and not of the mucous lamina of it. The same principle is employed in causing the growth of either sort. There are some of them that appear to have pressed them- selves, or rather to have been pressed down into the substance of the uterine walls, and sit, as it were, like an acorn in its cup, but attached at the bottom of the cup by a root, neck, or peduncle. These tumors are not in themselves painful. They may give rise, however, to pain, by irritating the organ from which they grow, or others among which they intrude their masses, and yet they are not unfrequently met with in considerable numbers in or upon the uteri of subjects who, having perished with other maladies, had never any sus- picion of being affected in this way. In the long run, they may be ex- pected, however, to bring on constitutional disorders by disturbing the womb, which, you know, is eminently a disturbing organ, when it is itself disturbed. Upon attaining a certain size, they are likely also to introduce a bad state of health by their intrusion in the places of other organs and parts, whose circulation, absorption, nutrition, and innerva- tion they directly oppress and contravene by mechanical displacement and pressure. POLYPUS UTERI. 295 People talk of taking medicine for such tumors; and they even take homoeopathic pellets in decillionths of grains! Ma conscience ! Leaving out of question the unspeakable nonsense of the homoeopathic dosings, I see not on what ground they should take even real physic for such complaints; since drugs cannot, and were never designed to heal such tumors, and make them return under obedience to the natural develop- ment laws of the organ, and restore its outline and contexture to a nor- mal form and dimensions. Don't you see that these are really chirurgical maladies ?—that is to say, they would be subjects for chirurgical manipulation and operation, provided they could become accessible to the fingers, or bistoury, or ligature, &c. ? True, Mr. Lisfranc has proposed to enucleate them, and possibly, when one of them happens to spring from the vaginal cervix, it might be turned out with the handle of a scalpel, or dug out with the finger nails. If you like such surgery, it may be well; but I confess I am not of that class of people. As to doing anything with those that grow outwards towards the peritoneum, I look upon it as hopeless. I detest all abdominal surgery, save that which is clearly warranted by the otherwise imminent death of the patient. I say imminent death, not inevitable death, for death is ordained for us all. It does not, however, follow that, because you have come to the con- clusion that nothing can be done in the way of curing a fibrous tumor of the womb looking towards its serous surface, you are to do nothing for the patient herself. Much may be done in a way of wise counsel and prudent prescription as to her conservation; as to putting off the evil day; as to obviating and combating all the provocatives to an unnecessary increase of the malady; and as to counteracting the effects of pressure and intrusion, the natural accompaniments of the tumor. She may be confined, by your orders, to the house, the sofa, or the bed, whenever the disturb- ance arises to a height rendering such interventions of yours desirable. If obstruction of the pelvis attend the complaint, the enema, the aperient, the strong purgative, are at hand under your direction. Her diet and clothing may be regulated wisely and usefully. If inflammation and pain be threatened, or actually make the attack, you will save the perilous organs by your venesection, your leechings, cuppings, counter- irritants, stupes, and cataplasms; by your tartar of antimony and pot- ash, your calomel, and your opium. So that, though you cannot cure the fibrous tumor, you see I do not advise you to turn your back on the patient, leaving her to an inevitable fate, rendered tenfold intolerable by unwise treatment, or by no manner of treatment. For I deem those who are doomed to an inevitable and not distant death from incurable 296 POLYPUS UTERI. disease, to have no less need of the physician than those who are cer- tainly curable; and I think no higher exercise of the medical functions can ever be found than in those euthanasial benefactions that can smooth the way of the dying, and through composure, and comfortable counsels, and charitableness, and "sweet oblivious antidotes," divest of some por- tion of their terror and pain the last fast-fleeting hours of the children of men. I fear I am, my friends, in danger of making a rambling sort of letter of this, as well as the last one; for I find myself disposed very strongly to come back again in this one to the contemplation of prin- ciples that I find I have but partially discussed in the former. I hope, however, that, as I am writing letters, and not a book, you will pardon me if I depart from the regular epopceia form of book-making, and pre- serve in this series of communications the liberty and latitude which would be unbecoming in a regular gradus operis. In fact, I am very desirous to lay before you a translation of part of Article XVII. of M. Serres's Anatomie Transcendante, which is at page 130 of that admirable work: and I do this, because I feel very sure that no one is likely to republish the work in this country, and that you will probably not have an opportunity to see the passages in question, unless I give them to you here. You will judge whether the citation be germain or not to the matter in hand, to wit, the abnormal developments to which the womb is liable. Mr. S. says: "The structure as well as the form of organs is subject to various metamorphoses. An organ passes through various phases or gradations before it reaches the condition in which it is destined to re- main throughout the rest of its existence. An aberration of its form produces monstrosity; an aberration of its structure produces disease. Both these aberrations are subject to certain rules, and very nearly to the same rules. " In order to conceive just ideas of an aberration of form, we must follow the successive evolutions of such form from the moment of its first manifestation up to the period of its complete development. " To conceive of aberrations of structure, we must adopt the same plan. But, inasmuch as a case of monstrosity is nothing more than the retrocession of an organ towards another and more simple condition of such organ, or its arrest at one of its embryonal and primitive conditions; in the same sense, an organic disease is often nothing else than a return of an organic tissue towards a textural condition, which it naturally possessed at some one period of its embryonal life. " Diseases consisting in retrocession of tissues correspond to cases of monstrosity by default; and monstrosities from excess approach in POLYPUS UTERI. 297 their nature those morbid conditions in which there is a new organic production. Now, as a monstrosity by excess is but the repetition of an already acquired organization, so, productive maladies can never give rise to any other than already existing tissues. They reproduce tissues, as monstrosity reproduces organs ; and these tissues as well as these organs almost always have their analogues in the normal and regular organization. " Thus, the reproduction consists in a cellular tissue—in a membrane, the basis of which is cellular tela, or albumen; or it is a cellular part, becoming a fibrous part; and the latter passing into the osseous, or carti- laginous state ; or, the product consists in natural cartilages, in which ossific matter is deposited ; in strange muscular fibres that exhibit themselves ; in organs of secretion that are formed, either in the state of cysts or of crypts, whose analogues already exist in the economy ; or there are bloodvessels rising up spontaneously in newly-formed tis- sues, and, in fine, the nervous system itself may come to add itself to these accidental products. " Notwithstanding they are formed in the midst of disease, these productions are subject to certain laws. The first law is this ; and it confirms one of the laws both of physics and chemistry, viz., that as a slow action is necessary for the operation of a regular crystallization, so a slow action is indispensable for the accomplishment of these for- mations. A rapid action would produce either the destruction of the organs, or a hemorrhage, or collections of sanguine, or serous matters, or even purulent deposits, in which no organic movement is discernible. " The second law is a consequence of the former ; and it is that the growth of these products is effected by means of juxtaposition. The membranous layers superimpose themselves, one above the other where the membrane is plane; if, on the other hand, it is bent or curved, so as to form a cyst, the addition is made upon the interior, in a concen- tric manner. The exterior in this manner becomes the internal mem- brane of the cyst, which is nothing more than the membrane rolled up. This difference in form, slight as it is, produces a very great difference in the result; for whereas the membrane can acquire nothing beyond an individual existence, limited, at most, to the mere production of the sanguiferous apparatus, the cyst frequently becomes a real organ, the interior of which deposits fluids of various nature and consistence. It may even constitute a being, self-existing, and become a first degree of animality. The third law relates to histogeny, properly so called. " It was, no doubt, an error of the ancient anatomists to persevere, as they did, in the search after an elementary tissue or fibre, the origin of all other tissues or fibres. Yet, underneath this idea lay concealed 298 POLYPUS UTERI. the profound and true notion that tissues apparently very different have, in fact, the very same origin ; and consist but of the same element sub- jected by the powers of nature to diverse modifications. " Thus, the cellular element, when disposed in areolae, or in fibres, constitutes the system to which it gives name : in bundles, it is the fibrous system ; rolled up so as to form a closed sac, it becomes the serous system, &c. These various systems are nothing but natural and normal transformations of one common element. But, if it be in nature to undergo these transformations, we may perceive how a cellular part in man may, like the posterior cervical ligament, become fibrous in certain animals; how a ligamentous part, such as the stylo-hyoid ligament, may be transformed into an osseous chain ; how cellular parts may become serous membrane, while the serous membranes of the last order may become replaced by cellular tissue, &c. " We may also conceive that diseases, by modifying this common element, as nature modifies it in a normal state, shall cause cellular to become fibrous, cartilaginous, osseous, and serous parts, &c. All these modifications of a common element may be converted one into another, while still circumscribed within their proper limits. The same will be the case as to the nervous and muscular elements, each of them forming systems analogous to themselves, although differing among themselves. In fine, the vascular or sanguiferous element intervenes in all these diverse systems, as a condition of all, in a somewhat advanced formation. " These analogous systems transform themselves each into the other, without, nevertheless, overleaping their respective limits. The cellulur will never, under any circumstances, clothe itself with those characters that are proper to the nervous or the muscular element, nor will the nervous or the muscular elements ever exhibit the evident conditions of the cellular. However varied may be such accidental products, you will ever find them circumscribed by their true special nature. " The very contrary of these statements is to be found in most of the treatises on pathological anatomy, wherein you are told that all the tissues, commencing as cellular, may again take upon themselves this transformation. In those treatises, you find accounts of cellular, fibrous, cartilaginous, and even osseous transformations of the nervous system and of the muscular system. The fact is true; its explanation is not true : the nervous system is never, in any phasis of its develop- ment, cellular. According to our views, therefore, it cannot, under any circumstances, manifest the transformations that are peculiar to the cellular element. But, incontestably, these metamorphoses are observed in it: then it must be because the cellular element intervenes. How should it intervene ? Always by accident. A solution of continuity POLYPUS UTERI. 299 suddenly separates portions of the nervous matter of the encephalon or spinal cord and nerves ; a cicatrix repairs the injury. Such cicatrix, at first cellular, may become mucous, provided it fills with pus ; it may become fibrous, cartilaginous, and even osseous ; I have met with, and reported cases of each sort. But we see that, in these cases, which I have analyzed with the greatest care, the nervous element remains entirely a stranger to these transformations. It is the cellular tissue, which, supervening pathologically in the nerve-matter, becomes the basis and the seat of these metamorphoses. Here, as everywhere else, it undergoes the evolutions peculiar to it, and to itself only. " The practical consequences of these principles are so easily dedu- cible, that, for the present, I shall refrain from deducing them. I will, however, remark that these new-formed tissues never do attain the full degree of development of the normal tissues to which they approximate. Thus, the osseous transformation may produce laminae, or granules, but never anything comparable to a bone. The cellular transformation of cicatrices is very far removed from the natural disposition of that tissue; a serous cyst can never produce a pericardium or a pleura ; nor will the accidental mucous membranes ever rise to the height of that rich or- ganization which we observe, for example, in the intestinal mucous membrane. Disease produces an abortion of tissue, just as mon- strosity produces an abortion of organs." There, gentlemen, I know not what you will say, or what you will think of such a long extract in this letter; but I know what you ought to think ; and that is, that you ought to think yourselves much obliged to me for giving you an opportunity to read the above beautiful and philosophic exposition. I advise you, before you go any further, to turn back and read M. Serres's remarks over again. It will do you good to read them again, and it will do your patient good, for they are replete with the wholesomest doctrine, constantly applicable to clinical ministrations, and perhaps indispensable to a correct understanding of the diseased morphology of the uterus, which is the special subject of this letter. I did not intend to make so copious an excerpt from any- body, but I could not resist the temptation to present this one from that admirable philosopher. And I am sure there is not an ingenuous and intelligent young man among you who will not concur with me in thanking M. Serres for even this much of these profound thoughts of his. Having now laid before you M. Serres's observations as above, let us proceed with the more direct object of this letter. What was the real nature of that immense and very firm mass of polypus that I mentioned in the beginning of this communication ? I 300 POLYPUS UTERI. said it was fibrous, and I suppose that the fibrous matter, though not truly a mass of uterine matter, must have nevertheless been deposited under a development or accretion law identical with that which origi- nally developed the fibrous matter of the womb itself, though modified in its operation by disease in this instance. Uterine polypus may be cellular or cellulo-vascular. In such cases, the vascular and cellular elements become the subjects of diseased deposit; in the former, the muscular or fibrous portions are chiefly the subjects of it. But you saw specimens, last winter, in which the entire mass of the womb became altered, having grown to a vast size, and retaining in its augmentation very few of the characteristic features of its normal fabric. It, in fact, is become, under such circumstances, a heterologue organ, or, rather, is converted into a tumor. Those cases wherein the whole womb is converted into a tumor are very different from the mere hypertrophic modifications of its volume and weight, and the tumor is different in different samples, according as one or as another of its normal elements has been the chief subject of the morphological transformation, and the departure may be greater or less in different specimens, some retaining, and others losing every trace of the original character. In regard to all the possible forms into which the material elements of the womb may become converted under the wild heterologue operation of its development force, where it has abandoned its generical law, it seems to me nearly bootless to inquire. Some of the writers on these strange appearances have endeavored to classify them, and reduce their arrangement to a scientific scale. For my part, it seems to me enough to know that the elements may, each of them, undergo changes by a morbid act of deposit, and I am not, therefore, surprised to find a hygroma, a haematoma, a lipoma, a cancer, &c, formed upon the basis of the uterine textures. If the morbid development deposits in the uterus a mass of cartilaginous structure, there is no reason for surprise when that cartilage passes into bone, since it is one of the functions of cartilage to do so. All such cartilage deposits are effected through the agency of cells, and Thomas Schwann has shown, in his Comparison of the Development of Ani- mals and Plants, that, in each of those kingdoms, the cell-life force is the agent of nature in the work of evolving her living forms. You will readily admit that this cell-force moves in a true generic line, partly in virtue of an original nature or bias with which it is endowed, and partly in virtue of certain chemical attractions that concur with it; for example, the cells of the chorda dorsalis of a tad- pole are probably very different in their original life endowment from POLYPUS UTERI. 301 the cells of the pollen tube of a cactus or a lily ; yet, even if you pre- sume them to be not different in the essential nature of their nucleated nucleoles, they are very different as to the circumstances in which they are placed; for the chorda dorsalis cells could not possibly be developed in such a cytoblastem as that which is provided for the pollen cells in the stigma or style of a vegetable, and vice versd, for the pollen cells could find no proper elements in the albuminous fluid out of which the spinal marrow is evolved. Now, as to the morbid tumors of which we have been speaking, the cell—the mother cell—finds a new cytoblastema in a morbid deposit; and it appropriates it to form a tissue, a morbid one, but still a tissue, which is heterologue; and to such a degree, that it will be difficult in many samples to ascertain which is the deviated element in the case. If you examine the cells of a malignant tumor, you shall often find no appreciable difference between their appearance and those of the healthiest young growing part; as, for example, the cells of the chorda dorsalis, those of cartilage in very early embryos, or those discovered by compressing the pollen grains of a flower, or the plumule of a bean. The caudate cells of some of the cancerous tumors, the acicular crystals, and the granules, laminae, and masses of earthy phosphates and carbonates that we find in these masses, ought not to excite our surprise, though they may well overwhelm us with grief, if, like the good Sir Thomas Browne, whom I have already quoted, we be not only grieved, but thoroughly ashamed, that there is in the world, not only the greatest of evils, death, but that other great evil of diseases incur- able, for, such as these are incurable. I do not imagine, my young friends, you will make any very great progress in real knowledge by burdening your memories with all the varieties of nomenclatural distinctions that are in the books concern- ing tumors of the womb ; there is already far too much classification. Dr. Hooper's costly and beautiful volume, The Morbid Anatomy of the Uterus and its Appendages, is one of the clearest of them ; but I think you will find in it too elaborate a systemization'of these vagaries of the development forces, an attempt to classify what need not, and indeed cannot, be classified, videlicet the freaks of nature, acting without generic law, or end, or aim. It is far better to study M. Serres's beautiful doctrine, that I have quoted for you from his Ana- tomic Transeendante, in which is explained the true philosophy of such extraordinary operations. You shall probably meet, in the course of your long experience, with cases where the womb, that weighs in its natural state only two ounces, 302 POLYPUS UTERI. has become as large as a man's head, and weighs many pounds. The texture here is not uterine texture; it is a mixture of fibrous and cel- lular material, with greatly diminished proportions of vessel, nerve, and absorbent. It seems to me that the process of production for this ab- normal uterine matter is one that has no natural term: it is limited only by the life of the patient, and there is no power to recall it. It is, therefore, useless to give drugs with that view. It is true, I have met with several examples of enlarged and heterologue uteri that have ceased at last to grow, and I can well imagine that, now and then, in the pro- cess of extension, there will be attained a final term of the development force. That is to say, the uterine and spermatic arteries that serve under the registering power of the accompanying nerves, may convey material sufficient to carry out the morbid formation to a certain extent, but cannot transcend that certain extent, because the caliber of the vessels will not admit of a sufficient quantity of blood to pass to effect any further accretions, or haply the accompanying nerves will lose, by their extension, their indicating or controlling vital power over the morbid organic acts of accretion. Such an effect as I have just spoken of would doubtless follow the tying of both the uterine arteries, or, perhaps, even of one of them; and in any case where a uterus should be known to be aboHt to convert itself into a solid tumor, it seems to me not an impracticable surgery to secure the uterine arteries, with a view to suppress any further development. Suppose, in any such case, Robert Lee's ganglions of the cervix uteri could be carried off by a dextrous operation, would not the further development of the tumor certainly be arrested ? I repeat that I have seen some cases of morbid augmentation of the womb carried to such an extent as nearly to fill the whole of the excavation of the pelvis; so much so, indeed, as greatly to impede the functions of defecation and urination, and wherein the patients, after years of great suffering, have recovered their activity and good health. In such samples, there has been, however, a loss of appetite, or a regulation of the*diet amounting almost to the dike absolue: and there is reason to suppose that the cessation of development has arisen from the extreme reduction of the development force, partly by feeble health, and partly from the diminution of the sources of supply under a rigorous diet. I consider that when a woman conceives in the womb, that organ is compelled to grow or augment pari passu with the growing ovum. Such a womb at the beginning, weighs about two ounces: by the time the ovum is completely developed, which is about the 280th day, this womb has acquired a weight of a pound or some- POLYPUS UTERI. 303 times of two pounds. It has undergone a process of hypertrophization, which might properly be called a physiological hypertrophization. But as its evolution requires 280 days, it must also require a certain time to recover its non-gravid volume and weight by its return or involution. It might well be said that the first act of involution is expressed by its first labor-pains or contraction. To recover from its physiological hypertrophy, it is only necessary to remove the cause, expel the ovum. But, as often happens, the processes of its involution become arrested when half done, or more, and the womb remains enlarged, heavy, and inconvenient to the patient's comfort and even her safety. If you diagnosticate the case, you will pronounce it to be a case of hypertro- phy of the womb, and you would pronounce correctly. But if you should discover the cause of the arrest of its involutive act to be a retroversion, or some inflammation that might have attacked the neck of it, you could venture to promise a cure provided you could remedy the retroversion, or remove the inflammation. Put the womb in its true place and posture, or cure the inflamed neck, and then the involutive processes, no longer prevented or arrested, would soon bring the organ back to its non-gravid volume, weight, and power. No such good for- tune could be expected in the treatment of a heterologue uterus; yet I saw a cancerous mamma, as hard as cartilage, ulcerated, and firmly adherent, that was totally removed by absorption, in a long paraplegia. Many of these great tumors of the whole womb are accompanied with dreadful hemorrhages. After death, you find a uterine cavity longer than natural, but not much more spacious. The walls of the cavity, however, are many inches in thickness. I attended, for a long time, a lady with a vast tumor of the whole uterus. She had enormous uterine hemorrhages. The uterus weighed many pounds; its cavity was not much larger than the normal size; in the right ovary, which was as large as the fist, was found a quantity of human hair. Probably, the fatal development of the womb was pro- voked by the irremissible irritation communicated by this ovary to the uterus. In case the womb begins to develop itself as a uterine tumor, it will in the stages be sure to sink low down in the excavation of the pelvis; and, as it develops its magnitude more and more, it more and more interferes with the parts upon which it presses. If you touch such a mass, you scarcely shall fail to find it firmly packed, or jammed in the pelvis, putting you in mind of those cases of immobility of the womb that I spoke of in my XVth Letter. If you let the uterus go on in- creasing in size and weight while inhabiting the excavation, you will be sure to have much trouble from complaints of urinary and intestinal 304 POLYPUS UTERI. tenesmus, that must inevitably accompany such pressure and intrusion. Reflect for a moment on the facts, and you will perceive that, though apparently immovable, the mass is not really so; and that it is only apparently so from the condensation of the tissue about the vagina, and from its weight. If you could get the tumor well raised upwards, so as to carry the mass of it above the superior strait, you would do the woman a great service, by relieving her of all the painful and annoying accidence of the malady. But, when you try with your hand to raise it, it will not go ! Don't be disheartened; make it go. How? Place a globe-pessary or a gum-elastic bag in the vagina, a small one ; one of an inch and a half, or an inch and three-quarters; leave it in situ for a week, more or less; then adjust one of two inches, and next one of two and a quarter inches. In this way, you may very con- fidently expect to raise the tumor out of its narrow bony chamber in the excavation, which is too small for its accommodation, and get it up into the free and large space of the abdomen, where its pressure is scarcely inconvenient. But think, gentlemen, if you take away, by this means, a constant and irritating tenesmus, you turn aside in that very act a strong and perpetual provocation of the sanguine and nerv- ous systems to excessive activity, and thus diminish the tendency to rapid growth of the tumor. Nay, might it not be that the growth should find itself completely arrested in this way? I am convinced that the abolition of a constant and vexatious tenesmus would be far more efficacious in diminishing the tendency to morbid nutrition and development of the womb than half a dozen leechings, cuppings, or blisterings, to which you would resort as your chief therapeutical arma- mentaria medico-therapeutica. But in this I speak not as one theo- rizing only; I speak from what I regard as well-observed clinical experience of my own ; for I have many times done that very thing, and succeeded most happily. Try it. One is greatly tempted, under such circumstances, to prescribe ; and, if we must prescribe, let us allow the woman to test the power of the deobstruents, as they are called. Such is the iodine. I have no clear rationale to offer you as to the therapeutic action of iodine. Its probable efficacy, as combined in the spongia usta, in the cure of bronchocele, led it into a great vogue as a means of promoting the actions of the absorbent system; and there can be no reasonable doubt as to the disappearance of swellings of glands after its exhibition • of the disappearance of various cutaneous eruptions ; and also of certain engorgements of organs. But, whether tumors are obedient to its power is a question not yet settled; for a tumor is a new material, and not simply an old one, modified as to size, sensibility, and resistance. POLYPUS UTERI. 305 Nevertheless, you would probably give the patient iodine. Let her take it for a long time. Let her take it in combination with some of the diet drinks ; as Zitmann's decoct., or decoction of the woods, or simple infusion of sarsaparilla; or, what is the least inconvenient of all, the compound syrup of sarsaparilla. Let her have five drops of Lugol's solution of iodine, with half a fluidounce of syrup of sarsaparilla, twice or thrice a day. One good effect of such a drug may be counted upon ; and that is an improvement in the state of the skin, which becomes warmer, more humid, and better colored under its use, and if so, then the internal determination is in so far lessened, which is a great point gained. The use of the bath at 96° or 98° of Fahrenheit will conduce favor- ably to the same end. If repeated too frequently, it will be found exhausting. I advise you to order the bath about three times a week, and that the patient go from the bath to bed at night. Seeing that the womb is subject to a monthly hemorrhage, in conse- quence of the periodical ovi-posit by the ovary, and that this mensual hemorrhage absolutely depends on a periodical hemorrhagic engorge- ment and nisus of the internal reproductive organs, it is a clear duty to regulate the patient so as to cause the monthly periods to pass by with the least possible injury to the womb. If the woman whose womb is about converting itself into a tumor should be careless of her menstrua; if she allow them to be checked or prevented, and if the vessels and the nerves of the organ remain too long, or too considerably under the influence of the mensual nisus, the tumor will be surely aggravated by that protracted or too violent san- guine and nervous determination. Let her, therefore, be advised to stay at home; to keep her feet from cold pavements, or grass, or earth ; to maintain a soluble state of bowels ; to diminish her rations; to be calm and gentle in all her movements, and in all the affections of the mind, during the existence of the mensual crisis. It will be advisable also to abstract from her constitution the too considerable irritation communicated by the tumor, acting upon and vexing that constitution day by day, and nightly, for weeks and for months. Small doses of opium in the form of Dover's powder at night, alternating them from time to time with enemata of black drop, or lau- danum, will be the most powerful means within your control for such ends. But, as you will have a long case before you, you should be careful to avoid oppressing the nervous system by a profligate use of such narcotic remedies. The nervous system is more apt to be de- bauched than saved by the intemperate use of such drugs. Let your 20 306 POLYPUS UTERI. doses, therefore, be the smallest possible ones consistent with the pro- duction of a moderate therapeutical result. I cannot close this letter without again saying to you that women, in whom the whole mass of the womb becomes converted or metamorphosed, are very liable to uterine hemorrhages. The change in the constitution of the uterus does not of necessity implicate the healthful vitelliferous and germiparous operations of the ovaries ; but the ovaries, and not the womb, contain the cause of the menstrua. Hence, the menstrual action goes on in some of the specimens with great regularity. It is to be noted, however, that the new condition of the uterus itself commonly renders it hemorrhagic, and the same causes and influences, therefore, which produce the healthful mensual elimination in the healthy uterus operate to cause an excessive discharge of the menses in some of these altered uteri. As to two females, in each of whom the womb was as large as a man's head, the monthly waste was very great. To combat such wasting discharges, you have at your command the usual resources of local cold, of recumbent rest, of opium, of saccha- rum saturni, of alum, of krameria, kino, &c. &c. But I have seen all these fail, and yet the hemorrhage held in check by doses of a decoc- tion of dewberry root and black currant root, taken in half-teacupfuls at a time, and repeated pro re natd. I mention it here, as an article worthy of your attention, especially in the examples of hemorrhages in which you find yourselves baffled. The ultima ratio, the tampon, will, of course, ever supply your wants in the instances wherein it may be indicated. Lastly, never despair; never give up the patient; never pronounce the case hopeless, even when it is to all appearance hopeless. Not that I advise you to deceive the sick, or their friends, which would be cruel and useless; but you should remember that men and women and chil- dren have recovered from even apparent death. In these cases of en- larged womb, you have the hope that the growth will cease, and you have the example that they do sometimes diminish again. It is time enough to pronounce that there is no more hope when the life has left the body. I have seen the life resumed, even when I had regarded the signs of death as complete. I wish, my friends, I had more comfortable prospects to hold out for you than those which, as to tumors of the womb, are contained in this letter. Medicine is always making progress, however; and let it be your duty so to study, to observe, and to reflect upon these mighty dis- orders, as to enable you, in the next half century, to leave more con- solatory counsels to your pupils than I can to mine. C. D. M. CARCINOMA OF THE WOMB. 307 LETTER XXIII. Gentlemen: There is a frightful malady to which women, the sub- jects of these letters, are very much exposed; I mean carcinoma or malignant degeneration of the womb. I have little to say on this subject, and I might add, there is little to be done for those who are attacked with it'; I mean little to be done under prospects of relieving the persons so attacked, or restoring their health. It is enough to make a physician's heart sink within him to make the diagnostic of cancer uteri, for such a diagnostic is ipso facto a prognos- tic of death; and when the physician has made it, and is brought to the point of giving true expression to his opinion, he might be sup- posed to be as painfully situated as the judge on the bench, when he puts on his black cap before the final announcement of the judgment unto death. It is probable that the double functions of the uterus, as a menstru- ating and a childbearing organ, render it more liable to the attack of this atrocious malady; and that its structure, also, which in the health- ful state is solid, hard, and elastic, without excessive abundance of cir- culation or nerves, exposes it more constantly to the causes of carcino- matous change. What is that condition, that carcinomatous -vice, which results in ulcerative or open carcinoma of the womb ? and how is it originally es- tablished and set up in the texture of the cervix ? Do you say it is cancer—cell-life begun and carried on there ab initio ? How is the cell- life begun?—what gives origin to it?—when does the cancer-cell develop- ment begin?—is cancer always an inoculation, and whence the inocula- tion ?—can the healthy actions of the womb deposit mother cancer-cells in a healthy texture, and furnish them with the indispensable cyto- blastem, without which they themselves would die ? These are questions more easy to propound than to answer; because, physicians very rarely enjoying opportunities of inquiring into the rise and progress of these disorders, do not begin to observe them until they have reached a stage of development so advanced as to leave little ground to expect any ad- vantage from treatment beyond the mere benefits arising from cleanll- 308 CARCINOMA OF THE WOMB. ness, and some suppression, perhaps, of the progress as well as of the pain and irritation. Such cases cannot be studied ab initio. A mere scirrhus of the cervix does not give pain, and the woman herself will not ask our aid or our opinion on a case of whose existence she is not aware. I say, then, we cannot study these carcinomas ab initio. They can be reasoned of, however. I have never been able to bring myself to consent that these diseases are the results of anything but inflammation. I have always regarded the transformed materials of a carcinomatous cervix as transformed deposit, elaborated by inflammatory action. And, if you will keep in view the remarks of M. Serres as to the gentle and slow progress of those actions that result in morphological changes, you will not find it difficult to agree with me that a carcinoma is an inflammatory result; for the slowness of the process, of which M. Serres speaks, is an attri- bute of those chronical inflammatory movements which produce, not hemorrhage, not secretions, not pus, not sphacelus, but new textures. But a carcinoma is a new changed texture. It is an imperfect, an abortive texture. It is a texture whose combination of vessels, absorbents, and nerves is a perishing and non-generic one; one that, from the very nature of the proportions of these instruments and agents of life, can- not exist long in one tenor of life, but must change and decay from the very fault of their crasis or composition. In a healthy cervix, the ac- cretion and waste are duly balanced, because the absorbent and the nerve are there to regulate them both; but when, in consequence of a slow a chronic inflammation of the cervix, the interstitial textures be- come filled with laminae, or fibres, or bands, or granules of coagulating lymph, or fibrine of the blood, it is manifest that the vessels are to become collaped or compressed and closed by these deposits outside of them, as is clearly shown by Pujol in his admirable doctrine of inflammation; and that the absorbents are sealed or compressed so effectually, and the nerves so absolutely destroyed, that the quasi organization of the carci- nomatous cervix has come to its end, its ter*m, and no longer, in truth, exists as to the sum of the particles of the cervix; and then commences a process of absorptions, and sloughings, and suppurations, and hemor- rhages, and macerations, and sanious putrid excretions, which proceed until the constitution of the victim being entirely exhausted or over- thrown, she sinks into the grave, her only and her last best refuce. In the progress of this half erosion or maceration, and half phage- denic ulceration of the parts, the mother-cell makes its beginning; and once begun, the parts once inoculated with this new and wild uncon- strained, uncontrolled form of life, the destruction goes on with rapidity nothing stays, nothing arrests it, and the sole resource of our art con- CARCINOMA OF THE WOMB. 309 sists in the exhibition of opium in some one of its forms, for the subduction of the distress. The principal matter, however, is to make a correct diagnosis. There is danger of an incorrect one in this, that if you come to the clear con- viction that the case is one of veritable carcinoma or cancer, you will be paralyzed by that conviction ; and, like everybody else, will settle down in the conclusion that nothing is to be done beyond the adminis- tration of those palliatives which, though they cannot cure, yet can console and comfort the patient. I have certainly met, in the course of thirty years, with several cases of diseased uterus, which I had the greatest reason to suppose cancerous, but which yielded to persevering treatment, and ended in the perfect recovery of health. For example, a few years since, I treated a case of what I then had the greatest reason to regard as cancer of the os and vaginal portions of the uterus, in a young woman, then pregnant about two and a half months. She recovered her health and gave birth to a healthy child at term ; since which she has continued to enjoy the most consummate health. As I have a most distinct recollec- tion of the physical characters of the case, I feel very sure that, were I now called upon to make the diagnosis of a precisely similar malady, I should be compelled to pronounce it a carcinoma uteri. Far be from me the intention to proclaim that I have been more fortunate than my brethren, and that I have cured cancer of the womb. My desire is to say that I was mistaken in my diagnosis, and that I treated a curable and not an incurable malady. I am of the opinion that everybody holds on the subject of this terrible evil, viz., that it is one of the opprobria medicorum, and that it cannot be cured. No, not even by the excision of the part affected. I speak of the true cancer. Dr. Muller, in his work on the Nature and Structural Characteristics of Cancer, &c, combats the opinion of Wenzel, that scirrhus and car- cinoma are mere inflammatory induration followed by ulcerative action. Yet, notwithstanding my ready assent to the doctrine of cells, as the agents of vital development, I confess myself to be quite in favor of the doctrine of Wenzel, and of those who, while they deny not the destructive activity of the developing cells, which are so readily detected in various forms of ulcerated carcinoma, and of fungoid disorders, yet regard the antecedent of cancer as inflammation. Perhaps you, my friends, may be in favor of Prof. Muller's views, and I acknowledge his arguments are very powerful, and that his citations of examples and varieties in the forms of cancerous degenerations, add to the force of ^ his reasoning. But I cannot bring myself to believe that cancer ever commences anywhere, as a punctum saliens of disease. There is always 310 CARCINOMA OF THE WOMB. an antecedent state of alteration of tissue; a state which lays the found- ation for the wild evolution and multiplication of cells, out of and be- yond the control of the accretion and waste laws of the part or organ. When a part has once become changed by a certain sort of indura- tion, the control of the generic nerves is abolished in it; and a cell deposited or inoculated into it, might live and multiply upon its morbid cytoblastema, so as to result at last in the strangest modifications of the texture ; becoming carcinoma reticulare, alveolare, fasciculatum, melan- odes, or medullare. These several forms of degeneration depend on the loss or retention of more or less of the nerve power of the part, by which one or another of the constituent elements of a fabric may be held in check, or allowed to run into riot and ruin, under the action of the dis- ease. But it is not my purpose, and I confess I have not sufficient infor- mation upon these points, to enter into a discussion of the microscopic characteristics of the various forms of cancer. I barely remark that I have little reliance upon the microscopy of cancer cells as a matter of clinical importance, because I do not believe in the existence of an infinite variety of them. There seems little profit in such discussions beyond that which enures to the enrichment of our possessions in histology. They will probably have but little influence in a utilitarian sense, since they add not to the power of the therapeutist, nor to the success of the surgeon. I cheerfully refer you, therefore, to Prof. Muller's beautiful work, hoping, however, that you will always en- deavor to exercise an independent judgment on all matters of science ; not without that due respect to the superior knowledge and oppor- tunities of such men as John Muller, whose great learning and noble devotion to the enlargement of the boundaries of medical science have earned for him so distinguished a name. I shall refer you to Colombat for a fuller description of the phenomena of scirrhus and cancer of the womb; merely saying here that, when the os tincae becomes covered with hard lumps, that feel like shot lodged under the epithelium; that give sharp pain when pressed with the finger; that deform the os uteri by causing it to open unequally ; or that cause unnatural discharges • you will have a right to suspect scirrhus. If it have gone so far as to bleed for a touch, and to give rise to sanious discharge, with a peculiar odor, not very different from that of carious ulcer it is ulcerated cancer, and the patient will probably die soon. You will find that many of the European surgeons have treated can- cer of the cervix by cutting off the diseased part, and that they assert the patients have been sometimes cured by the operation. I think the remark made to me by an eminent Philadelphia surgeon, some time \ CARCINOMA OF THE WOMB. 311 since, is worthy of being repeated: " If the cervix was cut off," said he, " and the woman recovered, it affords the most incontestable proof that the operation was unnecessary." It is probable that the course of your future experience, in recovering certain forms of enlargement, induration, and ulceration of the cervix uteri, will bring you, in the end, to a similar conclusion. In fact, there have been so many cases of excision of the cervix, within thirty years past, with so little happy result, that the operation is understood to be nearly abandoned by the German and the French surgeons. T. S. Lee says : " I have seen but one case of this kind (excision of the cervix); the neck of the womb was entirely removed, leaving an open cavity in the womb. After the operation, the patient remained in the hospital some long time, until the ulcer caused by the operation had entirely healed ; but, after her dismissal, she shortly had a return of the deep-seated pain in the pelvis, the dragging at the groins, inability to walk far, and many of the same symptoms of which she complained before the operation. M. Lisfranc states that the success of this operation is very great in his hands ; but he can hardly be relied on. It is an operation not much practised by our own surgeons, on account of the liability of the disease to return. Caustic is our only resource when the granulations become too luxu- riant ; but I have never seen it do much permanent good. Opiates are constantly necessary to allay the deep-seated and other pain which disturbs the rest and breaks up the constitution. Conium and hyos- cyamus are the best; they affect the head less, but frequently are not sufficiently powerful; then opium, in some form, must be had recourse to. The bowels are to be kept gently open; but diarrhoea is to be avoided." What more ? I am out of heart, and ashamed to name cancer of the womb ; and yet, what is the miserable victim to do without the aid of the physician? You must aid her. You must wash away the foul and putrid collections that actually sometimes gush from the diseased surfaces. If you treat such cases, you may add greatly to the comfort of the woman by the upward douche. You can suspend a glissoir, and con- duct into it a pailful of water, at such temperature as you please to indicate ; the lower end of the glissoir, if provided with a gum-elastic tube, may be carefully introduced into the parts while the patient re- clines in a bath, or sits on a bench over a proper basin or bidet, so that the douche may be directed to the affected parts with the effect of less- ening the accidental epiphenomenal inflammation, and carrying away all the detestable odor of the sanies. Or the patient may go daily into a sitz-bath, and cleanse herself of the odious exhalations of her malady. 312 CARCINOMA OF THE WOMB. What a comfort for a woman ! The pillar syringe is a very convenient one for these uses. Dr. Lee says that caustic is the only resource. Take a small phial containing acid nitrate of mercury, a camel-hair brush with a long handle, a speculum of ivory and a speculum forceps, a small sponge, some honey of roses containing wine of opium or black drop, or extract of conium, or extract of hyoscyamus mixed in it. Let the patient lie across the bed, her head, not the shoulders, on one single pillow; her hips at the very edge; her feet on the upper bars of the backs of two chairs; her knees widely separated, covered with a sheet. Introduce the cylindrical or conical speculum, not too far, wrap the edge of the sheet all round the tube, so as completely to conceal the person, leaving only the projecting portion of the tube to be seen. Press the speculum down slowly and gently until you disclose the diseased part. You will be sure almost to find some of it upon the vaginal walls: Don't burst them, nor hurt them by jamming your tube into them. When they come into sight, take your bit of round soft sponge, filled with Castile soap, dip it in tepid water, thrust it into the mouth of the speculum, and then, holding it in the forceps, carry it to the bottom of the speculum and wash the ulcer clean. A soft sponge, well filled with fine Castile soap, is as soft as the mucous membranes them- selves, and may be freely but gently turned round and round over the granulations and shreds, without inducing hemorrhage or the least pain. On the contrary, the patient is greatly comforted and consoled by the process, both physically and morally, for her pain is diminished and she feels herself to be less an object of aversion and disgust when the frightful fetor of her cancer is even temporarily taken away. Having cleansed the surfaces and dried them with soft dossils of charpie or linen cambric, if the indication calls for it dip the camel- hair pencil in the acid nitrate, and, carefully conducting it to the granu- lating surfaces, touch them with the solution; whereupon they immedi- ately assume a gray or ash color and the secretions are, for the while, suspended by the coagulation and cauterization of the orifices and sur- faces of exhalations. When you have made the contact of the caustic, carry your sponge, filled with warm or tepid soapsuds, to the bottom of the speculum, in order to neutralize any excess of the acid that might flow off upon surfaces you do not wish to act upon; and then, having dried the sore again, dip a small bundle of charpie or soft linen cambric in the mixture of honey of roses, attaching a strong thread to the bundle; place it in contact with the ulcers, and keep it there with your forceps, until, by gently withdrawing the speculum, you observe that the collapse CARCINOMA OF THE WOMB. 313 of the vaginal walls will hold it in sitd. The patient may withdraw the pledget or plumasseau in the course of four, six, or ten hours, according to the heat of the apartment and the heat of her body. The thread serves to draw it away.. Dr. Lee tells you to use conium or hyoscyamus as your anodyne; but he also says they are not very reliable resources, and that you must come to the opiates at last. In the matter of opiates, you should reflect that, in addition to the debauching influences of opium on the nervous constitution, and on all the secretory acts, there is a directly pernicious impression on the primas viae. But you should save the digestive power as far as you can. Use the laudanum, therefore, as enema, and use it wisely. Teach the poor creature not to waste so great a blessing as that which God, in the midst of his chastisements, has vouchsafed to her. If, like a spendthrift, she uses her anodyne too much its power will soon be gone. Let her, then, learn to quell, not to abolish, the pain, for it will begin again. She should be provided With a proper syringe, one that will hold two fluidounces, and no more, and the fistula plumbea should be of a good size and sufficient length. Let her add to two tablespoonfuls of clear starch twenty-five to forty-five drops of laudanum, or eighteen to thirty drops of black drop, or two to four teaspoonfuls of solution of morphia, to make the injection into the rectum—an injection that may be repeated once, or twice, or thrice in twenty-four hours. She should be clearly informed that the progress of her malady will surely require larger doses, and the larger the doses the worse the influence upon the digestive and nervous power. Teach her, then, not to be profuse in the expenditure of that treasure of comfort which she possesses in her opium. Where you have under your care cases that are attended with wasting discharges of blood or sanies, from cancerous tumors of the cervix proper, that sometimes are tuberous in form and of a large size, I presume you will readily counteract the bursting tendency of the tumor, or its tend- ency as rapidly to pullulate like the granulations in what is commonly called proud-flesh, by using the acid nitrate. You may, perhaps, prefer the caustic potash. But the most efficacious and sudden of these pow- ers is that you possess in the actual cautery. The greatest objection to it in this country is the terror and the talk it would excite. But it does not give pain nor cause sensation, and the death of the points touched by the hot iron is so complete and so deep below the surface that it is more efficacious than any potential cautery, and leaves a better base after the fall of the slough. It is very easily applied through an ivory or horn speculum. You 314 CARCINOMA OF THE WOMB. ought not to employ a silver or metallic speculum for this operation, because, in using the actual cautery, you must have the iron intensely hot; if it be merely cherry-red, it will adhere to the surfaces that you touch with it, and you will tear them in removing it. Your bouton should be white-hot; when, indeed, it burns before the actual contact, and does not adhere to, but rather repels the surfaces. Now, if you pass a white-hot cautery down the whole length of a metallic tube, you will heat the tube, and burn the whole vagina, whereas, if you pass it down an ivory or horn cylinder, which is a non-conductor, you will give her no pain at all. Many of you living in remote country places will, perhaps, not find it convenient to procure the beautifully turned ivory speculum ; but there is everywhere to be got a cow's horn. Cut one to the length of six inches ; drill or reame out the interior to the diameter of one and three-quarter inches at top by one and a half inches at the lower end ; shave it thin and polish it, and you will have as good a speculum as if Charrie're himself had made it. You would do well to have several, of different sizes, for, in some of the carcinomata of the uterus and vagina, you will want a very small cylinder, inasmuch as a full-sized one would give pain and even endanger the laceration of the vagina. M. Jobert de Lamballe, one of the surgeons of St. Louis, at Paris, is very famous, in Europe, for the common use he makes of the actual cautery in the treatment of diseases of the os tincae. It is, in fact, for him a great specialty. M. Jobert, in a publication, has supposed the cervix to be nearly destitute of nervous sensibility. He treats a great variety of disorders of the cervix by this means, and asserts that many of his patients are completely cured by it. I have seen him apply the cautery to many women who came, in succession, to place themselves on the bed arranged in his lecture room. The iron was always brought to him by an aid, as soon as the speculum was properly adjusted. The hiss of the burn was distinctly audible, but the women were never sensible of the contact, as I was assured both by carefully observing their expression of countenance, and by their own avowal; for they assured me they felt nothing, though, in the course of a little time afterwards, there were heat and pain, which soon passed away. M. Joubert himself is very confident of the vast benefit of this process; but the English, on the opposite side of the Channel, detest his process, and condemn it. There is no objection, however, to your making use of it for the suppression of otherwise irrepressible fungoid growths, or perverse hemorrhagic discharges; but remember well, that when you do use it, the contact must be barely a contact, and always an instantaneous one. CARCINOMA OF THE WOMB. 315 So much I have said as to cancer. I sincerely wish it were in my power to say more or better; but I can find no encouragement in my own melancholy experience, nor in the writings of RCcamier or Lisfranc, or Duges and Boivin. But, for the cases that simulate it, that present the hardened and patu- lous os uteri, with granulations that bleed for a touch, and that sit on a hard and swollen base ; if the patient be not already reduced in strength and flesh, bleed her from the arm, purge her every alternate day with compound powder of jalap and cream of tartar, until she has taken four, six, or eight doses. Touch the granulations with the nitrate pen- cil every few days; keep the woman in bed; direct the frequent use of the bidet; let her have a tepid bath three or four times a week ; give her a diet, in which she shall have some meat every alternate day at dinner, and only then. Dissolve a grain of corros. chloride of mercury in a pint of compound syrup of sarsaparilla, and direct a tablespoonful for a dose, twice a day ; to commence after the close of the course of purgatives. An anodyne enema at night will not only procure sleep, but procure that sort of hebetude as to constitutional impression that is highly curative under these circumstances. Such a diet as I have advised above I have for many years been in the habit of recommending in long cases ; and I have preferred it to a continued abstinence from animal food, because the digestion is less apt to give way under it than in a diet of lavage or mere vegetable matters; and, moreover, the patient submits with greater cheerfulness to a re- striction that is not absolute. In such a course of diet, the patient, in thirty days, will have taken only vegetable matters on fifteen of those days, or thirty days in sixty, which, for many cases, will be found a sufficient degree of abstinence. Certainly, I have cured some very unpromising forms of diseased os and cervix uteri by such a course. As to the cases of cancer of the cervix, in pregnant women, it is unnecessary to say, perhaps, that no- thing in practice can be more dreadful. In such cases, those portions of the cervix that have become heterologue in histological character can afford probably none, or, if any, only a small proportion of the dilatable materials for the transmission of the foetus. I saw a lady in labor in March, 1848, who was twenty days short of term. She was seized with the early symptoms of labor with too free a discharge of blood, and, upon examination, a tumor connected with the posterior and left segment of the circle of the os uteri was discovered. In this case, two-fifths of the os were undilatable, leaving three-fifths to afford the whole dilatable tissue. I expected a fatal laceration, but was agreeably disappointed. The child was born, but not until the carcinomatous lip 316 DISTENSION OF THE WOMB. was detached and expelled by the pain. It is in my collection. And now I shall desist from further remarks on this painful subject, refer- ring you to the publication already mentioned, where you may find greater details, but little more encouragement; and I rest, very truly, &c. * C. D. M. LETTER XXIV. Gentlemen: If you will look into the books, or listen to the rela- tions of your patients, you will, perhaps, be led to believe that the womb is occasionally to be found distended with air, which, after having caused it to expand until it attains the size of a womb six months gone with child, more or less suddenly escapes; whereupon the signs of the woman's pregnancy disappear, to the great astonishment of the hopeful patient, as was the case in the celebrated instance of Mrs. Commodore Trunnion, of whose baby the author said, " tenues in auras evadit." These ventose pregnancies are nonsense, and no thoroughly-bred and close-thinking physician ought to be for a moment misled by such a story. It is against physiology ; it is against pathology; and it flies in the face of common sense, to talk of collections of wind distending a material like the womb, a material which creaks under the edge of the bistoury, and expanding it like a normal ovum, whose gentle slowness of growth is the sole reason for the deployment of the gravid uterus. Air is too subtle to remain quietly locked up in an elastic bottle that has no cork in it; Don Cleofas was obliged to help Asmodeus out of the phial into which he had been conjured by the magician; and you all know very well, there is no womb into whose cavity you could not thrust a large quill, or male catheter; how, then, is air to remain in the womb, and blow it up like a Freshman's football, not only against the resist- ance of the womb itself, but against all the succussions of the abdominal muscles and diaphragm, and the resistance of the skin of the trunk of the body to boot! It is an idle conceit. What! is there no such thing, then, as physometra and tympanites uteri; or a discharge of wind from the womb ? Has it never been heard ? Yes, I have heard it many times, both in childbed women and in others. Yet I repeat that inflation and distension of the womb with gas, the ventose pregnancy, the pet vaginal, are not diseases, but pure accidents. Madame Boivin and M. Dug&s, at page 134, say: "We have DISTENSION OF THE WOMB. 317 never known the existence of an aeriform body in the uterus, except in obstetric cases, as in retention of the membranes, or of portions of the dead foetus, or of putrid coagula, causing gaseous exhalations, found in the uterus after death, or escaping per vaginam during life." Let me explain this matter to you; for I cannot patiently endure to think that a pupil of mine, be he settled in Maine or Wisconsin, at the Sault St. Marie or Monterey, should admit to a patient that the womb can become filled and distended with gas, as a result of dis- eased secretion ; for such secretion is impossible, and to admit it ridicu- lous. Dr. F. Ludwig Meissner, in his great work on Diseases of Women, Die Frauenzimmerkrankheiten, treats, at page 97, vol. ii., of Physo- metra, and he says expressly : " So Komme auch nur dann eine Pneu- matosis uteri zu stande, wenn durch verschleissung des Muttermundes der abgang der in der gebarmutterhole sich ansammelnden gase gehin- dert werde." Dr. Meissner devotes many pages to show that flatus uteri may be produced by gaseous secretion, and that a variety of causes, such as remnants of ova, coagula, &c, are the causes of it. I cannot, however, bring myself to his way of thinking upon these points, and prefer to rely upon the clinical experience, and the reasonings that are personal, than upon the reports of others whose facts I receive, while I adhere to my own explanation of those facts. I have often noticed the discharge of large quantities of gas from the genitalia of sick women. A woman when seized with her last labor- pain, and, bearing down with great violence, shall thrust, not the child only, but the placenta also, forth upon the bed; and, in bearing down with the violent force of the labor-tenesmus, she will push the very womb itself to the bottom of the pelvis, shortening the vagina in so doing, wrinkling and crushing it down to the os magnum. As soon as the tenesmus is over, the resiliency or elasticity of the tissues recovering its power, the womb rises again to a certain height within the excava- tion of the pelvis ; but, as it is a cul-de-sac that rises, it is natural for air to follow it, and the vagina, and the womb itself, may thus contain air that has been drawn up within them, upon the same principle as that which makes it follow the upward movement of a piston in a cylinder. Then comes a new pain—an after-pain; or else I apply my hand to the hypogastrium to make sure of a good contraction of the womb; if I compress the womb with my hand, and particularly if I push it down- wards in the pelvis, I am very apt to cause a quantity of air to rush out at the ostium vaginae, with considerable noise. This I have heard a great many times. So, in making the examination per vaginam, when 318 DISTENSION OF THE WOMB. the uterus is very low down, or when, in making use of the speculum, I push the os tincae far away from the os magnum, air enters the passage, and follows the retreating: womb. If it be left there and the woman is seized with a fit of coughing, or if she moves quickly, or changes her position, the air is pressed out with the sound of the pet vaginal. And there is no other way to account for it that is reasonable. So, also, if a woman has a heavy womb with a large loose vagina, when she lies on the couch or bed, the uterus retreats, as La Motte says, drawing air after it but if she rises, or coughs, or turns, the air is expelled. These occurrences give you no colorable ground to suppose that she secretes air from her genital mucous membrane; did you ever hear of air being secreted by the bladder of urine ? Never. Air is not secreted. The bubbles of it that you see upon the skin are not bubbles of secreted air; they arise from the vaporization, or from the transformation of fluid products on the skin. I am aware that it is said that the quality of the air contained in the swimming bladder varies in a ratio of the depth from which the fish is taken, and that some fishes have large openings by which the swim communicates with the throat. But though Delaroche and Need- ham contend for the idea that the gases are secreted, I cannot partake of their opinion, and must hold to the opposite sentiment. Those who desire, however, to have authority for the contrary opinion, may find a good statement of them by Hippolyte Cloquet, in the Diet, des Sci. Nat., under the head " Vessie." A fish does not secrete the air of his swimming bladder. He comes to the surface for it. If a woman sends for you, with a distended abdomen, with suppres- sion of her catamenia, and other signs of pregnancy, and complaining also of the pet vaginal, I pray you be not so thoughtless as to tell her that her womb secretes air, for it does not. Auscult the patient, and percuss the abdomen, and explore it by means of palpation, and, if she be not pregnant, you may say she has a tympany, or ascites, &c. ; but do not say she has a flatulent womb. I would as lief hear you had told her she has a flatulent right ventricle of the heart or ventricle of the brain. If, as Madame Bovin says, there be a putrid placenta corrupting and rotting within a lately delivered womb, or lying in the vagina like a huge putrescent tampon, you would not be surprised, upon taking it away, to find it followed by a gush of foul air, which, it is said, has even been found to be inflammable. In extracting the putrid placenta, I have not only had to submit to the horrible offence of this putrid blast from the womb, but I have found the decaying mass of the after- DISTENSION OF THE WOMB. 319 birth crepitating under my hand like a piece of putrid emphysematous lung. But in these cases the passage has been closed by the decaying mass ; and you might suppose that a very firm clot, or a quantity of chorion and amnion, left in the womb after labor, might in like manner so shut up and close the orifice as to detain within the globe the putrid or other gases formed or extricated within. It might possibly happen that an ulceration of the canal of the cervix, with luxuriant granulations, should shut up the mouth of the womb ; and that some of the fluids detained above the obturation might extri- cate gases: but that they could expand the uterus so as to make it as large as the womb at five months, is what I cannot conceive of; and if I should, like Frank, meet with such a case, I would not believe it. I would much rather believe I had made a mistake in my diagnostic. A woman might well have an escape of air from the os uteri, who had had a utero-rectal fistula, a thing quite possible after adhesion of the utero-rectal peritoneal cul-de-sac. Well, then, as I do not believe in the physometra as a disease, but only as an obstetric accident, I have nothing more to say about it, except that, when your patient complains of it to you, and is disquieted and alarmed about it, I hope you will make her understand that she is not the subject of any sickness, but only of an accident. Although I have nothing more to say about physometra, I have some- thing to observe about those supposed pregnancies that consist merely of wind—wind in the bowels. Certain nervous women, of childbearing age, and certain women about the change of life, are liable to suppose themselves pregnant be- cause the abdomen has become enlarged and the catamenia have not returned; and there are many women who have excessive meteorism of the belly which lasts for months together, and which you can cure only by curing some chronic disorder of the womb: I say this, because I do know that most of these tympanies are produced by the disturbance in the abdominal tissues, provoked by some womb complaint. A young lady of my acquaintance was married, and went to another city to reside with her husband; there she became pregnant, as she sup- posed, and when about seven months gone, came to see her family. Her physician, who had seen her in her new residence, had pronounced her pregnant because she grew and did not menstruate, and all the charming prospects and tender sentimentalities connected with these new scenes for the newly married, were hers. Soon after her arrival here, I was hastily called on account of a threatened premature labor, as she had a considerable show. Upon 320 DISTENSION OF THE WOMB. reaching the apartment, the scene of much anxiety, and after making inquiries as to the stage of the gestation, the amount of the hemorrhage, &c, I placed my hand upon the abdomen to discover whether the womb was condensed, and found the belly so uniformly distended up to the scrobicle, and so soft and so free from any hard uterine outline or delimitation, that I pushed the bunch of my fingers gently down to the plane of the superior strait, and could almost carry them to the proinon- torium without encountering any obstruction from womb or child. Next I obtained permission to examine by the Touch, and discovered the uterus to be certainly non-gravid. What did I do next?—or what do you think I ought to have done ? My patient was already sufficiently agi- tated and nervous with all these palpations and explorations. If I had at once communicated to her the result of my researches, I should have had a scene. I reassured her—I told her there was no danger; and then, in another apartment, I communicated to her mother the disap- pointing intelligence, warning her to break it gently to the young lady, which was judiciously effected. My patient, after having some treatment adapted to the morbid innervations of her alimentary canal, recovered, and returned to her home. The symptoms, after a few months, returned, and at six or seven months of the gestation, the same medical man, who declared on this occasion that she was not pregnant, resolved to bring her doubts to a final term ; whereupon he gave her a strong dose of physic, which brought away a young dead foetus. The same patient afterwards crossed the Atlantic, and became pregnant in Europe. Her medical men per- mitted her to embark for the United States at an advanced period of ges- tation, and she reached her native place in safety. When she came here, I discovered it to be another attack of tympany. After this, her health being better, she again conceived, and had an abortion of about two months' gestation. Since that event she has not again conceived. Now these were not examples of physometra, but of tympanitis. A lady twenty miles from town was pregnant—her physician agreed that she was. Her monthly nurse was engaged here, and, near the term, was conveyed to the country residence to be in readiness for the accouchement. The accouchement came not: the nurse remained six weeks in waiting. The physician at length wrote me a letter, giving an account of the case, and sent the lady to town. I percussed the abdomen with flatulent resonance on the whole superficies of the belly, which was a uniform tympanitic tumor, and not a uterine tumor. " You are not pregnant," said I; " you are resonant upon the whole abdo- men, down to the very hypogastrium, and there is no click of the foetal heart. The motions you have felt and the distension you have suffered DISTENSION OF THE WOMB. 321 were motions of borborygmi and the inflation by gases in the intestines. Take these doses of physic: buy a yard of fine flannel; tear it into strips, four inches wide, to make a swathing bandage; wrap the long bandage round the abdomen, round and round, as tight as you can bear it without inconvenience, and reapply it daily. Compress the bowels, and they will not yield to the lateral distending pressure of the gases developed within their tubes: your abdomen will become as small as ever." And so it was. She took her physic; she wore her bandage; she recovered her digestive health, and her physometra or wind preg- nancy disappeared. She afterwards became really pregnant, and I delivered her here. I had a lady about forty-eight years of age under my care. She was anxious to have a child: had been long married, but there was no blessing. At length, I was apprised of the approaching good fortune. I percussed the abdomen, and I detected the denying resonance every- where. I ausculted in vain: there was no click of the heart, and I announced my diagnostic. My flannel roller on the abdomen, some aperients and tonics, cured the physometra. How many cases of this gestatio-ventosa have I seen! I have assuredly never, no, not in a single instance, announced or admitted a pregnancy in such circum- stances ; nor will I ever do so; because I will never say to any woman, "You are pregnant," until I know it. The faults in these cases of chronic tympany—I mean those samples of it that are unattended with any severe or violent and dangerous local disorders, such as ulcers of the bowels, &c.—are readily curable with a roller of flannel, about four inches wide and three or four yards long, which should be turned round and round the belly, covering the half of the last turn with the succeeding one, and securing them all neatly with strong pins or a needle and thread. Other examples, and they are very numerous, depend upon disorders of the uterine health, such as chronic inflammation of the cervix, &c. Nobody could have chronically inflated bowels but from debility or insensibility of the circular muscles of the alimentary tube. Now, that debility or want of action may arise from a faulty innervation, begotten in general debility, sedentariness, certain affections of the mind, and in many examples, symptomatically or sympathetically, by reproductive disorders. A woman, for example, ought to menstruate regularly; she stops menstruating—nobody can tell why—she has not very visibly lost her embonpoint, nor has she taken cold, or met with any moral or con- stitutional shock, and yet she does not see; who can tell whether she produces germs or not ? It is very possible that her ovi-posit goes on as regularly and perfectly as ever it did, but that the consentaneous 21 322 DISTENSION OF THE WOM15. irritation and excitement, instead of being propagated to the womb, are propagated by the various plexus-connections to the splanchnic system of the belly, and betray themselves in these false or wind pregnancies. I do not know that it is so; but if any one should suddenly die, or be killed while so affected, and a recent cicatricula or corpus luteum should be detected in the ovary, I would hold it a strong evidence of the above rationale, and of course I would say that the tympanitis had been an hysterical manifestation. Tympanitis is often an hysterical manifestation. I was called into a jail, in the State of Georgia, thirty-two or thirty- three years ago, to see a young girl who was seized there with an alarming attack of hysterical convulsions. I well remember to have been sitting by her bedside as her convulsions went off, and seeing her abdomen rise and rise and rise to such a vast size of distension, and that visibly, as to its progress, that not I only, but all the persons about her, feared the belly would burst like a shell. I have never seen such an example since. It required but a few minutes for the abdomen of the girl to become as large as that of a woman at term. Now, pray take notice that these distensions could never exist were they not permitted to occur by the yielding of the circular peristaltic muscles: wherever these peristaltic muscles do their physiological duty, they do it by compressing the contents of the bowels, whether solid, fluid, or gaseous, while those contents are compelled to move along the intestinal tractus, in the direction of or in a line with the peristaltic motion. If you discover, therefore, that your patient has lost this power of compressing the intestinal contents, you will reason about it, and you will say: " I can re-excite this lost power. How ? By giving the patient a purgative or an aperient, or eccoprotic dose, for that is the meaning and intent of such a dose. I shall give some rhubarb, senna, or purgative drug, and I will cause all this gas to be expelled." It is very well for you to reason in this way, but you will be disap- pointed upon the trial, for your purgative will purge the patient, and the bowel will discharge all its stercoraceous contents, and much liquid and mucous matter, but the gas will stay in, and the belly be as big after as before the operation. You cannot get along, however, without your purgative, or aperients; and when you choose them, pray take my advice, and use one of Dr. Brown's formulas. I have used it for many years, and if it was not unprofessional to do so, I would imitate the epigraph I have seen in many old ladies' family recipe-books and write over it probatum est. Dr. Brown was a famous physician who lived at Port Tobacco in Maryland, many years ago. He was one of three brothers, all of DISTENSION OF THE WOMB. 323 whom obtained considerable eminence in Medicine, in their own districts and States. He was the Dr. Brown who was called in consultation with Dr. Dick and Dr. Craik at the last illness of Washington. My master, Dr. Thomas Hanson Marshall Fendal, of Georgia, was his pupil, and he told me, thirty-eight years ago, that this was one of Brown's formulas. Dr. F. used it in almost all severe cases of tympani- tic disorder, and I have used it ever since, in similar cases, and ever shall. Take one ounce of manna; One drachm of anise seed ; Eight ounces of boiling water. Mix them, and let the mixture rest for half an hour, then strain the liquor. To the strained liquor add three drachms or four drachms of carbo- nate of magnesia, so as to make a perfect mixture. A wineglassful may be given for the dose, to be repeated every two hours, or three hours, until it operates. This is Dr. Brown's carmina- tive cathartic: and if a man may venture to speak on an experience of thirty-eight years, I am willing to say that I have all that time found it the most dependable carminative physic that I know of; and I heartily recommend Dr. Brown's formula to you. I do not pretend to know why it is the most efficacious dose in tym- panitis; nobody knows why one medicine acts thus, and another so; it is enough to know that ipecac, makes you vomit, and that jalap purges you. The why is a metaphysical, if not a psychological question. If, in the treatment of these wind pregnancies, or tympanies, you can get the bowels once to discharge the flatus which seems to keep up, in some instances, for weeks and months, one even tenor of tension, you will gain an important point. If you can do this, then pray tighten the flannel roller, and keep all the advantage you have gained, by aid- ing the weakened intestinal muscles more effectually to compress the intestinal contents. Keep up the activity of the muscles of the bowels by means of an aloetic, such as Lady Webster's pill, or by draughts of infusion of rhubarb, quickened with some compound tinct. of rhubarb or senna. Take of sweet tincture of rhubarb and tinct. of gentian, of each one ounce. Mix and direct two teaspoonfuls for the dose, twice a day. This would be a very good medicine for such a case. Let her drink brandy and water with her dinner, and a hot glass of punch at bedtime ; have a good index expurgatorius of eatables, in which you should carefully set down sour-krout, pork, veal, duck, goose, beans, beets, corn, and id genus omne of the wind-begetting vegetables, 324 DISTENSION OF THE WOMB. that are fitter for the dura messorum ilia than for the tender intestinal constitution of hysterical ladies. Some of the doctors will tell you, for they still do insist on it with me, that these wind-swellings, these tympanites are produced by collec- tions of gas secreted in the peritoneal sac. I should be astonished at any one of you, could I hear him say he had a case of tympanitis of the pericardium, arising from secretion of gas by that serous sac. I should be not less astonished to hear any one of you attribute an ordinary tympany of the belly to such a cause. The air in tympany is always in the bowel; never outside of it. Fare- well. C. D. M. LETTER XXV. Gentlemen: The womb is sometimes distended with water, which, after having enlarged it to a certain size, suddenly gushes forth, leaving the organ to return to its non-gravid size. This state is called hydro- metra, or dropsy of the womb. Now, as to hydrometra, I do not believe in it. It is indifferent to me who has seen it, or who has heard of it. I repeat, I do not believe in such a malady, and therefore I was inclined to pass over it in silence. The womb is a cul-de-sac, which can hold no water, except when the mouth of the cul-de-sac is turned upwards, in which I admit it would be possible for it to hold a little water ; but, when the mouth of the cul-de-sac is turned downwards, the water would run out of it, as surely as it would fall out of a teacup or tumbler that you should turn upside down. Still, they say the womb fills with water, and becomes as large as the gravid womb at seven months. There is no doubt of it; I have seen it; but that does not make a dropsy of the womb ; it is only a case of the womb expanded by a body growing or enlarging within its cavity. It is said that one acephalocyst, or a half million of acephalocysts, might develop themselves in the womb. These hypothetical acephalo- cysts, or bladder-worms, fill with water by some process of absorption, or endosmosis, and, as they expand, the womb, which does not know it is not pregnant, yields to the delusion, and gives way to the internal pressure, just as it does under the pressure of a growing healthy ovum. The acephalocysts fill more and more, until, at last, the womb will no DISTENSION OF THE WOMB. 325 longer tolerate the incumbrance, and, beginning to contract, soon ex- pels the intruding masses by a regular process of labor-pains. . When the mass is expelled, it is found sometimes to be in quantity sufficient to fill a wash-hand basin, and you call it a mass of hydatids. These hydatids look like bunches of grapes; like the finest Malaga grapes; and they are of various sizes, from an inch in diameter to the diameter of a small pin's head. Each one is attached to a mass of partially organized matter, consisting mainly in laminar cellular tela, with bloodvessels creeping among the grapes. I have seen them come off with very great hemorrhage, even to fainting. I said they are ealled acephalocysts. I ask you whether that is likely; and whether each one of the grapes of a bunch of hydatids is to be esteemed an independent ens ? I have never heard of hydatids in the virgin, nor do I believe that a virgin could have a hydatid or anything like it developed in her womb. I have met with them only in married women. I do not regard them as hydatids, or acephalocysts ; but I think they are morbid products of conception. A woman shall conceive healthfully, and carry on the gestation for a few weeks, when the embryo dying, she ought to throw off the ovum by an act of abortion; but she does not do so. The ovum, having formed its mesenteric attachment, keeps up a sort of life within its tpxtures, and the floating extremities of the villi of the chorion imbibe, by means of the endosmosis, the transparent fluid which you see in the bunches of hydatids. They are not animals; they are dilated and hypertrophied villi of the chorion. A bunch of hydatids is a dropsical placenta, and a dropsical placenta is the dropsy of the womb, or hydro- metra, of which you have heard. To have a true dropsy of the womb, you must imagine the os uteri hermetically sealed, and the cavity of the organ filled, and distended with serum. That would be a dropsy. It is said that a single acephalocyst, or living hydatid animal, has filled the womb to a great size, and then, suddenly bursting, discharged its whole fluid contents at a gush. I have never seen such a case, but have many times seen a pool of water on the floor, from supposed rup- ture of the ovum, where I know the ovum was not ruptured. Such pools of water were hysterical discharges of urine. And, as I cannot conceive of a cysticercus or an acephalocyst, large as a child's head, I prefer to suppose that the doctor and the patient have both been de- ceived, rather than that so improbable a magnitude should ever be attained by an animalcule. In true pregnancy, the womb is occupied by the ovum, whose growth 326 DISTENSION OF THE WOMB. causes the womb to grow pari passil. The ovum in pregnancy, consists of the embryo or foetus, the ford, the placenta, the amnion, and the chorion. The ovum is a living, independent, self-supported creature. It may well be likened to an acephalocyst, whose head might be stated to be the placenta, which, attaching itself to the uterine walls, sucks or draws from thence the materials for the development of itself, and its dependencies. Its dependencies, I say ; and by that word, I mean to imply the child, and all its parts. The child may be regarded as one of the complex organs of the acephalocyst, which perishes at the end of a prescribed term, leaving the organ it has developed, a complete and self-existent creature, as it had itself been before it. This is the only true single acephalocyst that I can conceive of, as filling and dis- tending the womb to a great size. And this acephalocyst may become morbid, that is to say, it may become enormously overgrown, so as to distend the womb beyond measure, and greatly interfere with the woman's health by the distension and intrusion. The womb itself may be injured, or weakened, by the extension ; and the constitution may suffer from pressure of an overcharged womb on the vessels and nerves, and other organs in the belly. In pregnancy, the physiological evolution or hypertrophization of the womb proceeds at a rate which is fixed or normal; two hundred and eighty days being demanded for the normal evolution of the womb and its contained ovum. The powers of the organ are equal to this demand, but not equal to a demand for a redoubled rate. To make it grow faster than it can healthfully grow is to make it sick or diseased. An ovulum conceived within a Fallopian tube has a law of growth which ordains its completion in two hundred and eighty days; but the Fallopian tube has no such law, and it cannot fulfil the command, but must give way about the one hundredth or one hundred and tenth day, when the woman will lose her life. Now if a quantity of hydatids are in the womb they may grow twice as fast as the womb ought to grow, and so it will become irritated, diseased, or opened for the discharge of its contents. I have seen women nearly killed in this way, and I lost one patient from the too rapid growth of the ovum in a true preg- nancy, because the excess of waters constituted a dropsy of the womb. A womb, in this sense, might be said to be dropsical; but I think it would be truer to say the ovum is become dropsical. In general, there is no therapeutical remedy for this dropsical state of the womb, of which I now speak. Not that you could not readily bring it to an end ; for nothing could be easier than to do so, by push- ing a catheter through the os uteri, and through the chorion and amnion, to let off the water. The escape of the water would end the dropsy ; but I hope you will not think of resorting to such a treatment for any DISEASES OF THE OVARIES. 327 degree of inconvenience that might arise from the over-distension, short of one manifestly involving the woman in danger. You have no right to bring on anybody's labor, but upon the strongest and most clearly understood motives of necessity, and of indispensable necessity, to do so. It should always be determined on in a formal Consultation with persons of ripe judgment, and enlarged clinical experience and know- ledge. Where the necessity for removing the accumulation exists, it is, I repeat, easy to effect the removal. Certain I am that a mass of hydatids growing within the womb may grow either faster or slower than the rate of a healthy ovum. If it grows very fast it must distress the constitution, for the coincident development or evolution of the womb will be so hurried as to induce a morbid state of that organ, which will fret the nervous system, sometimes very dangerously. But I find I am lapsing insensibly into an obstetrical topic, and shall, therefore, cease to discuss it here, in hopes of presenting it at fuller detail in my work on Midwifery; and as I have now treated, tant Men que mal, on all the particular maladies of the womb, I shall close this letter, in order to take up some of the questions as to diseases of the uterine appendages, as they are called. It would be far truer to call them the reproductive organs, for I am always of the opinion announced in an early letter of this series, that the stroma of ovaries is the true sexual tissue of females; in fact, that stroma is sex for them. C. D. M. LETTER XXVI. Gentlemen: I have now to offer you some remarks upon the dis- eases of the ovaries ; and I wish that in doing so I could feel that the study and treatment of such affections had enabled us to give to the medical student clearer views as to the origin and the means of provid- ing for an early detection and control of such maladies, than those which the labors of the numerous writers have opened up to us on these subjects. I am persuaded, however, that our early knowledge of the disorders of these most important organs is vague, and that the most serious of their maladies are of a nature so insidious as to allow them to become considerably advanced and firmly established, long before they are detected by the pain or inconvenience or interrupted function to which they give rise. The ovaries are the reproductive organs, and they are endowed with 328 DISEASES OF THE OVARIES. a life-power that is variable in its operation, alternately torpid or qui- escent, and highly excited ; pale and oligaemic, or red and hyperaemic ; so that the life-power does not act steadily and continuously, or in one even tenor, but is diminished and augmented by turns, exposing the texture to the multitudinous accidents that are ever ready to happen in tissues or organs of an unsteady rate of vital action. One or other of the ovaries matures an ovule in the Graafian follicle every twenty-eighth day, and discharges the egglet either into the fim- bria of the Fallopian tube or into the peritoneal sac, and this with the greatest regularity in all healthy women that menstruate. Each of the ovaries contains fifteen or twenty of these Graafian follicles, of various sizes, from the bigness of a mustard seed to that of a pea. The smallest ones are generally to be found buried deep in the substance of the stroma; while the larger and more mature ones are found nearer the surface of the organ, and even protruding above its surface segments of spheres more or less considerable, as the cell is more or less prepared for the act of ovi-posit. Seeing that only one of the Graafian cells is as a general rule, ma- tured at once, and that the later days of its ripening process are those in which the process goes on most rapidly, we may well conceive that such greater celerity of development takes place in consequence of a greater activity of the vital processes concerned in it. In fact, if we examine such a rapidly developing cell and germ in the body of a per- son who has perished during such act, we find the necrologic proofs of that extraordinary excitement. These proofs are seen in the highly in- jected state of the portion of the ovary immediately in contact with and circumjacent to the swelling follicle, where numerous arterioles and venules may be observed with the naked eye, and more plainly with a lens, surrounding and burying the growing cellule among a mass of en- gorged bloodvessels. It is also presumable that the nerves of a part, bathed in this manner with a luxuriant circulation, will be in like manner in a hyperaesthetic state; and hence that the life-force in the said part will be in a highly exalted condition of activity. Whenever you shall examine an ovary, under these circumstances, I doubt not you will find the state of the case as I have represented it; and I can but perceive in it a close analogy to what happens during the last stages of dentition as to the gum over a growing tooth. The gum, in such state, becomes swollen, succulent, sensitive, and painful. In like manner, I suppose, the stroma of the entire ovary may become en- gorged, swollen, red, and, in some instances, sensitive and painful. But the Graafian cell having at length become perfectly mature, opens by DISEASES OF THE OVARIES. 329 a sort of hila or small porule, in order to allow the yelk to escape; and the crypt, left upon its escape, fills with coagulated blood, while the edge of the pore is left granulating and bloody, but at last heals over. In process of time, the coagulum left within the crypt, and the vitellary matter secreted on the exterior surface of the inner concentric spherule of the cyst to constitute the corpus luteum, are both absorbed, leaving the surface of the ovary indented with its puckered cicatrix, the mark of the last menstruation. If an advancing tooth may excite such ma- ladies as are attributed to dentition in children, what must be the extent and power of complication of the ovary, in the monthly act of develop- ing and eliminating the ovulum; especially in the last days of the process when the life status is to be presumed to be highly exalted! A monthly, or bi-mensual repetition of this process, continued for years, is in some women followed by diseased or morbid life in the ova- rium; and we ought not to wonder if so delicate and important an organ should sometimes be found to succumb to such violent revulsions of its physiological action, repeated for months and years in succession. I should think we have greater reason for surprise at the rarity than at the frequency of the rise of ovarian diseases, under this view of the nature of those organs. Besides the above-mentioned causes of liability to the superinduction of disordered ovarian health, we ought to take into consideration the state of the ovaries in gestation, one in which both their innervation and circulation may be supposed to be subjects of considerable modifications. Labor, too, and the lying-in state may be supposed to bring them into no little hazard of a change in their life-action. There are certainly many women to be met with who complain of ovaric pain during the menstrua—for they are frequently found to indi- cate, not the uterus, but the left or the right ovarium, as the seat of the distressing sensations of painful menstruation. The ovaria are moreover occasionally the seats of ovaritis in an acute form, betrayed by pain in the region of the organ, and demonstrated by purulent disorganization after death ; and inferentially, by collections of pus, which discharge themselves at the groin or above it, with recovery of the patient. It is probable, as Madame Boivin states, that acute inflammation of the ovary, in the non-gravid state, has rarely been observed; or, rather, has rarely been with clearness made out; and yet, as I have met with many samples of very distressing pain and tenderness in the region of the organ, connected with painful and hysterical menstruation, I deem I had good cause to suppose the ovaries were actually in a state fit to be called ovaritis. Very certainly, many of the cases of puerperal 330 DISEASES OF THE OVARIES. metritis and peritonitis commence with pain in the iliac regions; and, where the case has proved fatal, dissection has revealed greater ravages in the ovary than elsewhere ; and it is by no means rare to find the organ filled with pus, or converted by the inflammation into a mass of softened tissue, which had undergone the process of ramollissement, one of the results of inflammation in this special tissue. These facts lead me to think that puerperal fever often takes its rise from a topical in- flammation in the ovary. I regard the following case as one arising from acute ovaritis. I had for a long time charge of the health of a lady here, who at her mensual periods suffered the most terrible paroxysms of hysteria, during which she experienced such distress in the regions of the ovaria as to cause her to scream and to make the most violent complaints. She recovered of her dysmenorrhoea, and gave birth to two children, the second one about two years after the elder. Subsequently to the second confinement, she discovered a small floating tumor in the left flank, which I ascertained to be an en- larged ovary. That tumor may have been three and a half by two inches in diameter, and for the last four years has not sensibly increased in size.—The catamenia are regular and no longer painful, and she uses great precautions as to exercise, diet, dress, &c, at the mensual periods, which have thus passed over her without seeming to aggravate the tendency of the ovary to grow. When an ovary has become the seat of either a hypertrophic, or a heterologue development, it probably ceases to produce and evolve germs, but it is still liable to periodical augmentation of its life-action, as propagated from the healthy ovary to the womb, and from the womb to the diseased ovary. If this be so, then the most hazardous period for the female with a diseased ovary, especially in the early stages of such diseases, ought to be esteemed the menstrual period; hazardous, I say, as to the danger of increasing the propensity to morbid develop- ment, not hazardous as imminently dangerous to the life of the woman. I trust that you will reflect upon views of this sort, when you come to give advice under such circumstances, and institute such a course of treatment and management of the health as may enable the woman more safely to pass these mensual crises. You will counteract by vene- section, by leeches, &c, the too great degree of periodic hyperaemia. In a case of acute ovaritis, attended with constitutional disturbance in the form of fever, and with pain in the region of the ovarium, you would resort to venesection and leeches, or cups to the iliac region, to stupes or cataplasms, to the obtaining a soluble state of the bowels, and the use of tartar of antimony and potash, or Dover's powder, with re- cumbent rest. DISEASES OF THE OVARIES. 331 The vast extent of growth in these morbid states is shown in the fol- lowing instance: A few years ago, I opened the body of an elderly woman, who died with an immense collection of water in the abdomen. The fluid amounted to several gallons, and after it had been removed, I continued the incision from the sternum to the pubis, and when I had finished the incision, and, with the medical friend who was with me, looked into the cavity, we were both for some time very much astonished to behold only a smooth mucous-serous surface in the cavity, and looked for some time in vain to find any liver or stomach, or alimentary canal. It seemed that we were examining an abdomen from which all the vis- cera had been carefully removed. I was greatly astonished, and quite at a loss what to think of the case, or imagine what had become of the abdominal viscera, since the line of the spinal column was strongly drawn at the back of the cavity we were inspecting, and we seemed to look quite up into the empty concave of the diaphragm. At length, in examining the cut edge of the incision, I saw that we were looking into an empty cyst, whose edge was there to be seen, and the outer super- ficies of which was adherent to the peritoneum. The cyst adhered pretty firmly everywhere, but was cleavable. I detached it completely, discovering the atrophied organs behind and below it, firmly compressed against the back part of the abdomen. I have no doubt this cyst held more than a thousand ounces of serum; probably twelve hundred. There was, at the lower part of it, a small solid or hardened portion, which was the altered remnant of the left ovary, all the rest of the cyst having been developed out of that body. I gave the specimen to Dr. Horner, who preserves it still, I believe, in the Museum of the Univer- sity of Pennsylvania. It was the largest single cyst I have ever met with. Now, gentlemen, what was this cyst ? It was certainly no longer an ovary, but a new tissue, heterologue, formed on the generic basis of a true ovary, and commencing, perhaps, as a Graafian cell, which, instead of bursting to discharge its ovulum, continued to fill and to strengthen itself, appropriating to the extension of its heterologue walls all the nutritive results of the ovaric circulation and innervation. It was a case of encysted dropsy of the belly. The cyst was an altered ovary. It was a single cyst. It does not always happen that the ovary, in developing itself out of, and beyond its generic form, assumes the character of a single cyst, like the one above mentioned. It more commonly, I think, consists of much solid interstitial material, containing within it cells of various sizes, from the magnitude of a walnut to that of a child's head; and in 332 DISEASES OF THE OVARIES. these instances, the fluid is ropy or albuminous, and sometimes almost as thick as melted calves' foot jelly or glue. In some of the samples, there is a great bunch of solid material lying partly within and partly above the plane of the superior strait, with one vast cyst holding eight hundred to one thousand ounces of fluid, that fill out and distend the belly as a fluctuating mass, like a common ascites. If you do not see the patient in an early stage of the disorder, nor until the abdomen has become very tense from the vastness of the col- lection, you will scarcely be able to make a good diagnosis of the tumor, since the hardness and resistance of the belly will not admit of your fingers indenting it sufficiently far or deep to make out the existence, much less the size and form, of the more solid masses of the altered ovarium. It is not until the woman has been tapped, that the relaxa- tion of the abdominal walls permits the palps of the fingers to estimate the existence, and size, and form of the solid portions of such tumors. Hence, when you shall be invited to give your opinion in a case of this sort, as to its nature, as whether ascitic or cystiform, you will be unable to answer positively the question ; or, if you do answer positively, you will do so at the risk of compromising your own reputation, and injur- ing that of your brethren. You have no occasion to hesitate in such a case. If the means of discrimination are not at your command, why should you not say so ? If you owe a thousand dollars and have not the money, you should say so. If you cannot tell what is the nature of a tumor or a collection, are you afraid somebody else will know bet- ter, and thus discredit you ? Let him know better, if he can ; but he cannot. If you cannot touch the altered and solid masses, either by the vaginal or the external exploration, how can he do it?—If you cannot extract a clear history of the formative stages, how can he do it ? If you can estimate the fluctuation, what can he do more ? Let him make his declaration—he does it at his peril, not yours. There are some that will be ready to make it, hit or miss—with all my heart! Let them hit or miss. If they hit, they are like rockets, that go up with a whiz and a great light—if they miss, they are like the rocket- stick, which falls stinking to the ground. There are two ways to hurt the profession, which any one may understand. One is to act immo- rally and unconscientiously; and the other is to make mistakes in diag- nosis, treatment, and prognosis; both serve with equal force to bring physicians, as a body, into disgrace. The whole herd of quack doctors and charlatans, who perform such inexpressible wonders of folly in diagnosis, treatment, and prognosis, are sustained upon the shoulders of our Medicine. They could not exist in an enlightened community, but upon the strength of that confidence which mankind cannot with- DISEASES OF THE OVARIES. 333 hold from medical science; but which is so peculiar, and therein so far beyond the reach of the outsider classes, that those classes cannot dis- criminate between the true physician and the unlearned and bold pre- tender to medical science. Hence, we, that is the physicians, who are the conservators of Medicine, and her representatives in the world, must bear all the odium of every vile quackery and charlatanism. These encysted dropsies are often very chronical in their movements. I know a lady who has borne one for more than twenty years—it has never been tapped, and is not larger now than it was fifteen years ago. Another lady here, with a very large encysted dropsy, gave birth to several of her children after the cyst had become very large indeed. She ceased to bear children, after having been swollen for fifteen years; and at length, the weight and tension becoming insupportable, she was tapped with great relief, and without any inflammatory result, or any inconvenience. In about five years, the sac was insufferably full again, and she was tapped a second time, discharging a vast quantity of fluid. She recovered apparently, but, about twelve days afterwards, rode twenty miles to a funeral. Soon after reaching the country place, she was seized with symptoms of peritoneal fever, from which she barely escaped alive. The sac has again filled. You see how chronic the case is. She has not been tapped for near these six years. A lady here had a very enormous encysted dropsy. She was never tapped. After bearing it for many years, the size of the abdomen diminished, and more and more rapidly, until every vestige of the malady has vanished, and she now enjoys good health. I saw a patient in the Pennsylvania Hospital with ovarian dropsy. The tumor gradually disappeared, and was followed by crural phlebitis of the left leg, or milk-leg. Now the question arises as to the quo modo of these disparitiorfs of ovaric dropsy. You will not, I presume, imagine it to be possible that the collection within the cyst—a collection that has existed within it for a series of years—could be taken up by absorbents of the sac, and carried off as in ordinary cases of absorption. You should recollect that the sac is only like a true organ, but not a true one; it is not in truth a human tissue, or a tissue of a mammiferous creature ; it is something different from any of the organic materials that enter into the composition of such a being ; it is a monstrosity by excess, a case in Teratology. Such a cyst, though it has arteries, and capillaries, and veins, and nerves, has them in a new and non-generic way. It cannot be supposed to possess the just proportion of absorbing apparatus; and it cannot, therefore, absorb the products of its exhalant or secretory elements. But still, such tumors do disappear now and then. 334 DISEASES OF THE OVARIES. May 23, 1852. I this day examined the hypogastric region of Miss M. This lady, who has a very great spinal curvature, was examined by me about nineteen or twenty months since. I then found a very solid, incompressible, and immovable tumor, large as a child's head at term, which occupied the hypogastric region, and which was not a womb. It appeared to come up out of the pelvis. I considered it to be an ovarian tumor—and of course my opinion was that it was incura- ble, and must, in the course of time, destroy her life. To day, no trace of it is discoverable—nor is there any reason to suppose it exists. I take comfort from this example-—one of the most extraordinary I have met with, for all future cases of a similar character. I am wholly at a loss to account for its disappearance, since I am sure it was not a hypertrophied womb that I detected nineteen months ago—and that it was not any glandular or hygromatous tumor. She is well in February, 1854. Without pretending to dogmatize on the subject, I may be allowed, I hope, to say that, in all such cases of disparition of the collection, I have supposed that an accidental aperture being made in the cyst, the fluid has passed into the natural sac of the peritoneum, and, being there subjected to the action of a true natural absorbent apparatus, has been taken up and carried away, leaving the sack itself to collapse and shrivel, and sink back towards the pelvis, where it might exist during a long lifetime, an innocuous mass that never fills again, and whose inner parietes, perhaps, become coherent from long quiet con- tact. In the case of adhesion of the cyst to the peritoneum, in the elderly woman that I mentioned a little while ago, the cohesion was equal in force to that of a full-developed placenta with the uterine paries, or equal to the cohesion of the skin of a ripe orange to the fruit. That such apertures and leakages of the ovarian cyst into the peri- toneal sac do take place, has been proved by Dr. Bennet, in his account of a case referred to by Prof. Simpson in his pamphlet on " Ovarioto- my," page 5. Such a leakage, to a greater or less extent, must, I think, always follow the tapping of an ovarian cyst, when the cyst does not adhere. Yet the traumatic leak, thus produced, rarely cures the patient. It is not improbable that the danger of the operation of tapping, in these encysted dropsies, arises, in the main, from the irritating influence of the contents of the cyst effused suddenly into the peritoneal cavity, upon withdrawing the canula. When the cyst opens spontaneously, and the leakage is small and gradual, probably the inflaming tendency is less. Possibly the tension hinders inflamma- tion. This, however, is mere hypothesis, although it is certain that a great many of those persons speedily perish who are for the first time DISEASES OF THE OVARIES. 335 subjected to the paracentesis. If my hypothesis is correctly founded, it would seem to be less dangerous to tap in the compound dropsy of ascites and encysted collections, than where the sac is still unbroken ; for the peritoneum, that had learned to tolerate the leakage, would not suffer from a greater leakage made by the trocar. Certain I am that, where a female has been once tapped for an encysted collection, and escaped death, she is but little liable to perish from subsequent opera- tions ; such at least has been the result of all my experience on this head. Dr. Lee, Tumors of the Uterus, p. 175, has furnished some highly interesting information on the subject of tapping these cysts. He avers that, where the collection exists in a single sac or unilocular cyst, the danger is much less than in the cases where the collection is contained in many different cells or chambers of the tumor—and this, I think, is to be expected; inasmuch as the multilocular cysts are always of a more massive and solid material, and afford greater basis for inflamma- tion and its products ; whereas the uniloculur cyst is like a vast blad- der, possessed of scarcely an organization, and not so readily obedient to the provocatives to inflammation ; or, if inflamed, not admitting of such vast masses of inflamed material. Dr. Lee has made some curious, interesting, and valuable researches on the effects of these tappings. He has collected forty-six cases wherein the effects were observed, eight of them by himself, five by Dr. Ashwell, five by Dr. C. Smith, six by a London surgeon of high standing, and the remaining twenty-two taken from journals. Of these forty-six patients, thirty seven-died and nine recovered. Of the thirty- seven who died, fifteen died within one month after the operation, at various periods from a few hours to the end of a month. Seventeen died by the expiration of two years, and five died in from three to fif- teen years. Eighteen of the thirty-seven were tapped but once ; the others more than once, say from twice to seventy-eight times. Dr. Lee furnishes also a table of twenty cases from Mr. Southam, from the Lond. Med. Gaz., Nov. 24, 1843. Of these twenty cases, fourteen died within nine months, two within eighteen months, and the remain- ing four in several years, from four to nine. Dr. Lee gives, at page 180, another table, showing that of fifty-seven patients, from his own tables, and Dr. Southam's combined, who died, twenty-four died after the first tapping, and all of the twenty-four within a period ranging from a few hours to eight months. I have made the above citations from Dr. Lee's work for you; I should much prefer that you consult the book for yourselves. I think the statements of the author highly useful, and am sure that they agree 336 DISEASES OF THE OVARIES. very nearly with my own observations. As to the cure of dropsy of the cavities, or of ovarian dropsy by tapping, or after tapping, I have never met with an instance of such success, though the case mentioned on page 333 seemed for several years to be a cured one. In the end, however, the collection was renewed, but has never been tapped. I trust that what has now been said may serve to put you on your guard against an opinion, very prevalent in our profession, that para- centesis abdominis, is a slight operation, that may be performed with safety to the patient. I have assuredly not observed it to be so, since I am under the impression that of first tappings, of which I have been a witness, wellnigh one-half have been speedily followed by the death of the subject from peritonitis, developed soon after the performance of it; while all of them ended fatally, sooner or later, save the case above mentioned. These encysted dropsies may occur in young and unmarried females. I now remember seven cases of this kind that have fallen under my immediate notice: I have certainly seen a much larger number of them, and a great many in married women. You will in vain attempt to cure them by diuretics. Diuretics and hydragogues cannot enter into competition with the powers concerned in excreting and augmenting the fluid contents of the sac. The sac does not obey the laws of the system, and laughs at your therapeutical nonsense. It is wrong, therefore, to assist the disease in uprooting the foundations of the constitution by poisoning it with drugs, most of which are exceedingly enervating in their influence on the stomach and bowels. In the conduct of all such chronical, long-continuing maladies, you ought never to lose sight of the liability of those important organs to be injuriously deranged by the protracted employment of remedies addressed either directly to them or through them to the parts, or to the whole constitution of the patient. We have hitherto spoken chiefly of the unilocular cyst constructed out of the ovarium. It is necessary to observe that some of the ova- rian tumors are solid degenerations of ovaric tissue enormously increased in mass, and totally destitute of the anatomical characters and physio- logical powers of the stroma. Such a tumor, when felt through the abdominal parietes, is found to be hard, resisting, presenting a defined outline of an irregular figure; because the surface of the tumor is broken by large lumps or protuberances divided by sulci of various length and depth. Some of these tumors, when cut open, present either a sort of haematomatous or a cerebriform appearance as to color. Others are filled with numerous cells or loculi, containing viscous or serous matters of effusion, and sometimes pus or puriform excretions. DISEASES OF THE OVARIES. 337 The loculi are of various sizes and shapes, some communicating together, and others entirely isolated. The tumors are found sometimes of a size to fill up the cavity of the belly so as to make it as large as that of a woman in an advanced stage of gestation. In many of the sam- ples, adhesions of the peritoneal surfaces of the tumor to that of the intestines or the abdominal walls are observed, the results of ancient, or recent, or oft-repeated attacks of peritonitis. But why describe the peculiar forms and aspects of tumors which embrace within their out- line the possible modifications of the cellular, the vascular, or fibrous elements of the altered organ; modifications so infinitely varied and mixed, that the usual and clearest description given of them in a necrological account is a "mass of disease?" Tumors of this fashion, large as a man's head or larger, draw nearly the whole of their support from one ovaric artery running off from the aorta, or emulgent, and reaching the points of distribution after a long tractus, while its strange vitality and economic connection are main- tained chiefly by the accompanying spermatic nerve. It is clearly a case of physical sin and absolute rebellion against the specific authority and laws of the economy, so that it can neither be recovered nor sub- dued. What idleness, if not what folly, to give medicines ! Medicines for a tumor! Give medicines for a swelling, for a disease, but not for a tumor! " What, then! Shall we not treat such cases ?" Yes, surely; they require treatment; they admit of it; and the patient is benefited and even preserved by it; but the tumor is unaffected—it pursues the even tenor of its way, indifferent to the condition of the woman upon whose person it has attached itself, and on whom it preys. I have before said that you cannot make a very certain prognosis of it, for you cannot know whether it will grow continuously larger, or whether, becoming the seat of a disorganizing activity, it shall soften and deliquesce or suppurate within the abdomen, pouring its fatal products into the peri- toneal sac; or whether, preserving for years its quasi organization, and losing the power of increase from atrophy of the most distal and atten- uated branches of its vessel and nerve of supply, it shall stop at a term, and continue there for years without apparent change. For example, there was a lady here of whose health I had principally the charge for about eighteen years. For eight years before I became acquainted with her, she had suffered from an enlargement of the right ovarium. The tension, and pressure, and intrusion gave her at times much pain in the right inferior portion of the abdomen; and at different times since my being first called to her, she had attacks which I regarded as peritonitis, brought on by the pressure and friction of the mass. These 22 338 DISEASES OF THE OVARIES. attacks pretty readily yielded to the appropriate antiphlogistic treat- ment, consisting mainly in copious depletion and recumbent rest. The tumor, which scarcely changed in the course of eighteen years, except, perhaps, in a slight increase of its magnitude, never exerted the least influence on the nutrition of my patient, a robust, ruddy-faced, even fat woman, who walked freely in the streets on affairs of busi- ness or amusement; and there was good reason to suppose, from her condition, that she might attain to an age not the least curtailed by a tumor of the ovary as large as a man's head, and so firm in its resist- ance as to yield not at all to pressure, and afford no reason to suspect the presence of fluid within it. In all these eighteen years, I never gave my patient any medicine with a view to act upon the tumor. I bled her many times for the accidents arising from its pressure, and administered many doses of medicine with a view to obviate the effects of those accidents. Had I been occupied always with the preposterous idea of curing her tumor, she would have taken physic enough to establish a Chestnut street apothecary, and cui bono, I pray, save to the apothecary ? She grew old, and falling in the street, got a com- pound dislocation of the elbow. This ruined her health, so that in the course of a year or two she died. I examined her body and found the tumor gone, leaving only a small portion of indurated substance within the pelvis. These solid tumors nobody, in his senses, would propose to tap; and, you see, I insist there is no medicine can do them good. What then is to be done ? Can ovarium tumors be cut out ? Yes, they have been cut out, and the patients, in certain instances, have recovered. As to the question of cutting out the ovarium tumor, it is a question in Surgery, which, as an Accoucheur and a Practitioner of medicine, it may be supposed that I have no special claim to speak to. Still, I have an undeniable right to lay before you a statement of the motives that should govern me in any question as to the performance of this operation on a patient of mine; and, I trust that, in entertaining the opinions I do on this topic, I may be held to do so not without due respect to the en- terprising and courageous surgeons who have advocated the extirpation of the diseased ovary. Nevertheless, as, in an article on ovarian extir- pation, by Dr. Atlee, in the Amer. Journ. of the Med. Sci., I am very imperatively informed by that gentleman that I ought not to possess "influence" in questions of Surgery—though he compliments me as an Accoucheur; and as the very ancient advice to the shoemakers ne sutor, &c, seems hardly applicable as between members of the confra- ternity to which both he and I belong, I reject his authority over me. Dr. Atlee's coolness in cutting open a woman's belly does not, I should DISEASES OF THE OVARIES. 339 think, entitle him to judge more clearly than I as to the morals of such surgery; for, in such operations as those under consideration, the de- termination to do or forbear is certainly a question of high morals, in which, as a professional man, I have an interest as great as that of any mere surgeon. Dr. Atlee likes them ; on the contrary, I detest them, and should be glad to see them prevented by statute. Indeed, as to surgical operations in general, I hold to the sentiment that prevails very extensively in this quarter among surgical gentle- men of the highest standing, that it is a dire necessity that compels a resort to the bistoury; and that the fact of a surgical operation being necessary in any case, is a reproach to medicine. This is a noble sen- timent, and one that deserves to be upheld and propagated far and wide by all the true lovers of our divine art. It has, in a prime degree, governed the conduct of the surgeons of the Pennsylvania Hospital these many years, and is one of the titles to that general confidence that has been given so steadily to that admirable establishment. I should be glad if you would look over the statistics of ovariotomy to discover how many bellies have been ripped up by the surgeons in the expectation of having the blessed satisfaction and praise of curing a tumor; whereas they very often have found only a womb, which they dared not cut out. Suppose a surgeon to open a woman's belly to ex- tirpate an ovary; that he finds no ovary there—that he then sews up the gash; and next, that she dies! what should the attorney-general say? Doubtless, in the history of Surgery, many cases are to be found of operations performed without necessity. That this is the case no one can deny who will refer to the examples of the Caesarian and Sigaultian sections; not to allude to many others that are on the files of cases. I regard all ovariotomy as in this class. But, as "life is short, while art is long, occasion fleeting, and judg- ment difficult," to use the language of the first aphorism, there must have been, and must still exist many cases where the actual circum- stances cannot admit of the exercise of a perfect judgment; so that operations are performed under the spur of a seeming necessity. Many a limb, for example, is sacrificed by the catlin and saw, that might be saved by the use of a more sober and cautious judgment. In regard to the Caesarian section, for example, which is, perhaps, the most important of surgical operations, much is to be left to the judgment and conscience of the surgeon and the gentlemen of the consultation, since, even at the present day, it is not decided what precise degree of reduction of the pelvic diameters makes the operation 340 DISEASES OF THE OVARIES. not lawful only, but indispensable as an act of professional duty and charity. For a medical man, called to and placed in charge of a labor with deformed pelvis, there is a most solemn obligation resting on him to protect the lives of both the mother and the child ; and if he be truly competent to the exercise of that wise discrimination and judgment that alone are suitable to such great and trying occasions, I can clearly perceive that, with the calmest and most untroubled conscience, he may recommend and perform the Caesarian operation, which he knows will result in the death of the mother in about one-half of the cases in which it is performed; and I deem that, where he has both advised and performed the operation, he might look with an undisturbed aspect upon the body of the victim he vainly strove to save. Such a person, being in charge of the case, cannot escape from the stringent necessity of acting in it. He cannot go out of the lying-in chamber saying that there is a chance for recovery by the Caesarian section, yet declining to do it. Not so in any tumor or other malady developed by diseased action. For example, in a cancerous breast, a man may refuse or consent to perform the operation for its ablation; but he cannot refuse the opera- tion of lithotripsy, or that of cutting for the stone in the bladder, in a case proper for it. In the case of the cancerous breast, he may decline or consent, according to his opinion of the risk from the operation or of a return of the disease. In the case of the stone, he cannot refuse, on account of the urgent distress that appeals to him for relief. In forceps operations, and embryotomy operations in midwifery, I do not understand how any one can have the right to decline interfering where the safety of the mother or that of the child clearly requires his intervention. In such cases as stone in the bladder, in amputations for railroad accidents, for white swellings, &c. &c, the requirements are instant and pressing, and the exigency admits of no refusal nor delay. It is a hard and dire necessity then that makes the act of the surgeon not only excusable, but charitable, and even noble. Any surgical ope- ration founded on other principles—on some cold and calculating com- putation of benefits possible, I regard as of doubtful propriety; and I believe that no surgeon ought to operate where he can escape the duress that binds him to do his cruel kindness. I will add that, in the Caesarian operation, there is but one rule for the conscience of the physician, and that rule has reference to the mother. The Caesarian operation ought never to be performed for the sake of the child. If a man perform the operation for the sake of the child's safety, and the mother perishes, who might have been saved DISEASES OF THE OVARIES. 341 by some other method, I see not how his conscience can ever recover its composure and complacency. No ! Whenever you are tempted to perform the Caesarian operation, let it be done from a conviction, and a clear one, too, that to deliver per vias is either impossible or equally hazardous with the section. When you can come to this intelligent conviction, then you can enjoy the high gratification of hoping to save both the mother and her offspring. Having said so much, it is clear why I am opposed to the operation for extirpating the diseased ovary; the ground of my objection resting in that principle of surgery, which I hold to be one of its highest prin- ciples, that there can be no duress, no binding obligation to perform it, and that the surgeon's conscience may be at peace, though he refuse, and though the patient perishes by the progress of the malady. While I have read with great pleasure Professor Simpson's remarks in favor of ovariotomy, for a copy of which I am indebted to his polite- ness, and while I admit the considerable force of many of the arguments arrayed in his publication, yet I see no parity in the duress of the sur- geon who decides upon an ovariotomy, and that of the surgeon who performs the operation for the stone; or an amputation; or the ligature of an important vessel, &c, which he dare not refuse to perform ; whereas no such urgent, imminent, and definite necessity can ever be supposed of an ovariotomy operation. In the one case, the surgeon resorts to the operation under com- pulsion of an imminent and pressing danger ; in the other, he takes his instrument in his hand under the dictation of a cold calculation of chances as to human health or life. Now, who, I pray, has the right to calculate as to the value of a man's life, even for an hour?—much more, for a week, a month, a year, or a quarter of a century ! I am opposed, then, to the operation of ovariotomy, and I am op- posed to it on grounds of objection that I consider valid against all surgery that is not unavoidable. Jobus a Meekeren, Observ. Anatomico-Medicse, gives us an account of a horrible operation on a woman affected with a supposed proci- dentia uteri. After long and doubtful consultations, it was resolved to operate for the extirpation, which was accordingly done. " In diem usque quartum omnia bene se habebant, ast circa sextum, septi- mumve, vires vald& imminuebantur; febris contra et animi deliquia, augebantur sic quidem, ut brevi, Deo animam, nobis corpus exhi- BERE cogeretur." It would scarcely be unfair to say of all the fatal results of operation for extirpation of the ovary that the patient is compelled to render her soul to God and her carcass to the surgeon. See 3Iangetus Bib. Medico. Pract. iv. 1026. 342 DISEASES OF TnE OVARIES. Ovariotomy operations are not unavoidable, since no one, I presume, would think of operating for a patient not remote from dissolution ; and since, in any case not menacing a speedy termination of the life of the patient, the unavoidable necessity has not arrived. In a note that I added at the 415th page of the American edition of Colombat's Treatise on Diseases of Females, I stated that I fully con- curred in opinion with M. Colombat, who disapproves of the ovariotomy operation, and that I look upon operations for the extirpation of dis- eased ovary as not to be justified by any amount of success. There are certain medical facts that belong not to us as a body of physicians alone, but which enter into the common treasury of human knowledge, and which no array of statistical results can ever, I imagine, change or abro- gate, and it is certainly in the nature of things that wounds, even small ones, of the great cavities are dangerous wounds ; and, a fortiori, wounds of vast dimensions, and wounds, too, requiring that other deep-seated parts should be cut away and vessels tied within those cavities, are so dangerous, by the common voice and consent of mankind, that I should in vain endeavor to reconcile it to myself that I am bound to do such things, except under the duress and stringent necessity laid upon me by my position as physician or accoucheur. No man's statistics can change or abrogate the opinion of society on this point. I have already shown you, from Dr. Lee's work, how dangerous is the simple operation of a first tapping in ovarian tumors. What I have already stated as to my opinion on the binding nature of the chirurgical duty in serious operations may excuse me from giving you such trouble, for I hope I need take no further pains to show you that what you must do, and what you may prefer to do, in the way of surgery, are categories wholly different from each other. It is clearly a mistake to found your approbation of ovariotomy on any comparison of the safety of that operation with the safety of amputation, lithotomy, &c. &c, because you cannot avoid the latter, while you must simply prefer the former. In surgery, there should be no preference ; surgery depends upon I must, not upon I will. CD. M. DISEASES OF THE FALLOPIAN TUBES. 343 LETTER XXVII. Gentlemen: The Fallopian tubes, like the ovaries and other reproduc- tive tissues, are liable to disease ; but it unfortunately happens that the Fallopian tubes, being hidden within the bony cavity of the pelvis, and unapproachable either by the vaginal Touch or the hypogastric palpa- tion, may be the seats of disease, proceeding to the most inconvenient or even dangerous extent, without our being enabled to detect its ex- istence by any process having the clearness of demonstration. I pre- sume, indeed, that, for the most part, Fallopian disorders will scarcely be clearly made out until a necrological examination may serve to reveal them. This opinion, I think, is well founded, except, perhaps, as to some samples of tubal pregnancy, of which the signs, too late discovered, are sufficiently clear to admit of our pronouncing boldly upon the case. Affections of the Fallopian tubes may serve to condemn a female to incurable barrenness. Thus, if a female, in early life or later, should experience an attack of acute peritonitis, marked with the characters of adhesive inflammation, the Fallopian tubes, one or both of them, might become attached by adhesive bands to the broad ligament, or to the bladder, so as effectually to prevent a tube, ever afterwards, from serving as vector of the ovulum to the womb. In such an instance, it would be impossible for fecundation to take place, and equally impos- sible to make the diagnosis of the accident during the person's lifetime. An adhesion of one Fallopian tube to the broad ligament, leaving the other one free to fulfil its office of excretory duct to the ovarium, would not, however, necessarily interfere with the reproductive power of the woman, since one ovary might produce germs for the fecundative con- flict. Neither would such an adhesion expose the woman to any danger of suffering from violent traction and disruption of the adhesion, in case she should become pregnant, when the womb must rise upwards to the height of the scrobiculus cordis ; because the broad ligament itself equally yields to the distending force of the growing womb, and thus carries the adherent tube upwards along with itself. No great incon- venience, therefore, is to be apprehended from an adhesion of one tube. When both are adherent, so as to prevent the fimbriae from reaching the ovary, barrenness is inevitable. A Fallopian tube may become the seat of inflammation, at its fimbria, 344 DISEASES OF THE FALLOPIAN TUBES. resulting in the closure pf that extremity of the organ, while the uterine orifice of it also becomes closed. In this situation, it sometimes is found to be filled and greatly distended with water. A beautiful drawing representing this condition of the Fallopian tube is given by Dr. Hooper, at page 61 of his Morbid Anatomy of the Uterus, &c. M. Duges supposes that pain and inflammation in the region of the Fallopian tube, unaccompanied with swelling or hardness there, may be held as signs of inflamed Fallopian tube; but I do not discern how such signs can be taken as evidence of that particular malady; since they may be as well marks of disease attacking the round or broad ligaments, and I should place very little reliance on the diagnostic skill of any one for the particular diagnosis in question. All such maladies are and must, during their course, remain obscure and unknown, except as far as they introduce constitutional disturbance. The Fallopian tube has been found full of blood, probably menstrual blood. I am not aware that any one has perished from the escape of a quan- tity of menstrual fluid from the uterus, in atresia of the vagina or womb; and yet it seems wonderful that, where the uterus is expanded to the cubic content of twenty or thirty ounces of menstrual excretion, the uterine orifice of the tube should never suffer it to flow off into the peri- toneal sac. The surprise is increased upon remembering that the tube is so expansible as we see it in some morbid specimens. For example. I attended a lady in her accouchement in June, 1841. She had a favorable labor, and all the usual circumstances of a lying-in woman attended her for a period of many hours, when she complained of heavy and distressing pain in the region of the right Fallopian tube. The pain, and the complaint of it were great. Of a sudden, the pain began to spread over the lower belly, and the constitution evinced its participation. The pulse became alarmingly excited and accelerated, and she was soon seen to be far gone in a puerperal peritonitis. As she had complained of pain in the right side for some time before the ac- couchement, I feared that some local malady, suddenly aggravated, was at the foundation of the danger. She died; and upon inspecting the abdominal cavity, much pus and sero-pus were observed. But what most particularly struck me was the state of the Fallopian tube, which was much larger than a stout man's thumb ; and its cavity, which would freely admit of the introduction of a finger into the tube, had been filled with pus. I have little doubt that acute inflammation of the tube, sealing the ovaric extremity of it, and afterwards filling and greatly distending its caliber with pus, which was at length discharged into the belly, is the true rationale of this fatal attack. DISEASES OF THE FALLOPIAN TUBES. 345 As the Fallopian tube conveys the ovulum from the ovarium to the womb, it is occasionally liable to destruction from an arrest of the fecundated ovulum in some portion of the tractus. An ovulum, when fecundated, whether it be arrested in the tube, or whether it be arrested in the uterus, makes its mesenteric attachment to whatever vital surface it is confined, and as no doubt is entertained as to tubal gestation, so no doubt, can be had that, in all such instances, the ovulum was fecundated before it had passed down the whole length of the tube. When such a tubal conception hath taken place, the woman will probably deem herself pregnant; since the rational signs of conception, such as nausea, deeper-tinted aureoles, and even failure to menstruate, may attend the misfortune. No suspicion of the dreadful fate that impends the victim is aroused until the tube has attained the utmost degree possible of its expansibility. That degree will rarely allow her to go beyond the third month, before the tissue, gives way; when the ovum, bursting, pours its contents into the peritoneum, followed by torrents of blood effused from the ruptured arterioles and venules of the tube. See what I have said at p. 327, as to the incapability of the tube to grow pari passu with the ovum. If the patient complains, for some days before the accident, of pain in the region of the ovary, it is probable the pain will be attributed to some other than the true cause, and the first moment of the rupture will be characterized by an instant burst of distress, and a rapidly de- veloping inflammation, attended by the evidences of simultaneous hem- orrhagic exhaustion and the signs of speedily approaching death, seen in mortal pallor of the face, coldness and clamminess of the limbs, shortening respiration,- and a vanishing pulse, repeated with inappre- ciable frequency. Suppose you should be spoken to, on the subject of a pregnancy just commenced, for your counsel as to the conduct of the patient. If, after the lapse of six weeks or twelve weeks, you are hastily called to her, and find her in the condition above described, what other diagnosis have you to offer than that of a ruptured Fallopian tube ? You see very clearly that such phenomena could by no means attend a sudden internal strangulation of a bowel; and the antecedent health of the woman would not allow you to attribute her symptoms to the perfora- tion of an intestine. You have no other diagnosis to offer, and, un- happily, the only consolation for you, under such circumstances, con- sists in your ability clearly to point out the nature of the causes, and predict the verification of your decision after the death of the victim, which may be pronounced unavoidable. 346 DISEASES OF THE FALLOPIAN TUBES. I was the distressed witness of a case of this kind, a few years since, in a fine young woman, who had been several years married without offspring, when she came at last to tell me, with unfeigned pleasure, that she was pregnant, and to ask my advice as to her hygienic man- agement. When her pregnancy had proceeded a little beyond the second month, she arose from her bed in good health and spirits. She took a broom and began to sweep some part of her apartment, when, in an instant, she felt violent pain in the region of the ovary, became sud- denly of a mortal paleness and coldness, and, by the time I reached her apartment, was already sinking from the tubal hemorrhage. Here is another case that fell under my notice. Mrs.----, aged thirty-two, a healthy woman, mother of four chil- dren was in excellent health on Sunday, October 7th, 18—. At six o'clock in the morning, she was gayly singing and playing with her young children at her country seat, about two miles from town. At seven o'clock, an hour later, her husband, who was sick in his chamber, heard her slowly ascending the stairs, and groaning heavily. Upon her entering his chamber, he perceived her to be alarmingly ill. Her physician, Dr.----, was immediately sent for. He found her with a pulse at 140, and complaining of violent pain extending from the top of the thorax, on the right side, quite down to the iliac region. He attended her all day, applied a blister to the right side of the belly, and gave her a cathartic, &c. She passed a dreadful night, but was easier the next morning at eight o'clock, when the pulse was but 120 per minute. He left her for a short time, but found her symptoms ag- gravated upon his return. I was invited to see her with him, and met him at half-past two o'clock, when she appeared to be dying. As she had vomited very much, and labored under excessive tym- panitis, with violent pain in the whole belly, she got an enema, which brought off a great deal of stercoraceous matter, but without any relief of pain. In half an hour, she said: " Raise me up—my breath is leaving me!" and she was slightly elevated on a pillow, when she im- mediately swooned, and died. Twenty hours after her death, I inspected the abdominal cavity, which contained about thirty ounces of blood and bloody serum. The pelvis was filled with coagula, and much blood was lying among the intestinal convolutions. This blood escaped from a rupture in the left Fallopian tube, which contained a foetus of six or seven weeks. The ovary was somewhat enlarged. The womb contained a deciduous lining, and the canal of the cervix contained a claret-colored mucus or lymph. The womb was larger than a non-gravid womb, though not much larger. DISEASES OF THE FALLOPIAN TUBES. 347 There is a lithographic print which very faithfully represents the appearance of the specimen, which you may see at page 107 of my Philadelphia Practice of Midwifery, second edition. What, alas ! can we do in these cases ? We could make an incision in the abdomen, and clear away the coagula and the serum. But who is he bold enough to do so ? Who is he astute enough to discriminate betwixt all the possible causes of such phenomena with so much clear- ness as to warrant him in the performance of a gastrotomy for Fallo- pian pregnancy ? There is no such wise and bold surgeon; and, there- fore, nothing remains for us but to extend all the relief within the narrow boundaries of our power, and calmly await and submit to the inevitable end. Such are painful scenes to the sensitive mind. They cast a color of gloom over the pathway of the medical man, whose whole walk, indeed, is among those who are in pain, in weakness, in fear, or in the valley of the shadow of death. A physician may be calm, and even cheerful, but a merry doctor is a very singular phe- nomenon. The diseases of the Fallopian tube, then, you perceive, are obscure, and very unmanageable where they become serious. Doubtless they are many times unsuspected while they are the true causes of disor- ders treated under another name; and doubtless their inflammations, spasms, neuralgias and engorgements may yield to constitutional and local remedies addressed to symptoms supposed to depend on modifica- tions of other tissues. I did not say anything as to ovarian pregnancy when I wrote to you my meagre letter on the ovaries, because I intended to say what I have now said on tubal pregnancy, and preferred to reserve my remarks on ovarian gestation for this connection. You know, for I have many times spoken with you of it, M. Pou- chet's opinion that ovarian pregnancy cannot exist. M. Pouchet says, at p. 421, ThSorie Positive de VOvulation Spontanee, $c, "I formally deny the existence of ovarian pregnancy. I admit, indeed, that the egg, in the act of escaping from its capsule, may become fecundated by the sperm brought into contact by means of the fimbria, and that it may subsequently be developed at the surface of the ovarium in consequence of adhesions contracted with that organ. But I have no idea of an ovarian pregnancy as understood by writers, that is to say, a develop- ment of an ovulum still contained within its Graafian vesicle, and which by its development engenders a foetus inclosed within the very ovary itself." M. Pouchet, to whom we are indebted for the fruits of very great labor and research on this subject, can hardly, we should think, escape 348 DISEASES OF THE FALLOPIAN TUBES. from the necessity of admitting a true ovarian pregnancy, if he will consult Dr. Granville's account of the case published by him in the Lond. Phil. Trans., part i., 1820. In July, 1845, I had the honor of an interview with M. Pouchet, at his house at Rouen, and a conversation took place, among other topics, upon this very one of the ovarian preg- nancy. I stated my own conviction that it is impossible to deny the existence of the ovaric gestation, and that the embryo might well be developed in the Graafian follicle, which I see M. Pouchet, in the above sentence published in 1847, does not admit—he adhering to the opinion that the development can occur only at the surface of the organ. It seems to me, gentlemen, that if you assert the mutual presence and contact of the generative elements to be necessary to fecundation, you have no occasion to doubt the presence of the male element in the tube, in all cases of tubal pregnancy at least; and M. Pouchet himself says that it may be possible for fecundation to take place on the surface of the ovary by the contact of the germ with sperm brought into the fimbria. My opinion at Rouen was, and is still, that the porule being formed for the escape of the ovule, while still retained within the capsule by the granular retinacula, it might be 'the subject of impregnation by sperm brought to it in the fimbria of the tube. Let us suppose such impregnation to have been effected—then some change of position covering the porule with a peritoneal superficies allowing of adhesion; the ovulum would be necessarily shut up in the crypt or cell, which having now become again a shut sac, development of the germ would go on absolutely in the interior of the ovulum, and Granville's fact, for facts are stubborn things, would be explained with- out at all shaking the conclusions of M. Pouchet as to the oviponte. I cannot predict what may be the opinion you shall adopt on this point. I presume, however, there is not one among you to believe that the macula germinativa, which is perhaps the real embryotroph, and which is found on the inner wall of the germinal vesicle, buried as that vesicle is among the vitellary corpuscles of the egg, which itself is in the centre of the granular masses contained within the inner concentric of the Graafian follicle, hid below the tunica albuginea and indusium of the ovary, can be exposed to the sexual presence and contact by any process other than the spontaneous ovi-posit, which M. Pouchet de- scribes. For my own part, I cannot imagine any other way in which the mutual influences of the generative elements can be brought into effectual activity. I do not, then, believe that in the ovaric pregnancies the fecundation has ever been effected, except through an already opened Graafian cell, DISEASES OF THE FALLOPIAN TUBES. 349 which, being subsequently closed by adhesive inflammation at the edge of the porule, has allowed the pregnancy to go on within the ovary itself. The womb is so constituted as to admit of a physiological hypertro- phization or evolution continued throughout the nine allotted months of a gestation; its provision of materials being ample for that purpose. No such provision has been made for ovaric or tubal gestation: hence, within three months, probably in most cases earlier, the fatal rupture of the containing walls will take place, and the patient will lose her life. As I am on the subject of extra-uterine pregnancy, let me here remind you of the opinions I expressed in my Lectures as to ventral pregnancies. I said I had met with specimens of abdominal or ventral pregnancy, but always considered them as instances of foetuses deve- loped within the womb, and afterwards deposited within the belly, in consequence of the womb having given way to allow the contents to es- cape into the peritoneal sac. Some of them have been known to re- main in the belly for fifteen or even thirty years. Upon investigating the cases after death, even the placenta has been found, and adhering to the mesentery or other peritoneal surface. But you are too well in- formed, I should think, to allow you to suppose that a full-grown foetus could possibly be developed by means of a placenta resting on a serous membrane only !! It would be very stupid of you to imagine such a thing possible, since you know that such development requires that even the womb itself should become exceedingly vascular in order to furnish the due supplies of oxygen and plasma. Besides, how could a placenta grow, except the base on which it rests shall grow pari passu ? Don't you see that when a large placenta is found in a ventral pregnancy, it could not have grown on a mesentery, or other superficies of perito- neum? They could not grow with it. I have now treated in succession of many maladies and accidents of the external and internal genitalia. There are many points which I have passed over in silence, because I have wished to avoid expressing an opinion upon subjects on which I have had no practical or clinical knowledge. Others I have postponed to a future page, in order that I might not be compelled, on the one hand, to anticipate, nor, on the other, to separate subjects that have a sort of natural alliance. For example, ruptures or lacerations of the womb and vagina, it appeared to me, might better be arranged under the head of those diseases and accidents of pregnancy of which it is my intention to treat. It will be my duty to say much upon the subject of the menstrua, an important item in the history of the female, and one whose modification and dis- orders exert a mighty influence on her health and happiness. In order to approach this subject properly, I ought to make remarks on that 350 PUBERTY". important and interesting crisis which is called Puberty in the female. and, therefore, my next letter shall be on the subject of puberty, or the puberic age. C. D. M. LETTER XXVIII. Gentlemen: I know not whether I shall in this letter succeed in setting forth, with clearness, the views I have long entertained, or rather those which I have supposed myself to entertain on the subject of puberty in girls; I fear I shall not. I know a man may think he has clear views on points in physiology or in general philosophy, and particularly in any metaphysical consideration, while, in fact, his notions are not clear, but confused, indefinite, dim, and not readily explainable in words. In such a state of his mind, a man will be found unable to set forth a lucidus ordo of thoughts, for there is no such characteristic order in his opinions on the special topic; and if a writer doth in this way fail, you have fair inference that he fails to be distinct and clear and coherent in his exposition, because he is himself indistinct, confused, and incoherent in his own appreciation of the subject under discussion. If you had happened to be eye-witnesses of a certain historical event, you would, doubtless, expect to be able to relate all the successive inci- dents thereof in a regular order, as they occurred; but, should you not be able to do so, it would be because you had observed badly, and kept no memorials or records worthy to be depended upon; in fact, you would not know or understand the events of which you had been an eye-witness, and which you supposed yourself to understand and re- member perfectly well. We see daily examples of this uncertainty and imprecision of knowledge in testimony given before our courts and juries by witnesses called in the case. The truth is elicited only by cross-examination. I wish you were present here to cross-examine me on the subject of puberty—perhaps we might then be able to come to a clear understanding, together. When in this letter I come to speak to you on the subject of puberty in girls, I consider myself as having been an eye-witness, in the cases to be taken up, as to the events and circumstances that attended upon the puberic age; for the major part of my long professional life has been passed amidst such scenes and histories. During many years, I have frequently been charged with the conduct of the health of young females entering upon, passing through, or already gone beyond the PUBERTY. 351 common puberic age; yet, notwithstanding I have witnessed so many cases requiring medical interposition, I confess that to write you a letter on the subject of puberty appears to me a difficult task. Certainly it is one I should prefer to avoid, both because of the doubts existing in my own mind as to the peculiar nature of the puberic affections, and of the jejune and little practical notions upon it that I find in the author- ities ; which I take to be a proof of the difficult nature of the subject. I must pray you, therefore, beforehand, to scan very closely the senti- ments that I shall express in this letter; and, if you find them to coin- cide with what is true, or probably true, then to adopt and apply them in your practice; whereas, if they should prove to be hypothetical, and unfounded in truth, or in facts, you ought to reject and condemn them. I desire only that they should be useful, not merely that they should be acceptable. The writing a letter upon puberty would not be a difficult under- taking, were one to confine himself to pointing out, in the usual man- ner, the period and general phenomena of the change from the girlish to the womanly estate, and furnish a copious statistic of the dates of the eruption of the menstrua in different countries. Nothing is easier than to say that, at the age of fourteen or fifteen years, the pelvis be- comes expanded and consolidated; that the internal and external geni- talia and the lactiferous apparatus become completed, &c. &c. But such statements, that are to be found in all the books on these matters, serve to throw but very little light on the abstruse subject of puberic disor- ders ; they always put me in mind of the holy text, where it says: " They fill their mouth with wind, and their belly with the east wind," which, being interpreted, is in Latin vox et preterea nihil. I shall endeavor, then, to relate to you what are the opinions I en- tertain on the subject, and point out the indications of treatment for those young people who approach dangerously and pass with risk through the great and important crisis of the puberic age. What is meant by the word puberty ? Stephens, in his Thesaurus, says: " Pubertas. Aetas in maribus qui est annus xiv., in foeminis xii. Pubertas plena xviii. annus est. " Pubertas est emissio pubis, a qua anni pubertatis dicti sunt. "Pubertas, generandi vis." Dr. Noah Webster, in his Dictionary, says : " Puberty. The age at which persons are capable of procreating and bearing children. This age is different in different climates, but is with us considered to be at fourteen years in the male, and twelve in females ;" and Dun- glison, in his Medical Dictionary, tells us that it is " the period of life at which young people of both sexes are pubescent or nubile. Accord- 352 PUBERTY. ing to the civil law, puberty occurs at twelve years in females, and fourteen in males. You see that Stephnnus, and Webster, and Dunglison—I shall not take the trouble to examine any others—agree that puberty in females is the age of reproductive power just begun, and that that power is acquired at twelve years of age; Stephanus says it is pubertas plena at eighteen ; but yott, even as young students of medicine, know that neither of these Dictionaries speaks truly, for the reproductive power is not attained at twelve years, in the average of cases; nor does the average come at all near to twelve years—it is beyond fourteen years in this country. The first true and veritable eruption of the menses may be taken as the evidence of the girl having reached her puberic age ; for that eruption is the evidence of germ evolution in the ovary, and even of the ovi-posit. This occurs between fourteen and fifteen years of age. Instead of limiting the application of the word puberty to the state of the girl at the first mensual manifestation, I prefer to use it as re- ferring to a long stage of preparation for the menstrual office, and to a stage, also, which extends far beyond the date of the first show, into the period when the function has become regularly established ; so re- gularly and firmly, I mean, as to leave no doubt on the mind as to the permanent and normal acquisition of the power ; a pubertas plena. The fact is that many persons are to be met with in whom it has never been perfectly established ; persons in whom the power to menstruate exists, but exists feebly, morbidly, interruptedly. All such persons have failed to pass through the crisis of puberty. A girl may have a sanguine discharge from her genitalia without having any pretension to be menstrual. It may arise from a scratch, an ulcer, a wound, &c. I have observed such discharges in children at birth, in the month, and in little children under six years of age. When I have been consulted about these cases as extraordinary samples of precocious menstruation, I have been far from joining in such a pre- posterous notion. And I hope that you will always discriminate between bleeding from the genitalia, and the regular physiological discharge, which alone is menstruation. The young child is but the sketch, the ebauche, the mould in which are to be formed the organs of the woman. She employs some fourteen years of her life in consolidating and forming her body, in order to fit it for its high destiny as a reproducing agent: but the apparatus and the force necessary for the fulfilment of that destiny are not added, except as the last and crowning power of her constitution. It is the complement of her forces. Her weak and tender tissues, in the early years of life, could not possess the strength and solidity, nor could they PUBERTY. 353 furnish the materials, for the evolution and perfecting of the new being, which is, for a series of following years, to represent its parent, as one of the integers of the immortal genus, man. The earliest years of her life are occupied, then, in bringing her up to that point of perfect development of her alimentary, respiratory, innervative, and circulatory life, that may fit her for taking on the last great reproductive force. The time for taking up that force is the time of puberty. Puberty is the term of preparation to produce and mature ovarian ovules or germs, and discharge them from their cap- sules in the ovary. Having duly acquired this power and faculty, she has passed through the crisis of her puberty. She has transcended the puberic age, and has become a woman. She has become possessed of a faculty that she is destined to enjoy for nearly half of her lifetime, and then, losing it again, she turns on the reverse of the path of life, and begins to de- scend to the bosom of the dust from whence she originally emerged. It might be true to say that the whole menstrual period of life, ex- tending from fifteen to forty-five years of age, is a continual crisis for the female ; yet, when once fully formed and established in the economy, it is become a nature and a habit, and ceases to have that character of crisis which more truly applies to the stage of preparation or inception of this great power, and its positive and firm establishment as a part ' of her life-offices. A girl grows up from infancy, and from childhood, continually devel- oping, confirming, and consolidating her tissues and organs, appropriate in their magnitude and their density to the particular stage of existence through which she is passing. In weight, stature, proportion, vigor, and intelligence, there is a continual conformable progress—not a non- conformable progress. The last faculty she acquires is the reproductive, the crown and glory of them all. It would be an unconformable pro- gress in development, should its acquisition be either greatly anticipated or postponed in point of time. In growing up from the infantile to the womanly estate, she passes through many crises, great and important ones; but the greatest and most important of all is the puberic crisis. Thousands, and tens of thousands, nay, millions of young children fail to escape the dangers of the age of their first dentition, and the bills of mortality are swelled with the returns of death in children. The first, or milk set, having served their turn, the child incurs great hazard at the quasi paroxysm that waits upon the second dentition. Many children now lose their appetite, their embonpoint, their gayety ; they cease to play, and utter the glad voice, among their shouting and 23 354 PUBERTY. laughing companions. The pulse becomes compressible and frequent, and, upon the slightest motion, the heart beats with redoubled haste, and soon subsides again into an habitual languor of action. Fretful- ness of temper, and frequent crying for any slight cause, or for no perceptible cause, mark what is very commonly, in families, known as the " cry-baby" age of children in their second dentition. Children suffer frequent distressing pains in the decaying and loosen- ing out of their first teeth ; and a strange erethism of the parts about the mouth attends the tension of the gums coincident with the bringing forward of the permanent set. I have had many patients under my care whose health had been rendered wretched by these causes. Such patients have had convulsions, deranged bowels, palpitations, and hy- pertrophic throb of the heart, loss of appetite, cephalalgia, and other disorders, attributable to the difficulty experienced in forcing them through this especial crisis of life. Under circumstances of a crude, imperfect, saburral digestion, thus brought about, the growth is sometimes arrested for a time. Thousands of children attacked at this period by disease are hurried to the grave. Measles, scarlatina, pertussis, &c, assail them at a time when they cannot resist the combined influences of a severe malady and a dental crisis, either of which, encountered alone, would probably be far less dangerous. In the progress thus far, also, some of the organs and parts of the child are occasionally observed to be unequally developed. The heart, for example, which in its evolution of substance and power ought to move pari passil with the entire economy of the child, is not rarely found to get ahead of the other organs ; and we observe, by auscultation and other modes of inquiry, that the child of six or eight has a heart suitable for a child of eight or ten years of age ; and that the non-conformable power of this prime agent of the circulation exposes the patient to danger of excessive determination of blood to the head, to the lungs, to the liver, the spleen, &c. &c, afflicting it with epilepti- form convulsions, pulmonary engorgements, hepatic obstructions &c, according as the excessive momentum of the circulation happens to be determined. Nothing is more common than to observe an excessive and non-con- formable growth of the head in young persons, by which they are exposed to great risks, but Avhich is corrected, at a later date, by the rest of the system recovering its due proportion to the encephalon, whose progress, becoming slower, allows it finally to be overtaken whereby all the parts become equalized again. If the child, even after difficulties encountered, should get well and safely through this period it is safe for a term of years. PUBERTY. 355 In like manner, the girl approaches the greatest of all her critical stages of existence. She has concluded all the preparatory acts, and they having all been perfected and completed, she turns over from the child- ish or girlish to the womanly condition, without stay, let, or hinderance. She glides onward, and is found to be a woman, and that without the least inconvenience or disorder of health. The epiphyses of -the bones, and all the individual pieces of which they are constituted, have become solidified and compacted. The coxal bones and the several portions of the os sacrum have each acquired the due firmness and solidity. The pubes are covered with the marks of womanhood, and the external genitalia acquire larger proportions. The transverse and antero-posterior diameters of the pelvis have sud- denly and visibly increased; the mammary glands and the aureole and the nipple are augmented in size. A growth of fine downy hair is observed on the upper lip, near the angle of the mouth; a more con- siderable deposit of fat lends roundness to the limbs and grace to the contour of the young maiden. A new and different lustre sparkles in her eyes, which more promptly veil their brightness by downcast glances, or the continual dreamy and thoughtful drooping of the lids above them. Heightened color in the cheek and lips shows the greater intenseness of the glow with which the fires of life are burning within. It seems as if the forces which had been employed to perfect the beau- tiful machine by arranging and completing the quantitative synthesis of all its organisms, were now occupied with a sort of paroxysmal inten- sity in adorning it with all its graces and attractions, and setting upon it the seal of perfection. She is perfect; in a few months, she is habitually, naturally perfect—the crisis is over—inveni portum, spes etfortuna valete. It is pubertas plena. Let us suppose, on the other hand, that these acts of preparation have been duly effected, yet the girl is not ready. Why is she not ready ? She is seemingly ready for the great change; what lets its accomplishment? She marches up to the critical age, and it flees before her. In vain the progress of weeks and of months urges her to- wards the goal of change; but she changes not. Insensibly and by the slowest degrees the conformable relations of her organs are found to be dissolved. Her nutrition gives place to marcor and atrophy; her bril- liant hues are replaced by sallow tints. The bright laughing eye is grown dim and sunken; the heart beats hurriedly, especially upon exercise. Her appetite fails, or some craving pica or malacia takes place of the normal desire for food. Debility, exhaustion, mucous diseases, diarrhoea, or constipation, make daily inroads upon her feeble life-domain, and, while everybody knows that she would be well if she 356 PUBERTY. could become a menstrual creature, few deem that, to make her so, it is only required to cure her of a disease of the blood, a disease whose ex- istence is incompatible with the exercise of that great function. There is no reason to hope, under these circumstances, that the great transformation will be effected. Such nutrition, circulation, respiration, and innervation as hers will not admit of it. It is far more probable that one system of functions after another being perverted, prostrated, and overthrown, she will become more and more diseased, feeble, and exanimate, until some local inflammation finds her an easy, unresisting prey. You have no reason to expect to cure her of her emansio-men- sium until you cure her of her puberic malady. What is that malady ? —how will you prescribe for it ?—what is the indication ?—is it that everlasting calomel?—is it snakeroot, senna, rhubarb, quinia?—what is it?—what ails the patient ? She is impuberic, though advanced far in the puberic age. Look at her—measure and weigh her—compare her with her former self. Don't you see what enormous efforts her constitution has made to transform her, as it has done, from the condition of a child to that of a woman? Her great haunches are no more like those of the boyish pelvis she had ten months ago than her bust is like that of a boy. Her wide womanly pelvis, and the vast glutaei, the expansive levatores, the iliacae and psoas, have been almost created as by magic; and all this at the expense of effort by the iliac arteries and their branches, and accompanying nerves. The same apparatus has been laboring with a surplus of activity to develop the uterus, the tubes, the vagina, and the external genitals, and all these parts are, perhaps, perfectly formed ; but the sexual concrete, the vitelliferous tissue, the stroma of the ovary, is incomplete. No yelk matter can it produce; there is no germinal spot yet, no germinal vesicle, no vitellus, no Graafian follicle, and, so, no menstruation. She has lost her health ; she has fallen sick. She is useless in her present state and prospects as a reproductive agent; and the repro- ductive vitellary element is withheld from her. Cure her health, re- establish the conformable relations of her organisms. Let her innerva- tions become equable in her whole body, and she will give you the proof of her restored health in the assumption of her catamenial power. Open your books of therapeutics and materia medica. You find in them a great catalogue of plants, and minerals, and animal sub- stances, under the head of menagoga, or emmenagogues. Does the young lady want an emmenagogue ?—and what emmena^oo-ue ? Is it tansy, is it hellebore, is it madder, that shall cure the puberic disease under which she labors ? I ask you again to consider the PUBERTY. 357 question—what ails her ? Let us try if we can learn what really ails the patient. If you will advert to the state of the creature in the earliest em- bryonal period, you will remember that it passes first from the embryo- nal into the foetal state, and then into that of the child, the girl, and the woman ; and that all these mutations are affected by, and solely dependent on, the power of accretion, or nutrition of the parts. This accretion takes place at the expense of the blood, which is the pabulum, or the magazine, out of which all the new molecules are taken, and deposited under the indicating and controlling force communicated by the accompanying nerve. In fact, all life is but a continued scene of development; and but for the waste and detritus of the organs, no limit could be assigned to the extension of the body. It is the generic nature, or rather law, of a creature that compels all animal forms and parts to remain within certain boundaries, according to a pre-existing idea of such genus, or such species. Without such generic delimita- tions, it is plain that the whole zoological series, as well as all the vege- table forms, would be lost in the progress of a few generations; whereas, they have been kept, until now, the exact copies of those archetypes which, in the Garden of Eden, were commanded to go forth and increase and multiply, and fill the earth, each after its own kind—It is the greatest miracle of all. Have we, then, any reason to be surprised, when we find that this long development of the foetus, the infant, the child, and the girl, some- times exhausts the powers concerned in its effectuation ? For example, when the child grows too fast and falls sick ; are you surprised at such an event ? If the waste of the forces and materials of the blood is rapid and great under the double necessity of both maintaining the existing stage, and also of adding thereto in order to rise to a higher stage of development, what wonder have we to perceive that the child that grows rapidly tall also grows thin, and weak, and pale, and sickly ? or to hear its mother say it is sick for growing too fast ? Is the body in truth the " fixed and rigid blood," and has it grown too rapidly ? Has the blood, which is the fluid body, become exhausted ? I assure you I think it must often happen that you shall be called to give your opinion on cases of the sort, in which you will have occasion to observe that, when nature, after a violent effort and crisis of develop- ment power, shall have ceased to develop the child in stature, it will be found to augment in breadth ; and when that process is fairly instituted, it will cease to be lanky and thin; for, in fact, in the growing up of children, you shall almost always find that they grow alternately tall and bulky. When the elongating crisis comes on, they grow thin to- 358 PUBERTY. wards the end of it, and are said by the vulgar—very truly, too—to " outgrow their strength." As soon as this weakness comes on, they cease to grow in longitude, and then commences the development or growth in latitude : so that the child becomes stout again ; and so on it goes, growing by turns, first taller, then stouter, then taller again, and next stouter, until, at last, it shall have acquired its true generical limits and form. A child, I said, grows from the appropriation of materials taken out of the mass of its blood, which is the pabulum nutritionis. There is then a constant and wasteful call for supply. But whence the supply, gentlemen ? and shall we not expect sometimes to find that the organs of supply become wearied and exhausted of functional power by the sheer excessive exercise thereof ? And now we come to the gist of the matter : what is it that makes the blood ? what is the haematosic tissue ? That is the true question ; and, if we can settle that question, we shall succeed in setting forth, in a clear and lucid order, our doctrine as to the principal maladies of the puberic age in the female. An army of one hundred thousand men can be manoeuvred and marched according to the will of the general-in-chief upon one condi- tion only, and that condition is that its rations shall be supplied ; for no courage, no discipline, no conduct on the part of the officers or men can keep it afoot without the aid of the commissariat. The one hun- dred thousand men would fall faster by famine than by the bullet or the sword. The daily rations which keep the army up to the faculty of the highest activity and courage are essential to supply the daily waste, consumption, or detritus of the life actions of the soldiers. The ration is converted to chyme ; it next becomes chyle in the thoracic duct; and it is poured as chyle, not as blood, into the mass of the blood, when it is precipitated into the auricle of the heart. The churn- ing power of the chordae tendinae mixes the new material with the old sanguine mass, and it is hurried off into the system of arteries, capil- laries, and veins, and, after a few revolutions, it is—what ?—blood. How has it become blood ? If you answer, by the unknown force of the cell-life, I reply that a condition of the exercise of that cell-life force is this, namely, that it shall be in contact with a living solid— and what solid ? It must be in contact with the membrane commune of the vascular cyst, the membrana vasorum communis, the endano-ium, as Burdach calls it. Even in the very earliest manifestations of the presence of blood in the punctum saliens of the incubated egg, where the blood-disk seems most like an independent, self-creating physical ens, which makes its own vascular tractus, we cannot deny that the PUBERTY. 359 power to form itself is a transmitted power—transmitted from the living elements of the ovum itself, by which it is surrounded, and from which it receives its inducted life. The sanguine body could not have become blood in the stomach, the duodenum, or jejunum, nor in a lacteal tube, or thoracic duct; but it can become blood while in contact with the inte- rior lining of the vessels, and even the living power of the egg inducts the life-force into the material which it elevates up to the calling and the mark of the perfect blood of the embryon. Hence, I infer that the membrane which lines the interior of the heart, of the aorta, and all its branches; of the capillary vessels, and all the veins, is a blood-mak- ing membrane, and that there is not and cannot be found any other blood-making tissue in the economy. When this tissue, this membrana communis is in perfect health, and the supply of chyle passed into it is perfect, we have perfect blood; when the tissue becomes diseased, we have diseased blood ; or, at least, it acquires a dyscrasy that prevents it from exercising its due influence on the organs and tissues. Some physiologists have proposed that the haematosis is in a chief degree the result of an action carried on in the lacteal vessels, perfected still more in the thoracic duct, and completed in the lungs, and that these gradual perfectionings are a sort of progressive oxygenations or aerations, effected through the walls of the vasa lymphatica, &c, but, if they will insist that the haematosis is the work of the lungs, they cannot deny that the vessels of the lungs are the agents in the work. I pretend not to deny the agency of oxygen in all processes of vitali- zation, to all which it seems indeed indispensable. But I contend that oxygen, out of the living tissues, can have no such power. It can have no such power as to the blood, at least, since that fluid changes and loses something of its real nature and character the moment it quits its contact with the living surfaces. The presence of the endangium is essential to its existence. If drawn into a basin, or shed among the tissues—if it abandon its delimitary membrane, it alters, it loses its fluidity, its elements dispart and separate, and though it may still be a red fluid, it is no longer blood, though so called for convenience sake. Like a dissolved crystal, it is no longer a crystal; or like a liquid crys- tallized, it is no longer a fluid. The elements remain, but the form and the forces are changed. So little is as yet known concerning the true nature and powers of the common membrane, that I dare not trust myself to speak of it without much hesitation and doubt of my correctness as to its diseases. But at least we do know that the membrane is liable to simple inflam- mation, to pseudo-membranous diphtheritis or inflammatory exudation, to pyogenic inflammation, to adhesive and to destructive inflammation, 360 PUBERTY. and ossific degeneration; and that is enough to show us that it is also liable to debility, and to imperfect and unequal exercise of its functional office. Where it becomes the seat of a pyogenic inflammation, it carries death in its function ; for it may then produce innumerable pus-corpus- cles, which, being washed away into the circulation, poison the whole mass of the blood, and curtail existence by a purulent infection of the blood. When, again, it is endowed with a preternatural activity and force, it, the blood-membrane, fills the vascular cyst to overflowing with a rich and excessive blood ; so that the patient labors under all the symptoms of plethora; and when it has lost its tone, or has exhausted its force by excessive exertion of it, we have the appearances that appertain to the anaemic state. Allow me to lay before you some remarks made on this membrane by Dr. Burdach, for which I refer you to the French copy, vol. vi. p. 194, of his Physiology, whence I have taken the following extract, which relates to a point in this discussion of the greatest interest. " § 698. A vessel is the special delimitation of the vital fluid, which constitutes a liquid, apart and distinct from all the other humors; that is to say, the blood. It traces out the career which that liquid is to run, and marks out the direction it is to follow ; it may be considered as the expression of the blood in space, for it was formed by its current, and makes but one with it. " Hence it follows that the most essential part of the vessel must be in direct contact with the blood and be the internal layer of its walls. This internal membrane (membrana vasorum communis, endangium) extends uninterruptedly in the heart, the arteries, the capillary vessels, and the veins. It is an elementary tissue, of a special nature, and cannot be referred to any one class of the membranes. According to Meckel, it possesses greater analogy to the serous membranes than to my others ; and it is so by its structure, its vital properties, its tend- ency to adhesion, to inflammation, and ossification. It appears to me that it approaches in character nearest to the character of the epidermis, seeing that it separates the blood from the rest of the organism, as the epidermis separates the whole body from the external world, and as its essential properties much resemble those of the epidermis. In fact, it is a uniform, thin, transparent, whitish coagulum, without anything special in its structure; and the microscope reveals in it neither glo- bules, nor fibres, nor interstices, nor pores. It is true that Geri pre- tends to have discovered longitudinal fibres in it after macerating and drying it; but such an appearance, manifested by a body in a state of PUBERTY. 361 putrefaction, cannot be alleged as proof of the existence of organic fibres. The internal vascular membrane has neither vessels nor nerves. Ribes stated that he has seen vessels in it when inflamed; but every- thing tends to the belief that they were the vessels of the fibrous coat seen through its transparent tissue. It is fragile, as it readily breaks when a ligature is drawn round a vessel; but it heals readily, and is reproduced." I cannot see how M. Burdach can dispose of the difficulty that sur- rounds his view of the membrane—a tissue, possessed of vital pro- perties, capable of the adhesive inflammation, of healing processes, of being reproduced, &c, while he asserts it to be anhistous or without organization, a mere coagulum ! And I am the more surprised because he expressly states, in a subsequent paragraph of this 648th section, that— " When the blood engages in immediate conflict with the organs in the most delicate vessels admitted within their very substance, it is covered only by this common vascular membrane." Such also is the opinion of M. Raciborski, in his work on the veins, published in the Trans, of the French Royal Acad, of Medicine. Now it appears to me that, if the vessels have any powers anywhere, except the mere mechanical power of their office as common carriers, they must enjoy those powers in the interior of the very substance of the organs ; and there, by Mr. B.'s admission, the vessel is only the endan- gium, and nothing else. An artery and a vein are mere channels— mere carriers from and to the heart. It is the capillary system, that is, the true bloodvessel system, for it is within their domain that are effected all the changes of the blood into solids, and of the solids into fluids. Hence, I cannot agree with M. Burdach. I leave it to you to decide for yourself as to the probable correctness of his view of the case; but, I advise you to read on this head, the work of Raciborski on the veins ; a work in which he examines very much at large the history of their nature, uses, and maladies. Raciborski, you will find, also holds that the veins, in penetrating into the most interior structure of organs, carry with them only the endangium, the membrana communis, which, if that idea be well founded, is equivalent to asserting that this inner membrane is the essential organ or agent, and that the fibrous and elastic, and other materials of the structure of bloodvessels, are merely the protective investments of the blood-making organ. As for me, I shall continue in the belief that I have long entertained, that the endan- gium is not only an organ, and a living one, but that it is one of the most susceptible to morbific impressions, and one whose modifications 362 PUBERTY. of health or disease exert the most important and diversified influences on the state of the entire economy. This blood-membrane, this hemapoietic organ, is interested in all the blood diseases, particularly the pyaemic affections, as well as the hy- draemic ones. I doubt not it is one of the prime seats of the patholo- gical lesions in erysipelas and scarlatina. (See my work, entitled Observations on Certain Disorders of Young Children, in the chapter on Scarlatina.) It suffers in all the protracted intermittents; it be- comes diseased in multitudes of pregnant women ; in women during lactation; in men over-fatigued and exhausted with vigils; in the badly fed and badly clothed; in the intemperate; in the broken-hearted, and in all those who are long deprived of solar light in dungeons and mines. It is the sole pathological organ in many samples of frequent deliquium ; in many cases of supposed dilatation of the heart, or the large arteries ; in neuralgia, and other neuropathic maladies. It is constantly affected in children during dentition, and very often in girls approaching or passing through the puberic crisis, and in such as do not regularly menstruate. Disease, or debility of this mem- brane, is in most cases, the puberic malady in girls. It is the chief seat of the pathological deviations in all the cases of what the French call pdles couleurs, and which we term green-sickness, or chlorosis. Its continuance is continuance of the malady ; its cure is the cure of the patient. If you will read Mr. Hassc's article on Endocarditis, in his Pathological Anatomy, you will perceive that this endangium plays an important part in the diseases of the interior of the heart. There is as little difficulty to admit the same power of the very same tissue, whether in the heart, aorta, veins or capillaries, the mem- brana communis, to exert that influence on the health. You may remember the occasion on which I spoke at considerable length to the Clinical class, in Nov., 1846, on the case of a pale young woman, who came into the clinic on account of a goitre; and I beg you to allow me here to make for you a memorandum of what was said by me in the clinic on that occasion, and give an explanation of the motives that led me to recommend a particular therapeutical course for her. I think I counted her pulse for you, and found the beats were 75 per minute ; her respiration was equable and natural as to its fre- quency and completeness. Her face of a dead-white or blanc-mdte hue. She was not emaciated ; her catamenia were suspended. This was the state of the patient while sitting at ease on a chair. But I wished to learn what would be the effect of a slight muscular exertion upon one who, with perfectly sound lungs, ought to be able to make a considerable effort without adding considerably to the number either of PUBERTY. 363 the respirations or the pulsations. In order that a muscle should con- tract, there must be sent into it a stream of nerve power—call it excito- motor, if you prefer. But that stream is developed in the brain or spinal cord, and the stream will not flow if the source be not supplied. In a sitting posture, the supply was abundantly equal to the demand. But let us see whether she could obtain the supply under strong effort, with the heart and lungs acting at their present rate. I presume she cannot; and my reason for so thinking is this : I find her pulse soft, compressible, large; her skin pale; the rosy tinted mucous membranes of the mouth and throat whitish, bleached; her lungs, on percussion and auscultation, perfectly healthy, and, in fact, while she sits here and has nothing to do, she is well enough; because, with the present rate of her circulation and respiration, there is generated a sufficient amount of nerve-force to innervate all her muscles, and, indeed, all her organs. Were she lying down, the necessity for all muscular exertion being suspended, the supply of innervative power is superabundant, per- haps. How is this nerve-stream produced ? Is it not evolved by the action of the blood upon the matter of the brain ? I mean, in strictness, the action of oxygen on the matter of the brain. Can black blood, or venous blood, or hydreemic blood, determine in the brain the evolution or extrication of the sufficient nerve-force, the nerve-stream ? If you enrich the blood by good diet; if you highly oxygenate it by exercise in the air; if you increase the impetus of it by motion, by champagne, by nitrous oxide gas, by the exciting passions of the mind, do you not increase the energy of the innervative force by sending into the brain larger supplies of oxygen in its vehiculum the blood ? But in the present case, if I am correct in supposing this girl's blood to be thin, watery, aqueous, how can she, upon any considerable necessity for ex- traordinary evolution of nerve power—how can she get at that evolu- tion, sending there, as she now does, a dilute, aqueous, hydraemical fluid instead of the rich stream which circulates in your vascular system. If she must make the effort, she must apply the material; she must inject the oxygen into the brain: and how? By increasing the rapidity of the injection : how ? By doubling or trebling the number of pulsa- tions, and increasing their force. That immortal physiologist, Xavier Bichat, has set this matter in the clearest light for us. He has shown us that life, in the mammal, consists in a trinitarian power of the brain, the heart, and the lungs. When once endowed with the gift of life, we cannot put it off but at one of the angles of this triangle. The blood is oxygenated in the lungs, the heart injects it into the brain; the brain, touched by the oxygen, is compelled to send forth 364 PUBERTY. the stream of innervative force to all the organs. If the lung dies, no more oxygen, no more nerve-stream, and the cessation of all motion, which is the consequence, is death. Again, if the heart dies, no more oxygen reaches the brain, whence flows no more the nerve-stream to the lungs; if the brain dies, no more motion, no oxygenation of blood in the lungs, and no motion of the heart to inject it to the brain. This is Bichat's view. But do you not, under this aspect, perceive that, if the blood in the lungs is not healthful, the oxygenating power will be incompetent, to a certain extent, and the brain, to a certain extent, will fail to radiate its nerve-force to the organs, and so, as to all the consequences of such a dyscrasy of the blood ? The pale girl near us has blood incompetent to be endowed perfectly with oxygen. But so much oxygen, so much nerve-force—so little oxygen, so little nerve-force! In the healthy individual, fourteen or sixteen respirations per minute suffice to oxygenate the blood perfectly; in the unhealthy, there may be required twenty-eight or thirty-two respiratory acts per minute to produce the same result. It is not rare to see the respiration rise to sixty; for without our oxygen we die: and if fifteen breathings will not endow us with enough, we must breathe fifty, sixty, or one hundred and twenty times per minute. Suppose the blood of this patient to be represented by corpuscles 50, albumen 80, fibrin 10, then the water must be 860; but it ought to be 790. Do you think that blood, whose water stands at the figure 860, can carry so much oxygen to the brain as that whose figure is normal, or 790 ? And, if there be demand for considerable nerve-force, can it, without increase of the pulsations and the respirations, be yielded either to the reflex innervations or to the voluntary ones ? Do you not know that, when the ordinary rate of the respiration becomes insufficient, the free will of the patient comes to add the force of its innervative power to the ordinary respiratory innervations, and that an instinctive feeling of the necessity of air com- pels all the nerves connected with the act of breathing to lend their aid in carrying on that functional act ? The medulla oblongata knows the system will die if it redouble not its power and influence. On the 7th of Dec, 1840, Professor Allison, at a meeting of the Royal Society of Edinburgh, read a paper " On certain physiological inferences which may be drawn from the study of the nerves of the eye- ball." From that paper, Trans. Royal Soc. of Edin., p. 83, vol. xv., I shall quote the following paragraphs :— " The indirect, and probably modified, influence resulting from voli- tion, and transmitted through the ganglia to the involuntary muscles, and of which we have this unequivocal example in the eye, is in itself, PUBERTY. 365 in all probability, an important part of the design of nature in the con- struction of the sympathetic nerve and its ganglia. "I perfectly agree with Miiller that it is in this way only that the effect of muscular exercise on the action of the heart, and much of the beneficial strengthening effect of exercise, can be explained." Let us try the experiment in our case. Accordingly, the young woman descended the staircase to a lower floor, some twelve or fifteen feet, and then returning on the ascending stairs, came to take her seat again in your presence. Her pulse, when she left the amphitheatre, was at 75, and when she had come up the stairs, after an absence of two minutes, it was 150. The respirations, at 18, had become 36. She was out of breath, and the heart in a state truly deserving to be called palpitation. As I am desirous to be understood, I am sure you will allow me to give a rationale of this change. The act of descending the stair was, probably, not accompanied with any, or, if any, with slight augmentation of the heart's frequency, be- cause little muscular effort is required to descend; but the labor of lift- ing a body in opposition to gravitation is great—hie labor, hoe opus est —and the brain could not supply the nerve-force, when stimulated to do so by a hydraemic blood, injected at a moderate rate. The first step in ascension is therefore caused by a great effort of the free will, which is itself a FORCE, and which determines the muscular innervation; but such an exertion of the Free will is consentaneous with augmented evolution of the excito-motory force determined to the heart. The mere intenseness of the effort to rise upon the first step is sufficient to determine an increased activity of the heart's motion, perhaps, upon the principle of the physiological reactions. M. Dessaussure, in his ascent of Mont Blanc, found that, at the height of ten or eleven thou- sand feet, none of his party could move more than a few feet without panting for breath and being compelled to rest a few moments before renewing the attempt to ascend. Dessaussure and all his men were, though in good health a few hundred feet lower down the mountain, actually in the state, as to respiratory power, in which the anaemic girl is found at the level of the base. That is, the blood, though its crasis was not different on the mountain, could not convey to the brain the necessary quantity of oxygen; for with the barometer at sixteen or eighteen inches, so great is the rarity of the atmosphere that two or three ordinary aspirations of air could not impart so great a quantity of oxygen to the blood as one moderate one would endow it with at the sea-level. My patient, coming from the lower floor, is compelled to breathe fast, and to redouble the systolic efforts; and thus you see is 366 PUBERTY. set on foot a train of innervations of the locomotive muscles and of the heart's muscles commensurate with each other and commensurate with the wants of the occasion. Her state at this level is precisely like that of Dessaussure at an elevation of eleven thousand feet on Mont Blanc. By the time- the young woman had regained her seat, the heart, the brain, and the lungs were all in a fury of excitement, which soon sub- sided, as it always does, upon a cessation of the effort. Here, then, is a case, in which the organs are imperfectly innervated while the patient is in the act of taking exercise, from want of power to supply the brain with the normal quantity of oxygenated blood. The Dessaussure party presented the same phenomena, merely because they were breathing a rarefied air: they were not diseased. The girl who manifests the same phenomena is diseased; she has too little oxygen; and the disease is de- bility of her endangium. I do not say, endangitis or phlebitis, but loss of tone of her blood-membrane. What is the indication ? To restore the tone to her blood-membrane. If you can effect that, her cerebro-spinal axis will innervate all her organs healthfully—and she will be restored to health. I hope that you now understand my meaning on this subject; if you do understand me, it is because I have been enabled to explain a mean- ing that I myself understand ; if you do not, I have reason to fear that my own views are confused, unclear, indeterminate. Be that as it may, it is very certain that, for some years past, I have acted under these views, in my therapeutical prescriptions, for a great number of such cases; and that, with a result so satisfactory, both to the patient and to myself, as to confirm me in the validity of the theory or rationale under which I make choice of the remedies for the case: the prime indication being to cure the membrana vasorum interna, the endangium, the lining membrane of the bloodvessel—the blood-membrane. Let us now return to the consideration of the girl approaching to her puberic age. She is turning from childhood into the new paths opened for her career. Her bones are to become solidified and expanded in their dimensions. The little hipless creature that you leave at home in January as a child is found, when you return in November, to have been changed into a woman. The great broad haunch bones are already formed, and in so short a time. The epiphyses are consolidated and indissolubly attached; the marks and traces of distinction in the pieces of the sacrum and the coxalia are all gone; for the pelvis has been prepared during your absence to bear the weight and the strain of gestation and labor. The organs within have acquired the consistency, and the forms, and the capacities requisite to enable them to fulfil their great PUBERTY. 367 destiny and office. The stature has increased ; the round and swelling limbs and the panting bosom have taken the place of that angular, and lean and awkward form that you left behind at your departure, and the whole creature, as to her physique and her morale, has been transmuted as by the stroke of a magician's wand. Does this cost nothing of life- force, life-effort, life-expenditure ? Is not this great and sudden trans- formation and loss a stage of crisis and danger ? Do you not perceive how needful it is to watch over and provide against the assaults of dis- ease for the young girl ?—how her alimentation should be sustained by food, by the stimulation of insolation, of the open air, and the habitua- tion to exercise, which is the absolute requisite of a perfect nervous induction. Suppose she be badly managed, and, feeling badly, as often she does, she is indulged in a lounging life at home, with the imagination on the rack of some passionate novel, and the digestion on the rack with cates and comfits, and every trashy aliment which her pica and malacia could prompt her to indulge in. But this is not all: the young lady must be educated ; she must learn astronomy, God wot! and algebra ! she must speak French and Italian, at least; it is imperative for her to have studied Latin, and geography, and rhetoric, and history, and natural history and chemistry, and music of the piano the harp and the guitar, and drawing and embroidery, and dancing; but she cannot make puddings, nor milk the cows, nor confect an apple pie, nor sew, nor knit, nor spin, for her destiny is to rival the lilies of the valley. Behold them ! They toil not—neither do they spin—yet Solomon, in all his glory, is not arrayed like one of them. But they are truly the she lilies of the world—pale, feeble, flitting, and not living through life. See how a strong-minded, well-educated woman deems of them:— "It would seem," says she, "as if the primeval curse which has written the doom of pain and sorrow on one period of a young mother's life in this country, had been extended over all; so that the hour sel- dom arrives that ' she forgetteth her sorrow, for joy that a man child is born into the world.' Many a mother will testify, with shuddering, that the most exquisite sufferings she ever endured were not those ap- pointed by Nature, but those which, for week after week, have worn down health and spirits, when nourishing her child. And medical men teach us that this, in most cases, results from a debility of the consti- tution consequent on mismanagement of early life. And so frequent and so mournful are these and the other distresses that result from the delicacy of the female constitution, that the writer has repeatedly heard mothers say, that they had wept tears of bitterness over their infant daughters at the thought of the sufferings they were destined to under- 368 PUBERTY. go. A perfectly healthy woman, especially a perfectly healthy mother, is so unfrequent, in some of the wealthier classes, that those who are so may be regarded as the exceptions, and not as the general rule." Such is the language of Catharine E. Beecher, and I wish you would all read it, and the rest of her wise and common sense, and yet wo- manly observations, in her delightful Treatise on Domestic Economy. You will find the above passages at pages 42-43. If a girl grow up like a pine knot, she can't be hurt—you may do what you please—she is too tough and strong to be hurt by any educa- tional process. But if she be truly a lily—lily white in her complexion— tender and trembling in her feebleness, like the flower on its stem—what hope have you to be able, in the binary consumption of the thought- power and the development-power (both coming from the same ence- phalon), to carry her securely through the dangerous way in which her puberic age must walk ? The girl has need to grow and become of full size and strength ; but, if you send her to the boarding-school, and place her on the school- form, and put before her some dull and unintelligible gallimatias of grammar or mathematics; if you compel her to commit to memory mille versus stans uno in pede, how can she be expected to preserve her health and attain to those important developments ? There is a passage in Raciborski's pretty work, De la Puberte, &c, at page 44, which concurs with my own observation and experience as to the influence of studies on the young girl. " I learn from a physician attached to one of the largest boarding- schools in Paris, that the young ladies of the establishment are, for the most part, very tardy in making their change ; and that, when they have become catamenial, the menstrua are often very irregular." M. Raciborski adds that " the physician could not well account for this peculiarity otherwise than by referring it to the nature of the diet, which, he thinks, is not sufficiently tonic. When these young ladies go home to their parents during the vacations, and remain there a short time, the catamenia become very regular, but are deranged again soon after their return to school." I have attended at different times in some of the boarding-schools in Philadelphia, and I have never attributed the failure of menstruation to any dietetic cause, because young ladies are well fed in those esta- blishments. Yet, I assure you that it is very common for me to find young women who have grown up admirably, and have turned through the straits of the puberic age in perfect safety and with complete suc- cess, to lose, in five or six weeks, the habit of menstruation, upon bein<* brought to town, and set on the school-form and compelled to undergo PUBERTY. 369 the fatiguing labor of mental and educational discipline and culture. Such a patient is too busy with the mind to attend to the body—the confinement, the study, the devotion of innervative power to thinking in one train of thought, interfere with the healthful innervation of the muscles, the skin, and the alimentary apparatus; the biliary organs give way, the kidneys fail to cast out the nitrogenous surplusage of the economy, and the whole mass of the blood loses its fine and delicate crasis, while the endangium itself loses the power to keep up the con- stitution of the blood to its normal standard. In this condition of the whole system, where the organs have lost that harmony of life that is essential to the well performance of all the functions of life, there is no need for us to be surprised if certain of the offices of the economy, those exquisite deuto-biological offices, that rest like the topmost stone on the summit of the pyramid, should first fail to be manifested, or that they should be' among the first to disap- pear where they have been once already made manifest. Indeed, almost the first perceptible change in the health of the fe- male is the disappearance of the catamenial force. Do you not remember that, while I was discussing this subject in the lecture-room, I said that life in the general might be likened to a rocket? The flashing train rises out of the thick darkness of night, and, glowing more and more the higher it rises towards the heavens, gives out, at length, when at its highest point of ascension, the last brilliant flash that fills the whole air with sparkling diamonds of light—the most per- fect part of the exhibition : so in the female—the life has reached its high ascension when, at its culminating point, these sur-vital manifesta- tions are beheld. But a woman in health will menstruate : therefore, when a woman does not suffer her regular monthly evacuation, it is because she is not in health. There is want of harmony somewhere in the play of the organs. She, in general, does not become sick because she does not menstruate, but she ceases to menstruate because she has fallen sick. To make her become regular again, it is only necessary to restore her health—for she is a menstruous creature, and will always fulfil her natural law if something does not prevent her by acting upon her con- stitutional health injuriously, and so prevent that constitutional force from developing all the antecedents of the visible signs of the mensual office. This is true of woman in general, but I deny not that the first blow may be struck at her health by suppressing her catamenia. Yet, I think, this is a rare case. Certainly it is a rare case, as far as my opportunity for observation has enabled me to judge of it. 24 370 PUBERTY. For example, I have known many to lose their catamenia by severe application of the mind to studies ; many to lose it in consequence of catarrhs, fevers, consumptions, &c. &c. It is true, also, that I have many times been consulted on account of a suppression of the evacua- tion from cold, and from other slight causes. Yet, out of the vast majority of these last-named cases, there have been very few who had any lasting trouble from the suppression ; inasmuch as the next opera- tion of the periodical cause being perfect, the evacuation has been regularly restored. It is easy for you to understand, however, why it sometimes happens that a sudden suppression of the menstrual flow, in mild cases, or at the very commencement, or in the case when a suppressing cause has been applied just before the apparition, should lead to a long train of morbid actions. Here is a case in point. A young lady, in consummate health, wished to go to a ball. But, unfortunately, in the afternoon, before the time for dressing arrived, she was seized with her courses, which were generally profuse; and she began to fret at the occurrence, as she was afraid to appear at the gay scene of the dance, situated as she was. Her nurse, an old and confi- dential servant, much attached to her, said, in order to quiet her grief —" My dear, if you won't tell on me, I will arrange it so that you shall go to the ball." " Oh! dear nurse, do, and I'll love you forever." The nurse brought a large tub full of fresh cold water, and bade the blooming girl sit in it. She did so ; the menstrua disappeared. She went to the ball ; came home before the end with a blinding headache ; was attacked with a brain fever ; lost her bloom, and her embonpoint; and now, at the age of near fifty years, still feels the miserable effects of such a scandalous dereliction on the part of the favorite and confi- dential servant. The uterus and the ovaria, and all the branches of the hypogastric, the sciatic, and the ovaric arteries, were full—it was full tide with all that system of vessels—the accompanying nerves were all ripe and rife with the periodical excitement. The cold hip-bath produced instantly a spasmodic closure of the excreting orifices in the womb, and the uterus and ovaria became instantly the seats, not of an out-flowing affluxion, but of intense engorgement, which, reacting as a disturbing force upon the cerebro-spinal system, laid at once the train for years of ill health. That lady's whole life was rendered a scene of bitterness—of vapors and caprices—by that single hip-bath ; it shocked her nervous system ruinously. Many women, who were in the full flow, have sent for me, to say the flow had suddenly ceased from wet feet, from cold drink, from cold PUBERTY. 371 bathing, from pathema mentis, &c. &c. I have found them in agonizing headache, neckache, backache, nausea, courbatisme, throbbing pulses, and the most exaggerated calorific power. Such cases do not excite in my mind any solicitude for the safety of the patient. A venesection, an aperient emollient enema, a dose of castor oil, some camphor and opium made into pills; these are usually followed by remission of the distress. The constitution is again brought into obedience to the laws of healthy innervation. The next Graafian follicle fills, rises to the surface, bursts, and the mensual hemorrhage goes on, at the due point of time, as if nothing had interrupted for a moment the regular play of the functions. So often have I found this representation of the case to be carried out in the action of the organ- isms, that I fear not to allay the alarms and misgivings that arise in the mind of the patient, or her friends, with assurances that nothing is to be apprehended from such incidents in the health. Nevertheless, interruptions of the monthly efflux, produced suddenly, as above supposed, may leave the whole reproductive apparatus engorged, and even subacutely inflamed. The currents introduced into them by the spermatic and uterine arteries, and the branches of the ischiatic; and the nerve streams that accompany all these vessels as their regents and moderators—these are disordered in their very structure, crasis, and chemical constitution, and the next period of elimination may fail because the ovarian stroma is become unhealthy. But this ovarian stroma—this vitelliferous, and therein germiferous, organ, whose import- ance I proclaimed in my second letter, has now become a disturber of the constitution. Its nervous connection and relation to all the plexuses and nerves of the whole splanchnic system enable it to call them into sympathizing disturbance, and the health is overthrown. The emulgent artery, the cceliac, the mesenteries, and all the concomitant cortege of nerves are disordered, and now we have disordered renal action. The vast portal system no longer plays its healthful part in the eliminations for which it is provided and appointed. Emaciation, opaque skin, dyscrasia of the blood, palpitation and irregular action of the heart, with consequent morbid states of the innervations, proceed from bad to worse, and we behold the victim of a checked menstruation laboring under all the complications expressed in the term chlorosis, or green sickness. But if all this may come from a check of an established men- strua, a fortiori, it may accompany a hindered or prevented one. If the mass of the blood becomes affected with dyscrasia, from what- ever cause, we have at once a diminished power of the nervous system, whose force, whose product (the neurosity), is the result of the contact of oxygen with the matter of the brain. I have not forgotten that, 372 PUBERTY. though neurine and oxygen give out neurosity, there may be qualitative differences in the neurine, and quantitative differences in the oxygen; that a brain and nervous system may be good or bad, healthy or sickly, vigorous or feeble; yet that all these differences may, to a certain extent, depend upon the qualities of the blood, its capacity for oxygen, or for heat, its pressure, its momentum. The nervous system, though it be the essential Ens, is produced from the blood, out of which all the solids of the body are made and constituted into organs. I have no doubt the brain itself is frequently altered in its density, in its perceptivity, and its power to extricate neurosity for the innerva- tive acts of the economy; in some cases acquiring a double portion of such faculties, and in others nearly losing them. When lost, it is death. There is a hyperneuric as well as a hyponeuric health, as stated by Dr. Cerise. Since the introduction of the process of etherization, in surgery, we see abundant examples of the modification of the powers of the brain and nervous system made by that agent. M. Flourens has shown that inhalation of ether, to a certain amount, siispends first the action of the hemispheres, next that of the spinal marrow, next the quadrigeminal tubercles, then the cerebellar lobes, the spinal marrow, and lastly, the medulla oblongata, which last he regards as the noeud-vital. As long as the noeud-vital remains unaffected by the ether, respiration goes on, and the other parts of the brain may recover; because the noeud-vital, being the seat of the respiratory power, can compel the oxygen of the air to enter into the blood, and arouse the rest of the cerebro-spinal axis from the insensibility into which the ether may have plunged it. If the noeud-vital becomes engourdi, respiration or oxygenation of the brain ceases, and the animal is dead. You see, then, that, you can in a moment render the brain hyponeuric by ether, as you can also render it hyperneuric by champagne or nitrous oxide. I have no inclination, and, indeed, it would be out of place in this letter, to enter largely into explanation of the state of the system in chlorosis. Chlorosis is often something more than anaemia; it is often glandular disease—and is connected with various states of hepatic and intestinal disease. What I have said, I have said with the design of inviting you to reflect upon this important question, viz : What are the evils to be feared from a puberty imperfectly effected and ignorantly conducted ? My representations above ought, I think, to show you that the puberic age is one that deserves to be carefully watched and wisely treated, for certainly, in this country at least, too little regard is paid to the dangers of the crisis ; and when the threatening consequences of mismanagement or misapprehension have become startling, those PUBERTY. 373 fatal mutations are attributed to some trivial cause, and the victim passes away to the sound of the passing bell, and no increase of know- ledge, acquired by such a mournful experience, stands in the way of the next victim to a management as unwise and as thoughtless. I find that I have, in my letter on puberty in girls, lapsed into a discus- sion of some points of the doctrine of menstruation, in which I have anti- cipated observations more appropriate, perhaps, to that special topic; but puberty in girls, after all, has reference chiefly to the establishment of the menstrual office, and I could not well avoid falling into such a train of thought. I wished to show you that, if you do not take wise care of the health of the growing females of a family committed to your care, as physicians, you will have the pain to witness their early sub- jection to dangerous and fatal disorders ; or else to see them, even after the puberic phenomena shall have been all made manifest, and the age of puberty indeed past, suffering those derangements of the health which serve to render them useless to their friends, inefficient as the heads of families, and unfit to encounter and discharge the stern obli- gations and duties of life. Many are the examples I could cite from my memory of persons who, even after being married for years, and after having been regularly menstrual, still continued to labor under the effects of a badly passed puberty ; showing these effects in an over- excitable circulation, excessive nervous susceptibility, dysmenorrhoea— though regularly menstrual—sterility, and the impatience and discon- tent that necessarily wait on feeble health and disappointed expectations; some, recovering completely under a careful treatment; and others falling into weakness, and becoming, at last, victims of consumption, menorrhagia, or other disorders of which the foundations had been laid in an improperly conducted physical and moral education. As to our own fair countrywomen, I think it is true that, as a general rule, the women of the United States break very early. I appeal to your own observation for support*of this assertion. A lady here, with two or three children, is generally without color—pale—fatigued, and attenuated. Perhaps this early break-up of the constitutional force of females may be, in part, attributed to the nature of our climate, which, from the violent and rapid revulsions of its temperature moisture and pressure, as well as from the intense force of its light in summer, is more exhausting to the life-powers than the cooler and more steady skies of Europe, where women certainly preserve their youthful ap- pearance to a later period than here. Those of you who reside in the Southern States, will have observed the very striking difference be- tween the appearance of persons who have spent the summer in the North, and those who have waited during the hot months, in Georgia, 374 PUBERTY. Alabama, and the other southerly regions of the United States. Hav- ing spent the early part of my life in the South, I was accustomed to see my friends and acquaintances return from the North, at the close of the hot season, looking ruddy and healthy in comparison with the fatigued and exhausted aspect of those who had drawn out the long summer season at home—and I am sure that no one can arrive even in our northern ports in August and September, from a trip across the Atlantic, without being struck, and even painfully struck with the air of ill health that is visible in the faces of the crowds on the wharves and streets of places so far to the north as New York, and even Boston. The cold weather of winter and spring restores to them the hues of ruddy health, in order that by the close of the ensuing hot season everybody may be again pulled down, to use an expression much in vogue in our country. The western coasts of Europe do not possess such brilliant skies as ours. The veil of mist or cloud from the Atlantic, that is almost al- ways spread over their heads, prevents the excessive radiation of solar light and heat, and the powers of the body are, consequently, not ex- hausted by over-stimulation from these causes, as is exhibited in the hurried pulse, the profuse diaphoresis, and the almost universal bilious or sallow hue, acquired by the complexion on this side. If I am not incorrect in attributing to the brilliant skies of the United States morbific powers of a most inconvenient kind, then I am surely correct in the opinion that young girls, approaching and passing through the puberic crisis, ought not to be incautiously exposed to those influences. I speak only of those whose condition may seem to require your counsel, and not at all of those (the infinite majority) hardy and healthful people who never give cause for apprehension as to their sana- tary condition. Your delicate patient requires light as one of the conditions of health, but not too much light. I have already, in my putative con- versation with Miss Helen Blanque, in my XII. Letter, expressed my opinions as to the necessity of light as a condition of healthful life, and I have no reason to distrust the sentiments therein expressed. But an incautious exposure during the summer heats is exceedingly enervating. Such exposure excites the movement of the blood, and augments too considerably the calorific power of the lungs. It pro- duces a quasi feverish state of the body, which is only kept down by copious perspirations, that exhaust the activity of the cutaneous capil- laries and nerves, and introduce derangements of the secretions that depend on the termini of the great splanchnic or digestive vessels of the abdomen. All those secretions are effected at the expense of the PUBERTY. 375 cceliac and the two mesenteric arteries and their termini, and it is un- deniable that the sanguine circulation in those vessels and the portae has a close connection with and dependence on the cutaneous organ. Do I recommend that the young girl, at the season of puberty, should lead an idle and inactive life ? Far from me the thought! I repeat that I think every such person should be exercising in the open air, to the extent of walking many miles daily. But from the 20th May until the autumnal equinox, that exercise cannot be well taken later than nine o'clock in the morning, and at evening hours when the sun has descended so near the horizon as to lose the power of a too violent ra- diation. There is freshness, as well as humidity and coolness, in the early morning air, that imparts greater vigor to the constitution than that of later hours. Early rising and early walking, then, ought to be recom- mended to all such persons as are directed in a course of training for health. But early rising is unendurable except for those who retire early to rest. They go hand in hand with each other. The young girl should be at rest before ten o'clock at night; then at five o'clock in the morning, she will be fitted for a walk of two or three miles ; it is easy to walk three and a half to four miles an hour. Such a walk in the early morning air, after eating a biscuit and drink- ing a glass of water, would give appetite for breakfast and power for its digestion. A walk of three or four miles in the evening, before and after sunset, would furnish the requisite amount of out-door exercise, say seven or eight miles a day. An amount far, I fear, beyond that taken habitually by the young portion of the sex in the United States. I am much accustomed to make inquiries on this head; and I lament to learn, as I often do, that young persons of the class under con- sideration frequently pass many consecutive days without walking a mile per diem in the streets, or roads, and paths in the country; and even without going out of the house. Physicians are the health officers of society. I would that physicians, as a body, were awake to the importance of so guiding the public mind on all topics connected with the conservation of health, as to exert the whole influence of the profession, a great influence, in im- pressing upon the public mind clear and sound notions in regard to those hygienic uses and appliances which the public either know not, or overlook, perhaps, in the hurry and cares and embarrassments of the business and occupations of the world. It appears to me that common sense and daily observation ought to teach the necessity of exercise as a means of preserving the health of 376 PUBERTY. man, since in a natural state he is compelled to do so. The social con- dition of man has in some degree lessened this necessity; for by nature he was doomed in the sweat of his brow to eat bread. Society has enabled him to eat bread without perspiring for it, and the luxurious and effeminate manners of the times seem likely to grow more and more Sybaritic under the labor-saving results of the improved machinery of these modern days. A physician ought to exert the intellectual power which, by his posi- tion in society he is presumed to possess, in protecting society against the evils of ignorance on hygienic subjects. Forty thousand medical men in the United States should not always allow their day and gene- ration to pass away without leaving some signs of progress and effect- ing some amelioration of the condition of society, beyond the mere restorative results of their therapeutical prescriptions. I fear that so much intelligence, so much power is nearly restricted in its beneficence to the cure of the sick alone; whereas, it ought to be capable, not only of preventing the onset of many diseases, but also of greatly lessening the violence of the cases. Have we not reason to be ashamed that our profession has not advanced one step, in a progress towards the public approbation and confidence, since the Revolution of 1776 ? It is to be doubted whether there is not more quackery in the United States, and in Europe also, than there was two centuries ago. We the true custo- dians of our Guild, how have we guarded it ? It is filled with hydro- paths and homoeopaths, until the people can make no distinction of Doctors. Will it be ever so! You who are young, and who ought therefore to be both ingenuous and generous, will you not do something to place our vocation in the clear light and just confidence of which we know it to be worthy ? See to it then that your generation shall not pass away without leaving some mark upon society. If nothing else, strive at least to make the people see and know that, as a class, we are in the main, the most educated, moral, and dependable men of the age. In the conduct of those cases where doubts as to the successful effectuation of the change into menstrual life may cause you to be con- sulted, I trust that you will never confine your attentions to the mere point of compelling the young person to have a show. Indeed, if you take up just views of the nature of the catamenial office, I am persuaded you will not do so; since you will know that, if she produces and evolves germs, the girl will menstruate; while, if she does not produce them, you cannot cause her to menstruate. You can make her bleed, perhaps; nay, you can, very certainly, make her bleed by leeches, with cups, or with the lancet; but every tyro knows that to bleed a woman PUBERTY. 377 every twenty-eighth day is not to satisfy the physiological demands of nature in menstruation ; because nature does not require merely the loss of so many drachms or ounces of blood, but she does require that the important organs should all enjoy the power of exercising the functions appurtenant to their several natures. When they do so, the economy is healthy; when they fail therein, it is sickly. A woman has the shoiv solely because she is ovulating. It is a small matter whether she have the show or not, provided she ovulate properly, for that is the thing; and I assure you I have met with several instances of women who had no womb at all, not the least, yet they were very healthy, very pretty, very strong and ruddy-looking women. They had all the signs of a pubertas plena, except the show. You cannot doubt that these women, whose passions were remarkably strong, did ovulate as regularly as any women. They never had nor required to have any vicarious excretion, and to ovulate, was for them to fulfil the menstrual act. The prime interest in the conduct of the case is, first, to explore and understand its nature and all its peculiarities and wants. This seems to me by no means a difficult task, provided one goes the right way about it. For example, suppose a young person presented to you for examination, and that you proceed in manner as follows, by question and answer:— " What is your age, child?" " Fifteen years, sir." " Are you sick?" " No, sir. They say I'm sick, but I don't feel so !" " Have you ever been sick ?" " Yes, I had measles, and scarlet fever, and whooping-cough; but that was a long time ago. I have also had some bad colds, occa- sionally." " Do you feel strong and healthy ?" "No, not very; but I'm not sick though." " Are you as fat as ever you were; or are you thinner than you used to be?" " " Why, I am thinner, I suppose; but not much." " Do you go to school ?" " Oh, yes, I go to---------'s school." " When does school let in ?" " Eight o'clock in the morning." " How long before it lets out ?" " Half-past one." 378 PUBERTY. " That's five hours—a long session ! but what are you doing all that time ?" " I am studying my lessons and reciting them." " What lessons ? What is your daily work in school ? Tell me all about it. Tell me the whole course of a day's schooling." " Why, when we assemble, we have prayers, then a chapter in the Bible, then a hymn, and close with a short prayer; after which I recite my lesson in spelling, then English grammar, and next, one in geog- raphy." " Why, when do you get all these lessons ?" " In the evenings, at home." " Do they keep you late up ?" "Until nine or ten o'clock, only." " Well, what comes after geography ?" " Oh ! I write copies, and then study my Latin grammar. When I've got the lesson, I conjugate the verb, and decline a few nouns and recite some rules." "What next?" " I study fifteen or twenty lines in Virgil, which I construe for the teacher." " Does he make you parse it and scan it ?" " Oh yes, sir, to be sure ; always." " Have you any other studies ?" " Y^es, sir, French." " And you commit to memory in French, too ?" " Yes, and read, and translate, and write exercises." " Anything more ?" " Algebra." " What, algebra ? Oh !" " Oh yes, sir! And then we have lessons in drawing." " What do you draw ?" " Landscapes, maps, &c. &c, as figures, flowers, and what not." "Any music ?" " I have a lesson on the piano three times a week; but mother makes me practice two hours every day; one before I go to school, and one in the evening." " My poor child, I am sorry for you." " Why are you sorry for me, doctor?" " I am sorry to find that you work so hard." " Oh no, sir, I am delighted with it." " No doubt! no doubt! but it will ruin you. I don't believe there is anything the matter with you now but schooling. Bless your dear PUBERTY. 379 little heart, you ought to be chasing butterflies, or training flowers, or weaving them into pretty coronals, such as white morning glories, pale as yourself, would make ; or you should be dressing dolls, or galloping the pony, or dancing, or dawdling. You must not do so much work at school, my poor little thing, and you shall not, if I can prevent it. But come, tell me about your health. Do you walk out to the Schuyl- kill every day ? or as far as the College ?" " Oh no, I've no time ! Didn't I tell you I go to school at eight o'clock and come out at one ? And then I have two hours in school, afternoons." " The d—1 you have !" " What did you say, doctor?" " Nothing, only an ejaculation ; from a sudden pain I had. When do you get to bed, my dear ?" " About ten o'clock, or soon after ten." " Do you sleep soundly ?" "Not always; I often get frightened in my sleep with what they call nightmare." " I don't wonder at it. I should think your poor little head would be too tired to sleep soundly ; and that you would have a nightmare in the shape of a monstrous folio grammar, or dictionary, sitting up on its hind legs, just like a great big kangaroo with a pair of spectacles as big as two moons on its nose, staring at you from a pair of dead- looking eyes." Why, what a notion, doctor !" " Notion ! I'm sure so many books are enough to make you dream, and spoil even your appetite by disturbing your sleep. Do you eat hearty breakfasts ?" " No, doctor ; I have but little appetite for breakfast. I take some cold water and a slice of bread and butter, and after my piano practice, make haste to school; for I am so tired in the morning that I can hardly get up, and that keeps me late." " How's your dinner ?" " Oh, I like pies and preserves, but I can't bear meat; and as for soup, I hate it." " Oh, dear! poor child! Alas for you, you poor little thing ! Those pies and preserves ! Do you remember Queen Mab who drives over ladies' lips ?— "Which oft the angry Mab with blisters plagues, Because their breaths with sweetmeats tainted are." Come here; sit by me, and let me feel your pulse. Don't be frightened. There, now. Your pulse beats eighty times a minute; and you are 380 PUBERTY. fifteen years old, you said. You are breathing twenty times a minute. Are you oppressed in breathing ?" " What do you mean, doctor ?'' " I mean to ask if you can draw a great long breath. So—try it now." " Why, it hurts me." " Where does it hurt you ?" "Nowhere in particular; it is rather disagreeable than painful.— It seems like weakness and a tired feeling." " It does not make you cough, does it ?" " No, doctor." " Have you headache often ?" " Oh yes, my head always aches when I wake in the morning; and if I run or skip the rope, it aches and swims, and beats dread- fully." " I should think so. When a body is pale like you, any exercise makes the head beat and ache. Do you remember ever to have had red cheeks ?" " Oh yes, doctor. My cheeks, when I was ten years old, were red as the inside of a conch-shell." " Have you grown much of late ?" " Oh, monstrously; I have grown half a head taller in eighteen months." " Where's your mamma ?" " She's up stairs." " Go, call her to me. You need not come back yourself. I shall send for you if I want to see you again." "Pray, madam," said I to Mrs.----, when she came into the parlor, "what do you suppose ails Miss Mary ?" " I can't imagine what it is that has changed her so, doctor. She used to be the healthiest child in the house ; merry as a grig, always singing and dancing ; but now she is dull and moping, and has grown pale and thin, and has no natural relish for food. I suppose it is a change working in her. Dont you think so, doctor ? She is fifteen !" " I cannot tell. It is probable that her constitution is making an effort in that way ; but I wished to ask you some questions that I did not like to address to the child herself. Can you tell me what is the state of her digestion ?" "As to that she is very irregular; sometimes costive, and then again very much the reverse, and that without any evident cause for it. I suppose it may be owing to her living, for I can't get her to eat any PUBERTY. 381 good food. She likes nothing but cakes and sweetmeats, candies, and all such trashy stuff." " Is there any change in her temper ?" " Yes, doctor. She is more irritable and cross than is her nature to be, and she is easily put out; the least thing makes her cry.—Indeed, we find her very much changed of late." " She has never been unwell yet, I suppose." " Once, about four months ago, her nurse told me she had seen a very slight mark of change, but it was merely pour marquer, not any- thing of consequence, and has not returned since. We are very much concerned about her, for we find she is growing pale, thin, and loung- ing ; she cannot be persuaded to walk out, nor does she like to go out in the carriage. Nothing pleases her so much as books. If you give her a book and a sofa, she is perfectly satisfied. But I fear she reads too much, and that her lessons are exhausting her." " My dear madam, I think if I might venture to speak Latin, I should say rem acu tetigisti—you have hit the nail on the head ; and I am much afraid you will destroy her health unless you make some change in her mode of education." " But, doctor, that is very difficult. You know that schools are managed by classes, and that we must educate our daughters; they must be with their classes, you know. They cannot be always put back ; it disheartens them. What is one to do in such a case ? You wouldn't have her brought up in ignorance, would you?" "No, certainly, not in ignorance; but I should much prefer to have a daughter healthy, sweet-tempered, sensible, and beautiful, without Latin, and algebra, and grammar, than to have one ever so advanced in her humanities, with her health ruined, or, perhaps, lying under a marble urn at Laurel Hill." " Why, doctor, you shock me !" "I intend to shock you, madam! I know what love you bear to this dear child. I am aware that her great beauty and intelligence, and sweetness of temper, render her not only your admiration, but that also of all your friends ; and I am grieved to see that, in the impetuous hurry and press of her intellectual and moral education, you have wholly lost sight of a part of her bringing up, without which the others are of no value, of no effect, but rather poisons, that destroy. I wish to shock you; I wish you to learn that, unless you change the treat- ment, you will lose her. She will die, madam!" " Are you serious, sir ?" " Serious, dear madam ? Serious ! I am more than serious ; I am grieved. I saw a sweet creature within a year, an only daughter, an 382 PUBERTY. only child, indeed, worth to her parents more than a chrysolite as big as herself, done to death by mere schooling. Why, can you not per- ceive that, if this child of yours had nothing to do but grow and enjoy herself, she would be as beautiful as a houri, instead of breaking one's heart, as she does now, with that painful conviction of uncertain health, that inseparably attends a look at her?" " What are we to do then, sir ?" " Do ! dear madam ? What are you to do ? Why, educate her as a sensible woman would educate her daughter." " But everybody insists on her learning all these things ! All the girls learn Latin now." " Not at all; not at all, madam ! Catharine Beecher does not think so ; and she, thank God, is a sensible woman. I hope you will admit that of her. She says, ' It is a well-known fact that mental excitement tends to weaken the physical system, unless it is counterbalanced by a corresponding increase of exercise and fresh air. Young girls, in pur- suing an education, have ten times greater an amount of intellectual taxation demanded than was ever before exacted.' But I will not stop to quote Miss Beecher any further. I will beg you to buy her book, and not only read it yourself, but make Mary read it; for it is full of salutary, every-day truths. All the girls do not learn Latin now, as you said ; and I tell you that to rack her little brain learning Latin is non- sense. She can't learn it, in the first place. She can only try till it makes her sick, and then she'll give it up. Tell me, now, who of all the women in America or England have learned Latin! Nobody. Madam Dacier learned Latin, I grant you, and so did some eminent English ladies of the sixteenth century ; but they would have been much better employed learning to make puddings and keep house." " Ah, doctor! that's the way you men all talk ; you think that women are inferior creatures, and that they cannot learn what is deemed very essential to the education of every gentleman." " Far from it. Instead of thinking that women are inferior crea- tures, I for one look upon them as infinitely superior, in many respects of their understanding, and altogether in morals, to men. But their lot is cast for them ; men did not make it; God made it. They cannot, in the present state of the world, and probably never will, participate in the affairs of nations or municipalities ; because, by the very nature of their moral and physical constitutions, they are bound to the horns of the family altar. If they let go ; if they flee from their refuge, they soon become captive to some tipstaff of an Asmodeus or other evil spirits, who, like constables and thieftakers from the lower world are wandering up and down in the earth, seeking whom they may devour PUBERTY. 383 among unemployed ladies. I do not believe that women are inferior beings. I regard them, on the contrary, as the ministering angels of the race ; as the source of happiness and virtue, as well as its reward. But, in order to be educated, it is surely not necessary to have a smat- tering of Latin and Greek. What is it to Mary that Horace or Virgil wrote their verses, or Tacitus his annals, or Terence his Comedies? She can read Pliny's letters better in Melmoth than in Pliny, for Melmoth is a better writer than his author; and as for Tacitus and Virgil, Da- vidson and Murphy will not rack her brain like the Arma virum-que cano, or the Urbem Romam a principio reges habuere. Mary wants to grow—she wants to grow up to be a woman—not to peer into the amatory elegies of Tibullus and Catullus, or pry into the detestable stories of Apuleius the Madauran. What does she want with algebra ? Shall she rival Leverrier or Arago ? The only arithmetical calculation she requires is the market relation between one dozen eggs at twelve and a half cents, and three dozen eggs at the same rate ; and the un- known quantity she ought to look for is, the proper gentleman, whom the fates and sisters three have in store for her as her future lover. Ah, madam, the ancient literature was much of it lost at Alexandria, and if that blessed St. Omar, who burned it nearly all up, had been lucky enough to get all the Latin school books into the bargain under the baths—I can't say I should be glad for my own particular sake, for I should not; but I am very sure the whole rising generation would be glad to contribute all their coppers and ten cent pieces to make a statue for the shrewd Caliph. The labor of life is a great labor and a long, but there is no toil like that of an overtasked schoolboy or schoolgirl. As for your child, it is true she ought to be educated ; but let her edu- cation fit her for her duties in life, not destroy her health and beauty. Lady Jane Grey and Queen Elizabeth could read Latin, but they had a different destiny from that of a republican's daughter. Let those who are likely to use to advantage the more elaborate parts of early instruction, let them have it, but do not kill them to get it. Ignorance is always to be eschewed; but if I was destined to be a doctor, what use was there in making me study logarithms or lunar distances, or compute the orbit of a comet ? I was brought up to my trade—let Mary be brought up to her trade. What is that ? It is taking care of a family —wisely, happily, elegantly, with a good temper ; to do that, let her learn the world and the ways of it—not too much, though. Educate her in truth and the love of it—in piety, which is the best grace of the sex. Teach her administration—domestic administration. Teach her to have a place for everything—and to put everything in its place. 384 PUBERTY. Make her an economist—not a miser. Teach her to be saving. Do not impress upon her the scoundrel maxim, as Thompson calls it, •A penny saved is a penny got; Till from her board it drives both plate and pot.' Teach her the great virtues, cleanliness and tidiness ; improve her natural propensity to adorn her person, under subjection to the simplex munditiis rule. Let her make herself beautiful and pleasing. Of all things let her be charitable and kind—for charity overcometh all things. Mr. Clay, Mr. Webster, Colonel Benton, and Mr. Calhoun will take care of the politics ; General Scott and General Taylor will take care of the soldiers ; let the daughters take care of the children, and learn to be bright at the breakfast table, elegant at dinner, enchanting as pourers out of tea, and the ornaments and grace of the saloon." " Ah, doctor ! I see how it is; you pretend to be a great admirer of the sex—but, like all the rest, you would condemn them to an in- ferior place." " 11—I condemn them to a lower grade of rank in the body social ? Not I. I am a convert to Burdach's views. I see in them the race, and we men but the supplements. They are the queens in the hive—we but a sort of mixed medley of drone and worker. It is far more noble, in my opinion, and far more elevated, to shed the benign influences that ever flow from the reign and dominion of a fine woman over the family and throughout the circle of society to which they extend, than to shatter men, women, and children, and churches, by ' shelling' out the enemy at Vera Cruz, or giving them ' a little more grape' at Buena Vista. No, madam, I do not disparage the sex by confining them to their domestic duties, but I rather magnify them and make them honor- able. But let us change the subject, or rather let us return to our subject, which is Miss Mary's health, and the conduct of it." " Well, what must we do, doctor?" " It is now the end of June. The heats of summer are come, and the doo--days will soon be here. It ought to be a general holiday. Take Mary to the mountains or to the shore. If you take her to the mountains it is well, if to the shore it is perhaps as well. Among the mountains, she will walk on uneven places, up hill and down. The air is pure, the streams clear and rapid, and there is no malaria ; walking among hills is admirable exercise ; it compels the blood to reach the most distant points of the circulation, and drives it from the deepest recesses of the body. It augments the development power pari passil with the invigoration of the appetite and digestion. There is shade in the deep valleys and dark ravines; and to walk by the side of run- PUBERTY. 385 ning waters, and listen to the plash of their falls, imparts a delicious calm to the soul, while the physical powers, as in a sort of waking sleep, seize the opportunity to renew and restore their wasted strength. " Take her to the shore. There you have the benefit of the breeze from the sea, and the ever-varying spectacle of the ocean's surface presenting new and pleasing sources of sensation. The sounding strand, the leap of the breaker, the ebbing and flowing roll of the waves on the sands ; ships heaving in sight and slowly disappearing: company, conversation, music ; the dance, and, above all, the bathing in the animating surf, present combined means of increasing the health and spirits, that are, perhaps, not certainly, equal to those derived from a visit to the mountains. " If you take her to the hills, let her walk, as much as you dare—at least six miles daily, and, if the country is very hilly, that is more than equivalent to a walk of eight or ten miles on level roads. " If she goes to the shore, be careful not to allow her to bathe too much, surely not more than once a day; nor too long, not more than fifteen or twenty minutes each time. I am quite confident that those who stay very long in the water are weakened by it. They generally come away from the coast thin, and shrunken, and lighter than when they go there. " The sea bath has great power on the body by its saline nature, which is stimulating to the whole skin ; by the motion and effort that those use who bathe in a strong surf; by the delight which the dash of the wave communicates, and by the gayety and joyous feeling engendered by the company of the bathers. ." If she remain very long in the water, her hands and feet will be shrivelled or puckered when she comes out, and it will be after a long time and with considerable effort that the blood will again reach and distend the tissues on the surface and the most distant parts of the limbs. In order to receive any benefit from the bath, there ought to be some degree of such a reaction; but it is wellnigh morbid when it comes too slowly. A person coming from the bath and remaining cold, or even quite cool, for half an hour, has been in it too long. Many persons suffer, from the bath, such a concentration of blood in the great cavities, as the chest, and head, that they find themselves oppressed in breathing, or giddy and affected with headache, upon leaving the water. I have seen many such coming from the bath unable to see, and with intense cephalalgia, and only relieved by the act of vomiting; all which was dependent on the rushing of the blood to the brain, where it had been driven by the cold water from the extremities and the skin. 25 386 PUBERTY. " Take care of Mary's diet. "Let her eat beef, mutton, or poultry, once a day; don't give her the sort of vegetables so correctly denominated in this country, trash. Indeed, you ought to give her eatables with one sole view; that is, to nourish her, to make her grow—to make her stronger and healthier. Don't allow her to swallow a morsel, merely because it tastes good. It would not be amiss, in educating her, to educate her palate. I wish you would buy her a copy of Brillat Savarin's Physiologic du Gotit; it would do her more good, and make a better woman and wife of her than Massillon, or even Telernaque, or Paul and Virginia; for it would teach her what every woman ought to be taught, the difference between an elegant gastronomic taste, and that horror of horrors, foul-feeding in a lady. Only think! only think of a lady eating tripe—or devouring fried haslet!! Oh mon bon Dieu ! It is surely but one step above the dinners of the Bosjesmans or the Galla. " Take care of her dress ; when the weather is hot, don't heat her; when it is cool, or cold, don't let her be chilly for want of a flannel petticoat, or a mousseline de laine, instead of a gingham, or a fine print. Nobody is well who has not a proper state of the bowels. The upper bowels are well enough for most people. It is the large intestine that is the seat of costiveness. Y"ou must avoid that. How ? By regu- lating her diet. Bran bread regulates the bowels, keeping them soluble. So do mush and milk, cracked wheat or semouilles, baked apples and milk, ripe sweet fruits, food not too much salted. We eat too much salt, in this country; it heats the blood, and over-stimu- lates the digestive organs. I believe half the charm of the French cuisine lies in the perfect apportionment of the salt. No spices. Not too much drink. Everybody drinks too much. In the cities, they drink too much iced water. Half a tumbler of spring water slakes thirst more than a tumblerful iced down to 45°. If her bowels are slow, you can make her take a pill of aloes and soap, or a pill of aloes and rhubarb; one grain of aloes to two grains of rhubarb. Such a pill, taken daily early in the morning, or on going to bed, will keep the bowels regular enough. " Perhaps there is no pill to be found that is preferable to Lady Webster's pill, called also Lady Crespigny's pill, or the English Dinner- pill. It is made after the following formula:— R.—Aloes 3vj. Mastiches 3ij- Ros. rub. 3ij- Syrup absinthii, q. s. M. ft. massa in pilul. No. cc. dividend. " One or two of these pills, taken from half an hour to an hour after PUBERTY. 387 dinner, will rarely fail to procure an evacuation without purging; and for the impuberic or the now puberic girl, it is admirably adapted as to various indications. "Don't suffer her to be violently excited; take every precaution to keep the mind not stupefied, certainly, but in a calm and complacent mood—rather gay than grave. " Examine her books before you let her read them. Keep out of her hands the Paul Cliffords and Ernest Maltravers, and all that sort of passionate novel reading. Walter Scott will never do her any harm. On the contrary, he is always on the side of virtue, decency, and order; his passions are not very passionate, except, perhaps, Dirck Hatteraick's case, and he was a mere brute, whose example nobody but such an one as himself is likely to admire or follow. But, as a general rule, works of fiction are of little value in the moral education of the young; they spoil the taste for more useful studies; and are for the most part dull and uninviting, except they be seasoned with the wild, the terrible, or the passionate, in revenge, in mysticism, or in love. "It is surely practicable, while her mind is evolving itself, to educate it and cause it to develop itself in a particular direction. You do not deny that she might be educated to become a devoted sister of charity, a calm, unimpassioned country girl, or a fantastic, uncontrolled opCra dancer. " If you educate her for the persistent zeal of the conventual life, for the dull complacency of the farm life, or the excitement and passion of the spectacle, do you not modify her whole nervous system by these several modes of education ? Is it not true, in morals as in gardening, that 'just as the twig is bent the tree's inclined?' and is there the shadow of a doubt that you could so educate your daughter as to make her a pattern for a nun, a milkmaid, or a prima donna ? "If there be no doubt as to the power of the moral educational pro- cesses to give such or such a bias and propensities to the mind, then you ought to consider what is the bias it is for her interest and your own that she should take. " If you wish her to be beautiful, steady, sensible, useful, and therein admirable, you should take heed to give her all the habits that may conduce to such an end of her physical and moral education. Let her know the history of her race; teach her the lives, that she may imitate the example, of the most illustrious women—illustrious I mean for vir- tue. Give her a good foundation of geographical and chorographical knowledge. Let her learn the uses of figures. Give her a competent view of chemistry, that she may understand the true nature of the physical things of the globe; a sketch of natural history, I mean not 388 PUBERTY. only zoology, but botany, ought to be clearly understood by her ; the purest and best poets, and writers of criticism. The use of one or more foreign languages, chiefly French or German, ought to enter into the plan of a lady's education. If she have a positive talent for music, let her be taught the use of some instrument and of her voice ; if not, pray don't make her ridiculous by a pretension to musical power she can never possess. Don't teach her the art of squalling. To draw is always a useful accomplishment. But do not let her learn that art by halves ; nor at all if she is without the taste and inclination that alone can give her real success. There is scarcely a more useful point in the ornamental part of education than the talent of drawing ; it serves pre-eminently to render one's ideas of form, dimensions, and distances more perfect. " As to the religious part of her education, I have no other words to say of it than that a woman who is impious is impious indeed. " I think in this country a woman is not properly marriageable until she is eighteen, and better so at twenty. If, therefore, you commence the literary education in earnest as early as nine or ten years, you have eight or nine years of applicable time to give to the daughter the elements of her education—to give her her school education—by which I nSean the acquisition of a love for letters in a proper direction. To think of any one being educated at eighteen is preposterous. All life ought to be a continued scene of education ; and the longest life is too short to allow us to do more than 'just to look about us and to die.' " As to the medical management of the child, I believe that to be a very simple matter. It consists in a wise regulation of her diet and dress, and in a careful attention to the state of her digestive organs. '• She is weak at present. She has grown very rapidly during more than a year, and has outgrown her strength. Under such circumstances, you would not do wrong to give her a small glass of sherry or port at dinner, diluted with water, though. There are a great many bitters that are useful in supporting the digestive organs, such as wild cherry bark, quassia, infusion of gentian and cascarilla, or bark and cascarilla, or sulphate of quinia ; the latter is probably the best of them all. But all these bitters are more or less disagreeable to young people, and they grow tired of them and give them up. If you please, you can compel her to take them. " While it is true that the vegetable tonics are endowed with great medicinal power, it is equally true that the mineral articles are also capable of increasing the tone of the solids of the body, by augment- ing the development force resident in the sanguiferous apparatus, and its nerves. PUBERTY. 389 "Among these tonics, the safest and not the least efficacious are those derived from iron. The chalybeates may be taken for an indefinite period, and they neither fatigue, nor disgust, nor poison the patient. " There is a large and free selection to be made out of the numerous preparations into which iron has been converted for medicinal uses. It is probable that they all partake more or less in the tonic properties of the chalybeate. M. Raciborski, in his Treatise de la PubertS, &c, seems to think the most powerful and preferable of them is the article proposed by MM. Quevenne and Miquelard, the impalpable powder of metallic iron, procured by passing hydrogen over an oxide of iron heated to redness in a porcelain tube, which reduces the metal, and leaves it in microscopic shining particles. This powder of pure iron unites with the acids of the digestion, and exerts its peculiar influences, whatever they are, with very great certainty. "Two grains taken for the dose, and swallowed soon after each daily meal, serve, in a pure unmixed anaemia, to restore the crasis of the blood in a fortnight or three weeks. Made into pills with pure honey, they are supposed to keep perfectly well, and they are both inodorous, and without taste, provided they be not chewed in taking them. " Procure two hundred or three hundred such pills, and you shall see what a power they have to steady the circulation, to render it powerful, and hence to give steadiness, firmness, and precision to the actions of the nervous system. I should advise you to give the medicine daily for many months. It is not very rare to take it for more than a year. I have very good reason, from my observation of cases to believe that, if a person, under these circumstances, recovers a good appearance of health and vigor under the use of iron, and then at once leaves it off, there is a propensity to relapse. Hence I insist upon a protracted use of it; and I have the less hesitation to do so, inasmuch as I do not regard it so much a drug that I administer, as one of the regular ele- ments of the bodily constitution. " Open your senses to the truth ; you shall see with your eyes, and hear with your ears, the sound that comes up out of the bosom of nature, proclaiming aloud that every violation of the laws of nature is a wrong. Anybody can perceive that, in a highly polished state of society, there are innumerable violations of the dictates of nature, which speak to us constantly, and cry out to us aloud. Numerous diseases are engendered by the constraints and the indulgences of the bienseance. Make your child therefore as natural a creature as possible in society; that is the way to secure her physical health. Make her also—wise—wise unto the end and destiny of her being. I grant you that, being at Rome, 390 PUBERTY. we must, in some degree, behave like the Romans, but not wholly so ; for we may live in society, and even be regarded as presentable people without becoming victimized, and wholly converted from a natural into an artificial condition, either as to temper, manners, or the love and practice of truth and sincerity. " As to rest and labor, as to dieting and dressing, as to amusements and studies, there is a degree and a time which common sense makes clearly known to any one who will reflect. " The health, the beauty, and the happiness of a girl may be impaired or perverted, and even destroyed by educational processes wrongly con- ducted. There is no Procrustean rule by which all capacities are to be measured, and it is the business, and it ought to be the sagacity and the skill of the directors of education to discriminate among the talents, and propensities, and abilities of those who are to be brought up. I shall relieve you from this long homily, by repeating the words that I heard in the spring of the year 1813, from the lips of our venerable and illustrious medical professor at the University of Pennsylvania, Dr. Rush. Those words were spoken in the ears of several hundreds of his pupils. He rose from his seat, for his age was great and his hair white as snow. He arose and stood up, and, casting his eyes over the large hall, looking to the left, and then to the right, and then to those in front of him, he said, ' I rise from my seat in order to pronounce two words in your hearing; and that you may remember them long, and apply them wisely: OBSTA PRINCIPIIS — OBSTA PRINCIPIIS. Oppose the very beginnings of disease.' And now I repeat them to you, madam, obsta principiis ; oppose the beginnings of disease in the child ; watch over her health, and, when you see that it is deranged, call the physician, and he will tell you whether you are to do something or nothing. Do not allow her to become slowly and insidiously, and deeply disordered, before you take prudent measures with her." Gentlemen, I have written you a very long letter about puberty in girls. Upon looking over it, I fear it will merit the character of a letter de quibusdam rebus et de omnibus aliis. Have I succeeded in my inten- tion and design ? That design and intention was to say why I regard the puberic malady as a malady of the blood, arising from a pathological state of the endangium, the blood-membrane. If you look through the volumes in your libraries, I apprehend you will not find in any of them so concise an opinion as that which I have herein expressed; and I beg to assure you that, so far from expecting PUBERTY. 391 that such opinion will be accepted by my brethren, who may chance to do me the honor to look over these pages, I even expect to be con- demned as hypothetical and visionary in my notions on this particular point. To any such reader, I would gladly be allowed to submit that, after many years of reflection and observation, which happen to have accumulated as to this particular malady, I have been unable to come to any other conclusion. I hope there is no person of sensibility who would be indifferent to the opinions of his peers, or his superiors, in any walk of life: I freely confess that I am very remote from any such in- difference, and that I should seriously regret the putting forth of opinions in medicine that might be supposed to injuriously mislead the young and inexperienced. I have, therefore, to express my hope that, if upon a perusal of this letter, it may appear to any of my brethren I am obviously in error as to my notion of the endangial disorder as a cause of the puberic malady, such brethren would do me but bare justice by inquiring how it is possible to explain that affection by any other hypothesis, seeing that it is purely a want of innervative force for ex- traordinary efforts, while that force is fully and absolutely adequate to all the functions of health, while the body is in repose; all, I say, saving and excepting the last climax of development force, to be exhibited in the production and evolution of ovarian ovules. My supposititious conversation with the patient and her mother, I thought might serve to lay before you, my young friends and pupils, less tediously, not less didactically, a manner of talking to my patients, that I have long used. I have nowhere asserted that other maladies may not enter into the category of the puberic maladies. I now say that, when they do so, they are pleuritis, rheumatism, hepatitis, gastro-intestinal diseases, and, in a word, all the various forms of diseased action that may serve to contravene the menstrual power and offices. But when they do so come, we are to treat pleuritis, hepatitis, rheumatism, &c, and not the puberic malady. That is an endangial disorder. Farewell. C. D. M. 392 THE MENSTRUA. LETTER XXIX. THE MENSTRUA. Gentlemen: It is universally known that the human female is dis- tinguished from the male not more by the peculiarities of her structure, than by those of certain functions, such as childbearing or giving suck, and the regular elimination, at stated periods, of a quantity of sangui- neous or bloody fluid. The functions of menstruation, of bearing children, and of providing the aliment for them in the mammary glands, are, then, the three distinguishing functions of the sex. Yet, though differing from each other so manifestly, they are to be consid- ered as intimately allied to each other, the one not being possible, as a general rule, without the existence of the other two. You know already, that the sexual functions are not assumed in this country until the fourteenth or fifteeth year, and that, when they happen to be assumed earlier than the fourteenth, or later than thesixteenthyear, they are to be deemed precocious in the one case, and in the other tardy. That individual is to be regarded as most fortunate in whom this occur- rence is first noted between the age of fourteen and fifteen years. A premature eruption of the menstrua is always to be deprecated, be- cause it is the evidence of a precipitate development of certain parts or structures, while others, not less important in the same category, are delayed and incomplete. The individual who passes at a usual and healthy rate through all the stages of growth and development, from infancy up to maturity, is most likely to enjoy a healthy and happy life, free from weakness, pain, and the danger of premature death. Death loves a shining mark, they say, and those children and youths who as- tonish us by the early perfection of their structures or their intellectual forces, are snatched soonest from the world, as the earliest blossoms are ever most exposed to the chilling frosts of spring. On the other hand, a late and procrastinated first-eruption of the menstrua is to be regarded as the sign of some weakness or disorder, preventing the manifestation at the average period of life ; and it always excites painful apprehen- sions as to the security and perfectness of the individual in whom it is observed. Differences of climate situation and condition, occasion differences THE MENSTRUA. 393 in the period of the assumption of these powers. There is no doubt that the women of Lapland, the arctic Highlanders, women who are brought up roughly to laborious employments and on coarse food, are later in the manifestation than those who reside in temperate or hot latitudes, those who are brought up luxuriously, and those in whom the susceptibilities of the nervous system are exaggerated by their moral and physical training and education. Such is the report made by writers who have collected statistics on these subjects—for which I shall refer you to the authorities, among whom no one appears to have taken greater pains to collect numerous statistical returns than M. Bri- erre de Boismont, in his Treatise on Menstruation. For my present purpose, it suffices to say that, in our country, girls become regular between fourteen and fifteen years of age. Nevertheless, many do not see until advanced in their sixteenth year, while a great number are changed at thirteen and a half, at thirteen, and even before they have completed their thirteenth year. I have known a great number of such; but I always hear it with regret. I say with regret, for I am assured that, if the pelvis of a girl, who had become regular at thir- teen, should be long macerated or subjected to ebullition in water, the several portions of her ossa coxalia would separate into ilium, ischium, and pubis, and the epiphyses and apophyses would also be found unconfirmed in their union. Here then is a proof of want of conformableness in the development of the machine—for to menstruate is to be fit for concep- tion, gestation, and labor; but to have unconfirmed union of the pelvic pieces is to be unfit for those offices. But all want of conformableness in development is disorder, not health. This is the argument that ought to be regarded as unanswerable against early marriages, which are sacrifices; nothing less. The menstrua, the catamenia, menses, courses, terms, periods, month- lies, monthly periods, purifications, and other names, consist in a periodical discharge of blood mixed with mucus and epithelium. In women in good health, they return once in twenty-eight days, and con- tinue during three, five, or seven days, less or more, according to the particular constitution of the woman, and the quantity eliminated greatly varies in different women, and even in the same individual at different times and ages. These monthly discharges return with great regularity from the fif- teenth to the forty-fifth year, except when interrupted by sickness, by pregnancy or by giving suck. At the age of forty-five, they cease to return; and thenceforth, the female is no more capable of conceiving, as she was equally incapable of it previously to its first eruption. It has, therefore, a clear connection with the power of reproduction. 394 THE MENSTRUA. As I love to read old Thomas Rainald's " Woman's Booke, or the Byrth of Mankinde," let me cite that spirited but quaint old gentle- man for you, to show his opinion as to the cause of menstruation :— " The cause and reason why nature created this perpetual course of termes in women is this: forasmuche as Almyghtie God had so institute that women should be conceaved, efformed, or fassyoned, augmented, nouryshed, and brought to perfection. This coulde not be done unlesse there were a commodious and convenient place to this office assigned and destinate, whereof nature created the wombe or matrix to be the sayde receptacle and house of office, wherein she mought, at her leasure, worke her devine feates about the seede once conceaved. " Agayne, it is not inough the seede to be placed, unlesse also it have foode and nouryshment, to the increase and augmentation of the same, wherefore prudent Lady Nature full wisely hath provided that there shoulde always be prest and redy a continuall course and resort of bloud in the vaines of the matrix, as a very naturall course, spryng, fountayne, or well, evermore redy to arouse, water and norishe the feature so sone as it shall be conceaved; yea, although the woman do never conceive, other because she accompanieth not with man, other els for some other infirmitie; yet is there no faulte in nature, who hath prepared a place and foode to be at all tymes in a redynesse." Here you see that, in the days of the great Queen Elizabeth, Dr. Rainald regarded the menstrua as the appointed aliment of the foetus in utero; this explanation satisfied his own mind; but it has long since given place to more accurate notions of the uses and designs of this catamenial office, which are now well understood, since we have become clearly acquainted with the cause of the phenomenon. For more than twenty centuries there has been a constant inquiry, among the learned, as to what should be the cause of a regular men- struation in women; a phenomenon that is common to them in all nations, climates, and ages of the world. It is not wonderful that an anxious curiosity should have existed on this subject, seeing that the regular and healthy performance of the office is related to the health, beauty, perfection, and security of the female; and this among all peo- ple of every age of the world. Nor should we be surprised to learn that many superstitious opinions, rules, and observances in relation to it, have existed in ancient times, or that such should still linger among even the better educated classes of society. Notwithstanding this great anxiety to learn the truth as to menstruation, and in despite of the researches, observations, and conjectures of so many enlightened philosophers and physicians, no certain or even probable conclusion was reached until very lately, that several illustrious medical men in THE MENSTRUA. 395 Europe have had the happiness, through a succession of fortunate dis- coveries, all tending to the ultimate conclusion, to place the matter in what seems to be a clear and perfect light: so that I am of opinion that ere long, there will be no difference of sentiment as to the causes and nature of this function. I believe that they have arrived at the truth of this doctrine. Truth is always precious, and never more so than when its rays, like a bright sunbeam falling into a darkened chamber, makes manifest objects never clearly seen or understood be- fore. The discovery of the truth upon this important subject makes many things plain to physicians, as to counsel and action, that were obscure and uncertain before: whence they are now enabled to' do much good they could not previously effect, and avoid much evil, which their ignorance of the real nature of the catamenia led them unavoidably to commit. The discovery in question should, therefore, be hailed as one of signal importance in the practice of our art, and it is proper that I should devote some portion of this letter to the object of explaining it to you, adding such reflections of my own as may arise in my mind in the course of writing this letter to you. Before I come properly to the particular subject, I ought to premise that great confusion and error have existed in the opinions heretofore formed concerning the wonderful periodicity and regularity of the cata- menia, and the wonder has been the greater, because the intervals be- tween the returns are so long. In very regular women, it returns on a day that they can count upon for months beforehand. To take a single example. January 3, 1843.—Mrs.----told me, this evening, that she became regular at thirteen years of age. During her whole menstrual life, now probably closed, she was six days unwell, and her returns were always on the twenty-eighth day from the day of the last attack. The returns never had reference to the phase of the moon, or the day of the month; nor had she ever any diseased or painful sensa- tion relative to her menstrua. She had four children. There are many women who menstruate earlier than the twenty- eighth day, while others experience the returns only every thirtieth or thirty-fifth day, or after a still longer interval. The recurrence once in twenty-eight days, or once in each lunar month, led to the general conviction that a lunar influence rules the re- turn. This notion has been for ages deeply impressed in the public mind; notwithstanding millions of persons could daily testify to the contrary, seeing that everywhere, in the same meridian, women are unaffected by any such influence; for there is probably not a moment of any day in which some women are not in the beginning, middle, or end of the term. If the influence of the moon could be justly supposed 396 THE MENSTRUA. to have anything to do with it, it ought to be felt by the mass of the female population on the meridian, and not by one of a hundred. Another hypothesis is that the courses are caused by a state of general plethora or vascular fulness, occurring regularly in the female, and rendered necessary to her as a reproductive or childbearing creature. Her liability to pregnancy, it was thought, required that she should habitually produce an excess of blood, so that, when a surplus beyond the requirements of her own constitution should be demanded by the growing embryo, that surplus might be at hand. But such a plethora would be inconvenient, unless it was reduced by menstruation, or gesta- tion, or lactation; hence out of the necessity of the case she menstruates. To say, however, that the woman menstruates from a necessity to eliminate a certain quantity of blood, once a month, is merely to pre- sent the proposition in another form; it is equivalent to saying that she menstruates because she menstruates. The fact is that all sorts of women are regular, whether plethoric or not. There are even some of them who menstruate, though quite hy- draemical, or to a certain extent bloodless. You do not prevent a female from having her returns next Monday because you take fifteen ounces of blood from her arm to-day, Satur- day; but you certainly do remove her hyperaemia by so doing. I have bled many women just before the return of the courses, without check- ing or at all hindering their regularity. The physiological laws of menstruation are not to be broken or prevented by any such act of re- ducing the mass of the woman's blood. Besides, there are many thin, scrawny women who lose much greater quantities at the time of being unwell than the robust, and fat, and florid people whom you would sup- pose to yield a vast quantity. There are even women, while laboring under severe chronical disorders, such as shall at last bring them to the grave, who nevertheless menstruate quite regularly and plentifully, until a late period of their decline. I say this of some women, not of the generality, for so delicate are the machinery and working of this catamenial office, that in multitudes of the sex, the slightest thing that can touch the health to disturb it, puts to instant flight all this power of life. Do you imagine, then, that a state of general plethora can be assumed as the cause of menstruation ? I should think not. The next idea was that a local plethora, or turgescence of the vascu- lar apparatus of the reproductive organs, is the cause of the menstrua; and that some unknown necessity, some unknown force caused this local plethora to rise to such a height as to produce the outward sign of the menstrual act, in the visible flow of blood from the genitalia. THE MENSTRUA. 397 Now, this is a true doctrine, as far as it states the fact, viz., that a local plethora or hyperaemia, occurring at stated periods, is the cause of the menstrual hemorrhage; but what is this unknown force ? what this power that recuperates itself for every lunar period ? The solution of this question is the solution of the long difficulty, and I shall proceed to lay it before you, with certain premises, however, because I wish to instruct you, not to dogmatize with you. If I should say, in a few words, that the local plethora is the result of the physiological function of ovulation, which is a vital paroxysm, common to all reproducing creatures, whether animal or vegetable, I should merely dogmatize for you; if I can lay before you the arguments by which I have been con- vinced, I shall be more likely to lead you to the conviction of what I deem a most essential truth. If you should pick up a pebble on the shore, or a handful of sand; if you should break off a bit of stone from one of the great rocky strata of the earth ; or, if you take in your hand some salt, or a piece of glass, or a bar of iron, or an ingot of silver or gold, and carefully examine them, and inquire into the laws of their production and continuance in a present condition, it will be easy to arrive at the conviction that they are destitute of life, of sensibility, of appetency, and incapable of pro- ducing or generating their like, and altogether without organization ; and that they are, in short, inorganic bodies, controlled only by the laws of the cohesive, elective, and gravitating attractions. If now you take into your hand a butterfly, or the smallest creeping thing, or infu- sorial creature, or any plant, blossom, or seed, or whatsoever thing that is endowed with life—with life-force, you will perceive at once the differ- ence between it and the inorganic masses that possess only the brute force of matter ; but if you attempt to set down in plain words the differences betwixt inorganic and living organic matters, you will be surprised to find how difficult is the task. Indeed, it is in some in- stances impossible for the naturalist to decide at what point, in a series, the organic ceases and the inorganic nature begins ; and there are cer- tain bodies, whose place has not even yet been ascertained, as whether belonging to the mineral, or to the vegetable kingdom. Burdach, at page 128, vol. iv. of the Physiology, says: " When a mass which is homogeneous as to its substance, develops antagonistic forces throughout its extent, and flows, and becomes fixed in certain determinate directions, the result of such motion is crystallization, or the acquisition of a regular form, which is determined by the nature of the mixture, and accomplished by means of the proper motions. The crystal is, therefore, the permanent expression of the moving forces; in it, motion has become rest and permanent extension : activity is meta- 398 THE MENSTRUA. morphosed into a corresponding existence; it is extinguished as motion, and is now only manifested as cohesion," &c. Neither Mr. Burdach's views, as above set forth, nor the opinion that organic matter is characterized by the binary combination of its elements, while a ternary, or quaternary combination produces animal or organic matter, can be considered as removing the difficulty in deciding where, in matter, organic and inorganic natures are to be trenchantly divided ; but we are left to the conclusion that there is not actually a hiatus, or a limitrophic distinction, but rather that they mutually pass into each other upon the confines of both. The philosophic poet Lucretius stum- bled over the same difficulty that lies in our way at the present moment. Ignoratur enim quae sit natura animal', Nata sit, an contra nascentibus insinuetur. It appears to me that the reproductive force is the eminently dis- criminating and characterizing force as betwixt the organic and the in- organic bodies, since it is clear that the ponderable bodies, as the metals, alkalies, earths, and gases, are incapable of reproduction ; whereas, all living or organized bodies are but the repetitions or reproductions of forms and forces with which their archetypes were endowed, from the commencement of the present cosmic order and arrangement. Mr. Burdach's extract, above given, would seem to warrant the opinion that there is this difference: viz., that in inorganic bodies, the cessation of molecular motions gives them a permanency and sta- bility, contemporary with the globe itself; while in organic matters, the cessation of motions is the signal for the final dissipation of their elementary materials. The one being permanent as the world, and the other unstable, transitory, vanishing like the morning dew, perishable as the new-mown grass, or like the flower that comes up and is cut down. You ought, however, to remark that the Divine Author of the world has so ordered his laws, that the fleeting and evanescent form of living beings is, after all, as permanent as creation itself, and that, while we are in our own persons such perishing creatures, we are permanent, I had almost said immortal, as a genus, or a kind—who have been pre- sent here since the beginning, and are destined to exist as long as the inorganic materials upon which we tread shall endure. Does it not seem, then, that God has impressed upon our nature a great Force a great principle of extension in time, and in space ; one which insures our permanency ? Judge, then, what must be the amazing power and necessity of that law, or that Force upon which the conservation here the permanency of the genus depends and alone depends! THE MENSTRUA. 399 But, if the Creator has fenced his genera about with such strong bonds as these, then it cannot be but that those bonds and laws are worthy of the close contemplation of the medical Student, since all their deviations, whether as exaggerated in intensity, or whether as feeble and imperfect in action, must exert a potent influence on the health and security of the individual. But if the physician should be able to know and understand these laws, he would be better prepared to provide the remedies for all the results of such disordered or inter- rupted action! Take further into consideration the thought that, if these laws are really so potent as to keep us forever here upon the earth as mankind, so that the earth cannot become again a wilderness, the abode of only inferior creatures, must it not be that similar laws and sanctions are provided for the conservation of all other forms of existence ? Do you not, therefore, perceive that each blade of grass, each tender blossom, or branching oak, or lofty pine, or trailing vine, repeats itself by means of the same Force, from age to age ?—so that the modest violet, peep- ing with its blue petals and yellow anthers from its shelter of dewy leaves, is in fact as durable as time itself ? and that its perpetuity is secured by the same force that perpetuates us, and all creatures besides? Every grain of wheat, every kernel, every seed contains a germ; every egg of the smallest aphis, the tiniest sparrow, the tallest ostrich, has a germ within it. All the spawn of fishes contains in each granule a germ. If you put a quart of distilled water in an open vessel upon your window-sill, it will soon be teeming with living infusorials, whose invisible germs float on every breeze through the air, and which, when deposited in the vase, evolve themselves and become instinct with life and motion. All the mammalia are likewise reproduced from germs contained within true vitellary bodies or eggs. The egg of a barn- door fowl is not more perfectly an egg than is the microscopic egglet you find in the Graafian follicle of a cow, a mare, a sheep, a dog, or a whale. Each egg consists not only of its germ, but its yolk, which is the pabulum or aliment of the germ. The viviparous creatures require but a small quantity of yolk about the germ, because the embryo soon attaches itself to the living solid of the mother ; the oviparous creatures require a large amount of vitellary matter; for the embryotrophic wants of the germ are great, and the amount of yolk must be conformable to the whole wants of the embryo. The germ in the egg of a humming bird is as large, probably, as that in a cassowary's egg ; but the hum- ming bird, when leaving its shell, is incomparably smaller than the young of a cassowary or ostrich. Hence the embryotrophic wants of the latter are supplied by a vast quantity of materials, and those of 400 THE MENSTRUA. the former by a few grains only of the same sort of reproductive matter. The germ of a whale of eighty feet in length is not larger, probably, than that of a perch. But the placental life of the balaena enables it to evolve its young of the length of twenty feet or more before it is born; while the spawn of the perch or salmon is not larger than the head of a pin, and its embryo of a conformable magnitude. I have now to ask you to inquire whether these ova, in all the living tribes, whether of an animal or vegetable kind, are produced continu- ously, or at stated times. How is it ? But why should I ask you to make this inquiry, since I know that you have already made it, and are well informed upon the point ? You know when to go into the gardens, in the early spring, to soften the soil and prepare it for planting. You know when the farmer mows, and when he reaps his harvest. You know when the lambs of the flock are yeaned; when the roses and tulips, when the migratory birds and fishes, produce their young. How often does the germ production take place ? Once a year. The flight of the pigeon, the migration of the swallow, the annual arrival on our coasts of the shad, the her- ring, and the salmon, and cod; the bursting of the leaf-buds of the forest; the springing up of the grasses and flowers in the vernal sea- son, are facts known to you, and which have taught you that germ pro- duction is not continuous and progressive, but paroxysmal and periodical. But if, throughout all nature, we find that germ production is a perio- dical occasion, a vital paroxysm, why do we hesitate to believe that we also live under the same universal sole law of reproduction? As well sup- pose half a dozen different principles of gravitation, or of cohesive or elec- tive attraction, as a variety of reproductive principles; there is but one, which is omne vivum ex ovo, and the ovum is produced not con- tinuously but paroxysmally. While I am considering the subject of the periodicity of germ pro- duction, I shall take the occasion to call your attention, more particu- larly, to a wonderful scene that is annually presented in the United States. I allude to the annual rush, into the American rivers of the different tribes of migratory fishes that force their way from the ocean into the mouths of our streams, and which, ascending as near as they may towards the head waters, find at length the suitable places for depositing their spawn, or in plain English for laying their ego's each one of which contains a germ. The fishermen of the Potomac and of the rivers of North Carolina not unfrequently catch at a single haul as many as a million herrings, while vast quantities of shad are also captured in all the rivers of the Atlantic American coast. In the THE MENSTRUA. 401 spawning season, the salmon in the Oregon rivers are so abundant as actually to check in a degree the current of the streams, as we learn from the traveller Mackenzie, as well as from Messrs. Lewis and Clark. The annual visitation of the shad takes place, in the United States, in the spring of the year. They come down from beneath the arctic ice and strike our coast north of Carnaveral, entering first the rivers of Georgia, where they are seen sometimes about the 20th of January. They next and in succession explore the waters of the Carolinas, Virginia, Maryland, and Delaware, entering the streams of Pennsyl- vania, New Jersey, and New York, in the month of March, and so on, at later and still later times of arriving, until the migration is over. Millions are consumed as fresh food, and an immense number put up as salt fish for later consumption and for exportation. It is rare to find one of them in the waters that run into the Gulf of Mexico. Thousands of millions of herrings annually pursue the same course. Most of the herring are said to come from the shores of Spitzbergen and the Green- land ice. They divide into two immense streams, one of which proceeds downwards near the coast of Europe, and the other by way of Labra- dor, and so south, until their instinct teaches them the time is at hand for securing the reproductive product, when they turn to the river mouths and ascend to the shallows where they may spawn. Now this vast migration through many hundred leagues of trackless ocean, is compelled by an instinctive Force, which is a part of, or at least attached to, the reproductive Force, just as the commencement of the nest for the mocking bird, or the darkening of the aureole for the impregnated woman, is a part of that force. That instinctive force it is which causes them to ascend to the shallows where the sun's vivi- fying light and the augmented temperature of the waters, at the proper season, may perfect the evolution and exclusion of the embryo fishes. In all the bony fishes, the male is destitute of any copulative appa- ratus ; and hence his only function is to follow the female, in order to shed his fecundating secretion over the places where her germs are deposited; and his voyage of hundreds of leagues is a compulsory one, under the stimulation of that great reproductive Life-Force. Once a year he returns from his distant feeding-ground " in number number- less," to perform this great act for the conservation of the genus. It is in a staccato, not a sostenuto movement that this great hymn of nature is performed. Could I possibly cite a stronger case to show the periodical, paroxysmal, pulsatory nature of the great reproductive function ? In like manner, the herds of the Buffalo on the great western prairies, 26 402 THE MENSTRUA. ten thousand in a herd, wander from the Internal Provinces to the banks of the Saskatchawan, annually repeating the same scene ; and so it is with the moose, the elk, the deer, bear, wolf, fox, and martin ; it is so with the saurians, the chelonians, the ophidians ; with every animal, and every vegetable ; why should it not be thus with the woman ? It is thus. Her term is mensual, theirs is annual; she has the repro- ductive paroxysm every twenty-eighth day ; they once a year. Some of the domestic animals have it every forty-fifth day ; and the vibration is longer or shorter, according to the nature and condition of the subject of it. A healthy woman matures, and deposits an ovum every twenty-eighth day, from the age of fifteen to that of forty-five years; failing only in case of pregnancy and lactation, and sometimes not even then. She sometimes suffers an arrest of the force during lactation; yet, in the majority, even that arrest is but of short duration, and in many it does not take place at all. The closing stage of the process of maturing and depositing, or discharging the ovum, is attended with a discharge of bloody fluid from the genitalia, which is called menstruation, because it takes place once a month. That bloody fluid exudes from vessels on the inner aspect of the womb, which has become engorged in common and along with the ovary, and which by this discharge is relieved of its hyperaemia. Such is the opinion I entertain ; such is the opinion I desire that you should hold. It is founded on evidence too strong to be resisted ; for the gentlemen who have been concerned in establishing it have left no peg to hang a doubt upon, so thorough and so diligent has been the care to fence it about both by reasoning and facts. C. D. M. LETTER XXX. Gentlemen : I hope you are not already fatigued with the discursive method in which I have spoken of the periodicity of germ production and deposit, throughout the two kingdoms of nature, vegetable and animal. I deemed it necessary to speak so, since this very periodicity has for twenty-five hundred years been a stumbling-block to the seekers in this path of inquiry ; and since, if it be truly observable in all crea- tures besides, it ought to be considered as established for our race, as well as for them. I shall now proceed to state that, in the economy of the human female, as in all the other creatures, there is provided an THE MENSTRUA. 403 organ for the evolution of germs, and that these germs cannot be pro- duced by means of any other of the tissues or organs of which any animal or vegetable consists. This organ is the ovary. In the woman, there are two ovaries, oval-compressed bodies, each about an inch in length, by half an inch in depth, and a third of an inch in thickness. But the size of the ovary differs in different women, being in some larger, and in others smaller than the above-mentioned average. Each ovary is attached to an angle of the womb, by means of the ligament of the ovary, which is a cylindrical cord, about an inch and a half in length, more or less, and as large as a small quill. Each ovary lies behind the Fallopian tube and round ligament, and is inclosed within the peritoneal or broad ligament, which gives it its covering, or indu- sium. Inside of this indusium, or peritoneal covering, is found the fibrous strong coat, or delimitary membrane of the ovary, which being taken off, nothing is left save the stroma, or ovarian substance, con- taining the Graafian vesicles, or Graafian follicles, or Graafian cells, as they are indiscriminately called. The stroma of the ovary is produced by the ovaric artery and nerve. I say produced by them, for it was originally evolved by them, and is constantly fed and maintained in its generical size, weight, and func- tional power by them, as the source whence are derived all the accretions required by the momentary waste, detritus, or life-combustion of its molecules. What a curious speculation it is that this long, wandering ovaric artery, and spermatic nerve, should be the only artery, and only nerve in the whole economy capable of producing vitellus or yelk matter; for, after all that can be said, they do produce it, and they alone. Nullam rem e nihilo gigni, divinitus unquam, is a dogma much older than Lucretius. The ovary being endowed with the power of producing vitellus as in the ostrich, where a vast quantity is evolved, and in the female of our race, where the quantity is so small that a good doublet is necessary to find, and a good microscope to observe it afterwards, it is also endowed with the power of producing germs, of which vitellus or yelk is the sustaining principle, or aliment, or cytoblastema. Even if the true germ be indeed Rudolph Wagner's germinal spot (macula germina- tiva), and is to be regarded as the nucleole of the cell, while the germinal vesicle is the nucleus, and the vitellary membrane of the yelk the cell itself, filled with its cell contents or vitellus, still, it holds good that the whole product, macula, vesicle, and vitellus, are products of the ovarian stroma, and that nothing of the nature of an animal concrete, save the stroma, could produce it. Hence the stroma is truly the ger- miferous or germiparous organ ; and hence, also, the dogma that I deem 404 THE MENSTRUA. true, stroma is the sexual tissue, nay it is sex, as I said in one of my former letters. The origin of germs is a subject that might well fill the mind with amazement. It is so difficult to come at, that the strangest hypotheses have been forced into the service of its explanation. Lucretius says^: " Semper enim partus duplici de semine constat." Lib. iv. But this epigenetic notion could not satisfy the demands of reason, and hence the doctrine of ova, or germs, must be resorted to, and the dogma of omne vivum ex ovo must be brought in to take its place. Supposing it true, and established as truth, that all life proceeds from germs, or ova, still, the aching void of an unsatisfied reason remains unfilled; wherefore, it has been averred that all germs, or ova, were original creations—each thing living at this hour having proceeded from a germ which was included within the germ of its antecedent, back as far as the original creation; so that the ova in the ovary of Eve con- tained the ova or germs of the whole human race down to the present day, as well as all that shall hereafter exist, and so of all descent, or generation. This evolution doctrine was opposed by the Pythagorean idea of a palingenesis, or metempsychosis, under which notion you are to suppose that the animating principle that has heretofore animated the bodies of the living, seeks a new union with organizable matter, upon the dissolution of its last tabernacle, and carries on the new evo- lution until again displaced, and set free to make new combinations. M. Huschke, by way of satisfying our insatiable hunger and thirst after truth on this point, proposes what seems a very ingenious opinion. It is extremely difficult, certainly, to conceive how the plastic and meta- bolic forces of a cell, or its nucleus or germ, could first be imparted to the germinal spot (macula germinativa). To do so, the mind must ac- cept the idea of a new creative force, a force to create the germ, and launch it on its career of development and power. Such a metaphysical stumbling-block is always in the way here. We have little difficulty in accepting the doctrine of reproduction by gemmation, and by scission, for we can readily follow out Trembley's experiments on the fresh- water hydra, or polype, and comprehend to the full satisfaction of the reason and judgment, how a hydra can be reproduced by scission, by gemmation, or by evolution ; at least there is a much smaller caret- or hiatus in the facts and the rationale. Now, M. Huschke supposes what I do not know that he has a histological right to suppose, videlicet that the ovarian stroma contains, and essentially consists of, acini and that an acinus being, by a physiological process, cast out of its gan^ue in the ovary, carries away with it the plastic and metabolic forces that enable it to become a new ovule; just as a bud from a plum or cherry THE MENSTRUA. 405 tree may carry away with it to another tree on which it is engrafted all the peculiar forces that enable it to bear plums or cherries, on a new and different stock. By this method of M. Huschke's, you see, we are absolved from the whole difficulty of the discussion, for, under such a view of the case, there is no necessity to imagine a new creation, an epigenesis or a palingenesis, but we have a series of successive evolutions, or rather extensions, or propagations, or perhaps we might venture to say scissions or gemmations of living matter, extending downwards in time from the acinus in the ovary of our common mother Eve to that which exists in every female now living, or that shall hereafter live on the globe. Under this view, further, we might conceive that Eve is not yet dead, but that by her acini she still lives in extension, after having evolved, in the six thousand years, all the bodies of all her descendants. Such is the inference from the theory that the stroma is aciniferous. I, however, do not know that the stroma is aciniferous. True, I have many times observed, in the microscope, the myriads of granular bodies which both Martin Barry and Gerber describe as visible in a particle of stroma. Still, I do not know whether those puncta be really acini or not. If they be not acini, of course M. Huschke's theory falls to the ground. Certainly, however, it is a very pleasant hypothesis, since it saves us from the rude difficulty of imagining a germ created by com- mon physiological law and without miracle. If you should plant a Lom- bardy poplar, or vine, or willow, your son who should plant a slip cut from it might propagate his vine, and so on with his son, and to the millionth generation of your children. It is no wonder to see the cut- tings grow; but to make a creature, de novo !—that is the hardest thing in reason or philosophy. Hence M. Huschke's hypothesis is a very agreeable one. I have thought it proper to lay the doctrine before you, and shall leave you to your own reflections upon it, begging you to arrive at your own conclusions. Let me add that Oken declares, in so many words, that " there are only two kinds of generation in the world. The creation proper, and the propagation that is sequent thereupon, or the generatio originaria and secundaria. No organization has been consequently created of larger size than an infusorial point. No organization is nor has one ever been created which is not microscopic. Whatever is larger has not been created, but developed." " Man has not been created, but developed. So the Bible itself teaches us. God did not make man out of nothing; but took an ele- mental body then existing, an Earth, clod, or carbon; moulded it into form, thus making use of water; and breathed into it life, namely, air, 406 THE MENSTRUA. whereby galvanism or the vital process arose." (Physio-Philosophy, p. 192.) At different times, I have exhibited to you, and great numbers of the class have come down into the rotunda to look at it, the yelk taken from the ovary of the cow, as well as that from the ewe. Y'ou remember that the ovarian vesicle was punctured with a lancet, and the drop of liquid which spirted from the incision being collected on a lamina of glass and placed under the microscope, the yelk, containing its germinal vesicle and macula, was shown you in one of Chevalier's microscopes. This yelk ball was contained within Graaff's vesicle, which I had opened with the point of the lancet. Graaff's vesicle has two coats : an inner one, and an outer one which contains the inner one—sphere within sphere ; but both the spheres are buried beneath the fibrous coat or albuginea of the ovary. The albuginea itself is contained beneath the indusium or the peritoneal coat. This statement, viewed in connection with the fact that the ova of birds and fishes, and frogs, &c, are discharged without the intervention of the male, or any antecedent sexual conflict, ought to convince any one that the fecundation of ova does not take place within, but outside of the ovaria; and, therefore, that the ova must escape from the ovaria previous to the impregnating act. In other words, it is a physiological function of the ovary to mature and discharge its ova, in order that they may be afterwards haply fecundated. If you admit that this statement is a correct one, then you accept the doctrine of the spontaneous expul- sion of ova, or the ovi-posit. Admitting the ovi-posit as a law of the reproductive force, then the question arises again, is this an irregular or a regular and periodical function ? I have shown that throughout all living nature it is periodical, not continual, not irregular, not acci- dental. I see no bar to the conclusion that it is so in woman. M. Negrier, of Angers, M. Gendrin, Dr. Robert Lee, M. Bischoff, and, more than everybody else, Dr. Pouchet, of Rouen, have taken pains to observe the state of the ovaria in women who have died during or soon after the act of menstruation. They have all found that at that crisis, the ovary exhibits a mark on its surface, a bloody spot a hole, a pore—into which can be pressed the point of a probe. Such mark is found only in coincidence with the act of menstruation or with the period of sexual excitement in the inferior animals. This hole this pore, leads to an expanded crypt, filled with a minute clot of blood : if the ovary be split with a scalpel, conducting the incision so as to cut through the pore, it will be found to lay open a Graafian follicle from which the egg has escaped through its pore-like hila, just as it happens in the ovary of the bird. These appearances are seen whenever an ovary is THE MENSTRUA. 407 examined during or shortly after a menstruation. You may remember that I showed you such an one in the ovary of a young woman who died shortly after her menstrua, and, what is more, I showed you the trace or cicatrix of the menses that preceded that last one, and I laid it open and showed you its crypt not yet closed up within, though healed on the outer surface. A specimen is now in the museum, which contains the uterus of a young person who died suddenly while the menstrua were present: the uterus still contained the fluid, and the pore was bloody. My own opinion is that you will never examine the internal genitalia, under such circumstances, without finding the fresh spot, and that you will not find it under any other circumstances. All this has been so clearly made out by M. Negrier, and particularly by M. Pouchet, that it is a loss'of time to talk about it by way of proof or corro- boration ; and I really suppose that he who does not see and admit the doctrine of a spontaneous ovi-posit coincident with menstruation must close his eyes to the light, and deny the most irrefragable demon- stration. M. Pouchet has recently, 1847, put forth an enlarged edition of his treatise, under the title of Theorie Positive de I'ovulation spontanee, et de la Fecondation des Mammiflres et de I'espece humaine, basee sur Vobservation de toute la serie animale. This superb work is accom- panied with an atlas, in quarto, containing twenty exquisite engravings, colored after nature, and exhibiting the appearances in the faithfulest manner. The plates are twenty in number, with many drawings on each one. M. Pouchet shows, in Plate XII. and Plate XIII., the microscopic appearances of the vaginal discharges in the menstrual and inter-menstrual periods of the female ; discharges that consist of blood- disks, mucus, and epithelium. Plates XIV. and XV. exhibit the men- strua of the sow, and the rabbit, showing that the sow and the rabbit, at the time of their erotic excitement, which is regularly periodical, also discharge a fluid consisting of mucus, blood-corpuscles, and pavimented epithelium. I regret that it is not in my power to furnish you, in this letter, with a faithful copy of these beautiful engravings, and still more, that that whole philosophical and admirable treatise of his is not in the hands of each one of you. M. Pouchet assures us, at page 262 of his work, that the sow, during its menstruation, " exhibits in the vagina a rose tint, and a small quan- tity of mucus ; the microscope shows that this discharge is composed of fragments of epithelium, whether pavimented or cylindrical, globules of mucus, and also a very small proportion of blood-corpuscles." His figures, representing these appearances in the rabbit and the sow, do not differ from those representing the catamenial discharges in the 408 THE MENSTRUA. human female, except in the proportion of the blood-disks, which in the latter are vastly more abundant. He declares that the womb below the bifurcation is highly red and injected, and the cornua as well. M. Pouchet has observed similar appearances, at the period of the ovi-posit, in many other mammals. He insists that, as it is more than suffi- ciently proved that the period of ovulation, in the mammifers, coincides with that of the periodical excitement, it is equally evident that similar phenomena rule the physiology of the female, at the ovi-posit, in the human being. Page 267. I deem it scarcely necessary to do more than refer to the obser- vations of Dr. Robert Lee, of London, M. Gendrin and M. Negrier, and M. Raciborski, in France, on the subject of a spontaneous ovula- tion and deposit in the human female. All these writers, however valuable their contributions on this point of human physiology, have but sketched and hinted at the subject, in comparison with the laborious researches and fine suite of reasonings of M. Pouchet as to this great physiological act. It is to him that we are most deeply indebted for clear views ; yet the name of M. Negrier, of Angers, is also to be held up and honored by all physicians for his most valuable work, which, though it be less full and complete than M. Pouchet's, yet is highly meritori- ous, since it is to him we owe much of the early light thrown upon our path. Dr. Letheby supposes he found in the Fallopian tubes of two different women, who died in hospitals while menstruating, the true ovarian ovules. If these observations of his are correct, then you have in them evidence on which you may rest the opinion that the ovulation may be completed before the sanguine sign of the menstrual act has disappeared. In birds, it is certain that the ova or yolks do pass into the oviducts without having been fecundated, as is the case in what is called the pullet's egg. Dr. Letheby's ova must have been non-fecun- dated ova—see an account of his paper from the Lancet, in Amer. Journ. of the Med. Sciences, April, 1852, p. 549. I conceive that what has been said, ought to convince you that the ovulation or spontaneous deposit of ova is completely independent of the sexual congress; and you ought to add, completely independent of, and disconnected with, any sexual excitement or sentiment, in the human being, though it is far otherwise in the lower mammals, &c. The reason of this difference is to be found in the high morals of reasoning and civilized creatures, as distinct from those beings that are governed by instinctive sense, and not by reason. If you accept the doctrine of the spontaneous periodical deposit of ova, then I think you have little difficulty to account for the mensual engorgement of the reproductive organs, or the monthly local plethora THE MENSTRUA. 409 or turgescence or hyperaemia, which is relieved so regularly and com- pletely by the catamenial or mensual hemorrhage, for the evolution of a Graafian cell is more and more rapidly effected, as it approaches nearer and nearer to its completion. The largest and most mature follicle becomes now enveloped, so to speak, in a mass of injected and engorged and hyperaemic tissues redolent with life. It is surrounded with red vessels, to carry on within it the development offices. The cell, like a growing tooth, is magnified and raised up so rapidly, that, like the gum over the tooth, the stroma around the Graafian cell becomes turgid, succu- lent—almost inflamed, we might say. Under such circumstances, what wonder have you to find the whole ovary swollen and turgid, or the womb itself affected in the same way ? what wonder to find the woman complaining of pain in the ovaric region, and in the womb—of aching, with heat and sense of weight and dragging in the pelvis; or to find, on examination, that the uterus is larger, heavier, and more colored than in the inter-menstrual periods ? The interior wall of the womb is highly vascular, and is lined by an epithelium of the greatest tenuity. The bloodvessels that abound beneath this epithelium, easily give rise to the bloody discharges whenever the hyperaemia rises to a certain height or intensity, for the turgid tubes easily allow of its extravasation. In fact, the womb, previous to the disengorging out flow of the men- strual blood, is redder and heavier, and more succulent than when it has been fully acquitted by the discharge. It is proved to be so upon examination in life, and the necroscopic examination confirms it to be so; what more! It is bootless to talk about it any further, for if the fore- going cannot, nothing can convince you, and I shall, therefore, desist from any further remarks for the present. Farewell. C. D. M. LETTER XXXI. Gentlemen: I concluded my last letter with remarks on the pe- riodical turgescence or hyperaemia of the reproductive organs, caused by the rapid march of development in the last days of the maturation of the ovulum. It is necessary that I should, in this present communication, explain the causes of the rise of the yelk from the centre of the stroma to the surface, whence it is ultimately destined to escape ; and in making this explanation I cannot avoid speaking of the corpus luteum, a yellow 410 THE MENSTRUA. body which is discoverable in the menstruating ovary, and more sensi- bly, in the ovary of the gravid animal. I have to beg you would remember that the title of this volume, which treats of woman, her diseases and remedies, gives me a very general warrant as to the choice of topics, so I but keep within the real boundaries of my subject; and I believe I shall not go beyond those bounds if I now address you on the subject of the corpus luteum. I deem it, also, a matter properly related to the doctrines of menstrua- tion, and one which it is requisite that you should take into considera- tion in your study of that important physiological function. I read a paper on the subject of the corpus luteum, which the American Philo- sophical Society has published in the Transactions, vol. x. New Series, p. 131, and the substance of that memoir is contained in the following remarks which I offer to you as part of what I wished to say in con- nection with the subject of menstruation. While I was engaged, in the winter of 1847, Dec. 18th, in my lec- tures at the College, and during my preparations for the lectures on this point, I became convinced that the views heretofore entertained as to the nature of the corpus luteum were so unsatisfactory, at least to my own mind, that I made some experiments which led to the inference that the corpus luteum is a vitellary body; I mean a body composed of the same material as yelk of eggs. Since the date of those lectures, I have carefully made researches, by means of the microscope and other methods, as to the comparative appearances presented by fresh vitellary matter taken from a hen's egg and matter collected from fresh corpora lutea. These researches suffice to convince me that the yelk of eggs, and the yellow matter from a corpus luteum, are of the same apparent con- stitution, form, color, odor, coagulability, refractive power, and micro- scopic appearance. Having placed a small quantity of yelk on the platine, I was struck with the appearance of a yellow light filling the whole tube of the microscope, just before the object is brought into the focus of the instrument. Whenever, in like manner, I have placed a bit of fresh corpus luteum of the cow or sheep on the compressor, and had crushed it by turning the screw, I found the tube filled with the same yellow tinted light before obtaining the focus. A portion of yelk placed beneath the objective, and examined with a strong power, exhibits numerous granules, corpuscles containing a yellow fluid, oil-globules, and a quantity of punctiform bodies, floating in a transparent liquor. THE MENSTRUA. 411 Upon turning the screw of the compressor upon a mass of corpus luteum, carefully dissected out from the ovary, there is, in like manner, seen to escape from the crushed object a quantity of granules, corpuscles filled with yellow fluid, oil-globules, and punctiform bodies, swimming in a pellucid liquor. The appearances observed upon examining a portion of yelk, and a portion of corpus luteum, are so similar that it would be difficult to discriminate between them, but for the exception that, along with the granules and corpuscles, oil-globules and puncta of the corpus luteum, there will be found flakes of laminated cellular tela, blood-disks, and other detritus of the organ destroyed by the compressor. The transparent corpuscles transmit a yellow light, whether observed singly, or in clusters or acervuli. The same is true of the corpuscles of the yelk. Upon crushing a bit of corpus luteum in the compressor, there escapes much granular matter, that accurately resembles the granules of the granular membrane, the retinacula, or the proligerous disk of the Graafian follicle. This is the case where the very greatest care has been taken to procure the bit from the outer portion of the yellow body, so that no portion of the crypt could be invaded. All the por- tion used was from the inner substance of a corpus luteum. This similarity of appearance leads me to infer a similarity or even identity of nature and origin. I think no person, accustomed to the use of the microscope, could detect any difference between the molecules pressed out of a bit of corpus luteum and those that escape from a rup- tured mammiferous ovulum (as of the cow or sheep), or those that are seen in common yelk of egg, except the debris or detritus, before men- tioned, should signalize the difference. I have so many times examined the mammiferous ovulum, that I suppose myself to be quite competent to compare its contents with those of the corpus luteum, and with that of the bird's egg; and I feel that I am entitled to say with confidence that the chief constituent bulk of a corpus luteum is a true vitellary matter, deposited outside of the inner concentric spherule or ovisac of the Graafian vesicle; that is to say, the vitellary matter of the corpus luteum is deposited betwixt the inner and the outer sacculus of the follicle. As to the correctness of this opinion, I must defer to the future observations of the micrographers, who may be able to confute or to confirm my statement and opinions. No author has expressed a similar opinion as to the constitution of the corpus luteum. That substance has been the fruitful topic of ela- borate discussions, and of researches, and hypotheses, for many years 412 THE MENSTRUA. among the learned, in consequence of the importance of the subject, both in a physiological relation and in a medico-legal application. It is surprising to observe how much has been said about it, without coming to any reasonable conclusions. You ought to know that, pre- vious to the year 1825, nothing was, in fact, clearly understood about it; but that in that year, John Evangelist & Purkinje, of Breslau, in Silesia, discovered the germinal vesicle in the unfecundated egg of the barn-door fowl. In 1827, Ch. Ernest Von Baer detected the mammal ovulum with its germinal vesicle. In 1830, Rudolph Wagner ascer- tained the macula germinativa or germinal spot. Yrou may therefore safely venture to say that, antecedently to these epochs, viz., 1825, 1827, 1830, all talk, all discussion, and all opinion on the mammal ovum was naught. Hence, I should think it bootless here to ask what the writers previous to 1825 may have said or supposed about it. Of those who have written concerning the corpus luteum since the above dates, I have to say, as to the constitution of the yellow body, that Drs. Carpenter, J. Miiller, Thomas Schwann, Henle, and Huschke, have not even hinted as to its vitellary nature. Dr. Henle, in his M- gemeine Anatomie, says: " So weiss man namentlich, wie die Graafschen Blaschen, in Folge der Congestion, welche dem fruchtbaren Beischlaf folgt, zuerst anschwellen und denn platzen, wahrend sie zugleich von Blut angefiillt werden, welches sie allmahlig entfarbt, organisirt und in eine Narbensubstanz verwandelt, die zuletzt verschwindet"—p. 894. In the passage here quoted, Dr. Henle attributes the swelling and the bursting of the Graafian follicle to the congestion attending a fecun- dative union of the sexes. He says the ruptured cell is filled with blood which colors it, becomes organized, converted into a scar-like substance (narbensubstanz), and after some time disappears. Dr. Huschke, in his Treatise on Splanchnology, though he elaborately details the opinions of authors on the corpus luteum, yet nowhere alludes to the vitellary nature of that substance. Messrs. Gendrin, Ne'grier, Robert Lee, Wharton Jones, Raciborski, Ollivier d'Angers, and Pouchet, make no such allusion; they all enter into details of the literature of the subject. Dr. Montgomery, Dr. Swan, M. Flourens, MM. Velpeau, Moreau, Jacquemier, Cazeaux, and Chailly, are silent as to the vitellary consti- tution of the yellow body. Bernhardt, who was assisted in the preparation of his Symbolse ad ovi 3Iammalium Historiam ante Prsegnationem, by Dr. Valentin, and in which admired work you may find a complete deduction of the whole literature of the corpus luteum, alludes not to its vitellary nature. The .celebrated letter of Professor Von Baer, de Ovi Mammalium et THE MENSTRUA. 413 Hominis Genesi, says of the corpus luteum, at page 20: " Me judice, minime corpus novum est, sed stratum internum thecae majus evolutum," which sets forth with sufficient clearness and great conciseness the opinions entertained in the rest of the paragraph. Dr. Bischoff, of Heidelberg formerly, but now of the University of Giessen, in his Entwickelung sgeschichte der Sdugethiere und der Men- schen, says, at page 33: " Wenn man die erste Entwickelung des gel- ben Korpers unmittelbar nach Austritt des Eies bei Thieren beobachtet hat, so kann man dariiber nicht in Zweifel sein, dass die Bildung seiner Masse von der innern Flache des Graafschens Blaschens ausgeht. Da sich nun hier die aus Zellen gebildete membrana granulosa befindet, und dieselbe als gelber Korper erkennbare Masse gleichfalls aus Zellen besteht, so ist es wohl gewiss, dass von einer starkeren Entwickelung dieser Zellen der membrana granulosa, die ich auch in der Peripharie des Eies noch nachweisen werde, die Bildung des gelben Kbrpers ausgeht." From the above passage, it appears that M. Bischoff was not far from discovering what I suppose myself to have discovered—I mean the vitellary nature of the corpus luteum ; since he says it is composed of cells, and proceeds from the inner membrane of the Graafian vesicle. I shall make for you no further citation of authoritative opinions here ; but I pray you to observe that, if the concave superficies of the true ovisac, or inner concentric sac, is indeed charged with the function of producing or excreting the corpuscles of the vitellus of the ovulum, or the material of them, which cannot be denied, there is no difficulty to conceive that the convex or exterior surface of the membrane may ex- ercise the same function, as dominant of the elective affinities, which must be supposed to effect this as well as every other vital excrete. Such a supposition is not a wresting of physiology, and it finds abund- ant support in the analogy of the organs; as, for example, in the peri- osteal and medullary membranes of bone, which, under certain circum- stances, are known to alternate their functional forces. The medullary membrane, in the cases alluded to, comes to be a depositor of phosphate of lime, instead of a remover, its natural office; whereas the periosteum, in turn, becomes a remover, instead of a depositor, its normal function. This mutation and interchange of powers, as to the inner and outer membranes of bone, have been too clearly exhibited and demonstrated by M. Flourens, in his admirable paper on the reproduction of bones and teeth, to admit of any doubt or cavil. But I am very far from claiming this illustration as proof in favor of my views, strong as I might deem it to be. It seems to me sufficient to know this, namely, that vitellary matter is germinal matter, germinal cyto-blastem, and 414 THE MENSTRUA. that it is the office of an ovary to produce it, and that nothing else in nature can produce it. It is with real deference to the opinions of persons more learned than I, and far more versed than I am in the use of the microscope, that I make public these opinions, which, I am well aware, cannot stand upon my single testimony. I therefore readily confide in the opinions to be hereafter formed as to these views by the micrographers, and I doubt not MM. Pouchet, Bischoff, Wharton Jones, or others, will confirm or reject these views according to their own more able observations, to be hereafter made. I refer to my Obstetrics, 2d edition, p. 134, for a citation from Prof. Coste's work on the Development of Organized Bodies, which shows how very similar are the opinions he expressed in 1849, on the subject which I first made public in 1847. As to some points of resemblance not yet mentioned, I have to ob- serve that boiled corpus luteum becomes, like boiled yelk of egg, very hard, and in like manner friable and granular—leaving a yellow stain upon the fingers, or on white paper, when rubbed on them. Dr. Thomas Schwann says he found the corpus luteum to become hard, coagulated, granular, and friable, upon being boiled. I threw a portion of fresh corpus luteum on a live coal; it gave out the odor of roasted egg. Hence, in coagulability, in friableness, in staining yellow, in becoming granular, and in yielding, when burned, the odor of roasted eggs, the corpus luteum resembles vitellus as much as it resembles it in its micro- scopic characters. I think that these circumstances warrant me in forming the opinion that the corpus luteum is a vitellary body. In reflecting upon this subject, the question arises, are the granules and corpuscles of the corpus luteum cytoblasts and cells ? I endeavored with a very high power to make out the nuclei of the corpuscles, but could not succeed in doing so; nevertheless, I cannot suppose that the invisibility of a nucleus is to deprive a body of the character of the cell. Even Dr. Schwann himself, at page 204 of that wonderful work, the Mikroscopische Untersuchungen, says: "Die kern- lose Zellen, oder richtiger ausgedruckt, die Zellen in denen bis jetzt noch keine Kerne beobachtet worden sind, kommen nur bei niedere Pflanzen vor, und sind auch bei Thieren selten ;" and he cites as sam- ples of the non-nucleated cell, the young cells within the old cells of the chorda dorsalis, the ceils of the yelk of the bird's egg &c Whether the non-nucleated corpuscle be a cell or not it \* . , iiyji>, n is very cer- tain that the milk corpusck: and probably the chyle corpuscle are of that nature; and no one can contemplate the evolution process of a THE MENSTRUA. 415 corpuscle or spore of saccharomycea cerevisiae, without admitting for it all the qualities and development forces of the mother cell; it is to the last degree reproductive ; while the filiform fungi, the muscardine, and many other sporiferous bodies claim to possess the same metabolic and formative powers. Supposing that my view is sound as to the vitellary nature of the corpus luteum, then you will observe how beautifully simple and concise is the machinery or apparatus by which the ovulum is brought to the surface and deposited ready for fecundation, on the ovarian indusium or within the fimbria of the Fallopian tube. In the bird's egg, which, as in the ostrich and the cassowary, con- tains a gigantic yelk, the simple augmented tension of the membranous sacculus of the ovary suffices to open the ovisac upon its hila. The same happens in the immense yelk of the larger ophidians, as the colu- ber Boaeformis, figured by Dr. Swan, and indeed in all the membranous ovaria. But, in the dense tissues of the mammal ovarium, a special provision for the opening of the porule or hila, for the escape of the ovulum, was required. How has it been effected ? Is it not as follows ? The function of stroma is to produce germs and vitellus. When the production of the germ on the inner face of the vesicle buried within the vitellus is completed, the ovulum is ripe; it has attained its gene- rical magnitude and weight; but the stroma continues to supply the vitellary matter; it deposits it betwixt the two concentric spherules of the follicle. The inner spherule yields to the pressure of the increasing mass, and becomes convoluted as it is crushed inwards towards the yelk ball, giving rise to the appearances by Negrier denominated bourses grises. The outer spherule is driven outwards against the gangue of the ovarian stroma, and the deposit goes on, particularly in the cow and in swine, to a vast extent, making, in some instances, a mass of corpus luteum equal to more than half the volume of the ovary. At the same time, the inner concentric, growing smaller and smaller from the pressure towards its centre, lifts the yelk ball to the albuginea and indusium where the resistance is weakest. The cavity of the folli- cle becomes reduced nearly to nothing, as the pressure augments, until at last the porule, being established by the absorbents or by rupture, the yelk ball escapes, along with its granular membrane, in fragments, leaving a crypt which fills with coagulated blood. The crypt being contained within the yellow mass of vitellus called corpus luteum, at some stage, as yet unascertained, disappears, and the vitellary deposit that envelops it begins to be absorbed as soon as the vitelliferous forces 416 THE MENSTRUA. of the stroma become determined towards the development of another follicle. It would be unreasonable to suppose that, upon the escape of the ovulum, the yelk producing force and activity should be immediately suspended: it is even probable that the corpus luteum may continue to augment for a certain but unknown short period after the escape. And, inasmuch as corpora lutea are supposed to be more considerable in ovaries of pregnant women than in the non-gravid, it may be, per- haps, reasonable to infer that the state of pregnancy reacts upon the ovary in a way to augment the size, and add to the duration of the luteal body. It is a periodical exacerbative or paroxysmal force that develops the ovulum. It is employed first upon one and next upon another germ point, and so on throughout the reproductive life of the woman or the animal: at the pairing season of birds; the rut of the mammals, and the reproductive periods of the reptiles, fishes, and insects. I am surprised to find that some able and distinguished writers still cling to the antiquated notion of ovarian fecundation. But I presume that M. Pouchet's illustrated work on ovulation will put to flight all cavils on that point. No woman can menstruate but in coincidence with the spontaneous ovi-posit. Every ovi-posit is followed by a corpus luteum, except where a failure of development may possibly, as a disease, prevent it. The corpora lutea are of various sizes. Many women have scarcely dis- cernible ones after conception. I recall to your memory the gravid uterus with its young seven months' foetus, in my collection, in which no trace of a corpus luteum is discoverable. The true and false corpora lutea of Dr. Montgomery are all equally true corpora lutea; and though different in size, are not essentially different in nature. My letter would be far more satisfactory to me, were it in my power to accompany these pages with copies of M. Pouchet's exquisite colored drawings of these objects; but it is not in my power to do so. I warmly recommend them to your attentive and careful study. And now, gentlemen, do you ask me what is the use of all these re- marks on the corpus luteum ? I answer, that my letters are about women, their diseases, and remedies. You would not understand the nature of women if you should not study their corpora lutea. In studying their nature and offices, you may find a key to much admirable pathology. In my own mind, there has long existed not the least doubt as to the power of these luteal bodies to develop the very beginning of lying-in diseases, and others. In fatal childbed fever it is common to discover on examination after death, one of the ovaries THE MENSTRUA. 417 in such a state of disorganization, that we cannot doubt of its having been the seat of the primary area of the inflammation whose spread had destroyed the life of the subject. Is it unreasonable to imagine this starting-point of the destructive train to have been an uncured, unre- covered corpus luteum ? If, in a court of justice, you should ever come to stand as a witness, sub- ject to the interrogations and cross-questionings of a lawyer, you would be thankful for the whole history of these bodies, as given by Bernhardt, and a fortiori, you would be happy to save some person accused, from the gross misjudgments of lawyers, judges, and juries, who might con- demn an innocent person, out of their ignorance of the true laws of ovulation and the spontaneous ovi-posit in the human female. It was on the 18th December, 1846, that I read my paper on the corpus luteum before the American Philosophical Society, which was ordered for publication in the Transactions. Deeply convinced as I was that I had fallen on a true and demonstrable rationale of the cor- pus luteum, I was willing to wait for the decision of the learned as to the truth of my explanation. Some of the reviewers treated me with less than civility for my innovation; but I perceived that they had con- demned me on a prima facie examination, and that their opposition de- pended rather upon a usual reluctance to abandon opinions already adopted, than on any improbability of the truthfulness of my statement of the subject. Professor Coste, whose 2d part of his first volume On the Development of Organized Bodies was published in the summer of 1849, has adopted my views nearly as to the vitellary nature of the luteal body. M. Coste regards the inner membrane of the Graafian follicles, and not the magma reticulatum lying betwixt the inner and outer cell, as the seat of the cell deposit. It is a matter of small moment this, though I by no means yield my opinion to the authority of even so great a name as his. Having sent my paper, which was published in the year 1847, to'M. Coste, immediately after its publication here, I cannot withhold the ex- pression of the surprise with which I find him acknowledging the receipt of it, and at the same time saying (in 1849, two years later) that I have arrived at the same conclusion with himself on this subject—that is to say, he got my paper in 1847, and adopting my exposition nearly,,says, in 1849, that I have attained to the same views as those he so elabo- rately sets forth. In order that the American student may have an opportunity to become acquainted with M. Coste's views, I here trans- late, from his Dev. des Corps. Org., p. 251, the following passages :— " Indeed, upon examining with the microscope the texture of the internal layer of the capsule a short time before the period of its 27 418 TnE MENSTRUA. rupture, we find that, in addition to its abundant vascular network, it is exclusively composed of small vesicles or cells, each containing colorless molecular granules; but, immediately after the dehiscence, they become so greatly developed that, when the convolutions fill up the cavity, they are found to be five or six times larger than they were at first. Hence it follows that the membrane whose wall they consti- tute must be proportionably, thickened. It also becomes softer, and more friable, because they cease to cohere so strongly as at first, while the wall itself becomes softened. This is the reason why, at a certain period, the capsular convolutions acquire an encephaloid appearance, a result of modification both of the constituent vesicles and their contents, as I shall proceed to show. In process of time, a stage is reached in which the disunion of the vesicles is so easily to be effected that it may be done by merely scraping the capsule which detaches nearly the whole of them, after which nothing is left save the marked vascular branches that run along every plait. I have made this preparation in several follicles, previously injected, so as to be able to see the facts in the clearest manner, and as I have before described them. " In proportion as the constituent vesicles enlarge, their contents are appreciably modified. In the cavity of each one of them is formed an innumerable quantity of molecular granules, which render them more and more opaque, and which under the slightest pressure pass out through the containing walls, that give way by laceration. These gra- nules are remarkable not only for their number but also for the yellow tinge which slightly colors them. Now, as they are very abundant and closely packed within the vesicles that contain them, it follows that the yellow tinge that is slight in the individual granules becomes very decided, as for the whole mass of them. It appears that something takes place here like what occurs in the vitellus of the bird while taking on its yellow hue. I have indeed already said, while explaining the material condition of this phenomenon, that it is produced by the crowding together of the granules with which the yelk corpuscles are gradually filled, and by the admixture of the oleaginous particles that are disseminated in it. The color of the corpus luteum seems to de- pend upon an analogous arrangement of the material contained in the voluminous vesicles that compose its mass, &c." Let the student do me the favor to compare this account by the learned Frenchman with that in the first edition of this work, and I feel sure he will do me the justice to admit the priority of my solution of this long-questioned problem. I beg leave to make one more quota- tion, which is from Coste, p. 268:— " Baer first understood the mechanism by means of which the plaits THE MENSTRUA. 419 or convolutions are produced. Pouchet showed how they become thickened; I think I can establish the fact that the color of them depends exclusively on the nature of the molecular granules or the globules with which the cells that form these walls are filled, and not at all, as supposed by Raciborski and Pouchet, on an extravasation of the coloring matter of the blood. I have observed, with pleasure, in a pamphlet sent to me by Dr. Meigs, that, in the last respect, that observer had come to the same conclusion as my own." !! C. D. M. LETTER XXXII. Gentlemen: My last letter was occupied with an account I desired to lay before you, of my views relative to the corpora lutea, one which I considered it proper to introduce into the series of remarks on men- struation. I know not what you or others may think of the idea set forth therein as to the vitellary nature of that body; but I hope, what- ever may be your opinions on that point, that you will, at least, agree with me in considering those bodies as a part of the normal results of the mensual ovulation, for that is the main point; and that is the point of interest in any medico-legal discussion or testimony you may hereafter happen to be engaged in. Is it not also worth your while to inquire, hereafter, what may be the concern which these corpora lutea have in developing certain of the disorders connected sometimes with the acts of menstruation ? Having said what I wished to say to you on the corpus luteum, we shall now, if you please, proceed with our observations on the menstrua. From what has already been remarked, I presume you have perceived that, in contemplating the nature and laws of the catamenia, I adopt the notion that the act of menstruation, rigorously construed, consists in the periodical maturation and deposit of an ovulum; of which act the flowing of the menstrual blood is but the outward and visible sign— so that, in fact, a woman may menstruate very regularly and exactly, without having the least hemorrhagic sign of that menstruation. Doubtless many women are perfectly regular who give no outward sign of it. Do you doubt the truth of this proposition ? If you do, then I ask you if it be not proved by the fact that a great many women who give suck do not have their courses until they wean the child. It is true, however, that a great many women, during their lactation, find 420 THE MENSTRUA. , -,. jg also themselves regularly unwell from the seventh month; and n ^ usual to observe that a woman lying-in, has a return of the coui» ^ weeks after the birth of the child. This is so generally the cas , ^ I always expect my patient to be unwell again at the sixth we?_'ru]e. to be regularly menstruous from the seventh month. This is ^ the exceptions are in those women who never see until they * child, of which class the number is large. For example ^^<>> 1847.-Mrs.____d told me this day that she never saw h« :men* ua while nursing, nor until three months after she had weaned the child. This is her fourth child ; she is a small and very delicate person. One of her children was suckled for thirteen months. _ Brierre de Boismont says, at page 159, that he inquired as to the return of the menses in eighty-two women who had been confined. In 1 the menses returned immediately after the labor! " " in 8 days! « " in 15 " " " in 3 weeks. " " in 1 month. " " in 6 weeks. " " in 5 to 6 weeks. " " in 2 months. " " in 3 months. " " in 4 months. " " in 5 to 6 months. " " in 7 to 8 months. M. de Boismont's statistical return ought not, I think, to influence you in your opinion. I feel very sure that a much truer statistics than the above is the one in which I told you that your patient may expect it to return in six weeks; and then become regular, and continue so, from and after the seventh month. But statistics often fly in the face of opinions as well as of the truth as acknowledged in the world, or by the public whom it may concern. You ought, further, to learn that some women do not see from the time of their first conception until they have borne a considerable number of children, because, becoming fecundated while they are nursing, they carry out the pregnancy to term, become again enceinte, and so on, never seeing their courses, as I said, until, being no longer impregnated, the ovulation is marked by a natural return of the mensual hemorrhage. I have met with several samples of this kind; and they are so abund- antly recorded in our books that there is no need to cite the cases; you may set it down as a fact, that it is so, with not a few women. How could it be otherwise with those women who have a child every year or In 1 In 2 In 4 In 9 In 38 In 7 In 7 In 6 In 2 In 3 In 2 THE MENSTRUA. 421 every eleven months ! I have seen a child born at ten months after its antecedent. Now, supposing the ovulation and spontaneous deposit of the ovule to be the true doctrine, do you not see that these suckling women, in question, did really produce ovules for fecundation, though they did not have the menstrual discharge ? They could not conceive else. I deem it no matter of surprise that they had not the menstrual discharge, be- cause I can perceive, in the function of lactation, an action derivative from the internal genitalia to the mammary glands, of power sufficient to turn aside the determinations of the constitution, whether sanguine or nervous, from the genitalia to the lactiferous apparatus. Many other things turn it aside in the same way. There are many women who may be presumed to have the inward menstruation, videlicet, the ovulation, without any bleeding ; a case that may take place without the least shock to the woman's health. A young woman, for example, may have reached the proper age for menstruation without having seen the sign, or show. She may be married, conceive, and bear a child, suckle it, and at the end of seven months have her first menstruation. This has been observed to happen more than once. Who can doubt that she had matured and deposited her germs, which were fecundated after her marriage ? Or will you go back to the idols, and embrace the old doc- trine that the germs were fecundated in the ovaria ? If you will go back to your idols, I have nothing to do but "let you alone." You might well suppose that pregnancy will put a stop to the ovula- tion—and perhaps, in a majority of cases, it is true that, when the womb has once fairly begun its career of gravid development, the san- guine and nervous forces of the reproductive organs are so completely absorbed in the business of gestation, that the ovarian function is sus- pended, or proceeds but slowly and feebly at most. Yet there are pregnant women, not a few, who have regular mensual returns for three or even four months. I had a patient here who was regularly unwell up to the eighth month, when I attended her. She went out her time, and was laid at the ninth month. Moreover, some women have the most insuperable tendency to mis- carry, and those miscarriages are found to take place at the period of their usual menstruation—in fact, the major part of the abortions and threats of abortion, you are hereafter to meet with, coincide with the women's catamenial periods ; a fact very important for you to know, because, you ought to take measures to obviate the danger at the time —and when the time is passed relieve the patient from the onus of an unnecessary treatment. All the foregoing may suffice to show you that you are not to take in 422 THE MENSTRUA. hand every female who does not have the show just at the time it is ex- pected, and that you may feel at liberty to suppose her constitution does not suffer the least injury; for, while she does not seem to be regular, she is, in fact, perfectly regular ; that is to say, she regularly matures and deposits her germs—for that is the physiological act of menstruation, and nothing else is. That is what her constitution re- quires her to do. If she bleeds, it is well; but she is often found to be well even if she does not bleed a drop. Is it not so with the suckling woman ? I am glad to have an opportunity to tell you these things, for I hope they may have the effect to make you keep clear sometimes of the drugging process which is too apt to be set on foot the moment a lady complains of amenorrhoea. Let me here mention, that I have met with several instances in practice, of women who had grown up and become wives, who after marriage were found incompetent to the sexual congress: a careful and regulated diagnosis convinced me that these were persons in whom no womb had ever been developed, and I suppose the cause of this want, was an arrest of development of the organ in a very early stage of the embryonal life. Nevertheless, seeing that these women were very healthy persons; with all the outer character- istics of the perfect woman, having abundant hair on the head, and on the pudenda ; with well-formed breast and strong sexual desire—even uncommonly strong and insatiable ; what reason is there left for us to doubt of their possessing perfect ovaries ? and if so, why should we doubt that they also were the subjects of a regular periodical ovulation ? I repeat, that these women were not only very healthy and strong, but even highly attractive by their form and beautiful physiognomy; yet it seems, they never menstruated, and never had any vicarious dis- charge ; and hence, I conclude that for them to ovulate, was to fulfil the physiological act of menstruation, and that the loss of the blood from the womb is in general a minor and even indifferent phenomenon. In a former letter, I said I had often seen young women lose their courses when brought to town and set on the school-form, though they yet retained all the outward appearances of valid health. Whenever I have been consulted as to such a one, I have made a very careful ex- ploration of the rate and degree of the various functions ; and when I have found that the intellection, the respiration, circulation, innerva- tion, calorification, digestion, secretions, &c., were all normal, and that nothing was wanting save the menstruous show, I have let the patient alone ; merely directing a close surveillance of her health, and propos- ing to interfere only in case some further signs of disorder should present themselves. The deviation in such cases I have attributed to the consumption of the nerve-force, the neurosity, by the hemispheres, THE MENSTRUA. 423 in the too constant operation of the powers of the intelligence. A holiday, or a return to their homes, cures them better than drugs. Do not, I pray, let me mislead you here. On the contrary, I repeat, that the state of the whole constitution should be carefully explored, and when therapeutical treatment is evidently demanded, see to it that the true indications be fulfilled. I have now another topic to speak of, and that is, a case where you are called to a person who complains of a retention of the menses, ap- pealing to you for relief. The stupidest thing a physician can do is to be misled by such com- plaints to the administering of drugs and medicines, which may bring on, not the menses, but an abortion, or a premature labor. How can a man look more like a fool than he who suffers himself to be entrapped to the commission of such a wrong ? What a snob! If a woman comes to your office, or if you be called to her dwelling to speak with her on such a subject, you may perceive at a glance that she is sick; or you may as readily discover by a single look that she pre- sents all the signs of the most consummate health. How can a woman exhibit all the signs of robust health, and yet fail of her menstruation, when she has always before been perfectly regular, and when neither disease, nor studies, nor misfortunes can be supposed to have had power to interrupt the course of a function always sure to be exercised when nothing stands in the way of its exercise ? I am far from advising you to be constantly on the lookout for sin and to be smelling out every possible iniquity. But I do advise you so to demean yourselves that you shall bring no discredit on yourself, or on your profession. Our profession, alas ! has a vast weight of incompet- ency among its own asseclae, and an immense onus of charlatanry among the whole race of quacks and pretenders to bear upon its ample shoulders. You will be in the good path if you determine early to give no occasion for additional scandal by your conduct as physicians. It will be your duty, then, in all these cases, not to suffer yourselves to be misled and imposed upon. I was sent for to see a young woman. Upon reaching the house, her married sister said that she wished me to visit-------, as she was quite out of health. " What ails her ?" " I suppose it is her courses ; she has not been right for several months. Go up stairs, and you will find her in the chamber." " Does she appear to be ill ?" "No, not at all." She was sitting in a chair, bending over a tambour-frame, where she 424 THE MENSTRUA. seemed to be most diligently employed passing the needle in and out of the stuff at which she was working. I observed that she blushed as I entered the apartment, and seemed agitated, whether from a modest timidity, or from a consciousness of impending disclosure. Her face was radiant with health and bloom, and her embonpoint was visible on her shoulders and arms. She told me, in answer to my inquiries, that she had seen nothing for near seven months, but was very much swollen—was fearful of a dropsy—had no pain—good appetite, sleep, digestion, and strength. The pulse was normal, except the slight precipitation, a pathemate mentis. She very reluctantly allowed me to place my hand on the abdomen, stooping the while over her tambour-frame. I held the hand there a long time, but could not discover any spontaneous motion, nor did I hint at the object I had in view—which was to discover the movement of a child. After some conversation, she allowed me to auscult the abdomen, which was as large and as regularly developed as in a gestation of seven months; upon adjusting the ear, I heard the click of the foetal heart. When I informed her of my discovery, she most indignantly denied it, and was angry with me for the liberty I took to say that she, an unmarried woman, was in the family way ; but at length gave in, and made her arrangements for the accouchement—which was very happily effected at the due time. The child was taken kind care of, and is well. She refused to marry her seducer—but two years later married a worthy man, after informing him of her mishap. They live pros- perously together, and are raising their hopeful children. I am aware it would not be well to fill up this book with cases of this kind, of which I have met with a great number, some of them very curious ones. I have only recited the above to show you how easy it would be to have taken----'s word as to her case, to give her a violent emeto-cathartic, some savine, ergot, or what not, and bring on a pre- mature labor at the risk of her life, and to the discredit of our divine art. You never will make such a mistake, if you will make a good rule and follow it religiously. Let that rule be, not to speak until you know. If you will conjecture, if you will guess, let it be a conjecture, a guess, or a surmise ; but when you know, then you can speak. Would you believe that I have witnessed a great many cases of the most ridiculous blunderings on this point! But it is not my duty to relate them. Take you good heed now; never guess, but always know, or else either hold your peace or confess your ignorance of the facts. I need not again advert to the case of non-appearance of the menses THE MENSTRUA. 425 depending upon atresia of the organs, having already spoken of that accident in a former letter. As to the quantity and duration of the menstrual discharge, I have to say that each woman, in good health, has a rate of her own. Some discharge one ounce of blood, and some twenty ounces at each period. The quantity a woman loses depends upon some peculiarity of her con- stitution. In like manner, the quantity a woman loses in her labor depends upon some such peculiarity. Many women bring a child into the world without staining the napkins and clothes about them, and I have many times taken away the placenta without a red spot on my hand; the woman afterwards having only a moderate lochia, not so considerable as the ordinary menstrua of other women. On the other hand, you will meet with patients who discharge a great deal of blood with the child, and always do so—while the post-partum discharge is also so considerable as greatly to reduce the strength. The great matter in the diagnosis, then, is to learn the amount and to ascertain the constitutional wants or demands and habit of the patient herself. One may be well enough able to judge of the quantity imbibed by a napkin; from one to two tablespoonfuls would render it uncomfortable. But a tablespoonful is half a fluidounce, then, twenty-four napkins would, by estimate, be twelve fluidounces. But it is often much more than that—for on some of the napkins there will be found from an ounce to an ounce and a half. Haller, in lib. xxviii., sec. iii., says : " The quantity of blood dis- charged is various ; it is greater in warm climates, being as much as a pound or even more—or it may be equal to ten ounces ; or it may go to the extent of producing deliquium animi, and even death itself. In cold climates, the discharge may be six ounces, five, four, or it may be as low as three ounces," &c. He speaks of the effects of diet, showing that those who live well are more free in their menstrua than those who are compelled so subsist on spare and poor rations. There is an observation as to the quantity of menstrual fluid pro- duced in a given time, that is unique, so far as I know: it was made by M. Brierre de Boismont, and is found in his work on Menstruation, p. 172. He says that one of his patients had the complaisance to lend herself for the experiment, which was performed by adjusting a specu- lum to the vaginal cervix, which it exactly fitted. The cervix remained like a plug in the speculum for ten hours. By this means the product was collected, and must have been free from any admixture with the excretions of the vagina. The quantity of fluid that escaped from the womb was twenty-two grammes, which is a little more than an ounce. 426 THE MENSTRUA. At this rate, twenty-four hours would have produced nearly two and a half ounces. This person had had several children. She was thirty- five years of age. She was of a delicate constitution—her menses usually lasted eight days—probably she would usually lose ten to twelve ounces, therefore, at each menstruation. When people consult me on these points, I am accustomed to inquire how many changes they have been in the habit of making during the whole menstruation. Now, many individuals have assured me they always use eighteen, twenty, twenty-five, and some of them thirty changes, in each mensual period. Others have employed only six— some three, and now and then I have met with a person who never used any in her whole menstrual life. Hence, it is easy to perceive what great differences there are among females as to the amount eliminated. I am but little inclined, gentlemen, to enter upon any further discus- sion as to the nature of the menstrual fluid, as to whether it be a secretion from the arteries or the veins. Such discussions are of little profit. At least, I am so fixed in the belief that I am correct in calling it the mensual hemorrhage, that I shall probably never adopt any other view of it; and it therefore appears to me idle to endeavor to reason one into the belief that it is a secretion—in the same sense that bile, or saliva, or milk are secretions. The menstrual fluid is blood. All writers and authorities are not agreed upon this point. Among others, I may mention that Mr. Hunter regarded it as differing from blood, on account of its not coagulating; but it does coagulate. Dr. Burns, the author of a System of Midwifery, was of the same opinion, as is also Professor Chapman of the University of Pennsylvania (see his note at p. 106 of James's Burjas). The late Professor Dewees, in his Treatise on Diseases of Females, at p. 87, observes: " I adopt the opinion that the men- strual discharge is a genuine secretion," &c. It is unnecessary to cite a great number of persons of the same way of thinking. I merely cite the above to show you that the opinion is held. I have had pretty numerous opportunities of inspecting the menstrual product, and I remain convinced that it is blood—but I am ready to pin my faith in this matter to the sleeve of a person better qualified to judge of it than you or I. I mean the late Madame Boivin, author of the Meynorial sur VArt des Aceouehemens—long Sage Femme en chef of the Maison d'Aceouehemens at Paris, and author of the admirable Treatise on the Diseases of Women, &c. Her writings prove her to have been a most learned physician, and, as she enjoyed a very large practice, her science and her great clinical experience, as well as her own personal knowledge, are more to be relied on than that of all the THE MENSTRUA. 427 male physicians together. She says : " The blood of the menses is just like that which is taken away from a vein." I say, I rely more upon Madame Boivin than upon anybody else. I do not see what particular privilege we men have to know best what the discharge consists of. I do know very well that women have a sensi- bility, a shame-facedness about it that makes them very reluctant even to talk about their courses, and they are very far from exhibiting the material. A woman will get drunk, she will prostitute herself for a shilling, she will walk in the public streets in rags and filth, she will curse and brawl, and become in all respects utterly, thoroughly profli- gate and debauched, but she will not show her napkin if she can avoid doing so. She conceals her menses from all eyes but her own, insomuch that even where her moral faculty has become a hopeless, cureless ruin, where decency and the last remainder of womanly modesty are clean gone, she still clings to the inherent respect and shame that she feels on account of this strange function of her body. She always dislikes to talk of it, and abhors the open exhibition of it. It was unclean in the sight of all Israel. How then are we doctors to become the best judges of it ? We may practice physic for half a century, and have a few rare occasions to inspect it, and those only when it is morbid. I say it again, I consider Madame Boivin's declaration worth more than the contrary opinion of a Consistory of Physicians. MM. Andral and Gavarret, in their frequent analyses of human blood, setted down to the conclusion that healthy blood, say 1,000 grains, contains of Water ...... 790 grains. Globules.....127 " Albumen.....80 " Fibrin..... 3 " The analysis by Becquerel and Rodier, of blood of eleven men, gives the following mean result on 1,000 grains— er . . . . . • . 799.0 1 constituents ... . 201.0 Fibrin . 2.2 Fat . . 3.2 Albumen . . . . . 6S.4 Globules . . . 141.1 Extractive matter and salts 6.8 I have quoted the above stated analyses of blood in order that you may be able to compare them with the following analyses of the men- strual fluid. M. Brierre de Boismont, in his work on Menstruation, gives at p. 428 TnE MENSTRUA. 172 this analysis, by Denis, of the menstrual fluid of a healthy woman aged twenty-seven years. It appeared to him to be a mixture of blood with mucus, and consisted of Water.......825.00 Globules Albumen Extractive matter Fatty " Saline " Mucus . 64.40 48.30 1.10 3.90 12.00 45.30 The patient of B. de B., who has been already mentioned, agreed to allow a portion of menstrual fluid to be collected in such a manner as to prevent any admixture of vaginal mucus. This was done, as I said, by adjusting the mouth of a speculum uteri upon the cylinder of the cervix. The fluid passing through the tube was collected from the other end. It yielded to the one hundred parts of Water......SO. 08 Fixed matter.....6.92 The fixed matter was composed of Fibrin, albumen, and coloring matter . 75.27 Extractive matter .... 1.42 Fatty ".....2.21 Salts.......5.31 Mucus......10.79 Rindskopf (vide Simon's Chemistry of Man, 337) found the men- strual fluid acid, and it contained Water.......820.830 Solid residuum ..... 179.170 Salts.......10.150 In a second analysis, he found Water.......822.892 Albumen and haemato-globulin . . 150.457 Extractive matter and salts . . . 20.651 Simon's analysis:— Water . . 785.000 Solid constituents.....215.000 Fat......2.580 Albumen.....76.540 Haemato-globulin . . . 120.400 Extractive and salts . . . 8.600 Dr. Letheby, Lancet, May 2, 1845, analyzed menstrual fluid deli- vered from an imperforate hymen. It contained THE MENSTRUA. 429 Water . 857.4 Solid constituents . 142.6 Fat . . 5.3 Albumen . 69.4 Globules 49.1 Haematin . 2.9 Salts . . 8.0 Extractive 6.7 Now that I have laid before you these statements of analysis both of pure blood and of the fluid of the catamenia, I leave you to judge whether the menstrual discharge is a mensual hemorrhage or a men- strual secretion. I presume you will feel inclined to look upon it as a periodical hemorrhage, like a periodical epistaxis, exhibiting modified appearances according to the quantity of epithelial scales and mucus that happens to be combined with it. For my part, I follow Madame Boivin, and I prefer her authority even to that of the chemists and micrographers. I beg leave to repeat that although, in the course of a long practice, a physician does meet with occasions where, upon some difficult diagnosis, he must ask the privilege to examine the napkin, it remains true that a woman in health never calls in the doctor upon that point at least, and that when he does find a necessity to examine it, there is disorder or suspicion of disorder. Wherever you shall see it, you are to suspect its quality to be abnormal. But, what's the use of quoting authors, or asking what A, B, and C think about it. Think about it yourselves, and ask yourselves whether there is blood in the menstrual fluid. Yes ? Then how can blood-corpuscles be secreted ? You might as well secrete a watch or a pair of boots! blood may be effused or extravasated, it cannot be secreted. Having laid before you the analysis and shown you what the material is, and hinted at the difficulty of examining it, I hope you will allow me to say a few words that are germain to those hints, and will not much interrupt the regular course of our studies of the subject. I wish you again to consider how difficult it is for us to be sure that such portions as we see are not diseased, or at least abnormal specimens. Let me beg you, in order to show how modest women are upon this subject, to remark, that while in this populous city, of more than 450,000 souls, half of whom are females, multitudes of them thronging the streets and the markets, you never saw one of them, no, not one, who allowed a single drop to stain her stocking, or spot the thin dress that she wore. You never met with such an horreur at the cotillon party, nor with those who waltz or move in the Polka or Cachuca. I know not how I could give you a more striking proof of the regard, the 430 THE MENSTRUA. respect, I was going to say the superstitious veneration with which the sex observe all the obligations of a perfect convenance on this subject. The fact is, that the sex have learned, by a time-honored tradition handed down through the mass of mind from age to age, that their life, health, comfort, fruitfulness, and beauty, have a strong alli- ance with and dependence upon this office. It has become, therefore, a public sentiment—a she vox populi, vox Dei—that commands it to be respected. Take good heed, then, that you always treat it with respect in your conversations, inquiries, and directions addressed to your pa- tients and their friends and nurses. If I had time, I could give you an account of many superstitious observances and opinions relative to the catamenia that still linger even among some of the better informed of the people. To show you how ancient is the respect with which it is still regarded, you should advert to the story of Jacob and Laban. You remember that when Jacob fled with his beloved Rachel, they carried off a part of the worthy father-in-law's images. In the 31st chapter of Genesis, the story is told in the following words: " And it was told Laban on the third day that Jacob was fled. And he took his brethren with him, and pursued after him seven days' journey; and they overtook him in the Mount Gilead," &c. "Now Jacob had pitched his tent in the Mount: and Laban with his brethren pitched in the Mount of Gilead. And Laban said to Jacob, What hast thou done," &c. " Yet wherefore hast thou stolen my gods?" &c. "And Laban went into Jacob's tent, and into Leah's tent, and into the two maid-ser- vants' tent; but he found them not. Then went he out of Leah's tent, and entered into Rachel's tent. Now Rachel had taken the images, and put them in the camel's furniture, and sat upon them. And Laban searched all the tent, but found them not. And she said to her father, Let it not displease my lord that I cannot rise up before thee ; for the custom of women is upon me," &c. Here you see at how ancient a period It was the custom of women to be unwell—and what is more, you see a man who, with an armed force, had pursued his run- away family for seven days' journey, manifestly with the most violent anger and eagerness, to recover his idols ; yet who, for the simple words custom of women, went out of the tent without making the lady violate the convenances belonging to her sexual custom. If she had not made this pretence, do you doubt that he would have dragged her from her seat to find the precious gods in whom he put his trust! The Hebrew Lawgiver doomed every Israelitish man to death that should lie with a woman at such conjuncture. The 15th chapter of the 7th book of Pliny contains the following THE MENSTRUA. 431 passage, showing what impression existed as to this discharge among a polished people. " But woman is the only menstrual animal (solum animal menstruale), and therefore the only one whose womb produces what is called a mole. A mole is an amorphous mass of inanimate flesh, which can neither be cut with the edge nor pierced with the point of a knife." " There is, perhaps, nothing in the world more monstrous than the menstrual fluid. Wine turns sour in its presence ; seeds, when touched with it, lose their germinative faculty ; hedges die ; and seeds planted in a garden where it falls are burned up in the ground. If a woman, with the menses, sits upon a tree, its fruit falls. Mirrors lose their polish, knives their' edge, and ivory its brightness by contact with it. Bees perish in their hives, and brass and iron are seized with sudden rust, and acquire a horrid odor if touched with the fluid. A dog that tastes it goes mad, and his bite is mortal," &c. The 7th chapter of his 28th book contains very copious details of the superstitious notions held concerning the menstrua centuries ago. The periodical discharge is an indispensable attribute of the sex— I mean the healthful part of them; and no faith is to be given to the idle reports of travellers who pretend that certain nations or tribes in the interior regions of South America are devoid of it. Nor is greater regard due to the oft-quoted notion of Roussel, that the habit of this discharge is not a natural one, but one acquired in past ages, and now become a settled and regular attribute. Roussel is celebrated chiefly for his small volume, entitled Systeme Physique et morale de la Femme, a work praised greatly beyond its deserts, although it must be admitted to be written in a very pleasing style. In Chap. II. of the second part, where he alludes to the hemorrhagies, by means of which men escape from the evils with which they are menaced in the shape of rheumatism, hyponchondriasm, gout, apoplexy, &c, he proceeds as follows:— " Women, from their sedentary and inactive mode of life, are less able to avoid them : the nature of their occupations favors the super- abundance of humors which they possess in common with the male, instead of diminishing them, as in the case with the avocations of men; but then they have an excretory organ, by means of which they can be freed from the superabundant, and thereby hurtful humors. Animals that are not withdrawn from the empire of nature's laws, and that act under the guidance of instinct, have no need of this resource ; they are not, like men, liable to hemorrhagies, nor, in consequence of such lia- bility, to the morbific affections which they serve to introduce. These hemorrhagies have become a necessary function, intimately connected with the human constitution; so that, in the present state of things, a 432 THE MENSTRUA. woman is born with a tendency to have her menses at a certain age, as she is born with a tendency to take the smallpox ; for we can contract a new necessity as we can contract a new malady. Were it possible to review all the changes through which the human race have passed since their origin, we should, perhaps, discover that they have not been al- ways the subjects of the same necessities, the same functions, and the same diseases as at the present day. Having once contracted some vice of the constitution, or some new disease, which, beyond doubt, happens in all the species of animals, such vice, or such diseases, are transmitted from generation to generation, and perpetuated until some contrary cause arises to destroy them. This is the reason why races degenerate, and become changed in the lapse of ages. Thus the men- strual evacuation, being once introduced into the species is communi- cated by an uninterrupted filiation, so that we might say that a woman has her courses at the present era solely because her mother had them, just as she would have been consumptive if her mother had been so. And further, she may be subject to the menstrua even though the primi- tive cause that established this necessity of the female no longer sub- sists in her constitution. In fact, many women are regular who are not subject to plethora, nor a surcharge of humors. In these women, the menstrual flow depends solely upon the habitual direction of nature's movements, like the periodical hemorrhagies that occur in men whose constitutions are already exhausted." Such are the views of the celebrated Roussel. You will readily per- ceive that, if such modifications of the human nature as he therein supposes to be possible can actually take effect, there are no bounds to be set to the range of modifications possible ; and that, if Roussel's views are just, the doctrines of the Vestiges of Creation are equally true, as to the gradual evolution of new specific and generic forms of creatures. It is not to be believed that Roussel would have entertained the opinion if he could have become acquainted with the functions of the ovaries, and the history of the early stages of the reproductive act. Pity for him that he was born before he had enjoyed the opportunity of reading MM. Purkinje, Von Baer, Wagner, Bischoff, Coste, Pouchet, &c. &c. Having already drawn out this letter to a considerable length, I shall adjourn to the next a further consideration of the subject. I am, &c, C. D. M. THE MENSTRUA. 433 LETTER XXXIII. Gentlemen: The distinguished Professor of the Theory and Prac- tice of Physic in the University of Pennsylvania, Dr. Chapman, begins, at p. 37, vol. ii. of his Discourses on Therap. and Mat. Med., an enu- meration of the names and the qualities of the Menagoga, or Emmena- gogues. The entire suite of his articles comprises— 1. Poly gala senega. 2. Juniperus sabina. 3. Rubia tinctorum. 4. Rosmarinus officinalis. 5. Mentha pulegium. 6. Secale cornutum. 7. Helleborus niger. 8. Cantharides (perhaps). 9. Terebinthinous preparations. 10. Phosphorus. 11. Cold bath. 12. Exercise. 13. Change of air. 14. Generous diet. 15. Bark. 16. The ferruginous articles. 17. Fetid gums. 18. Castor. 19. Musk.. 20. Venesection. 21. Aloes. 22. Blisters. There! you have Dr. Chapman's list; look at it, study it, and when you have done so, ask yourself the question—Is there an emmena- gogue ? No. Look at Murray's list, in his System of Mat. Med. and Pharm., at p. 284, vol. i. Read over Cullen's list, with Professor Barton's additions; indeed, without reading anybody's list, reflect upon the causes of menstruation, and see whether any animal, mineral, or vegetable thing is likely, in a direct way, to make a woman menstruate. Cullen, after a long experience and practice, with careful attention to 28 434 THE MENSTRUA. collect results of this therapy, comes to the melancholy conclusion that they are the most unfaithful" of medicines, not answering to the hopes awakened by their reputation. I have long since arrived at the same conclusion; and you will, I suppose, remember how often I have expressed this disbelief in their powers while lecturing upon the emmenagogues at the College. What then ! Is there nothing to be done for a retention of the menses ? Are we to say to the sick, There is no medicine for your case ? Far from it ; the sick require to be cured, and they may as often be cured of an amenorrhoea as of a rheumatism or colic ; but emmenagogues will not cure them. Dr. Cullen, as I have said, placed no confidence in them. Upon a review of Dr. Chapman's list and remarks, you will readily perceive that he has little confidence in them, as little, perhaps, as Cullen himself; and yet you find that what with the lancet, the baths, the aloes, the blisters, the martial preparations, &c, he arrays a really powerful armament for the combat against the causes of obstruction. The very array shows that Dr. Chapman seeks, rather, to cure the disorder which prevents the menstruation in order that menstruation may occur naturally, as it will do in a healthy woman, than to com- pel the woman to menstruate first, in order that thereby she may be cured. Perhaps you would like to call a foot-bath, or a suffumigation, by the name emmenagogue! A woman of a very susceptible and delicate con- stitution, who should, while unwell, get her shoes and stockings wet in a sudden shower, is liable to have her courses stopped, with pain in the pelvis, headache, and general soreness ; and even some degree of fever. If she afterward sit with her feet in a mustard or salt bath, for fifteen minutes—or, if she sit over the vapor of hot water for half an hour —it is very likely the flow may return ; or, if she will place herself in a sitz-bath, or go into a plunge bath at 100°, for twenty or thirty minutes, it is probable that her menses will return ; or, if she will take a large warm emollient injection, perhaps the flow will recommence ; but if it does, will the effect entitle you to say that these remedies are emmenagogues? I think not; for they do not compel, they do not lead, they do not draw forth. Such remedies serve, by removing causes of obstruction, or delay, to allow of the effectuation of the function. To break down a door is a very different thing from unlocking it, and set- ting it wide open. These medicines, perhaps, may serve in this sense to set open the door ; they do not break open, and thrust through, which is the idea and modus of a true emmenagogue. In the month of April, 1848, Z. E., in Ninth St., aged seventeen, THE MENSTRUA. 435 was confined to her bed with severe headache. The pulse was very soft, large, and slow. She was unwell on Monday and Tuesday, when the flow ceased; after which the headache and sluggishness presented themselves. This young girl laid in bed all day of the Wednesday and the Thursday. She took magnesia, which operated on the bowels. On Friday morning the flow came on regularly, and when I called to see her I found her down stairs quite well again. In this case, I did not expect the flow to return ; for, as every vestige of it was gone, and as she had no hypogastric or pelvic pain, I concluded she would not men- struate until the next ovulation, and I informed her mother that I could not expect to re-establish the discharge. If she had complained of hypogastric or sacral pains, I should have had reason to suppose the mensual engorgement of the reproductive tissues to be as yet unrelieved, and so, likely to relieve itself by re-establishing the flow. As the case was, I felt some surprise to hear of the return after so complete a sup- pression, and I am confident that such a return is in general not to be looked for. Now to have given this girl any dose of any one of the emmenagogues would, perhaps, have swelled by one integer the statis- tical sum of menagogal successes, which, like much other therapeutical experience, would have been false and deceptive. There are a great many cases of difficult or suspended menstruation that depend upon a rheumatic state of the womb. This pathological state of the organ preoccupies it, and brings it into a condition of sen- sivity and irritability incompatible with the performance of the mensual act. I am well persuaded that much of the dysmenorrhoea we en- counter is rheumatic disorder. It is characterized by all the pains and fulness, and heat and pressure within the pelvis, of which we hear women complain, while they appear, in other regards, to enjoy very good health. The uterus becomes sensible upon pressure with the index finger; a pessary in contact with it produces a sense of hot or burning pain, and yet the Touch reveals no change in the form, dimensions, or resistance of the vaginal cervix. I presume it is, in many examples, identical with what has been called irritable or neuralgic uterus. It may last very long without change, and without inducing any cogniza- ble change in the part. These are the cases that sometimes yield to the anti-rheumatic treat- ment. Is it not fair to presume that Dr. Dewees's vol. tinct. of guaiacum, when it has done good in the dysmenorrhoeas and suspended menstrua- tions, has effected that good by virtue of its anti-rheumatic properties ? I do not. apprehend why the guaiac should possess any power to bring on menstruation, save that it has it in virtue of its anti-rheumatic therapeutical force. 436 THE MENSTRUA. I advise you to study with care, in all your clinical cases that may be probably attributed to rheumatism of the reproductive organs, par- ticularly the womb, the phenomena that may present themselves, lou should carefully note, not only the signs given out by pain, and by sus- pended or altered function, but the influence of remedies; for you may rest well assured that a great many cases of rheumatism of the womb have long been, and still are, commonly mistaken for prolapsions and other affections; a false diagnosis that leads to a false and unsuccessful mode of cure. Rheumatism of the womb is becoming a more frequent object of inquiry than it used to be, and I am sure the subject is worthy of your special study and exploration. Even the gravid uterus is the frequent subject of rheumatic attacks, and it will be my duty to speak of it under the proper head. [Meanwhile, if you find a patient complaining of pelvic pains, heat, weight, tenesmus, dysmenorrhoea, you would not be apt to make a mis- take as to the true nature of the malady, should you after due exami- nation, come to the conclusion that you have a rheumatism to treat. Suppose you have made an examination, by the touch and by external palpation, or the metroscope; that you find the womb not .displaced, nor at all disordered, nor swollen, and, in addition to all this, learn that the patient has been subject to rheumatic pains; that she has accustomed herself to the use of the cold bath; that she is careless as to wet or damp cold feet, and that she wears no drawers; I see not what inference you could draw, save that she is rheumatic as to the uterus. If you cure the rheumatism the patient is cured; all the signs of a uterine disorder vanishing with the disappearance of the pain. But a local rheumatism may often be cured by a bath; or you may obtain great relief by the wearing of flannels. A woman with a rheumatic uterus should, in cold weather assuredly, be directed to wear drawers of flannel, with a view to keep the pelvis and loins and thighs well covered and protected against the pernicious influences of cold and damp. Such a patient should have a soluble state of the bowels, which may be obtained by any gentle aperient, and by none preferable to precipitated sulphur. If she have complained long and much, pre- viously to your first interview; if she be of a costive habit, and leave you to infer that some considerable accumulation of feces has taken place in the colon, she should be purged; and well purged, as a pre- liminary treatment. There is scarcely to be found a safer or more useful compound for this purpose than the mixture of jalap and cream of tartar with oil of anise. Twenty or twenty-five grains of jalap, forty grains of cream of tartar, and five drops of oil of anise made THE MENSTRUA. 437 into a powder, should be given for a dose, at an early morning hour. It may be expected that the dose shall operate five or six times. Two days later the dose may be repeated, and again in two days, which will probably suffice. This more active operation of the purgative will be indicated for the severer, while the sulphur may well serve for the slighter cases. After this, let the patient take, at bedtime, an anodyne enema of forty-five drops of laudanum, with the view to abate the neu- ralgic sensibility of the parts within the pelvis. Let her have a bath at 98° three times a week, before going to bed; let her keep herself warm as to her clothing; let her take sulphate of quinia, or quinia and iron, or Quevenne's iron, and the disease can hardly resist the treat- ment. In fine weather it will be proper for her to exercise in the open air. The diet should be plain, but nutritious, and the treatment directed to build up the strength of the whole constitution. There are such things in pathology as sanguine determinations, as they are called. A sanguine determination to the head may exist, giving occasion to cephalalgia; to flushings of the face; to buzzing, or droning in the ears; to hemicrania; to sopor; to apoplexy, or to coma. There are likewise such things as losses of determination of blood to a part. All those people who complain of cold feet and hands suffer from loss of determination to these points ; and they suffer so for months and for years. Now, there is a great difference between the cases of excessive determinations to a part and loss of determinations to a part. The former tends to procure excessive development; and the latter leads to debility, and even atrophy of the part. Well, a female may have an excessive sanguine determination to the pelvic extremity of the trunk, or she may suffer loss of such determination; if the former exist, she will be liable to excessive menstruations; if the latter, to amenorrhoea. Suppose a woman to have an amenorrhoea from the latter cause; then you will increase the pelvic determination by hot pediluvia; by the hip- bath ; by the use of frictions to the lower extremities; by tight garters, or bandages on the legs; by warm flannel drawers and stockings; by exercise on foot, which develops the lower circulation ; by galloping on horseback, which powerfnlly develops it; by the dance; and, lastly, by any medicines that tend to excite and stimulate the life-forces of the pelvic extremity of the trunk of the body. If a woman should have a violent strangury, or a violent tenesmus, brought on by your physic, she will, ipso facto, have an augmented sanguine determination to the pelvis, its veins and arteries and capil- laries, all of which are dependent upon the hyperneuric condition developed by the operation of your methods. But there are medicines that give rise to these phenomena. The resins; the balsams; spts. 438 THE MENSTRUA. turpentine; cantharides; aloes; such are the articles you would select. The tinctura sacra, spirits of turpentine, aloes, and assafetida; Lady Webster's pills, oil of Juniper berries ; Dcwees's tinct. of guaiacum, and tinct. of black hellebore; all these articles tend to fulfil the indication, which is to augment the pelvic determination. If they do fulfil the indication, then, the forces of life and development in the ovary being remodified and reinstalled, the germ production will recommence, the ovulation and ovi-posit will be re-established with monthly exactness, and the patient will have become regular again. A woman may miss of her monthly courses from debility; what debility! She may have been weakened by excessive menstruations. She may have lost twenty ounces a month, for many months, so that she has at last become really hydnemical. Or she may have had a con- stant drain of blood from some hemorrhoidal marisca, or other ex- crescence ; or she may have been reduced by malarious fever, which has engendered an ague cake in her left hypochondrium. Her blood is reduced in its crasis by any of these, or by whatever cause. To cure such a case, bark and iron and wine and meats, and air and exercise, are the indications to be fulfilled by your authoritative prescription. I refer you again to the so often proposed dogma, or rather truth, that neurosity is the result of the contact of oxygenated blood with the substance of brain. None of the innervations of your patient will be perfect and powerful unless there, be a just proportion between the dose of oxygen in the blood and the Biotic power to be evolved. Your thin, pale, oligaemic patient cannot take up enough oxygen out of the air she breathes to make her strong. Let your business be, nay, let it be your sole business, to thicken, to enrich, to ensanguine her blood, in order that that rich and perfect compound may be enabled to absorb and take out of the circumambient air the just and requisite amount of oxygen wherewith to deflagrate, if I may so speak, in the brain, and evolve from its molecules the neurosity, the life-force, the Lebens-kraft, as the Ger- mans call it. Meat and wine, and air and exercise, bark and iron, the sea-bath, and mountain air, a cheerful spirit, an attention to the dress, soluble bowels, frictions of the skin—why need I enumerate all the things that might concur in the great end of improving the general health, which, being renewed, the menstruation follows as light follows the uprising of the morning sun ? Georges Cuvier says: "La respiration est la fonction essentielle a la constitution du corps animal. C'est elle, en quelque sorte, qui l'ani- malise, et nous verrons aussi que les animaux exercent d'autant plus completemcnt lours fonctions animales qu'ils jouissent d'une respiration plus complete." THE MENSTRUA. 439 Examine your patient carefully, to learn whether the uterus may haply have become the seat of a chronic inflammatory engorgement that tends to produce an hypertrophic state of the organ which might render it disobedient to the normal influences that lead to the sensible signs of menstruation. In that case, should the state of the general health not forbid it, you would do wisely and well for the patient should you take from the arm several ounces of blood, say from eight to six- teen ounces, by one abstraction, in order to check the excessive vas- cular momentum directed upon the organ. I pray you be not afraid of the lancet; for very few persons are hurt by the use of that fine thera- peutical agent, whereas, hundreds and thousands are permitted to lapse in health, and fall into a premature decay and death, from the want of its curative power. I implore you to study carefully the nature of the therapeutical effects of bloodletting; endeavor to estimate its power over the Biotic forces ; try to comprehend how and why it is that the abstraction of blood modifies the general innervative forces, and, so, modifies the life-force in a dieased part; and you may safely be trusted in the world with the lancet in your hand, which you will never, or rarely, apply to the hurt, or even the smallest injury of your patient. If, on the other hand, you fear to bleed, you will permit many to perish, or fall into chronic ailments, worse than death, because you are timid, or ignorant as to the use of a remedy, which in all ages of the world has been, and in all future ages is likely to be one of the prime re- sources of our art against a host of maladies that are indeed not to be successfully controlled by other means. I have heard that illustrious man, our revered countryman, Dr. Physick, say: "It may be that, in some few instances, I have had occasion to think I have carried the use of the lancet too far;. but I have to lament very numerous instances in which my timidity has prevented me from using it with sufficient bold- ness to save my patient from death." Such a saying, of such a man as Dr. Physick, is worthy of your hearing, and your heeding; for he was, take him all in all, a man of matchless wisdom and skill as a physician. In the further treatment of these cases of engorged uterus, with a tendency to hypertrophy, I advise you to make occasional applications of leeches to the collum uteri. They are very readily applied by means of a Re'camier speculum, to which is adapted a cylindrical cup, that £ts into the larger end of the tube. This cup, being filled with the required number of leeches, should be inverted into the speculum tube, after that has been so adjusted as to receive into its uterine extremity the whole vaginal cervix or collum uteri. Instead of using such a cup, it is easy to push the leeches to the bottom of the tube by means of a sponge held 440 THE MENSTRUA. in the speculum forceps. The leeches generally fill within thirty-five minutes, and often in twenty-five minutes, when they may be withdrawn together with the tube. In applying leeches to the uterus in this way, you should not use more than a dozen at a time, and I confess I have seen very dangerous bleeding produced by only one dozen American leeches. Of Swedish leeches do not use more than four at a time. I have seen the hemor- rhage go to the extent of causing most alarming deliquium, restrainable only by the tampon. Such accidents are, however, very rare, and only accountable for, by supposing that some considerable branch of the rete vasculosum of the vagina had been opened by the leeches. No danger need ever be apprehended from such an accident, provided you are at hand to obviate it, and that you can always do, as above said, by the use of a tampon. By means, then, of general bleeding, and the topical extraction of blood by leeches, you will probably in most cases succeed in reducing the vascular engorgement of the womb, and overcoming the sanguine determination on which it may have depended. The use of escharotics for the cure of these disorders, has been so fully set forth in my Treatise on the Acute and Chronic Diseases of the Cervix Uteri, with plates; Philad. 1854, that I have to refer you to that work for my views on the subject. Yet it is sometimes proper to secure the good end by rest in a recumbent posture, and by the employment of purgative doses, particu- larly the hydragogue dose of jalap and cream of tartar, repeated on alternate days, for several days. These purgative doses, with the ano- dyne enemata at night, will restore the balance of the circulation, taking away the pain, heat, and pressure; after which, a regulated diet, and proper exercise and clothing, with the adjuvant power of bitters, or ferruginous tonics, will bring the patient up from the lowness brought on by the disease, and by the treatment, after which she may be ex- pected to menstruate again. I shall here close this letter, with the assurance of the respect and esteem with which I am your faithful servant, C. D. M. THE MENSTRUA. 441 LETTER XXXIV. MENORRHAGIA. Gentlemen: The word Menorrhagia means immoderate flow of the menses ; which flow consists of a purer blood than that of the regular catamenial evacuation. The blood is purer, inasmuch as the impetuous haste of the discharge causes it to come off less mixed with cervical and vaginal mucus and epithelium than in the more moderate or normal mensual hemorrhage ; and this, I believe, is the only difference between them. As the blood, in menorrhagia, is less mixed and combined with foreign matters, you would naturally expect to find it to coagulate more readily ; while this is quite true, it is not the less true that the real normal menstruous excretion does, in many women, coagulate without any suspicion of menorrhagia ; and it is reasonable, d priori, to suppose so, since one woman may be seven days getting rid of her six ounces of fluid, whereas another woman will part with ten or twelve ounces in three or five days. She who discharges the menses pleno rivo, will be sure to find some coagula; she who passes it slowly away, will find it to sink into her napkins without a clot—for the blood has time to be- come much combined with mucus and epithelium. I should think you would not be surprised to learn that a woman may be now and then menorrhagic, because you would reflect upon the highly hemorrhagic nature of the womb—a very small organ supplied by two very large uterine arteries, and over and above that source, de- riving into its sanguine circulation no small quantity from the inoscula- tions of the ovarian arteries. Under such circumstances, and with the propensity to effuse blood, established by the regular monthly habit of bleeding, women should be esteemed always liable to excessive men- struation ; though the vast majority of them do escape any such incon- venience. Even in the case of epistaxis, one may readily acquire a sort of habit of bleeding at the nose; and the discharge in that case differs not at all from that of the menstrua, except in respect to the nature of the epi- thelial desquamation, and, probably, also, some modified state of the admixed mucus. A patient shall bleed at the nose to the extent of losing only an ounce of blood on one occasion, whereas on some subse- 442 THE MENSTRUA. quent one, he may lose a wash-basin full in a continuous rill; just so is it with the menstruating woman. When she bleeds just enough, just her accustomed quantity, it is all right with her ; when she flows in excess, she is menorrhagic, she has menorrhagia. The word is derived from the Greek ^", month, and ^yw^., to break out. It is a true case of true uterine hemorrhage ; though we are accustomed to call it menor- rhagia, in order to indicate the opinion that it is connected with the mensual hemorrhage, and is not an accidental one. Hence, I advise you, when speaking of hemorrhages connected with the causes of men- struation, to call them menorrhagias, a word that expresses a whole phrase. It is a word that may be thus paraphrased. The woman is bleeding excessively because the ovi-posit, in her case, has induced an excessive nisus hemorrhagica, instead of the usual moderate and natural one. But when a woman bleeds because she has a phagedenic ulcer of the womb, or a detached ovum, or a polypus, or a bunch of hydatids, or a wound, then it is uterine hemorrhage. In this way you will speak with precision; and if all our brethren would be equally precise, there would be a better understanding of the meaning and value of the words menorrhagia and uterine hemorrhage. Take notice, how- ever, that a person with an ulcer that should not bleed during the inter- menstrual period, might readily have an attack of hemorrhage from the sore in consequence of the mensual hyperaemia; and then it would be, in one sense, a menorrhagia. Now the question comes up as to what can be the cause of the case of menorrhagia that demands your care, and it is a question difficult, in many individual cases, to answer. I say it is difficult to answer the question for a good many cases ; in others it is not difficult. There are some women who have a very powerful systemic ventricle, giving a large, full, hard pulse, like the synochus fortis pulse. In such people, the blood, driven forward with a great momentum by every stroke of the ventricle, reaches the distal parts of the circulation with such an impetuous movement, that we need feel no surprise to find the hemorrhagic surfaces, once begun to bleed, continuing for a long time, and abundantly, to discharge the sanguine fluid. Such hemorrhages are common incidents for those persons who have hypertrophy of the left ventricle. In men, these hemorrhages go to the lungs—the nose, the stomach, the hemorrhoidal vessels, or the brain ; and are called hemoptoe, epistaxis, hematemesis, apoplexy, &c. In women, the same dangerous tendencies exist, but the habit in the uterine and spermatic arteries of yielding to the force of the sanguine injection causes them to be more frequently attacked with menorrhagia. In such a state of the arterial pulse, a menorrhagic attack is readily THE MENSTRUA. 443 explainable by reference to the enormous force of the heart. Take notice, again, that those patients who in the later years of their men- strual life present the above-named characteristics are very likely to be the victims of paralysis, hydrothorax, or other disease of the circu- lation, whenever they shall have fairly passed through the change of life. It has been asserted that within two hundred years past whales have been captured of the length of three hundred feet, though it is at the present day rare to meet with a whale of seventy or eighty feet in length. The animal is so much sought for in the whale fisheries, that the large and aged ones have been in a good measure destroyed, the captures amounting probably to ten thousand a year. But a whale of three hundred feet in length had an aorta of twelve inches in diameter, the blood of which was impelled with the rapidity of a mill torrent by an enormous systemic ventricle. The power of that ventricle no dyna- mometer could estimate ; it must be enormous. It would drive an ordinary grist mill. My design in mentioning it is merely to suggest by it to your mind a reflection on the comparative power of the sys- temic ventricle in all animals. That power, in all the species, should be conformable to the resistance-power of the tissues that receive the sanguine injection. Now, you can perceive, that in our case of menor- rhagia, the injecting force may far transcend the resisting power of the tissues, and the consequences might be, a menorrhagia lasting until the abnormal energy of the injection-power comes back again to a conform- able degree or rate. But there are some weak and very susceptible people, on the other hand, whose hearts are soft and gentle in motion, who nevertheless suffer from menorrhagia. For such people you cannot bring the exces- sive development of the heart to the solution of the problem. It is better, and more consonant to reason, to suppose that such patients suffer these excessive losses in consequence of an adynamic state of the womb itself, a state which enables a moderate force of arterial and capillary injection to overcome the barriers to hemorrhage that ought to be set up in the distal extremities of the vessels—vessels that ought to be strong enough to resist the hemorrhagic force, but are not. Hence you must come to the conclusion that a menorrhagia may depend upon either an excessive power of the sources of the circulation, or upon an adynamic state of the organs towards which that circulation is directed. This last supposed case may be dependent upon some faulty action of the entire nerve system of the reproductive organs—a faulty state brought about by frequent pregnancies and abortions or labor—by in- I 444 THE MENSTRUA. dulgences in unlawful contacts—by excessive libidinous sensations— and lastly, in the wretched class of public women, by the habits which ruin and degrade them both physicially and morally. Again, you may encounter cases of menorrhagia dependent on malignant disease, on typhus, on smallpox, on scarlatina, on cancerous vice—for all these maladies vitiate the blood, and produce a state of the solids so utterly atonic, and of the blood so completely aplastic, that it flows away passively ; and it soaks, so to speak, through living tissues that are already half dead. A woman may have a menorrhagia because she has a polypus grow- ing within the womb; I say a menorrhagia, for the polypus may be a firm fibrous tumor, very sparingly supplied with circulation in its own substance, and without any abrasion of its superficies that might cause it to bleed; and in this very case the womb shall be so vexed and so irritated by its presence and pressure, as to be the subject of a monthly hemorrhagic nisus of the greatest intenseness, arising from the pre- sence, the pressure, and the irritation excited by the tumor, and not from the tumor itself, so that the flooding is flooding of the womb, and not bleeding from the polypus. You should note this distinction, for you may meet with many polypes that bleed themselves, though they do not make the womb bleed. A sample of this sort was the case I mentioned at page 249 of my XlXth Letter, and I have seen many such. I fear, my young friends, that, like some older persons, you will not be so careful as you ought to be in making the diagnosis of our case. I will not say that it is always possible to make that diagnosis with absolute assurance; but I presume that where a perfect periodicity of the bleeding, I mean a catamenial periodicity, is observable, you will be pretty correct in resolving that it is a menorrhagic and not a hemor- rhagic flooding. Indeed, it will, with such periodicity, be truly menor- rhagic, even if the causa ipsissima be a polypus, a carcinoma, a ges- tation, &c. &.c. If the case be not characterized by this periodicity, it will not be menorrhagic, but will, far more likely, on the face of it, wear the imprint of polypus, of ulcer, of chronic inflammation of the inner wall of the womb, of vegetations, &c. &c. &c. The consistence, hue, and abundance of the discharge furnish no means of discrimina- tion. In order to explain myself more fully, let me say that a hemorrhagic nisus once set on foot does not, in some cases, exhaust itself for days, for weeks, or even for months, and yet it might be a case of simple menor- rhagia. For example, I was, some time last winter, invited to give counsel to a lady, unmarried, aged about twenty-eight, very fat and THE MENSTRUA. 445 even ruddy in complexion, and strong. She had not been one day without copious bloody flowing, for full six weeks, or forty-two days. I found her pulse not preternaturally full, but the rather, I found it to be quite conformable to the state of her general constitution. Still, she kept on bleeding, as I said, for forty-two days, without a moment of intermission. My impression was that the texture of the womb had, from some unknown cause, become relaxed so as to produce a hyperaemic state of the organ, which all the discharge was as yet unable to reduce. I asked myself this question—What does the lady require for her cure —not what drug, but what change in any of her organs ? Does the heart want any change ? No ; it beats well and temperately as I could desire. Is there any extraordinary excitability or sur-excitation of the nervous system in general ? I can discover none. All the secretions are healthy; and this issue of blood, which is completely blood, is the only fault. What is most likely to cure it ? Anything that may con- dense the tissue of the womb ; that may serve to make the womb small- er, harder, more solid, stronger—for the womb is composed of uterine tissue, with its vessels, nerves, absorbents, and cellular tela. What can I do to bring about this state of advantageous condensation of the womb? I can order cold baths, astringents, rest in a recumbent position, cool air, cold acidulated drinks, cold enemata—but, of all remedies, the most clearly indicated one is the secale cornutum—because, if that should have any effect whatever upon the womb, it would be the effect of condensing the uterine solids. I gave some vinum secale cornuti. She took a teaspoonful, which was repeated three times a day, and in two days her menorrhagia was gone and returned no more—vel post hoc, vel propter hoc. At about the same time, I visited a maiden lady, forty years of age, who had long led a very sedentary life. She com- plained of a constant discharge of her courses, as she said ; and had not been free from a sanguine effusion for more than three months—nearly one hundred days. As the effusion was the sole symptom, save the accom- panying debility, I felt that I had a right to regard it as a case in which, if the womb could be made to acquire an additional and normal degree of tonicity, the complaint would cease. I said, if secale cornu- tum has the same power to excite the muscular innervation of the non- gravid as of the gravid womb, it will probably fulfil the indication; for if the womb, in its substance, shall become condensed, all its parts will re- ceive of the benefits of that condensation. I gave her vin. secal.cornut., a teaspoonful three times a day ; and she told me after three days that her trouble disappeared, since which she has enjoyed her usual health. Now, for my own part, I do not at all doubt the wine cured her, for here are two clearly marked cases of the therapeutic effect of the drug 446 TnE MENSTRUA. speedily manifested; and, for a great many years past, I have occa- sionally found patients complaining in the same way, who have been in like manner cured. Pray, take notice of what I suppose to be the rationale of this cure, for it is for the sake of the rationale that I relate the cases. I wish you to understand, not so much that I cured these people, as the principles upon which I relied for their cure. I wish you to understand that a woman may have a menorrhagia because she has a flaccid, feeble, engorged, adynamic womb, just as an accoucbe'e may have a post-partum hemorrhage because her womb will not condense itself. In the accoucbe'e, you will compel it to condense itself by various means, among which not the least nor last will be the secale. Sometimes the secale fails to evince the slightest power over the non- gravid womb, even over the post-partum flaccid womb; and in such cases, being disappointed of the condensing force of the secale, you must seek for other means of cure, requiring longer processes, such as styptics, tonics, cold, and wine. Very young girls are, some of them, subject to menorrhagia. I have seen a girl under eighteen using sixty napkins at every menstruation. This young lady died about a year afterwards, with some physical al- teration of the uterus, or ovary, I know not which, since she lost her life in a distant city. You will be very undutiful as physicians, in these disorders, if you do not attend to the greatest of all points of duty in them; I mean the establishing a sound and true diagnosis. Remember the heart of the Balaena mysticetus, and its aorta a foot in diameter. If your patient's pulse and heart's throb put you in mind of the Balaena, you would bleed her, I should think ; you would lay her in bed ; you would exclude all stimulants, all conversation, lights, rich food, &c ; you would' weaken her heart's injecting force by the lancet; and you would give her tartar emetic in small doses ; and digitalis, and cold acidulous and styptic, or haemastatic drinks. Or, on the other hand, you would find her circu- lating power to be normal, and in that case you would not proceed as above, but you would apply styptics, cold, rest, opium, secale, &c. &c. As a general rule, I suppose that were a young person to send for you on account of a profuse menorrhagia, you would tell the nurse to put her to bed, cover her lightly with bedclothes, give her cold drinks, feed her sparingly, apply to the hypogaster some cloths wrung out of vinegar and water, and tell her there is nothing to be feared. Such a counsel would, in most cases, comprise nearly all you ought to do, or direct; but now and then you must go further than this. A very extraordinary case was under my care last winter, which I THE MENSTRUA. 447 shall relate to you; and I hope you will not find fault with my conduct of it. A very delicate young lady, brought up in the lap of luxury and in- dulgence, and having at command all the benefits of fortune, possessed, of course, that nervous sur-excitability that often accompanies the higher advantages of the social state. Her age was eighteen or nineteen—an only daughter—her weight about eighty-eight or ninety pounds. She had a two months' amenorrhoea, which was followed by a rather profuse menstruation, succeeded by a three months' retention; during which she had no occasion to complain of ill-health, beyond the mere fact of the amenorrhoea. At the end of the said three months, she had in the morning a very slight show, which she was glad to discover; and, upon consultation with the mother, went out to take a walk, hoping in that way to secure a good elimination, by setting her blood in more rapid motion. She did not go very far, and upon returning to the house was considerably more unwell. Early in the afternoon, her mother sent me an urgent message. I learned that the discharge was excessive, with coagulations; but deeming it not at all alarming, I ordered her to be kept very quiet, in a low, recumbent position in bed. I gave her some powders made as follows : Take a drachm of alum and a scruple of nut- meg ; make a powder, to be divided into twelve parcels, of which one parcel is to be taken every hour, or every two hours, according as the flow is greater or less. She was allowed cold lemonade. At ten o'clock at night, I was recalled, and found a great alarm ; a night-vase was filled with napkins deeply stained, and with many clots. The pulse was weakened, the face pale, but the patient not at all dis- concerted. There seemed to be no hemorrhagic nisus discernible in the action of the pulse. There was no pain. The parents were deeply concerned, and asked me many questions as to the danger, and the means to obviate it. I told the mother that the arrest was in my power at any moment. " Well, sir, why not use at once the means that may put a stop to so frightful a discharge ?" In reply, I stated that I did not deem it necessary now to act; for there was reason to expect that the hemorrhagic propensity would soon be exhausted—that there were many therapeutical remedies of con- siderable force, and that I preferred not to resort to a chirurgical measure until compelled by the stress of circumstances ; for I should deeply regret to subject so young a lady unnecessarily to the Touch; without which the remedy in question was not to be applied. You will think it strange that I passed the whole night, until day- break, in that apartment, allowing the child to faint again and again ; opening the windows; using the fan; applying iced vinegar cloths to 448 THE MENSTRUA. the hypogastrium and thighs, administering opium, sulphuric acid, and rose-infusion; taking the pillows occasionally from under her head, and vainly endeavoring to reassure the mother, who repeatedly entreated me to use the tampon; but I would not. Towards morning, a remis- sion occurred, and I went to my home. She was calm until after breakfast; when, upon my return to her chamber, she began again to flood and to faint, so that I was compelled to say to the mother that the time was now come to put a definitive stop to the hemorrhage, whose longer continuance would compromise the young lady. This determi- nation she joyfully received. When she had provided me with a bundle of old linen, and cut it into squares of four inches each, and many of them, I pushed them one by one to the bottom of the vagina, out of which I first turned a handful of coagula. As soon as I had filled the vagina with the squares, I applied a napkin, folded up thick, in shape a parallelogram, that was carefully adjusted to the genitalia; and having secured the compress by the usual bandage very firmly drawn, the hemorrhage ceased. In twelve hours I withdrew the tampon ; no flooding came on. In a few days the discharge ceased completely. I gave her broths and meats, and wine and iron, and she has been ever since in excellent health. There, gentlemen, is the unexaggerated history of my conduct of a case of menorrhagia in a young lady. I am ready now to say, that if I had such a case at this moment, I should treat it in the same way, as far as to the chirurgical part of the treatment. I do not regret that I allowed her to bleed so much and so long. I would permit another young lady to do the same thing, because, having confidence in the power of the tampon to suppress such a flooding, I would let her go very far towards a dangerous state rather than subject her to the mor- tification of the surgical intervention. As to the mortification which overtook her at last, you ought to re- flect that it was sunk in the hazard. There was not, and there cannot be, any mortification for the mind when the consciousness of extreme distress or peril becomes the paramount sentiment. I have no doubt that the very perilous condition into which I allowed her to fall had the effect of removing wholly the shock, and the vexation, and the shame, that would have wounded her had I, like a remorseless barbarian, sub- jected her unnecessarily to .the Touch. I hope you will read this case with care. I say with care; and I mean to urge you, on the one hand, not to be too hasty with your chirurgery, and, on the other hand, not to let your patient sink so low as to make it out of the question to restore her. You ought in the be- ginning of your career to be ever thoughtful, ever circumspect, never in THE MENSTRUA. 449 a hurry to decide—always allowing yourself time to study the state of the case in all its bearings both present and prospective. A young man is as capable of doing this as an old one ; the only difference is that the old man has learned to look about him ; whereas, the young man will not, in his hot and hasty temper, take time to think, but snaps at his conclusions like a duck at a June-bug, as we used to say when I was a boy—excuse the homeliness of my simile; many of you have known it to be a common parlance, especially in the South ; at least it was so forty years ago, when I lived there. Styptics, in uterine hemorrhage, are not of very great power. The mineral acids are about as good as any of them ; ten to fifteen drops of elixir of vitriol, diluted with a wineglassful of infusion of roses, makes a very good dose that may be repeated every hour or two. Five or twenty grains of powdered alum, with two grains of nutmeg, made into a powder and mixed in syrup, or in a dessertspoonful of honey of roses, is a good dose, to be repeated hourly. I think, upon the whole, this is one of the best of the styptics. It is a very safe one. If you should make use of it in some bad case, and should find the flowing to continue notwithstanding your administration, take my word for it that you ought to make the patient swallow a large teaspoonful of the alum for a dose, and repeat it several times. It readily excites vomiting ; indeed, there is hardly to be found a more prompt emetic: but, an emetic is a good therapeutic against a hemorrhage or menorrhagia; because the state of nausea, and the emulging influence of the act of vomiting are capable of changing the determination of the blood, whilst it powerfully modifies the rate, not only of the heart's action, but also the rate and distribution of the innervative or Biotic force. Take, therefore, into your practice, the assurance that alum is one of your best medicines. See a paper on Croup, by my son, Dr. J. F. Meigs, in the American Journal for 1847, for an account of the uses of alum as a remedy; and also the article on Croup in my Observations on Certain Diseases of Children. Again, you have in opium a powerful modifier of the circulation. Opium always modifies the pulse; it checks the hemorrhagic nisus of the womb very effectually ; think, therefore, of the resources you have in your hands through this drug. Sugar of lead is thought to be a very powerful article in the treat- ment of these hemorrhages. I do not like it, nor do I believe much in it; perhaps I have not dared to give it in excessive quantities ; and having very rarely exhibited more than three grains in combination with opium for the dose, I am not sensible that I have ever been much 29 450 ON DYSMENORRHEA. struck with its hemostatic power, though I have made use of it many times, yet less frequently of late than in former years. The secale cornutum is a good and safe remedy ; I know of no ob- jection to its use in menorrhagia; I ought, however, to say that if you make a false diagnostic, and give the patient secale when she is preg- nant, while you deem her only menorrhagic, you will kill her child by making her miscarry. This you ought not to do, for it is discreditable to you and to your art to make such a mistake. But having on a for- mer page presented you my views on the use of secale, I shall not here iterate them. When a patient has recovered of the actual menorrhagia, you should give judicious orders as to her exercise, dress, food, and medicines, and take care, on the one hand, that the cardiac forces of the circulation become not again predominant in their power, and on the other, that the density or tone of the tissues of the body may be restored to a normal condition by those hygienic and therapeutic remedies and con- duct that are suitable in the case. In all anemias, pure anemias, iron is the best of the therapeutic remedies—the wine, meats, baths, &c. are of the greatest importance in the way of the adjuvant ordinances. Farewell. C. D. M. LETTER XXXV. ON DYSMENORRHOEA. Gentlemen: The Greek words 8vc fiVv pt« mean—first, difficult; second, month ; and third, I flow ; so that out of ovs^vptw it was easy to make the word dysmenorrhoea, which might be translated absolutely, a difficult monthly flow. Dysmenorrhoea is a more or less painful disease; sometimes not very much so, but not unfrequently so much as to give a color of distress and affliction to the whole life of the patient. A lady said to me, some time ago: "Doctor, I have for fifteen years suffered invariably at my periods such intense distress, that I can scarce think of anything else than that on a given day my pain is to be repeated ; language is incapable of expressing the degree of torture which I suffer under the pain, the ap- proach of which fills me with horror." A woman who suffers dysmenorrhoea is, ipso facto, unhealthy, as to the womb, and very likely to be unfruitful in the marriage-bed. It is ON DYSMENORRHOEA. 451 true, that dysmenorrhoea may last for many years, in certain persons, without bringing about any visible change in the health of the constitu- tion, which remains vigorous, and retains the normal powers of devel- opment, notwithstanding the invariable return of the pain at the men- sual term. You are not, however, from this statement, to take up the notion that dysmenorrhoea is an indifferent matter, viewed in the aspect of its influence on the health and security of the patient. The pain, the irritation, the imperfect performance of the function, and the state of the tissues that leads to it, are, all of them, circum- stances well calculated to excite the solicitude both of the patient and the physician, because it is certainly true, that the disturbance of the health of the reproductive tissues is very likely to exercise a dis- turbing influence upon the soundness and healthfulness of the entire rest of the constitution. The pain of dysmenorrhoea is a pain felt in the hypogastric region, in either or both of the iliac regions, in the tractus of the ligamenta rotunda, in the sacral region, in the thighs, and very frequently in the course of the distribution of the obturator nerves. This pain, not unfrequently, extends to the whole belly, and is from its violence at times insupportable, compelling the patient to lie down in the bed, or on the couch; forcing from her both tears and groans, and producing so great a degree of restlessness that she seems to writhe like a crushed worm. As a general rule, it may be stated that the pain disappears in six or eight hours, and that it is rarely intense during more than twelve hours, while the painful sensations, however, may continue one, or two, or three days, and in some women through the entire progress of the catamenial act. A person who is subject to dysmenorrhoea, for the most part, finds herself relieved in the course of the first day, or as soon as the flow of blood becomes fully and freely established, and regards herself not subject to considerable pain or inconvenience, until the cycle shall have brought back to her the hour of her affliction. There are hundreds and thousands of women, to whom the menses never bring any the least trouble or inconvenience; there are vast numbers of females, also, who are notified of the approach of their terms by some sense of fulness and weight, or dragging, in the region of the pelvis ; symptoms which disappear as soon as the nisus hemor- rhagicus has effected the opening of the mouths of the vessels, and begun to relieve the hyperaemia of the reproductive tissues. The woman's womb aches until nature bleeds her, as the pleuritic man's stitch torments him until his physician opens a vein in his arm. 452 ON DYSMENORRHEA. If the menstrual flow succeeds in relieving the turgescence of the vessels of the womb, it will, pari passil, have relieved the nerves of the organ of their hyperaesthesia. The pain is pain in the nerve, and, I suppose might be fairly attributed to the sort of compression which the distal extremities of the reproductive nerves must suffer in any case where an organ so solid in its tissue, so firm and elastic as is the uterine texture, becomes the subject of a very decided hyperaemia. I have already said that the uterus, or rather the reproductive appa- ratus of the female, is extremely liable to that form of disorder which is called rheumatism, a circumstance not to be wondered at, in view of the manners and customs, modes of dress, and habits of the females living in the various latitudes in which most of the people of Christen- dom reside. In those latitudes, women are rarely clothed as warmly as they ought to be: custom, bienseance, the power of fashion, cause them to clothe the pelvic region of the body and thighs too lightly, and the women who live in what are called the better classes of society, are constantly exposed to the morbific influences of cold and damp, applied to the lower extremities. The menstrual alternations of the life-force in the reproductive organs, which allows them never to continue in one even tenor of action, probably exposes them more peculiarly than other organs to the morbific, repercussive influence of cold and damp, which are admitted to be the most considerable provocatives to rheumatic dis- orders. Well, then, do you not perceive that a rheumatic womb is likely to be, during the menstrual act, a painful womb, and that much of the dysmenorrhoea which it will be your destiny to encounter in your future career as practitioners, may be justly regarded by you as a form of rheumatism ? Dr. Dewees was fully convinced on this point. I am desirous to impress this notion upon your minds, my young friends, because, if the notion be well founded, which I believe it to be, I am sure that it will teach you in your therapeutical prescriptions, and in your hygienical recommendations and ordinances, to take such pre- cautions as may tend to free the patient from the essential element of her maladive condition, which is rheumatism. But there are many causes besides rheumatic vice which may give rise to pains in menstruation; doubtless the womb may be like any of the other tissues, the seat of a pure neuralgia, by which word I mean a preternatural sensibility of the nerves of the tissues. Such a neu- ropathic condition would not fail to be aggravated at the inception of that vascular engorgement which, under every theory of the function is admitted to be the antecedent or attendant of the monthly flow; and ON DYSMENORRHEA. 453 it is quite reasonable to believe that the full establishment of the evacua- tion might be expected to relieve the woman from her neuropathic state. It may well happen, too, that the patient may suffer pains at the men- strual crisis, dependent upon the temporary aggravation of evils, derived from the presence of tubercles, fibroids, and of various heterologue formations, to which the womb is not unfrequently found to be subject. A displaced or a deviated womb is truly a dislocated womb ; but a dislocated organ cannot be supposed to have a healthful existence, since such dislocation cannot fail to produce distortion and traction of its nervous fibres, which render the organ liable to suffering under changes of its sanguine circulation and its innervation. I assure you that I meet with numerous examples of dysmenorrhoea, which, on investiga- tion, prove to depend upon a retroversion of the womb. In this case, the organ generally becomes enlarged and very sensitive—there is no ground for surprise then, to observe that the woman has extraordinary pain while menstruating. To cure her, it is indispensable to place the uterus in its proper attitude, and maintain it there, which alone is often enough to effect the cure. A womb that is maintained at its proper height and in its proper attitude in the pelvis, "will be, casteris paribus, less likely to be the subject of dysmenorrhoea than a displaced or de- viated one: a uterus that is retroverted will scarcely fail to be a dys- menorrhceal uterus. A uterus that is far prolapsed will rest with the os uteri upon the floor of the pelvis, and, resting there for a long time, the neck of the womb is likely to become bent at an angle approaching more or less to a right angle. But, if the cervix uteri is bent at a right angle, don't you perceive that the canal of the cervix uteri is, by that very fact, placed in the condition of a strictured canal ? But, if you have a strictured canal of the cervix uteri, will not irritation in the body and fundus of the uterus supervene from the difficulty which must necessarily ensue in the evacuation? Don't you know that a stric- ture of the urethra produces irritation of the bladder, of the ureters, and even of the kidneys ? and will you find it difficult to suppose that a stricture of the canal of the cervix uteri may, in the long run, lay the foundation for such irritation of the womb itself as shall result in the establishment of a true dysmenorrhoea ? I don't pretend to say that all the cases of stricture of the cervix uteri are to be attributed to anteflexion or retroflexion of the neck of the womb, although those flexions and angulations are among the fre- quent causes. It is very certain that some of the strictures of the cervix uteri are congenital; you will admit that this is the case, because you already know that congenital atretism of that canal is one of the 454 ON DYSMENORRHEA. possible circumstances hereafter to attract your attention and call forth your skill: I have had several such samples of great contraction among the anatomical specimens in my collection, and I have seen similar ones in some of the museums of Europe. It was upon the observation of this constriction of the canal of the cervix uteri, constriction so great, as to make it not a little difficult to introduce a common pocket probe to the fundus uteri, that that most ingenious physician, Dr. jMackintosh, author of the Practice of Physic, founded his successful treatment of cases of dysmenorrhoea. Dr. Mackintosh has given numerous cases of females, in which he observed that the orifice of the canal of the cervix was exceedingly small; so small, as scarcely to be perceptible to the touch : on pressing into that orifice a small bougie, which he carried up through the whole canal to the cavity of the body and fundus, he gently dilated the pas- sage, which he fully dilated by succeeding operations, in which he em- ployed larger, and still larger bougies, until the caliber of the passage was perfectly restored. The effect of these operations was to cure his patients of the most distressing and long-continued dysmenorhoea, which serves conclu- sively, I think, to establish the theory that I am laying before you, namely, that stricture of the canal of the os uteri may be a cause of dysmenorrhoea. Dr. Mackintosh's practice has been used everywhere, and with un- doubted success in cases proper for it. Some of the brethren have preferred to Mackintosh's method the use of a concealed bistoury, which, being introduced to the upper extremity of the canal, is slightly disclosed by a spring, and then, being withdrawn entirely from the os uteri, has divided the lining membrane of the canal, allowing of a com- plete dilatation of it. When I was in London, in 1845, Dr. Locock showed me one of these instruments, with the effects of which he ap- peared to have been much pleased in his practice. If you have read this book, you must have observed, in a former letter, that I strenuously opposed the use of all cutting instruments in the procuring of a requisite dilatation, upon the ground that every division must be followed by a cicatrix, which is, essentially, a morbid existence ; whereas, all necessary dilatation can, I am convinced, be as readily and perfectly brought about by a distending pressure, leaving the part, when the part has been thus cured, without a wound, and in a perfectly healthful and normal state. I repeat it, that a cicatrix is not a normal state ; it is always insecure, always dangerous. I, there- fore, profess my adhesion to Mackintosh's practice. My own experience in the use of the bougie has been to a certain extent satisfactory to me ; ON DYSMENORRHEA. 455 satisfactory to this extent, that it has not only, in some cases, relieved the woman from distress, pain, and other disorders of menstruation, but that it has cured her of a pre-existing sterility. A woman is likely to be sterile when her uterus is unhealthy, and particularly, when it is unhealthy from narrowness of its canal. Within two months, there came to me from a distant State, after a correspondence which I had with her physician relative to her case, a lady complaining of dysmenorrhoea. She had been for fifteen years perfectly regular; she never failed in her menses, but she could not.re- member a single instance of her catamenia in which she had not suffered the most direful distress. Her general health was excellent; she had a lively, brilliant complexion, a charming degree of embonpoint; but she had been many years married, and had had no children. After con- versation withr her, she was willing to submit to an examination by the Touch, and afterwards by inspection by the speculum. I found, upon the Touch, that the os tincae rested upon the floor of the pelvis, where it had long rested ; and I supposed that the weight of the uterus and the superincumbent pressure had produced an anteflexion of the cervix, bending it at about an angle of 110°. The opening of the os tincae was very small. Exposing that orifice by catching the collum uteri in the uterine extremity of a Recamier speculum, I pressed into it a linen bou- gie, which I conducted as far as the cavity of the womb. On the following day, I repeated the operation, succeeding with a larger bougie, and the operations were repeated four times only, when I desisted from further attempts, because her catamenial hour was nigh at hand. On the fourth day after the last operation, her courses appeared in due time ; they flowed freely, abundantly, and normally; and for the first time in her menstrual life, which, as I before said, had now continued for fifteen years, she passed through her menstrual crisis without the least un- easiness or distress, to her great satisfaction and that of her anxious husband. She soon afterwards returned to her own State, promising me to keep me informed of the progress of the cure, since which I have had tidings from her. She has never conceived. I will not cram this volume with cases of an analogous kind, and in the treatment of which I have sometimes been so happy as to be very successful, while at other times my patient has not derived the least advantage, from the process, probably because, in the unsuccessful cases, the remedy was not the one which I ought to have adopted. In Dr. Mackintosh's work, at p. 655, Washington ed., he informs us that he has treated twenty-two cases of dysmenorrhoea by dilatation of the os uteri, of which eighteen were permanently cured. " Ten of 456 ON DYSMENORRHEA. these women were married and living with their husbands; of these ten, seven subsequently fell with child. I beg you to be aware that the womb was not originally designed to be skewered, and I hope that in all cases, before you resolve upon this method of dilating the strictured canal of the uterine cervix, you will remember that the tissues being very delicate, all rudeness, haste, and improper violence ought to be avoided. It is very possible that your bougie might lay the foundation of incurable disease of the inner wall of .the womb. The bougie is an allowable method; but it is never allowable without careful reflection upon the evils to which it might lead, as well as the real necessity for its employment. I have already stated my belief that the uterus is the frequent sub- ject of rheumatic disease. In the cases in which you may have reason to suppose that the malady is derived from a rheumatic vice, it will be reasonable for you to employ Dr. Dewees's celebrated volatile tincture of guaiacum, on which, you know, he placed so great a reliance, but which, in my hands, I am sorry to say, has not fulfilled the high expecta- tions which were derived from Dr. Dewees's lectures and publications. I think you will find advantage in using, a few days previous to the attack of dysmenorrhoea, moderate doses of the golden sulphuret of antimony, combined with camphor and small portions of opium or mor- phia ; you will scarcely find an article possessing greater deobstruent powers, where an inflammatory excitement may be supposed to exist, than this special combination, which not only has efficacy to soften the pulse, to increase the perspirability of the skin, and promote the secretions, but is also an efficacious agent in the subduction of the nerv- ous excitement or erethism, which must be supposed in such cases. In any instance clearly traceable to a rheumatic condition of the fibrous texture of the uterus, and in which you can indulge in a hope of doing good by purgatives, allow me to suggest to you the employment of Scudamore's mixture of acetous tincture of colchicum, magnesia, and sulphate of magnesia combined with some aromatic distilled water; you should, for this purpose, combine three drachms of acetous tincture of colchicum, one drachm of magnesia, and three drachms of sulphate of magnesia, with four ounces of any aromatic distilled water, as that of mint, cinnamon, or what you will. The dose should be preceded by a moderate portion of blue pill, or calomel, to be taken at bedtime while the colchicum mixture should be administered the following morning in wineglassful doses, repeated every second or third hour until the ope- ration is sufficient. It is important in all those cases where you wish to clear the repro- ductive organs of any accidental disturbing influence that may arise ON DYSMENORRHEA. 457 from irritation of the rectum, dependent upon accumulation of feces or improper excretions there, to move the alimentary passages as prelimi- nary to some more direct treatment. The mere removal of the heat and excitement dependent upon irritation seated in the lower bowel may be sufficient to set the womb at liberty to perform its menstrual act without pain, or the least distress. I have already expressed to you my disbelief in the power of em- menagogue medicines, without withholding my assent to the opinion that certain medicaments are endowed with the faculty of increasing the determination of the blood, and of the nervous fdrce, toward the pelvic extremity of the body. I have found it safe, convenient, and efficacious, with this view, to administer for a long series of days, weeks, and even months, portions of the common tincture of Melampo- dium or black hellebore, and I confidently believe that for different in- dividuals to whom I have prescribed such medicament, the result has been most fortunate. I have prescribed from fifty to sixty drops of the tincture to be taken thrice daily, with an infusion of some garden herb, as pennyroyal, and, either post hoc vel propter hoc, the patient, who had suffered the greatest distress from dysmenorrhoea, has been in different instances entirely relieved of her sufferings. This result I have obtained so many times, that it has become habitual with me to make the prescription where some other indication has not had the pre- cedence of it; such as venesection, purging, leeching, the bougie, etc. I further believe that the use of the ferruginous tonics in the cases where the crasis of the blood is so reduced as to warrant them, ought not to be omitted, and that, in a person laboring under dysmenorrhoea, and in whom it is right to prescribe the tincture of black hellebore, it will be, in general, right to prescribe Dr. Blaud's pill, of which one may be taken three times a day; or a pill composed of two or three grains of Vallet's mass, thrice daily; or what, perhaps, is preferable to all the rest, two grains of Quevenne and Micquelard's powder of metal- lic iron. The patient, under these circumstances, in all the variable and cold seasons, should be compelled, as far as the authority of the physician will go, to wear drawers of woollen flannel. In the cases of dysmenorrhoea, in which there is pain in the uterine region during the intermenstrual period, and which is greatly aggra- vated during the menstrual epoch, an examination by the Touch might convince you that the organ is left in a subacutely inflamed state. In your treatment of an obstinate and serious malady of this sort, I should think you would deem it your duty to solicit an opportunity of inspect- ing the collum uteri by means of the Reoamier speculum. It is not rare to find the interior aspect of the lips, and, indeed, the whole os 458 ON DYSMENORRHEA. tincae, red, turgid, and injected to such a degree as to render the arte- rioles et venules visible, as you find them often in the chronic diphthe- ritis of the pharynx. A general bleeding, or a topical abstraction of blood, by means of leeches, is among the likeliest means to counteract this morbid state of the circulation of the parts, which, as long as it is allowed to persist, might effectually contravene your merely therapeu- tical efforts. To obtain a cure, bear in mind, also, I pray you, this solid therapeutical truth, namely, the nitrate of silver, applied to a superficies, is among the most powerful, and least painful, of the anti- phlogistic remedies in your power; and that, in aiding to cure the top- ical affections of which the uterus complains, it will aid you to rid the patient of constitutional disturbances arising from those lesions. Many of these dysmenorrhoeal patients complain of the discharge of shreds of an organized membranous material, which is doubtless exfo- liated from the caducous coat of the uterus. If you don't like this idea of the caducous coat of the uterus, then, I beg you to say that, when such a membrane is discharged in dysmenorrhoea, the half- organized mass is not and cannot be the result of coagulation, but must be a plastic deposit, like the plastic deposit in croup, and like that in phlebitis, in pleuritis, peritonitis, &c, and ipso facto, proves the existence of an inflammatory state, because plastic deposits are not found except in a condition which deserves to be called an inflammatory condition. Dr. Dewees regards this excretion as derived from a rheumatic con- dition of the uterus; you will see his reasoning on the subject, at page 106 of his essays on various subjects, Phil. 1803, and you will find that he was led from d priori reasoning to make use of the guaiacum in the cure of the complaint. At page 110, is his formula for the preparation of his celebrated tincture, which is in the following terms :— R.—Pulv. gum. guaiac. Sviii; Carb. sodae vel potass. 5iij ; Pulv. pimentse Jiij ; Alcohol, dilut. Ibij. The volatile spirits of sal ammoniac is to be added, pro re natd, in the proportion of from one to two drachms, less or more, agreeably to the state of the system. Dr. Dewees is justly to be regarded as one of the most eminent prac- tioners of midwifery in his day, and no American physician has acquired a wider-spread reputation, either at home or abroad, than he. His opinions are entitled to respect, and I refer you to his article on dysme- norrhoea, which every student ought to read; in that article you will find his directions for the administration of the volatile tincture of CHANGE OF LIFE. 459 guaiacum, with an account of the flattering results obtained from its employment. I do not consider myself as treating his memory with any disrepect, when I suggest to you that it is rarely the nature of rheumatism to pro- duce plastic secretions upon surfaces, and that in none but the most violent examples of rheumatic inflammation do we find plastic secre- tions, even about the articulations. Be careful, in all cases, about your patient's diet, about her occupa- tions, and about her whole conduct; think always what you have to do, and how it is best to be done. I think, gentlemen, I shall have nothing further to say to you, at present, of dysmenorrhoea. I am, Very truly, Your obedient servant, C. D. M. LETTER XXXVI. Gentlemen: In this letter, I shall speak to you on the "change of life," as it is commonly called, or that state of the female in which she finally loses the power of menstruation, ceasing from that time forth to be subject to the mensual law. If I have been correct in the opinion I have entertained, and which in former letters I have expressed, as to the causes of menstruation, then I shall have only a light task to make you acquainted with the causes of the cessation of the menstrua, or Change of life. It is obvious that, if women menstruate because of the monthly ovulation and deposit, they cease to menstruate because the monthly ovulation has ceased to be a physiological function. I have all along insisted that the power of germ production is a cli- max of life-force—one that is only attained when the body has attained its full and mature development, that is maintained as long as that body retains its healthful vigor and force, and that is lost often upon the smallest change of the health, and given up definitively when the powers of life, having been exerted during the prime and maturity of the forces, begin to fail, and the possessor to decline towards the last term of ex- istence, which is stated to be at threescore and ten years. There is something melancholy in the conviction, that must attend the final cessation of the menses, of a decadence of the constitution. The subject of such a conviction is compelled to admit that she has now be- 460 CHANGE OF LIFE. come—what ? an old woman ! Henceforth, what has she to expect save gray hairs, wrinkles, the gradual decay of those physical or personal attractions which heretofore have commanded the flattering homage of society—the slow augmentation of the weight of existence—when the grasshopper becomes a burden—when the keepers of the house shall tremble, and they that look out of the windows shall become dim. The pearls of the mouth are become tarnished—the hay-like odor of the breath is gone—the rose has vanished from the cheek, and the lily is no longer the vain rival of the forehead or the neck. The dance is pre- posterous, and the throat no longer emulates the voice of the nightin- gale. All these are melancholy convictions, and not even the fine false arguments of Tully, in his Treatise on Old Age, can drive away the pain- ful truth or make the wrong the better reason. To be sure, religion can bring its consolations, its hopes, and its triumphs;—for religion can make us triumph over death and the grave, robbing them of their sting and their victory. Still, human we are, and we shall be human while the clogs of mortality still hinder and bind us. What hope, then, has the woman who has come to the period of the change of life ? Have you any comfort for her ? Yes ! She is no longer exposed to the direful risk and pain of childbearing. She thanks God for that, and takes comfort in the thought. She is no longer to be the subject of the monthly trouble, which, while it lasted, and still held up her claim to be numbered amongst the young, yet was often connected with sensations of ill-health—and annoyed her by its failure—its pro- crastination—its anticipation—its violence—its protractedness, and its pain. She has become fatigued with it and tired of it. She had lost her color, and grown thin, for it exhausted and irritated her, but now that she has laid it aside forever, her constitution, no longer teased and taxed with the necessity, takes a new start of life and vigor; she begins to acquire a certain embonpoint, and, as Colombat beautifully depicts it, she seems to recover somewhat of the beauty, and grace, and attractions of an earlier date. Many women, in fact, do find that the health is greatly improved by the dispensation. The complexion re- covers its former tint, and new deposits of fat give roundness to the limbs, and efface the wrinkled traces impressed upon the features by care, and watching, and exhaustion ; so that, though the loss of the cata- menia brings with it the melancholy conviction that she is becoming old, there is a compensating conviction in the apparently renewed health and comfort that follow the change. A few short years, how- ever, renew, but in a gradual manner, the evidences of the decline of life. But the sort of moral impressions of which I have spoken, and which, CHANGE OF LIFE. 461 doubtless, are painful, are not the only evils to which the female is ex- posed at the change of life. I am sure that you will have no difficulty to conceive that an organ, or rather a collection of organs, that have been for thirty years concerned in the production of germs and in the performance of the great offices of menstruation, could not wholly cease from, and lay aside, those operations on which have depended both health and security, without hazard at least, or perhaps, without some fatal lesion of the health; and you should take into consideration that, during thirty years of menstruating and gestative life, the uterine arteries and nerves, as well as the spermatic nerves and arteries, have been subject to constant alternations of great activity and comparative repose. Should we not then be prepared to expect that, on the commencement of this long repose, these organs should become the subject of some un- healthy action of their innervative and circulative forces, laying the slow, insidious, but disastrous foundations of disease, which, too often is not discovered or ascertained to exist until it has passed beyond the curative stages ? Such reflections as these, it seems to me, ought to render you extremely cautious in inquiring into the causes of those complaints which women at the change of life often make, and which, I am sorry to say, are as often hushed with the unsatisfactory reply that such complaints are owing to the " change of life," and likely to cease whenever that change shall become complete. A physician has no moral right, by his opinion, to put to sleep the anxieties of his patient, and by so concise and unphilosophical a mode of proceeding save himself the trouble of thinking. Whenever, therefore, a female, at this period, which is universally admitted to be a critical and dangerous time for her, comes to you to complain of symptoms referable to some morbid condition of the reproductive tissues, do you not perceive that it would be most clearly your duty to give a considerate attention to her rela- tion, and not dismiss her until your judgment should be fully satisfied as to the therapeutical or hygienical indications of the case ? It will not be necessary, in all instances of complaints made to you of uneasy sensations in the pelvic region, to subject the female to the pain and mortification of the vaginal Touch ; but, whenever the complaints are so considerable as to give you just reason to suppose some congestive or inflammatory modification of the reproductive tissues has taken place, it will be your duty to insist upon a full exploration of the state of the reproductive organs. Such an exploration, made in the manner already pointed out in former letters, will enable you to be perfectly satisfied as to the existence of disease in those organs likely to affect seriously the health of the patient. If, upon such exploration, you should discover 462 CHANGE OF LIFE. no reason to suppose the organs within the pelvis the seat of any morbid action, then it will remain for you to inquire into the state of the whole constitution of the patient. I have so often, in my lectures at the College and in this series of letters, pointed out to you the mode of making a diagnosis by the successive exclusion of all the organs and functions that you are enabled to pronounce to be in a healthful condition, that I need not here iterate the directions for making such a diagnosis. It might well happen, one would think, that a woman, who for thirty years had been perfectly regular in her menstrual function, and who had, in a healthful manner, borne and nursed her children, might feel, upon the change of life, the want of her accustomed evacuations, and that without the existence of any mere local disorder. It is very certain that the habit of producing blood in quantities sufficient to carry on in a healthful manner, all the ordinary life functions, besides yielding an abundant material for the monthly waste, is likely, upon the subduction of that waste, to be followed by disorders in the state of the sanguine mass. You remember the opinion so frequently expressed herein, that the blood owes its existence to the activity of the Endangium or blood- membrane, as I have called it; but disorders affecting that Endangium modify the condition of the whole health. Under these circumstances, the health will be modified by a condition of the Endangium tending to produce, on the one hand, plethora; on the other, anaemia. Now, you will find many of your patients com- plaining of ill health, in whom it will be impossible to say that it is the brain, the lungs, the liver, the spleen, the pancreas, the alimentary tube, the great articulations, or indeed any special organ that is the seat of special malady, while the ill health is really due to a change in the crasis of the blood. But, if the doctrine be true that the Biotic force is a product of the contact and combination of arterial blood with the substance of the neurine, then it follows that you will have to discover the remedies, or the treatment that may serve to bring the blood back to an absolutely normal condition, which, when it shall have been effected, may serve to restore to the whole constitution the salutary influences of a steady, perfect, equable innervation; which will be health. The apparatus of digestion, in fact, may be said to stand at the very portals of existence, and any threatened invasion of the health is as likely or more so, to fall upon this point, as upon any other. Thus, in instituting inquiries into the state of the system in persons complaining of the change of life, it will be expedient for you to make inquiry into the wants of these alimentary organs. The peculiarity of their inner- CHANGE OF LIFE. 463 vation and circulation exposes them constantly to attacks of disease ; this peculiarity consists in this, that the whole of the blood of the digestive arteries—which, you may remember, are the cceliac and the two mesenteries—is carried back to the black circulation by the vena portae, which trunk itself is obliged to divide itself into a new series of venous capillaries, again to be reunited in the three hepatic veins, be- fore it is finally returned to the right side of the heart by the cava. Do you not readily perceive that so complex a condition of circula- tion in those vessels exposes them to constant engorgement and ob- struction, interfering with the great restoring and replenishing power of digestion ? Such disorders are frequently and carelessly expressed under the terms, biliousness, indigestion, flatulency, acidity, diarrhoea, costiveness; and it is not reasonable to expect they are to be instantly and promptly removed by the administration of one or two doses of some trifling aperient, or by the exhibition of the so much vaunted blue pill or calomel. The administration of a drug can never set aside the necessity for the observance of the reasonable rules of a hygienic method. Don't expect, therefore, to cure your patient without a careful prescription as to her whole conduct in relation to her diet, to her dress, her baths, her sleep and waking, her exercise, and a proper attention to the state of the alimentary organs. By means of the exhibition of portions of blue mass, of calomel, of rhubarb, of the compound aloetic pill, and, in weakly and cold persons, of some warm aperient tincture, such, for example, as a combination of the compound tincture of cinchona and sweet tincture of rhubarb, in moderate doses, with wise prescriptions as to the nature of the aliment to be taken—you may hope to bring the digestive tube to a state of perfect health; which, once effected, opens up the way to the removal of all the other difficulties that may have been connected with the de- velopment of the constitutional or local maladies of the case. It is easy to ascertain whether or not the digestive functions are re- stored to a healthy condition. The signs of such a condition are found by making inquiry as to the state of the appetite, digestion, defecation, and the sensations of the patient as regards the abdomen and the health generally. Reference should be had to the condition of the strength; the color of the skin, its perspirability, its elasticity, its temperature; the con- dition of the tongue ; the state of the lining membrane of the mouth and fauces, as ascertained by inspection, and the odor of the breath ; the nature of the urine, as to quantity, as to color, as to solidity ; the 464 CHANGE OF LIFE. respiration, and the action of the heart, the great source of circulation, to be ascertained by direct auscultation, and by an examination of the pulse; all these inquiries will give to you an answer to your question, " How is the patient ?"—and you will not lose sight of her, I trust, until the answer is entirely satisfactory to your mind. But there are circumstances, gentlemen, connected with the change of life, which often render it necessary for you to insist upon a direct examination by the touch as to the state of the reproductive organs. It will be rare for you to find, at this age, in otherwise healthy women, any signs of leucorrhoea, or any follicular malady of these parts : such affections appertain to an earlier period of life. YTou will meet with some cases of great relaxation of the vagina, which actually suffer the uterus to fall down upon the plane of the perineal strait, or even to take the position properly called procidentia. See Horace's Epodes, Ode viii. lines v. and vi. The uterus, fallen so far out of its proper position, becomes a disturb- ing force to the economy. I have already told you, again and again, that the nervous system of the womb and reproductive organs allies itself intimately to the system of voluntary and ganglionic innervation of the economy ; and it is as easy to suppose that a woman should feel perfectly well and comfortable with a dislocated humerus, as with a dislocated uterus; for I deem it perfectly true to say that a uterus, fallen from its just level in the pelvis, is a dislocated uterus—a term that expresses the idea of the case more completely and more trenchantly than the softer terms, uterine deviations and uterine displacements. I can't pretend to say that, if you would push the uterus back to its own level with your finger, and keep it there for a short time, your patient would be restored by that act to consummate health ; but I repeat that a dislocated uterus is a disturbing force in the economy, and that, whatever you may do or direct for the rest of her health, you will not be likely to have a perfect success, while you allow of the un- mitigated operation of that disturbing force. Therefore, in your plan of treatment, there should enter some means of placing the uterus in its natural position and retaining it so. The mode of effecting this de- sirable object, it is not necessary for me to dwell upon again in this letter; therefore, I refer you to my letter on prolapsus, and the use of the pessary. If, in the case, instead of finding simply relaxation and displacement of the womb, you discover upon its ballottement that the uterus is heavier larger, and more solid than it ought to be, you will at once inquire whether the state of the general circulation as to its force and vigor will warrant you in prescribing a bloodletting ; or whether you might CHANGE OF LIFE. 465 deem it more prudent to let blood by means of half a dozen or a dozen American leeches, applied to the collum uteri by means of a Rdcamier speculum ; or whether it might be deemed more advisable to take blood by means of cups applied upon the sacral region ; or whether you will rely upon the resolvent influences of the warm bath, or upon the applica- tion of some of the finer narcotic extracts to the interior of the vagina or the neck of the womb ; such as injections of infusions of cicuta, or extract of belladonna, or injections of laudanum into the rectum, in the hope of effecting a complete subduction of nervous excitement and pain. Twenty grains of the extract of belladonna, mixed with two ounces of mucilage of gum, will furnish you a compound, of which a tablespoon- ful may be injected into the" vagina once or twice a day. Half an ounce of cicuta leaves may be boiled in half a pint of milk, which, when cold, should be strained, furnishing a liquid, of which half an ounce or an ounce should be injected into the vagina two or three times a day. If you prefer it, you may make use merely of an anodyne injection, made of forty drops of laudanum, mixed in half a fluidounce of boiled starch, to be employed as an injection every night, and if necessary every morning, of which you are to be the judge. You ought also to remember the deobstruent power of contacts of the nitrate of silver with the vaginal cervix ; particularly when those contacts are made with such a force as to prove not destructive, but only antiphlogistic ones, as the happiest effects may then be expected to fol- low them. As to exercise, and as to rest, under these circumstances, it is im- possible for me to give you explicit directions, for these are momentous questions, which can only be decided in the presence of the patient, and upon a good acquaintance with her real wants as to those points. It is very certain that a long recumbency in bed, or upon the couch, is frequently found to exert a salutary influence upon the congestive and inflammatory conditions of the uterus, doubtless in consequence of the beneficent influence of what is, in surgery, called position, upon the circulation of the blood in these low dependent organs. I beg leave, however, to suggest to you a caution as to the too long continuance of confinement to the bed, or to the couch, which is dan- gerous to the health, since some exercise, some motion of the body, some breathing of the fresh air of the open day, some relaxation from the perfect conviction of ill health, only to be had in the conscious power of motion, is necessary to restore the spirits of the patient, suf- fering under long chronical ailments. 30 466 CHANGE OF LIFE. Instead of meeting with these relaxations of the vagina, and descents of the uterus, you will, about the change of life, meet with some cases of extreme constriction and condensation of these tissues. It has been my lot to encounter several examples, in which the greatest alarm and distress were, as I thought, traceable to vaginal contraction and stricture. I need not dwell on the disordered mental impressions of the patient, connected with the reduction of the caliber of the vagina, amounting almost to a state of atretism. I am strongly inclined to believe that a case of melancholy, which led to suicidal propensities and attempts, was justly attributable to such a conviction. Therefore, upon making such a discovery, I presume you would not fail to institute a treatment calculated to obviate such contractions, and I refer you to my letter No. IX., for directions as to the method of*proceeding. Among the most frequent and dangerous accidents to which women who do suffer at this critical period of life are liable, is the laying the foundation of carcinomatous disease. Y^ou will remember that I have already expressed the opinion that these frightful affections are the re- sults, not of a direct inoculation of reproductive cells, but of slow changes of structure, brought about by unsuspected and unknown in- flammations, which become, so to speak, the proper nidus, furnishing the requisite cytoblastema on which these cells depend for their devel- opment and indefinite increase. If, therefore, upon making your vaginal exploration and taxis, you discover some suspicious degree of hardening of the collum uteri, and especially of the os tincae; if you find some change of the form of the mouth of the womb, altering its oblong, or its dimpled shape, rendering it irregular in circumference, and imparting to the sense of touch the idea of botryoidal excrescences, or granules, then you will have just reason to fear that the fatal foundations are already laid; but, thank God that, as it is true every swallow does not make a summer, so every suspicion of the commencement of carcinoma will not warrant the con- viction that carcinoma is come. You will wholly fail of your duty, under such circumstances, if you omit to examine, by means of the speculum, the actual condition of the parts in question. For a woman who has a true carcinoma of the cervix, I believe there is no hope to be entertained; but, be sure of the diagnostic ; and if you can flatter yourself, or convince yourself that the malady has not gone to the extent of clothing itself with the direful characteristics of car- cinoma, then there remains good hope of a cure, by a wise and careful treatment. If it is not carcinoma, what will you call it? Is there any other name by which it can be named than the name of inflammation, whether CHANGE OF LIFE. 467 you deem it acute or chronical ? But, if it be inflammation, what remedies have you ? Have you not purgatives ? Can you not appeal to the aplastic powers of mercury, to the deobstruent therapeutical powers of the narcotics, to the antiphlogistic uses of the lancet, the leech, the cupping-glass, the bath, emollient injections into the vagina, anodyne injections into the rectum, dietetic rules, and rest and reas- surance of the patient ? Have you not at hand the almost miraculously antiphlogistic powers of the nitrate of silver? I assure you that on many various occasions, in which, in persons approaching the change of life, I have on the first exploration been shocked by the conviction that the patient was attacked by carcinomatous degeneration of the uterus, I have, on further exploration and diagnosis, been led to the institution of attempts to cure, which have been entirely successful. I repeat to you here what I have said in a former letter, that I do not boast of curing cancer, but in the course of many years of clinical experience, I have met with many extraordinary escapes from what I believed to be carninoma, but in which I had doubtless made a false, diagnostic. I shall not trouble you with further observations in this letter on the precise treatment of these cases, but refer you to the earlier letters of this volume for the principles and the treatment which you should adopt in their management. It would be but useless iteration to speak of them again here. And now, my young friends, comes the question as to the time when the change of life takes place. As a general rule, it is safe to adopt a public opinion, though it may not be absolutely true that vox populi vox Dei. That public opinion holds that the change of life takes place at forty- five years, and all our women look for the change at that time; but all our women do not change at that time; some women definitively lose their menstrua at thirty, and some even earlier. A lady with whom I conversed in March, 1844, told me that she became perfectly regular when she was twelve and a half years old; she bore twelve children; at thirty-five she definitively ceased to menstruate, and in her whole life never had the least trouble with her menstrua; she was as well at its cessation and since as she ever was. She was upwards of forty years of age. I have a patient now under my care who, at the age of seventy-three years, is as regular as a young girl, and has been so since an early age. Allow me to cite for you a passage from M. Brierre de Boismont, p. 209. " It has been said in a general way, that the cessation of the men- 468 CHANGE OF LIFE. strua takes place about the forty-fifth year in this country—a little sooner or a little later. The fact is true ; but we believe that a better appreciation would be made by presenting a table indicating the differ- ent periods of the critical age. We have here collected one hundred and eighty-one cases of women indicating the age at which they had ceased to see, and here are the results:— At 21 — 2 At 34—4 At 42— 7 At 50 —12 24 — 1 35—6 43—4 51—4 2G —1 36—7 44 — 13 52—8 27 — 1 37—4 45 — 13 53—2 28 — 1 38—7 46— 9 54—5 29 — 1 39—1 47 — 13 55—2 30 — 3 40 — 18 48—8 56—2 32 — 2 41 — 10 49—7 57—2 Making a total of 181. 60—1 This informs us that the cessation of menstruation may take place at very different periods of life, since here we have cases showing that it may take place in years, varying from sixty to twenty-one. But the proportions at which it occurs at the several ages are very different; for, while it rarely happens in the young, it happens very frequently about the fortieth year, is very common about the age of fifty, at which time it sensibly diminishes, and in the last years of the table it follows the proportions observed in the early years. M. Murat, in Diet, des Sci. Med., article Conception, p. 200, informs us that he delivered a person of her first child who was a few months beyond the twelfth year of her age. Haller has an instance of as early a pregnancy. On the other hand, certain women continue to menstruate until a very late period—for example, Valerius Saturninus was born when his mother was sixty-two; Valescus de Tarento had a case of labor in a woman of sixty-seven, and Haller mentions two instances, in one of which the woman was sixty-three, and in the other sixty-seven years of age. All these persons menstruated—so did not Sarai the wife of Abraham, who was old and well stricken in years, and with whom it had ceased to be as it is with women. Among the singular instances of reinstallation of the reproductive force, in advanced age, is the following from old Rembertus Dodonaeus, of whose pretty little duodecimo I happen to have a copy in my library. He tells it as follows—it is from his Medicinalium Observationum Ex- emplaria, &c, p. 292. The lady, it seems, was the prioress of a convent. She had long before ceased to menstruate, on account of her advanced age had become gray—had lost her molar teeth, and her breasts had HYSTERIA. 469 quite disappeared, while her face was covered with wrinkles. Being in this condition, her hair began to grow so as to cover the head with black tresses. She got a new set of teeth, and her menstrua returned with the greatest regularity, flowing as in her most healthful and vigor- ous youth. The breasts became again full and round and firm. All her wrinkles disappeared, and she regained the bloom and beauty of her early days, so that the virtuous and modest prioress was ashamed of her appearance, though she long continued her religious course of life. The same author, at p. 293, tells us of a woman of his acquaintance who had a child after she was sixty, and two others afterwards, being sixty-seven years old when her last son was born. I will not trouble you with any further statistical details on this point, which I consider as useless, preferring to refer you to the voice of public opinion, which, you perceive by this table, coincides with the truth. You should be careful, in your early wants as to clinical experience, not to take every assertion as the truth. A young Doctor would do well to adopt as his motto the new-fangled French word Panoptism, which, to translate in an expression very common in America, would be set down in the words "wide awake." You are not to take it for granted, because a woman thinks that she has arrived at a critical age, that she is at the crisis; you, and not the patient, are to be the judge. If she be in the crisis, it is well, and you will act accordingly; you will not pester her with your vain emmenagogue treatment; if she be not in the crisis, you will provide such ordinances as may seem to be con- formable to the requirements of the case. C. D. M. LETTER XXXVII. Gentlemen: There is a disease called the Protean malady, because it simulates so many other disorders that, like the fabled Proteus, it is supposed to be capable of taking on all forms. In common language, it is called Hysteria, from vottpa, the womb. The ancients used to call it suffocation of the womb, suffocatio matricis, and praefocatio matricis. It has been called nvi% va-ttpixtj, and also artvovf artvoi.a; the rising of the mother; and an Irish girl who came to our clinique, in 1843, as some of you may remember, replied, in answer to my question as to what ailed her, "The winding arrow, sir." "The what?" said I. "The 470 HYSTERIA. winding arrow," rejoined her mother. " The winding arrow ? I don't understand you," said I. "Why, it begins at the bottom of her sto- mach, sir, and it goes winding up along the course of her bowels until it gets to her throat, and then it chokes her, and she has a fit." So we'll put down among other titles of hysteria, if you please, Irlandice. the winding arrow. The question that first presents itself, after pronouncing the word hysteria, and when a person has already some knowledge of the phe- nomena of the disease, is this, videlicet, is it hysteria ? that is to say, has the womb anything to do with it? and if the womb has anything to do with it, can a man, who has no womb at all, have hysteria ? This is a question which has long divided the profession—many authors of rare merit, and great powers of discrimination, averring that it is an hyste- rical, that is to say, a womb malady; while others declare that it is wholly independent of the womb, and that males may have it as well as females. To reason this way may be said to be a reasoning after the Baconian or inductive method, which is not always the best way to reason, since a rational method may, in many circumstances, lead to results as perfect, as clear, and as stable as those obtained by the most careful induction. If hysteria depend upon the womb, then a man, who has no womb, cannot have hysteria ; then hysteria, you will say, cannot depend upon a disturbing force emanating from the womb alone. We seem to have come to a term in speaking in this way; but we have not spoken the whole truth, because while hysteria may, in fact, proceed from the uterus, hysteria may, in fact, likewise attack the male. As to this point, I think there can be no doubt, since the medical records are full of testimony bearing upon it. The medical writers who have asserted that hysteria proceeds from the womb or the reproductive organs—for which the word womb should be taken as a general expression—have probably not understood themselves ; doubtless they have intended to assert that, modifications of the reproductive power of creatures, which might be characterized as the aphrodisiac sense, or, if you will have it, the aphrodisiac force, are the causes of the protean or hysteric malady. I suppose they could not really mean to say that the uterus alone, disengaged from, and unconnected with, the other reproductive organs, is, by its disturbing force, the cause of the hysterical malady, for that organ itself is probably far less immediately connected with the development of the aphrodisiac force, in the economy of creatures, than certain other parts, as the ovaria or clitoris, for example; though it is perhaps just to at- tribute to this strange power of reproduction a wider range within the HYSTERIA. 471 economy than the narrow limits of the organs, properly called reproduc- tive or generative. It seems to me that, while we may, strictly speak- ing, confine our notions of the aphrodisiac power to a status of a tex- ture, or textures as parts of a general anatomy, yet we cannot deny its comprehensive influence upon the entire of the animal constitution. But, as the constitutional aphrodisiac force is an appurtenance of both sexes alike, then, if modifications of that force can produce that malady, they may be deemed capable of causing manifestations of the same phenomena equally in the male and in the female. To say, then, that an affection of the womb, as an organ, is capable of causing all the strange modifications of the innervative power, which are witnessed in hysteria, would be saying too much; but, if the aphrodisiac power is, in some at present unknown way, connected with a modality of the re- productive apparatus as a whole, it would not be travelling beyond the record to say so. That force, you will not deny, is capable of influencing the whole physical, intellectual, and psychological nature of the subject of it; and, if even the conscience and the free-will must be admitted to be subject to morbid modifications, what hardness do you find in admitting, likewise, that morbid modifications of a power, so intense, so universal, so determinative of the whole constitution, might be capable of exhibit- ing itself in any or all the parts of the constitution in the strange and, so called, incomprehensible phenomena of the hysterical paroxysm ? I have already told you, in former letters, that very slight modifica- tions of the state of the womb, as to its level or its direction in the pelvis, may exert a disturbing force upon the economy of the female, and it has been the custom, for two or three centuries past, to assign to the uterus the power of dispensing an aura—which might be inter- preted a vapor, or a halitus—which, pervading different organs of the body, draws them into diseased sympathy with the distressed womb itself. This term aura is probably at the foundation of the word so commonly used in speaking of the maladies of females—I mean the word vapors; for a nervous, fitful, wayward woman is said to have va- pors—which I have regarded as synonymous with hysteria—so that a woman with vapors is a woman who suffers from an aura hysterica, an exhalation, a halitus from the womb; but we have got too deep into the nineteenth century to entertain any further faith in the theory of va- porous exhalations from the organs, affecting other and distant organs. Nevertheless, this word aura may be admitted to have some useful- * ness, as it has both an important signification in Medicine, and is a common parlance, for it refers to the sensible progress of an irritation from some ascertained point of the body to some other point, as from 472 HYSTERIA. the womb to the throat, where it produces a phenomenon called globus ; or, from a distant point on a nerve in the leg or arm, to the brain, re- sulting in epilepsy ; from the os uteri to the pylorus, or the breast, ex- citing vomiting, in the one case, and tumefaction or pain, in the other; and so, from one organ to some other organ, exciting its powers into sympathy with its own. The dilatation of the cervix uteri in labor is, by many persons, sup- posed to be the not unfrequent exciting cause of eclampsia, which it produces by disturbing the brain, excited beyond all tolerance by the pangs of the dilatation. This you might take as a strong example of the power of the aura hysterica. Let me repeat that the rigorous meaning of the term aura, as aura epileptica, aura hysterica, etc., was that a vapor, a halitus, or an exha- lation arising from an organ, and proceeding to involve another organ within the scope of its influence, is the absolute cause of the morbid phenomena in the organ which is secondarily affected. Now this term docs express the fact that the suffering condition of one part of the body is capable of calling into sympathy other and very distant parts. It might be better, perhaps, and more precise, to use the word sympathy to express the idea attached to the word aura; and yet it is true, that in the case of what has been called aura, there is often a sensible trac- tus of irritation, or diseased perception, extending from some known leased point, as in the before-cited case. There are peculiar sensations experienced, from time to time, when an aura, passing either slowly or rapidly along the whole length of a leg or arm, and rising to the whole height of the head, explodes—so to speak—in the frightful manifesta- tion of an epileptic paroxysm. There is a most singular and most extraordinary exemplification of the influence of an excited condition of the aphrodisiac force, which you will find stated in the article Medication Antispasmodique, in Trousseau and Pidoux's Therapeutics. I will not quote it for you, but I advise you to take the first opportunity of reading it. You may remember that, in the course of my lectures last winter, I cited to you, as a proof of the most intense hysterical modification, the condition of a woman in the last moments of (he conflict of labor ; and, indeed, I think that if you will revolve the whole scene of a labor in your mind, commencing with the first phenomena, and observing the progress and extension of the complication it introduces in the action of the various organs, you will perceive the most perfect example in the power of the reproductive system of organs, when excited, to call other portions of the economy into sympathy with itself. At the com- mencement of a labor, all is calm. The first pain is felt in the cervix HYSTERIA. 473 uteri, which is strained a little by the positive contraction of the fundus and corpus uteri, which strain it, the cervix simultaneously resisting by its own contraction. From this point of the labor, through the whole series of influences exerted on the brain, the heart, the lungs, the ex- halants, the temper, the intelligence, I shall not follow the changes. I venture to say, however, that should you practice midwifery, you will have many occasions to compare all these modifications with those of the most exquisitely marked hysteria—and will be ready to regard them as proceeding from the same cause; videlicet, a modality of the repro- ductive apparatus, extending its organismal influence beyond its own boundaries, and into the domain of other organs with which it has ordinarily no direct anatomical connection. I presume there are few practitioners of some years' standing who have not met with examples in males, of disorder so closely allied to the nature of hysteria, as to be with difficulty distinguished from some of the forms of that affection. Dr. Marshall Hall, in his Principles of Diagnosis, p. 101, vol. i., has these words in relation to hysteria : " It is almost peculiar to the female state." I have only to ask to what other sex it could be almost peculiar ; and, if it be almost peculiar to the female sex, does not Dr. Marshall Hall admit that it belongs, also, in some degree, to the male sex ? I saw within five years a gentleman, thirty-five years of age, who was married, and who had symptoms of insanity. When I was called to him, I found him insane, with extraordinary hallucination. In con- sideration of the state of his pulse, temperature, and intellectual dis- turbance, he was treated by bleeding, leeches, and purgation; which, together with a rigorous diet, with rest in bed, restored him. The pulse, which was at first feverish and hard, became soft and natural; he recognized his situation and place, acknowledged the hallucinations with which he had been affected, and was soon after allowed to leave his room ; he rode out. After walking out too much, and having eaten immoderately, the fever was renewed, and the same extraordinary hal- lucinations along with it. The excitement was so great, that it was found necessary to bleed, purge, and confine him again to his bed. For the last three days, after taking a good many doses of laudanum in ten- drop doses, amounting in all to one hundred and forty drops, he was seized with a paroxysm, which I could characterize by no other name than that of hysteria. He had globus most exquisitely marked ; he had rhythmical beating of his breast with his right hand, frequent ap- pearance of strangulation, and clutching at his throat. These symp- toms alternated with the most uncontrollable laughter, followed by 474 HYSTERIA. floods of tears, succeeded with laughter again, palpitation of the heart, and cold feet and hands, all of which continued to trouble him for nearly three days. The paroxysms were relieved after my visit by a few ten-drop doses of laudanum. In my note of the case, I found these words : These phenomena are identical with those of hysteria in the female ; he says he has pain about the throat, in the region of the occipital bone, and in the nucha ; and he has a general uneasiness in the pelvis, strange sensations affect- ing the perineum, and this accompanied with frequent erections. I suppose I have never seen a more manifest example of hysteria in the male. In conversation with him, I find that one of his hallucinations con- sists in a supposition that all his late attacks of insanity were the effects of a violent attachment which he had formed for a very young lady, with whom, I believe, he is not acquainted personally; and with whom, I know, he has never spoken, though he thinks he has indulged this love for her for many years. I have reason for the above to suppose that, in this case, there is a morbid aphrodisiac element, which, if it be not wholly causative of his disorder, yet exerts upon it a modifying power. The tremor of his lip in speaking, and the childish tendency to cry, remind me of the case mentioned by Sydenham, in his letter to Dr. Cole, on hysteria. The case of hysteria mentioned by^Sydenham is found at the 320th page of Rush's Sydenham, Philadelphia, 1815. It is in these words :— " And by the way I must observe that men are sometimes subject to such crying fits, though rarely. I was called not long since to an in- genious gentleman, who had recovered of a fever but a few days before; he employed another physician, who had blooded and purged him thrice, and forbid him the use of flesh. When I came and found him up, and heard him talk sensibly on some subjects, I asked why I was sent for, to which one of his friends replied, if I would have a little patience, I should be satisfied. Accordingly, sitting down, and entering into discourse with the patient, I immediately perceived that his under lip was thrust outward and in constant motion (as it happens to fretful children, who pout before they cry), which was succeeded by the most violent fit of crying I had ever seen, attended with deep and almost convulsive sighs; but it soon went off. I conceived that this disorder proceeded from an irregular motion of the spirits, occasioned in part by the long continuance of the disease, and partly by the evacuations that are required in order to the cure; partly also by emptiness, and the abstinence from flesh, which the physician had ordered to be con- HYSTERIA. 475 tinued for some days after his recovery, to prevent a relapse. I main- tained that he was in no danger of a fever, and that his disorder pro- ceeded wholly from emptiness; and therefore ordered him a roast chicken for dinner, and advised him to drink wine moderately, at his meals ; which being complied with, and he continuing to eat flesh spar- ingly, his disorder left him." Dr. Sydenham, from whom I have made the quotation, does not appear to suppose that hysteria is a disorder proceeding from the repro- ductive organs; on the contrary, he says:— " Disorders which we term hysteric in women, and hypochondriac in men, arise from irregular motions of the animal spirits, whence they are hurried with violence, and too copiously to a particular part, occa- sioning convulsions and pain when they exert their force upon parts of delicate sensation; and destroying the functions of the respective organs which they enter into, and of those also whence they come; both being highly injured by this unequal distribution, which quite per- verts the economy of nature. " The origin and antecedent cause of those irregular motions of the spirits proceed from the weakness of their texture, whether it be natu- ral or adventitious, whence they are easily dissipated upon the least accident, and their office perverted ; for as the body is composed of parts which are manifest to the senses, so doubtless the mind consists in a regular frame or make of the spirits, which is the object of reason only. And this being so intimately united with the temperament of the body, is more or less disordered, according as the constituent parts thereof, given us by nature, are more or less firm. Hence women are more frequently affected with this disease than men, because kind nature has given them a finer and more delicate constitution of body, being designed for an easier life, and the pleasure of men, who are made robust that they might cultivate the earth, hunt and kill wild beasts for food, and the like." Among the samples of hysteria in the male, one of the most complete and perfect is given by M. Louyer VillermayK in the Dictionnaire des Sciences MSdicales sub voce. The question resolves itself into this narrow compass : Is hysteria a disorder proceeding from a status of the reproductive system, by which I mean the reproductive force? If it be not, then there can be no reason alleged why males should not be equally obnoxious to it with females. Males are equally with females liable to apoplexy, to pleurisy, to bilious, typhous and typhoid fevers, and to all the exanthemata; and, if our disorder is not a sexual, it is a non-sexual disease, and applicable to the race, the genus, and not to male or female. If you argue that 476 HYSTERIA. the malady is really sexual or reproductive in its essence, then I don't see why you should not admit that though it be far more frequent and far more intense in the female on account of the far greater develop- ment, alliance, and importance of her reproductive system, it might be reasonably expected that the reproductive system of the male should also manifest its power occasionally to disturb in a slighter or less in- tense degree; since the relation of his reproductive apparatus are less extensive, and less impressive upon his organisms, than is the case with the female. He possesses neither the germiferous, the gestative, nor the lactative powers; nor is there in him any analogy to the great catamenial office of the female. But, as I have already remarked, those great powers and functions cannot but exert a vast influence over the whole of the organisms which, in their very creation, must have been endowed with a proper adaptability to the varying exercise of the general system of forces. It is impossible to reflect for a short time, one would think, upon the nature of the aphrodisiac infusion in the sum of the vital powers, with- out admitting that aphrodisiac power to be one of the most essential for the conservation of the species ; that it is a great modifying princi- ple, both of the physical and moral character of the species ; and has been so recognized from remote ages. We control it in the domestic animals by the various operations in which we quell it for the purpose of reducing them to a more perfect obedience, as well as for the purpose of modifying the nature of their flesh, and rendering it more valuable in the market. Hear how beautifully Virgil descants upon its powers in his third Georgic:— Omne adeo genus in terris hominumque ferrarumque, Et genus aequorcum; pecudes, pictaequse volucres, In furias ignemque, ruunt: amor omnibus idem. Tempore non alio catulorum oblita leaena Ssevior erravit campis. Nonne vides, ut tota tremor pertentet equorum Corpora, si tantum notus odor attulit auras ! Can the violent ebullition of life, so admirably described by this writer, be accounted for on any other principle than that of some ab- normal or at least transitory exacerbation of the inherent power and influence of the reproductive system over the rest of the organisms ? Do you think you can explain its many forms of excitement by merely referring to a modification of the systole of the heart, to a greater de- velopment of a calorific power, or to some sudden exacerbation of the general innervation, independent of the action of this essential force ? Are they not explicable, rather, only in view of the impression made by HYSTERIA. 477 the aphrodisiac sense on the entire community of organs, lashing them into fury by its passion, and touching them with the contagion of its own exaggerated intensity ? Can you reason upon the continued existence of the species, or their perpetuation upon the surface of the earth, without perceiving that their perpetuity could find its guarantee only in some great principle im- planted deeply in the whole constitution of animals, able to exert, and able to manifest its might, dominion, and authority over their whole vitality ? Or can you contemplate the wonderful phenomena of repro- duction in the whole of the series of animals, and not admit that it is a great primal, indispensable force of animals, a force by itself, as much so as digestion or respiration, and irrespective of the mere circulation, digestion, &c, as such ? But where is the seat and throne of this aphrodisiac power, this sixth sense, this reproductive perception, this conservative force of species and genera, as distinguished from all other faculties and forces ? It exists in the reproductive tissues, and if you will excuse the figure, wraps them all in the embrace of its aura. It is diminished by their diminu- tion, it is augmented, pari passu, with their development, and declines and dies with their extinction. But, since these reproductive tissues are anatomically allied both to the ganglionic and cerebro-spinal system, they may be presumed therefore to interest the entire system of inner- vations of the economy. Have we not, then, sufficient ground here to establish the opinion, that certain states of the ovaries, and of the womb and its appendages, may be sufficiently impressed upon the rest of the system to waken among the organisms all those modified manifestations of vitality, which we observe with so much surprise in a paroxysm of hysteria ? What are organs, indeed, but mere productions of, or evolutions from the distal points of the nervous tractus that the nervous mass has projected from its own central self? If the brain is ONE, then the disturbances of the reproductive extremities of it ought, under certain circumstances, to excite similar disturbances in other organs, evolved, like them, from the sole unique nervous-mass. I do not propose that, in hysteria, the womb or ovary is acutely or subacutely inflamed; that it is in a hypoaemic or hyperaemic condition; the question is, whether the womb is the seat of such a mode of vitality as enables it to impose upon other parts of the economy a touch of its own distemper. Cannot the liver, the spleen, and the kidney do so; and shall a man deny to the stomach the power to distress the brain and other organs, in states where its own apparent modality does not depart from the 478 HYSTERIA. most healthful tone? How, then, does the cephalalgia, the stupor, the coma, the precipitate movement of the heart, arise from a stomach suf- fering, to say the least, no organic lesion and evincing not the least sensible sign of disorder ? It has been argued that the womb is not the seat and throne, the fons et origo, of hysteria, because we observe the most signal alterations of its texture, in disease, without the superin- duction of hysterical affections; as well might we deny the influence of the stomach upon the brain, because we sometimes find the whole pyloric orifice of the organ invaded by carcinoma, without the supervention of the least headache, or coma, or spasm. The causes of hysteria are to be found in a great variety of con- ditions, both of internal and external origin; among them may be named a highly nervous and sanguine temperament, the pathogenic propensi- ties of which are promoted by a sedentary life and luxurious living, hot rooms, hot beds, highly stimulating food, the use of wine, of aromatics; a mind ill regulated, indulged, intolerant of control, highly impressible. In such an individual, any abnormal degree of excitement that might serve to add to the purely physiological action of the reproductive or- gans, you could well deem sufficient to send its aura forth upon its mission of mischief throughout the entire economy. The greatest degree of the hyperaemic excitement is in the hypogas- tric and pelvic regions; but the blood may move commensurably with the hyperaemic status of the brain, and we see it rush in volumes to the vessels of the head where it manifests itself in the intense flush of the brow and the cheeks, and then commences the wild incoherent ac- tion of all the organs and functions that depend for their innervation upon the brain and cerebellum. The whole spinal cord vibrates under the tension of the vital forces, roused to excitement by the reproductive and aphrodisiac power; cries, sobs, peals of immoderate laughter, tears in floods, stolid silence, cata- phora, spasm tonic or clonic, tetanoid closure of the jaws, the most ex- traordinary rhythmical movements of the symmetrical halves of the body spasm of one side—rigid opisthotonos, sudden enormous meteoris- mus, profound coma, excessive secretion of limpid urine; all followed suddenly by the profoundest calm of the constitution, and a feelino- of the sweetest complacency and amiableness. Such are the symptoms which leap out, as it were, from a profound repose, with a sudden and startling exaggeration. Mr. Georget, in his observations upon hysteria, positively denies the assertion that any distress is felt in the hypogastrium, as asserted by Louyer Villermay, by Gendrin, and others; but I am equally sure that I have had my hand grasped with spasmodic force by a very delicate HYSTERIA. 479 lady entirely beside herself and insane with hysteria, and in spite of my efforts to the contrary, carried and jammed into the hypogastrium of the sufferer, and retained there with violence, amidst the exclamations of " Here, here, oh ! here !" I have seen three women, at the same moment, a mother and two daughters, all violently ill with aggravated hysteria, and all complain- ing of the most intense distress in the hypogastric region, all three promptly relieved of the paroxysms by pushing the uterus upwards in the pelvis, into which it had been deeply thrust by some supposed tenes- mic force. I have, in my note-book, under the date of September 5th, 1842, the case of a young lady, stout, healthy-looking, weighing about 130 pounds, subject to attacks of exquisitely marked hysterical passion—with sobs, laughter, and suffocation. In these fits, she always complains of some- thing grasping her—to use her own expression—in the left hypochon- drium, until she cannot breathe, and then suddenly letting go. I will not cite any further particulars of the case. There is connected with the aphrodisiac influence a singular pro- pensity in some females to simulate disease, and that, without any ap- preciable motive of interest. The skill and the perseverance with which the deceptions are carried on exceed almost the powers of belief. Dr. Laycock, in that most admirable work of his on Hysteria, a work for which he ought to be immortalized, as evincing in him powers of judgment reasoning and perception beyond what appertain to most mortals, gives us some extraordinary examples of morbi simulati. I must refer you to Dr. Laycock's book, a copy of which was published by my friend Dr. Bell, in that useful work, the Medical Library. It is within the reach of every medical student, and there is no medical student who should be without it. I have no time to cite those cases here. There are examples of women under the influence of what I believe to be the hysterical malady, who are capable of developing physical disease upon the surface of the body by some power of the mind con- centrating morbid actions upon parts of the surface, producing there the appearance of wounds. Such are the celebrated examples of the stigmated women, who, under an intense contemplation of the passion of the Saviour, have produced bleeding wounds in the palms, the soles, or even in the side; or at least seem to do so. We may believe this, sauf toujours, the fact, that morbus simulatus, the malingering power, is capable of deceiving all mankind. Persons instigated by interested motives, such as a desire to be discharged from military or naval ser- vice, or to escape from the performance of disagreeable duties, or to 480 HYSTERIA. excite the compassion of the public, are found to make use of extraor- dinary means of deception. But I have no doubt of the frequent oc- currence of malingering from hysterical causes; as I have known young women to require the use of the catheter for months in succession, under a diseased conviction that the urine could not escape but by the aid of the catheter, I being equally convinced that it was an hysterical affection ; a urinary monomania, in fact. I have seen a woman simulate intense spasm, followed by profound coma; pending which, she endured, without wincing, the most painful treatment. In this case, although I suspected malingering at the time, I was wholly unable to verify it, until long afterwards ; when she con- fessed to me that all her symptoms were assumed in order that she thereby might wreak vengeance upon her husband, whom she wrongly Buspected of infidelity. I have seen hysterical cough assumed by a woman and persevered in for many consecutive weeks, with such violence as to shock and exhaust in a great degree the health of the sufferer. She was in an eminent degree an hysterical person; and it is probable that she coughed three or four times a minute, save when asleep, during the whole of this time; and I know it was a malingering cough. In one unfortunate lady of great beauty and accomplishments, subject to exquisitely marked hys- teria, I was the distressed witness of the fatal termination in consump- tion of a cough that was merely simulated at first, under the impulsions of an hysteric state. What shall we say of the power of the aphrodisiac force when exag- gerated into erotomania and satyriasis—that power that drives from the conscience of the woman the last vestige of female purity; and from her cheek the faculty to blush ? The feats of Messalina are nothing in comparison to the manifestations of this power, sometimes met with in medical practice. The diagnosis of hysteria is in general not difficult. The means of distinguishing the hysterical convulsion from the ordinary epileptic form; the hysterical from the apoplectic coma; the hysterical tetanoid from the tetanic spasm, are to be sought for in the history and ante- cedents of the case, the sex, the age, and sanitary habits of the patient; in auscultation of the heart; in careful comparison and judgment of the pulse; in the condition of the calorific power; in the duration of the paroxysm; in a certain character of the physiognomical expression where there is absence of all those profound and dangerous impressions that are inseparable from such great disorders as I have just named. In hysteria, there is generally a moral cause, which sets in motion a machine already highly wrought and prepared for the movement. The HYSTERIA. 481 hysterical woman, like the highly electrified thundercloud, requires but the point to draw the flash. She sits, like Tam O'Shanter's wife, "Gathering her brows, like gathering storm, Nursing her -wrath to keep it warm;" when, suddenly and unexpectedly, some word, sign, or gesture, or the want of some word, sign, or gesture, gives the occasion; and we have reproaches, tears, screaming, laughter, sobs, wringing of hands, tearing of hair, clonic convulsions, tonic spasms, stupor, stertor, smiles like a May morning, loud laughter again, floods of tears, and then a gradual return to a state of gentle composure, wherein the tenderest affections of the female heart come to resume, with unusual supremacy, their wonted sway over the soul. It is very true that I have not always inquired, or have not upon inquiry been always satisfied, as to the state of the uterus, and its ap- pendages, in every case of hysteria that has fallen under my notice. But I have, in many of those cases, clearly discerned the connection between the morbid innervations and a known disorder of the sexual organs. In not a few instances, I have put a stop to the paroxysm of hysterical passion by balancing the uterus upon the point of my index finger, and thrusting it as far as I could carry it into the upper part of the pelvic excavation—thus temporarily relieving the innervation, from an irritation of the reproductive apparatus proceeding from a prolap- sion, or retroversion of the uterus, from which probably radiated the whole of the provocation of the hysterical attack. With regard to the treatment of the hysterical passion, some of the cases require therapeutical treatment, and some not: a patient may be brought to herself by letting her alone and leaving her alone ; but in the wild and confused operations of the nervous and sanguine systems, and with the impetuous force of the blood observed in certain of the cases, there may be danger for some of the great vital organs. I have seen a case of pure hysteria resulting in coma, which terminated in the death of the patient, probably from sanguine extravasation in the encephalon. I believe that whenever the momentum of the blood is increased to a dangerous violence by whatever cause, that danger ought to be obviated by the means best calculated immediately to reduce it within safe bounds. A simple antispasmodic medication will not do in these cases; and I think you will not do your duty to the patient under the circum- stances, unless by means of venesection you take away from the brain and the heart the material power to excite and to stimulate. You will always diminish the production of neurosity by diminishing the intensity of the contact of the oxygenated blood with the neurine. It is a very 31 482 HYSTERIA. common opinion, that in the nervous affections we do wrong if Ave take blood; and persons who dive not beyond the surface of things, for the most part hold to the opinion that you ought not to let blood except there be some inflammatory condition of organs, requiring that special ■ therapia. I hope you will lay it to heart that a mere simple sanguine engorgement, the beginning of which has no connection with any inflam- matory condition or propensity, may speedily terminate in the ruin of the patient by allowing of effusions or extravasations, and that such pro- pensities may as clearly demand the use of venesection as the most active and clearly marked inflammations. It is not true, in fact, that spas- modic, nervous, vaporous, hysterical disorders, neuropathias, require to be treated solely upon the principles of the antispasmodic medication, and he who adopts such sentiments, no matter by what school or by what authority they are instilled into his mind, thereby virtually ties up his hands in a thousand and a thousand instances, in which a perfect freedom from the bonds of such a prejudice would render him a power- ful and efficient practitioner of his art. If you should decide upon bleeding in any case of hysteria, you may, after the abstraction of blood, concentrate the confused, heterogeneous, disturbed perceptions, upon a point, or several points of the skin, by violent frictions, and slapping of the hands, or lower extremities; by hot sinapised pediluvia; by mustard cataplasms ; by Granville's lotion; by the powerfully concentrating sensation produced by the dry cup, especially if applied to the nucha, and on the interscapular region; after which, you may avail yourself of the antispasmodic therapeutical power which you can find in the assafetida, in the fetid gums, in castor, or in musk ; or perhaps more than all in valerian, and particularly in the fine extract now prepared by means of ether. The inhalation of ether in this stage of the malady will be a safe and useful resource. I mean not the inhalation of ether to the extent of what is called etheri- zation, and I advise you to make no appeal to such a power, since—in the disordered and heterologue operations of the hemispheres and of the tubercula quadrigemina, of the cerebellum, of the spinal cord, and of what is always a deep participant in the hysterical manifestation, I mean the medulla oblongata, and the vagus—no man ought to arrogate to himself the right to plunge these organs into the temporary annihi- lation of etherization; because, the co-ordination of their actions being destroyed in the hysterical paroxysm, there may be no regular succes- sion in the influences of the ether upon the several parts of the brain. In that regular succession, the part that last yields is the medulla oblon- gata. What if, in this anomalous condition of the functions of the brain it should be the first to yield? It is the source of the respiratory power- HYSTERIA. 483 when it ceases to act, the respiration ceases; and is not a woman dead when the breath is out of her ? I presume that there is not among the whole armamentarium medicum an article possessing the exclusive properties of an antispasmodic so perfectly as valerian; and I beg you again to take an early opportunity of reading Prof. Trousseau's remarks upon it, in his article on antispas- modic medication in his therapeutics. If you should resolve, in your cases of hysterical spasm and excite- ment, upon its use, I advise you to administer it as the fluid extract just before mentioned ; or, if that be not conveniently attainable, to give it in substance reduced to fine powder. A large teaspoonful of the fluid extract in a wineglassful of sweetened water is a good dose, which may be frequently repeated ; or a drachm of freshly-powdered valerian root highly fragrant may be divided into four powders ; of which, one is suitable for a dose. Mix it in half a tumbler of fresh water, and make the patient drink it. Don't tell me that she can't drink it, or won't drink it; or that her jaws are set, and you can't make her swallow it. Her jaws will never be set so tight but that you can open them. How ? Take two bits of ice, each as big as an egg ; wrap each of them up in the corner of a napkin ; then press the cold napkin against her masseter muscles on each side. As a gene- ral rule, the cold contact will scarcely be made before the masseter re- laxes. But suppose you find a case in which it won't relax ; then get the end of a spoon between her jaws, open them a little with this, and then substitute the end of a tooth-brush handle: now pour the liquid into her mouth. Do you say she won't swallow it? I reply she will swallow it, if with the end of the spoon handle you separate the base of her tongue from the velum pendulum palati, which will allow the mixture to get beyond the isthmus faucium, and when there, the oesophagus will transmit it to the stomach. Anybody can swallow; I was almost ready to say you could make a dead man swallow. I beg you never to say of your patient—He is past swallowing—unless he be laboring under a paralysis of the pharynx and oesophagus ; but you may practice for forty years, and never meet a case. But to return. If the patient does swallow the powder, you will probably witness a very speedy diminution of all the spasmodic inner- vation, and a return of the constitution to a state of the profoundest calm. Some time ago, I was summoned in a hurry, to see a beautiful little child seized with most intense convulsions, brought on by prava ingesta; among the attendants was a faithful nurse, who had lived a long time 484 HYSTERIA. in the family—a highly hysterical and nervous individual. Having been very much excited and alarmed, on account of the condition of her little favorite, she went into an adjoining apartment, where she fell into a most violent fit of hysteria. My attention being called to her, I wrote a prescription for half a drachm of powdered valerian, which was immediately brought to me, and I said to a young lady, standing near: " Please to mix the powder in half a tumbler of water, and bring it to me, and, with it, a tablespoon, and I'll show you something very curious. Now, see here"—said I—" here is this woman, whose mind, for the time, is abolished, and her body is, as you see, tortured by these violent spasms ; now, I'm going to make her swallow fifteen grains of the pow- dered root of valerian, and do you look on, to observe what strange powers are possessed by certain medicinal articles over the human body. You shall see that, in about fifteen minutes, this great storm shall become a great calm." The woman could not swallow, but I made her swallow the fifteen grains. " Now"—said I—" look at her." In two or three minutes, her spasms became less, and in a quarter of an hour she was perfectly well. " Now, what do you think of that, my dear?" —said I. " I don't know what to think of it, doctor ; but it surprises me very much." I have said nothing about opium. What need have I to mention the name of opium in connection with such circumstances ? It commends itself, by its very name, in all such cases ; provided that you can ren- der yourself sure that there is not connected with the paroxysmal manifestations some element of meningitis, or cerebritis, which you have not deprived of its mischievous nature by the salutary interposi- tion of your lancet. With regard to the treatment of persons in the intervals of the hys- terical paroxysms, to which they are liable, I should be guilty of the fault of iteration were I to say much upon that subject, since I have so clearly expressed the conviction of my mind that hysteria is truly hys- teria, and not ordinary nervous surexcitation. But, if hysteria be truly hysteria, it follows that, in the interhysterical periods, you should ad- dress your inquiries and your remedies to the condition of the repro- ductive organs, and those morbid states which are the " ipsissima causa morbi." But I have spoken so much at length, in these Letters, upon these morbid conditions, that I shall here close the present one, referring you to many of the antecedent pages of this volume. C. D. M. DISORDERS OF PREGNANCY. 485 LETTER XXXVIII. Gentlemen: The change in the condition of the reproductive organs brought about by pregnancy, is in the majority of instances, too great to fail in producing phenomena approaching perhaps to the nature of disease. It is necessary that the physician should render himself familiar with these phenomena. The pregnant state, in fact, is one full of interest to the medical Student or the practitioner of physic. I feel it a duty, therefore, to say in these letters something to you of the state of preg- nancy, and the maladies and the inconveniences with which it is accom- panied. The fecundated germ in attaching itself to the lining surface of the uterus, may affix itself to any part of the internal superficies of that organ. I say the fecundated germ, because I wish to express the opin- ion that the germ may become fecundated without being followed by pregnancy. The germ is fecundated by the contact of the male sexual element, which imparts to it the power to develop the organisms and the whole nature of the animal in question. But pregnancy cannot be deemed to take place until the germ has established a mesenteric connection with the living surface of the mother. When, then, the mesenteric attachment takes place, the woman has conceived. Doubt- less, thousands and millions of germs become fecundated that never form mesenteric attachments, and are consequently lost. The woman is only pregnant when the mesenteric attachment has been made. No matter where this mesenteric attachment is formed, the woman is preg- nant when it is made. It may be effected in some part of the tractus of the Fallopian tube; or it may be made upon the surface of the ovary, the ovary being covered at the time by the fimbria of the tube. If the porule of the Graafian cell have been formed, and the male sexual element have been translated through the channel of the tube, and come in contact with the exposed ovule, still contained within the Graafian crypt, the ovule may be there fecundated and form its mesen- teric attachment within the crypt, and then you will have an ovarian pregnancy case, and there is not another way in which you can suppose one. It is by some supposed that the germ may be fecundated within the grasp of the fimbria, and being once endowed with the development 486 DISORDERS OF PREGNANCY. power, if it fall into the peritoneal sac and there form its mesenteric at- tachment, it may then constitute a ventral pregnancy. An ovule may become fecundated on its passage from the fimbria to the uterus ; it may be arrested in the narrowest part of the tube where it passes through the thickness of the uterus: the delay and the pressure are probably the causes why it sometimes forms its mesenteric attachment there, and develops itself in the substance of the uterus outside of its cavity, thus constituting what is called interstitial pregnancy. Conception is never natural, never right, never safe, except when it takes place in the cavity of the womb. Please not understand me as stating that fecundation always takes place outside of the uterine cavity ; it is probable that it most frequently takes place outside of the cavity, but it may also, perhaps, sometimes take place within the cavity of the womb. The fecundation takes place in whatever place the con- tact of the sexual element happens to be made. Conception takes place whenever and wherever the fecundated germ becomes fixed. Conception is affixation of the fecundated germ. When a woman has conceived, the womb begins to increase in size ; the increase taking place at first in the body and fundus and not affect- ing the neck. This growth of the womb is so rapid that it passes from the non-gravid state to the condition of the organ at full term of utero- gestation, in the short space of two hundred and eighty days ; a space of time in which the most remarkable changes occur in the character of the organ, and in the influence of the organ upon the living economy. The non-gravid womb is about two and a half inches long, one and a half in the widest part, and one-half an inch in thickness ; and its weight shall scarcely be found to exceed two ounces. The gravid womb at full term is often twelve inches in length, and its transverse diameter is equal to eight or nine inches; its weight, freed from its contents, is scarcely less than one pound, or a pound and a half. It exceeds by from eight hundred to twelve hundred per cent, its normal weight. The superficies of the cavity in the non-gravid uterus, cannot be more than two square inches, and probably not more than one and a half square inches. Whereas the internal superficies in the gravid womb at term is more than two hundred and thirty-five square inches. The space occupied by it in the non-gravid state is, as you have seen, very small ; in the gravid condition it constantly intrudes itself among the other organs, pushing them aside, distending some and compressing others, interfering with the flow of blood in the vessels and the ascent of the lymph in the tubes, and calling out of the general course of the circulation vast torrents of arterial blood, which it returns to the venous DISORDERS OF PREGNANCY. 487 circulation after having deprived it of its oxygen, and of much of its solid constituent elements. Under such a view of the changes taking place in the womb, you have little reason to be surprised that the health of the woman is often dis- turbed. Do you imagine that the womb, when twelve inches in length by nine in breadth, and weighing a pound and a half, is the same organ that it was in the non-gravid condition ? You call it, it is true, by the same name, uterus. But, if you inspect it, if you touch it, if you weigh it, if you analyze it, you will find it a very different thing. Why is it that the womb suffers these wonderful changes of form, of dimensions, of weight ? They are compulsory. The uterus has re- ceived the fecundated germ; that germ is an animal, and was before it came into the uterus wholly independent of it; and it will be while it remains in the womb equally independent of that organ. That is to say, it will be as independent of the uterus as the plant is of the soil in which it grows; if the plant be torn from the soil, it will perish, because it can nowhere find the materials for its development; and if the ovum is torn from its attachment, it will perish for a similar reason: but the ovum grows by its own force; it finds on the surface of the womb the elements which it knows how to assimilate for it own purposes. That assimilation increasing constantly its weight and dimensions, it is inevitable that, if it is to reside in the womb, that organ must yield to the pressure of the growing ovum ; but, in yielding to that pressure, it is not destroyed; on the contrary, it is generically developed ; it is augmented in size and in weight; its uterine arteries and its nerves, and its absorbent vessels, being all increased, not in number, but in length and in diameter. Greater quantities of blood furnish the material out of which this new growth takes place; and thus the womb, under the constant pressure of the augmenting ovum, is stimulated or excited to new efforts of uterine development-force—augmentation, hypertrophiza- tion. The increased magnitude and weight of the womb in pregnancy is the result of a normal physiological hypertrophy. Labor is the result of the effort of the womb to recover its non-hypertrophic state. Preg- nancy presents, therefore, an example of a curable, nay, a spontaneously curable hypertrophy of the womb. You know this to be true, because you know that the uterus at any period of utero-gestation has a constant tendency, I had almost said a constant desire, to return to its non-gravid repose. You know that it will begin to return to that non-gravid condition whenever with the point of a bougie or other instrument you rupture the membranes of the ovum and allow the watery contents to flow off. You also know that it occasionally happens that the uterus refuses to yield to the distension 48S DISORDERS OF PREGNANCY. of the growing ovum, which is then ruptured and expelled; or it is even expelled unruptured by the action of the muscular womb. Such a womb has been augmenting by a power of evolution—it has grown tired of the process, and returns to its rest by a process of involution. I don't know what better argument I can present to you in favor of the opinion I have expressed, of the compulsory nature of the uterine development in pregnancy, than the one above stated. If you remove the cause, the effect ceases, is an axiom in philosophy: I say, that the cause of the growth of the uterus resides in the ovum, and I prove it by stating that whenever the ovum is destroyed, the effect of its growth, to wit, the growth of the womb, ceases ipso factd. I wish to make this statement to you, simply because it is a physi- ological truth, but more than that, because it contains the most import- ant chirurgical principle—a principle which you will apply a thousand times perhaps in your practice; a principle which, if you understand it properly, shall give you the gratification of rescuing multitudes of people from untimely graves, save you from the grossest errors in practice, and enable you to do honor to the divine art you profess, by showing its might and its beneficence, upon the most interesting and important occasions. When the womb first begins to develop itself under the influence of the growing ovum, it becomes healthfully engorged, and of course grows broader, longer, and offers a larger surface of pressure to the superin- cumbent viscera. Both its augmented weight and volume, therefore, give it a tendency to descend toward the floor of the pelvis, and as it is attached to the bladder by the utero-vesical septum, and presses upon the rectum, which is both behind it and below it, and weighs down the uterine end of the vagina so as to stretch inordinately the ligamenta utero-sacralia, the woman will scarce fail to have some symptoms of a prolapsus or descent of the uterus, evinced by a more frequent desire to pass urine, and a tenesmic feeling of weight and dragging about the loins, and in the two iliac regions. Such symptoms, therefore, in mar- ried women, or women exposed to the risk of conception, you should regard as rational or inferential signs of the gravid state; symptoms not absolutely to be relied upon, but still of no little value, when collated with those hereafter to be mentioned. When such descent does take place, it happens, notwithstanding the augmented volume of the uterus, that the hypogastric region of the womb becomes less protuberant than it was in the non-gravid state ; so that the woman does not begin to grow larger, but really grows smaller in the early stages of pregnancy. Hence, the oft-quoted French proverb, DISORDERS OF PREGNANCY. 489 " A ventre plat, enfant il-y a." Inasmuch as I do not profess to know what the essential nerve-force is, I cannot undertake to tell you how it happens that the earliest modification of the state of the uterus is commonly expressed by simul- taneous modifications of the state of the stomach and the female breast. Perhaps the truest expression of the meaning here would be, that all the nervous complications of the economy with the gravid state—I mean all the pathological complications—are really only so many forms of hysteria. If I use the word sympathy to express it, you see that I shall only use a word, and not give you an explanation. A man who thinks he has an explanation, because he has the word sympathy at hand, is like those people in the Old Testament, of whom the prophet says, " They fill their mouth with wind, and their belly with the east wind." It is better to say, and to think, that, as the life of the whole constitution is made up of the lives of all the organs and organisms which that constitution inholds, it is reasonable to suppose that the pathological condition of any one of the important organs may dis- arrange the normal, ordinary rate of action of some other, and even of all the other organs. Life, in the womb, is, under this view, the sum of that of all the parts of the womb; and so of the assimilating organs, of the oxygenating organs, and of the entire constitution ; but the life of one of the integers being disturbed, the sum total itself may be dis- turbed. If you have a cube made up of many smaller cubes, of which you take one away, or alter its form, it will no longer be precisely a cube; so, if the physiological condition of the uterus is changed, by preg- nancy, it will disturb the rate of action in other parts of the economy, whose properties and powers are modified, because an important integer of that economy is modified. The stomach sympathizes with the uterus as the breast does, and that sympathy is exhibited by anorexia, by acidity, by pica andmalacia, by nausea, by the most obstinate vomiting and by excitement of the salivary glands, which, however, are part of the digestive apparatus. Thus, all modification of the nutrition, the coloration and the calorifica- tion of the patient, as well as changes both of her moral sentiments and her intellectural powers, may be results of sympathy in the womb. The same sympathy, to use the word, introduces speedy modifications of the lactiferous apparatus. The milk granules of the breast glands, which have been inactive since the woman first acquired the menstrual or rather the ovulation power, now become roused into active conform- ability to the wants and forces of the constitution, and a new process of development is set up within them. This new force is at first mani- fested by an increase of the magnitude of the hemisphere of the breast, 490 DISORDERS OF PREGNANCY. dependent more upon augmented deposit of adipose tissue than upon immediate augmentation of the lactiferous apparatus; that augmenta- tion is, however, perceptible, but it becomes strikingly so at a more ad- vanced period. The new life moving in the female breast also exhibits itself in in- creased deposit of pigmentum nigrum on the mucous body of the skin of the aureole which surrounds the nipple, and the whole aureole be- comes so protuberant as to represent a segment of a sphere smaller than the hemisphere upon which it rests. The numerous papillae which are observed near the margin of the aureole feel the genial influence of the new excitement, and become decidedly developed in size. These mutations in the character of the female breast are such constant at- tendants upon even the earlier stages of gestation, that they afford strong rational or presumptive evidence of that state. Pray, my friends, perpend the words, presumptive or rational; and do not suppose your- selves authorized to decide the existence of pregnancy upon such grounds as these alone. It is but just to say that it deserves considerable re- liance ; so considerable that Dr. William Hunter, to whom we are all indebted for his great reputation, as well as for the valuable works he has left to posterity, was accustomed to pronounce from it alone; so that upon one occasion, being in the dissecting-room, Mr. Clift showed him the body of a young female; and Dr. Hunter upon observing the state of the aureole, which was deeply colored by a deposit of pigmentum nigrum, said to Mr. Clift that the young woman had died pregnant; Mr. Clift rejoined that it was impossible, since the hymen was still intact; notwithstanding that, Dr. Hunter insisted upon it that she was in a state of pregnancy, and upon opening the body, an early ovum was found in the womb. A woman who has become pregnant has the womb occupied and tam- poned by the ovum, and even if the causes of menstruation should still remain active, they cannot produce the bloody sign of menstruation, since the pregnant womb will not bleed: it may be the subject of the mensual engorgement, and doubtless is so; but that mensual engorgement does not result in the menstrual hemorrhage, but disappears after a few hours, or after a few days. The old writers thought that the menstrual blood was designed to " nouryshe the feature," as they called it; and in one sense this idea maybe assumed to be correct. What say you—Is it not probable that the process of hypertrophization by which the preg- nant womb goes on daily enlarging, may be much helped and forwarded by the monthly aid of a mensual hyperaemia coinciding with the process of ovulation ? Doubtless the ovulations do go on for several successive periods after the act of conception. DISORDERS OF PREGNANCY. 491 If the ovulation-menstrual doctrine is true, this is reasonable. Of the truth of that doctrine, I entertain no doubt; and I believe you will find it everywhere admitted on the part of practitioners, as well as on the part of writers, that early abortions are generally marked by a coinci- dence with the menstrual periods ; and it is but a fair inference that the menstrual effort, in overcoming the resisting power of the vessels of the womb, is often the real cause of the hemorrhage of abortion. Hence, you have the inference that women prone to abortion, ought to be protected against that danger, by all the convenient or proper pre- cautions, at or about the menstrual periods. Supposing the woman to become pregnant, and that the succeeding menstrual effort fail, then she will miss her expected courses, and she will say: "I have conceived." She will have good reason to say so, if the ordinary state of her health had given her good right to expect the normal return of her catamenia, and if no accident or morbid cause whatever could be accused of intervening between her and her natural function. Upon missing the return, the woman, as I said, will suspect herself to have conceived; but, as one swallow does not make a summer, so one failure of the menstruation will not give her assurance that she has be- come gravid. To show you, however, how strong this presumption is, on the part of women generally, any woman of the Upper Ten Thou- sand will so far rely upon it as to begin at once to make arrangements to procure her monthly nurse, and provide for the other exigencies of her accouchement. If she have the morning sickness, if she have the darkened aureole, if the next menstrual return should prove a failure, the inference becomes stronger. If the third menstruation fail, with the same accompanying phenomena, and with the addition of some slight protuberance of the hypogastric region, the inference that she is pregnant is greatly strengthened. The presumption that she is pregnant is greatly strengthened by in- creased protuberance of the hypogaster, and the other concomitants; and more considerably, if she fail at the fourth menstruation. Still, she does not know it. At the fourth month, or more probably at four and a half, the child quickens, or, as the lawyers term it, becomes quick with life. Then she knows it—but you cannot know it. Quickening has been understood, in the world, to mean that the child has become alive, whereas it was deemed to be not alive before. The lawyers begin now to recognize its rights in court; whereas previously, it had not any claims of the State. They will hang you for maliciously killing it after this act of quickening; but they will not call you in question on an indictment for the same act, committed antecedently to 492 DISORDERS OF PREGNANCY. the quickening. This is very great nonsense on the part of the law- yers, who would abolish their laws as to quickening if they understood the value of the term viability : then they would either defer the claim to the protection of the State to the seventh month, or, more wisely still, make it commence with the conception. Quickening is, however, in its true sense, not quickening; it is only the first perceived motion of the foetus. There was motion before— but motion so slow, so feeble, that the impulses against the womb were not strong enough to be felt, or perceived. The child at four or four and a half months has acquired so much muscular development that it can thrust its feet out, or move its hands, or suddenly extend its whole trunk and limbs, sufficiently to make the mother feel it. That is quick- ening. But do you not know that some children weigh four pounds, some seven, and some twelve pounds at birth ? i. e. children grow faster and stronger in some instances than in others. Hence, it must happen that the period of quickening will vary in different women, and indeed in the same woman in different pregnancies; whence, the woman may feel her child at three or three and a half months. Many have felt it at three months: but the child may be so small, feeble, or torpid that it makes not its spontaneous motion perceptible till the fifth or even the sixth month; and cases are recorded where it has never been felt until the birth had taken place. The quickening of the child generally removes all doubt of the wo- man as to the gravidity. She knows she is pregnant—for the child is quick with life within her womb. I say she knows it; but you do not know it—nor have you the right to say that she knows it. Many a woman thinks she feels the motion of the child, when she feels some other motion; and if you, relying either upon her relation, or her good faith, should express your medical opinion, you might place yourself in a very unpleasant predicament. Suppose you rashly, on oath, declare to a court that you know her to be pregnant, when she is really not so, and knows she is not so! Or suppose you assert she is not so, and your professional oath serves to prove you rash or igno- rant ! Don't you see how wrong it would be to make professional as- sertions whose incorrectness must be exposed ? and how much harm you do to yourself and to everybody else of the brethren ? The scoffer has words put in his mouth—and the despiser wags his head at us all through your foolishness. For, in the worldly sense, DOCTOR is a genus—and if the scoffer can scoff at you he can scoff at me, and all of us. Don't, therefore, by false diagnosis disgrace yourself, and disgrace me, who am your teacher and you my pupil. It would be reversing the DISORDERS OF PREGNANCY. 493 axiom—" The children have eaten sour grapes, and the father's teeth are set on edge." Depend upon it, if you confide in the rational signs of pregnancy, you will come to the day when you will be deceived. The signs of pregnancy are rational or sensible. I have men- tioned seven of the rational signs, and two of the sensible signs—to wit, the swelling of the hypogaster and the quickening. There are other rational and other sensible signs. Toothache is a rational sign ; since there are many women who never become pregnant without having toothache. I have heard them say: " Each pregnancy has cost me a tooth." Hordeolum, or stye, is also a sign upon which women depend; since some women always have a stye in the early stages of pregnancy. Ephelis, or the dark broad freckle which stains the brow, the cheek, and often the whole neck and bosom, is a sign which invariably accom- panies pregnancy in many women ; it probably consists in the deposit upon the inner surface of the skin, beneath the internal lamina of the cuticle, of a portion of pigmentum nigrum, and has an intimate con- nection with the operation of the same causes that invariably pro- duce deposits of pigmentum nigrum beneath the scarf skin of the aure- ole. The deposit of pigmentum nigrum is everywhere augmented ; there is a considerable deposit of it always in the axillae, upon the pe- rineum, the external surface of the labia pudendorum and the mons; and there is some connection, which it is difficult to explain, between the new life-force set up in the constitution, and the increased deposit of pigmentum nigrum. One of the most common concomitants of the early stages of gesta- tion is that which I incidentally mentioned a little while ago ; to wit, salivation. This probably has some connection with the disordered condition of the stomach brought on as symptomatic of the new state set up in the uterus by its gravidity. For the most part, it is merely an observable phenomenon, and does not call upon you for any therapeutical inter- vention ; but the examples are by no means rare where it has actually become so distressing a disorder as to require that you should give ad- vice in relation to its management. That it has a connection with, and indeed an immediate dependence upon the state of gestation, is to be inferred from the fact that it comes on with the beginning of pregnancy, and terminates with the termination thereof. Here is an extract from my case-book. " September 6, 1842. Last night I attended in her labor, Mrs. X. ; she was spitting saliva during the whole of the labor ; she says, and believes, that she has spit a pint 494 DISORDERS OF PREGNANCY. and a half daily for the last eight months. In the former pregnancy she spit about the same quantity ; in both cases, the salivation ceased within three days after the birth of the child. This lady, in her preg- nancy, therefore, lost 4,880 fluidounces of saliva, without appreciably acting in an injurious manner upon her health or strength. Mrs. Y.j in her last pregnancy, spit at least a quart daily, from the beginning to the end of the gestation. It ceased the day after the child was born. She discharged during her pregnancy at least sixty gallons of saliva, without making her the least weak or emaciated. This lady derived more comfort from keeping a few grains of burnt coffee in her mouth, than from any other remedy that could be pre- scribed to her, or could be found out by her own ingenuity or experi- ment. I am sorry to tell you that I know of no remedy, at all to be de- pended upon, for the management of these great salivations ; they are the troublesome concomitants of the gestation, and they cease with the cessation of the gestation. They cannot be cured by alkalies or acids; by venesection or purgation ; or by any therapeutical treatment with which I am acquainted. If it were just always to attribute the saliva- tion to a state of the stomach, then it would be reasonable to apply remedies with a view to correct a faulty state of that organ, in hopes of curing the salivation. But you will observe that the patient whose case I last cited to you computed that she lost sixty gallons of saliva during her gestation, without rendering her thin or weak. Her digest- ive powers must have been very energetic to have prevented great loss of weight under such circumstances ; and, in fact, her appetite was good throughout; and I believe you may generally calculate on finding it so in persons laboring under this affection. If I am right in this opinion, don't you see how idle it would be to tease the woman with sickening drugs, in the vain hope of curing a salivation dependent upon other causes than the state of the stomach ? If you should meet with a state of salivation so great as to bring the woman's life into danger, you might confidently promise to cure it if allowed to terminate her pregnancy by bringing on abortion. I am not to be considered here as advising you to bring on abortion or pre- mature labor on account of salivation, as I presume such a thin^ has never been done. I merely speak of it here as one of the possible re- sources of the art in very extreme examples. I mean samples in which the health is so greatly endangered as to warrant you even in propos- ing so extreme a measure. The nausea and vomiting of which I made mention in an earlier part of this letter, although they are not so rebellious against treatment as DISORDERS OF PREGNANCY. 495 the salivation of pregnancy, yet, in some cases, they occur so exces- sively as to give great embarrassment to the practitioner, and great distress to the patient. There are many of them which are unin- fluenced by any treatment whatever—uninfluenced, I mean, to any considerable extent. I attended, a few years ago, a lady in Arch Street, who began to be sick at the stomach coincidently with the conception : there was no day in which she did not vomit; and it often happened that she vomited many times a day. When she had reached the full term of her utero-gestation, and had fallen into labor, the parturient force was greatly contravened by the incessant sickness of the sto- mach, and the violent efforts to vomit. I was so much annoyed by the perpetual irritation of the stomach, which appeared to me to pro- tract her sufferings, by interfering with the functions of labor, that not- withstanding she was a primipara, I resolved to violate the wholesome rule which directs us not to rupture the membranes in primipara women. From the moment that the gush of waters took place when I ruptured the ovum, her sickness and vomiting totally disappeared, and never re- turned ; the labor hastening to a favorable termination in consequence of the relief of her nervous system produced by this discharge. You will sometimes be astonished to receive accounts from your patients of a vomiting that shall follow every meal; and upon careful inquiry it will seem—but it cannot really be so—that the patient shall throw up the whole of the ingesta. I had a lady in Spruce Street under my care, in her sixth or seventh gestation, who, from the sixth month until the completion of her term, vomited soon after taking her food every day ; and it was incomprehensible to me that under such circum- stances she grew neither weak nor emaciated. I mention this case as having surprised me ; and you will find your- selves much surprised and embarrased, when your patients apparently reject the whole of the ingesta. I have often been thus surprised during my long practice ; and I beg you to believe when you shall meet with cases where, as I tell you, people seem to throw up all they take, and yet do not become emaciated, that therefore they do not throw up as much as they appear to. September 18, 1842, I made the following note in my case-book : Mrs.----n was married three years ago, and removed to Texas. In the month of March she became pregnant for the first time. About the first of April she had sickness and vomiting, which she daily ex- perienced. In June she came by steamboat from Galveston to New York, and thence to her friends here: she has been vomiting daily since the first of April. " How many times a day ?" said I; " ten ?" 496 DISORDERS OF PREGNANCY. " Ten ! why, more than thirty." " What! thirty times daily since the first of April ?" " Yes, sir, and more than that: I vomited every five minutes from New Orleans to New York, nor did I sleep one moment. I sailed from New Orleans on the 19th of June, in the evening, and arrived on the 27th, in the morning, at New York. I never slept; I vomited all day, and all night." Her mother, who was present, says: "For many days together, I am sure that she has vomited more than sixty times a day ; and, after straining long, she often brings up a thick, brownish, rust-colored ropy fluid, at times stained with blood." A very large wash-basin filled with this substance stood by her bed- side : she was thin, but not very. I found her with a hectical frequency of pulse, and a red tongue: she had constant salivation, amounting to more than a pint a day. Any rude motion of the child made her stomach sick. She had distressing cardialgia : her bowels were regular. I ordered for her a mixture of one drachm of carbonate of potassa, forty drops of laudanum, and six ounces of spearmint water, of which she was to take a tablespoonful occasionally. She could not take it, as it make her sick. On Tuesday I directed her to drink freely of cham- pagne ; the following Friday she was very cheerful, had slept well, had eaten well, had not vomited, nor been sick at the stomach. She had been taking anti-emetic remedies, under the care of one of my friends, for six weeks without benefit; the champagne seemed to have been a perfect remedy thus far; but I feared it would not hold. On the 19th of September, I note that she vomits no more, that she has a good appetite, sleeps well, is not sick, and has taken the contents of a basket of champagne. She stopped taking it two days ago, and became sick. The champagne was repeated ad libitum ; that is to say, very freely, and her stomach recovered again. She drank the contents of two baskets of the wine. She rode twenty miles to a funeral without indisposition. She returned to the city, sick again, and then vomited until the child was born alive at full term. When she had completed the eighth month, I was strongly tempted to brino- on premature labor ; but she went to term, and got well. The child was unhealthy, and was covered with pompholyx and eczema; and died at last of atrophy. I have given you the trouble, gentlemen, of reading this lono- extract for the purpose of showing you that the vomiting of pregnancy may by long-protracted perversion of the innervation, pass into a true gas- tritis, or gastro-enteritis, as was doubtless the case with the lady whose history I have just related. You see that I could not cure her gastritis DISORDERS OF PREGNANCY. 497 while her pregnancy continued, though I suspended it for awhile by the use of the champagne, which, all things considered, I find to be among the best anti-emetics in these vomitings. I don't mean to say that it is always sure, but only that it generally succeeds: I have, at this moment, October 18, 1847, under my care, a young lady suspecting herself to be in the third month of pregnancy, and whose symptomatic vomiting has reduced her to a very extreme degree of emaciation, and whose stomach will by no means tolerate the champagne, which I lately prescribed in a confident expectation that it would put a period to her distress. I, however, dare very confidently to advise you in all cases of obsti- nate vomiting, connected with pregnancy, to allow your patients to drink champagne ad libitum; since, in so great a multitude of examples of the kind, I have found it to procure a perfect relief. In the case of Mrs. ----n, above related, the irritation of the stomach had passed evidently into inflammation ; and, notwithstanding I succeeded, by means of champagne, in apparently curing the malady of the stomach, you see that the provocative cause being still in operation, the disorder returned, and would not yield to the remedy; nor would it yield to any other remedy which I could employ. You will suppose that I employed a great variety of means, both therapeutical and dietetical, calculated to relieve the turgescence of the vessels of the stomach. But all my efforts were vain, for the cause still continued to act. The pregnancy was no sooner brought to its conclusion by the birth of the child, than all the phenomena disappeared, and, as I before said, she recovered her health. It is a curious fact, that a positive malady of the stomach, one which would lead to the supposition that ramollissement of the tissues had taken place, one characterized by such perverse and rebellious opposi- tion to treatment, should suddenly yield upon the withdrawal of the gestative provocation. Is not this a proof that the disease exists not, essentially, in the apparently diseased organ, but really in the nervous centre which created the organ and governs it ? In the simpler forms of the sympathy of the stomach with the grow- ing uterus, when there are acidity, nausea, and vomiting, a good degree of relief may be obtained by the administration of the alkaline mixture, of which I gave the formula a little while ago, and which may be re- peated from time to time, say every four hours. That particular com- bination of an alkali with the tincture of opium and an aromatic dis- tilled water, is well suited to the exigencies of such a condition. It will be proper upon occasion to add to the dose five to ten drops of the aromatic spirits of ammonia ; or to combine it with an infusion of gin- ger, or the fine extract of ginger, prepared by Mr. Frederick Brown, 32 198 DISORDERS OF PREGNANCY. of Philadelphia, a preparation which I am glad to recommend to your notice, as being quite equal in all respects to the celebrated extract of ginger prepared by Oxley, of London ; an article exceedingly useful in many of the gastric affections of pregnancy, as well as in some of the digestive maladies of children. In a great many instances, I have observed the vomiting and the nausea of pregnancy to be promptly cured by the following medicine:— Take of Sweet tincture of rhubarb, lij. ; Tincture of gentian, 3i. Mix. A dessertspoonful for the dose, once or twice a day; or a teaspoonful thrice a day, will suffice. I presume the aperient and tonic properties of this compound render it so useful as I have found it. I beg you to make trial of it for your patients, and assure you that in many instances it immediately effects the cure, for which the sufferer is most thankful. Many times have I been called upon to give counsel in case of morn- ing sickness, as it is called, or the sickness of pregnancy; and unwill- ing, as I always am, to prescribe drugs when I can in any way escape such a necessity, and finding that the nausea is absent during the night time, while in bed, and that it returns upon rising in the morning, I have advised the patient to direct the servant to bring to her chamber at an early hour a cup of coffee and a toast; recommending to her to take a preliminary breakfast before venturing at all to rise from her bed, and after taking the breakfast, to resume a recumbent posture, which she should not quit for an hour or an hour and a half. During this time, the gastric digestion is nearly completed, and the stomach, being fully occupied with and set upon the train of the vital actions upon which this gastric digestion depends, is enabled to resist the morbid sympathies to which, under other circumstances, it would in- fallibly yield. Whether the philosophy of the experiment be true or false, the fact is very true, as to many instances, in my practice. Where it fails, you have the consolation to reflect that it has cost nothing to the health of the patient; a consolation you do not enjoy when you have cupped and leeched, and blistered and calomelized, and teased both her inner and outer man, without having done her the least good, and with perhaps having done her a great deal of positive harm. As the morbid sympathy in the nausea and vomiting of pregnancy must be admitted sometimes to take its rise in a qualitative state of the uterus, or rather, the reproductive system, it is clear that we shall not DISORDERS OF PREGNANCY. 499 err in our philosophy, if we suppose that means capable of changing this quality of the uterus may be resorted to for the subduction of the remote and troublesome symptomatic irritation. It is under this view that I have long been in the habit of endeavoring to subdue what I sup- pose to be some morbid or morbific condition of the gestative organ, by obtunding its sensibility by anodyne applications or enemata. The sick stomach of pregnancy is in many instances greatly lessened, and in some of them removed, by the use of forty-five drops of laudanum, mixed in an ounce of mucilage or clear starch, as an injection, at bed- time, and, if necessary, repeated at an early morning hour. Riding in a carriage is often found to suspend the sickness of ges- tation. A soluble state of the bowels, maintained by the use of enemata, or by any simple aperient medicine, is an important part of the treatment. Benefit has accrued in some of the cases from the use of a tonic infu- sion, composed of red bark and cascarilla, slightly acidulated with sulphuric acid, and rendered a little warm by the addition of Huxham's tincture. Such an infusion, carefully filtered, is by no means disagree- able to the taste, and serves to promote the appetite and the digestive power. I have tried leeches to the stomach, anodyne plasters, sina- pisms, aromatic plasters, and a great variety of treatment, for the cure of the obstinate cases. After having been many years engaged in the practice of midwifery, I at this late day am obliged to confess that the sick stomach of pregnancy is a most intractable malady. I would cer- tainly, had I a case again under my care so distressing as that of Mrs. ----n, take measures to bring on premature labor. I have to condemn myself for having permitted her to suffer so long as I did. She was in imminent danger of losing her life ; and her happy recovery at the last does not confirm me in the opinion that I was right in allowing her to suffer so long. When the patient has attained the seventh month of her gestation, the uterus has risen considerably above the umbilicus, and the abdominal parietes are excessively distended in order to make room for the dis- tending organ. In proportion as the parietes become distended, the dimple of the umbilicus will become shallower and shallower. At the seventh month, it has risen to the level of the surrounding surface, or even forms a protuberance; and as the pregnancy proceeds, it even pro- trudes so far as to produce what is called the pouting of the navel, which is enumerated as one of the signs of pregnancy. The umbilicus is con- cave in the non-gravid state, because when the umbilical cord was cast off, six or eight days after the birth of the individual, the remains of the umbilical vein and the rest of the two umbilical arteries, which, 500 DISORDERS OF PREGNANCY. like the umbilical vein, are converted into ligament, by their condensa- tion or contraction have drawn the skin about the umbilicus very deeply in toward the peritoneal lining of the abdomen : these ligaments have retained it there until the intrusion of the womb has stretched them, so as to allow the umbilicus to pout, as it is said. Pouting of the navel is rather the sign of a big belly than a sign of pregnancy ; for you find pouting of the umbilicus in ascites, in encysted dropsy, in chronic tym- panitis, and in whatever condition it may be that may cause the belly to become enormously enlarged ; so that protrusion of the navel is worth something or nothing as a sign of pregnancy. Strange modifications of the appetite, or a desire for dry and absorb- ent substances, is a common sign of the state of gestation. Some women are fond of eating chalk or magnesia, or charcoal, or anything that has either an absorbent or an alkaline character. This is the result of some gastric want, and not perhaps a result of pregnancy; it is one of the accidents of pregnancy, not one of its necessary accom- paniments. Strange desires, called longings, are said to affect pregnant women. I have never known any woman affected with longings, but they tell very curious stories ; as of a baker's wife, for example, who longed to bite a piece out of her husband's shoulder. The value of such signs I leave you to appreciate. The ladies do sometimes bite without any longing. Pompey the Great came down one morning with a bite on his cheek ; I do not know, however, that Mrs. Pompey was breeding at that very time. There is a sign of pregnancy which is of some value. I mean the jutting of the hemispherical head of the uterus above the plane of the superior strait, where its presence may be detected by the palps of the fingers, while the patient lies upon her back with her thighs strongly flexed, to relax the abdominal muscles and integuments. But, such an experiment as this could only reveal to you the fact that the hemispheri- cal head of the womb is there present; and though the inference is strong that it is there because the womb is gravid, it carries with it no demonstration of the existence of pregnancy. When hereafter you should find the uterus thus developed, I put you upon your caution not to pronounce your medical opinion upon the cause of the development. But, if the hemispherical head of the womb is there, and the woman from time to time perceives certain movements or impulses in the uterine region, the inference that those motions depend upon a living foetus is a very reasonable one; yet still, it will not give you authority to pronounce your medical opinion, forasmuch as you are liable, under such circumstances, to be deceived by a uterine tumor, and by a fancied DISORDERS OF PREGNANCY. 501 and not real perception of motions on the part of the patient. You may be wellnigh sure, in your opinion, but you cannot be really sure in such opinion. The woman may be sure that she feels the movement —but you cannot be sure that she really feels it. Perhaps she only imagines it. Many a pregnancy has been mistaken for a tumor, and many a tumor for a pregnancy. I have a womb in my collection which has the scar of a trocar in it made to relieve a supposed dropsy. A medical man of the greatest experience lately declared that a girl was not pregnant. To prove that he was right, he pushed a catheter seven inches into the organ, whereupon he was convinced it was a tumor. The next day a foetus of seven months was suddenly, to his great dis- gust, expelled. It lost its life, of course, by the doctor's mistake. How could you misapprehend the truth of the diagnosis, if you should care- fully inquire whether the supposed tumor be alternately hard and soft, solid or unresisting ? There is nothing could make it so save a muscu- lar contraction. Hence, whenever you are at some trouble to decide whether the lump is a tumor or a womb, hold your hand on it for a long time—if it hardens and softens by turns, it is the womb, and it can be nothing else. There are signs of pregnancy which will not mislead you; these signs are to be looked for in the double sounds of the fcetal heart. It has been said that certain sounds perceived by applying the ear either immediately, or mediately through the stethoscope, over the uterus, and which are called by the French writers bruit de souffle uterin, are re- liable ; for it has also been supposed that these are to be taken as signs of pregnancy. For my own part, I have not any confidence unless these sounds are accompanied by the beating of the foetal heart; when that is heard, absolute knowledge as to the existence of pregnancy is obtained, for nothing but a foetal heart can give the double sound of the heart's action. The bruit de souffle uterin may be perceived under other circumstances, and therefore is not at all to be depended upon as a sign of gestation. There is a work called Traite ThSorique et Pratique d'Auscultation Obstetricale, by J. A. H. De Paul, of Paris. Paris, 1847: 8vo. pp. 400. This appears to me to be a very erudite and accurate work, containing a good exposition of whatever is known by the profession upon the sub- ject of obstetric auscultation. Dr. De Paul, at p. 243, commences some inquiries as to the earliest periods of pregnancy at which it is possible to perceive this beat of the foetal heart; and, after giving a statement of numerous experiments and observations which he had made for determining the question, he savs, at p. 246 : "From the foregoing facts, it appears that the double 502 DISORDERS OF PREGNANCY. sounds of the foetal heart have not been perceived earlier than three months and a half, although numerous attempts have been made to discover them earlier than this period. It further appears, that I have perceived those sounds in a much larger proportion of women who had reached the end of the sixth month ; and, finally, that in pregnancy at four months and a half the absence of these sounds is a yerj rare exception." Dr. De Paul says, at p. 247, " I was consulted two years since, by a young lady, eighteen years of age, who was married on the 28th of July, who had always been extremely regular in her courses, and had them last on the 18th of the same month, that is to say, some days before her marriage. At the end of October [three months'], when I was called to see her, all the rational signs of pregnancy had been for some time in existence. It was easy, through the supple and thin abdominal parietes, to feel the uterine globe, already jutting above the superior strait. As the lady manifested a great repugnance to the vaginal explo- ration, I was obliged to content myself with a stethoscopic examination, which I effected with all the precautions requisite in such a case. My first researches were for a long time without result; they terminated, however, in ascertaining the existence of the double pulsations. They were feeble, and difficult to hear; nevertheless, I could count them, and they were repeated one hundred and forty times per minute, while the pulse of the mother was scarcely eighty. The souffle uterin could not be discovered. Another examination, made eight days later, led to a precisely similar result, to obtain which I was obliged, as in the first case, strongly to depress the abdominal wall towards the pelvic cavity. This pregnancy went on regularly, and terminated by a natural labor, at the end of the following month of April." Dr. De Paul, at the 248th page, says that he " does not understand from this case, that the conclusion is established that such a result is always to be ob- tained." He is even inclined to suppose it a fortunate exception. I am tempted to cite another case from the same interesting volume; and, as that volume has not been translated and published in this country, I shall translate and lay the passage before you. The case is as follows:— " Mad. T----, who has already borne several children, had her courses from the 10th to the 15th of April. From the 17th to the 20th of the same month, she cohabited with her husband: he then left Paris on a journey, which was to last only a fortnight. Upon his return, which was early in May, he found his lady confined to bed, with the early symptoms of a typhoid fever, which, in a few days, became per- fectly well characterized, and lasted twenty-four or twenty-five days. DISORDERS OF PREGNANCY. 503 Her convalescence required a lapse of time nearly as long; and new sexual relations were not established until after her recovery. Never- theless, upon the first of August following, as her courses had not reap- peared, I was requested to see her with a view to determine whether this retention, which was very naturally attributed to the severe disease she had lately suffered, might require the employment of certain reme- dies for its cure. I confess, that I was at first very much inclined to give up the idea of a pregnancy begun antecedent to the commencement of the typhoid fever: I was little inclined to suppose it might exist, computing it from the new sexual relations that followed her convales- cence ; but the examination per vaginam, enabling me to detect a notable development of the volume of the uterus, I fell back upon the first opinion, of the propriety of which I became fully convinced, when, after having applied the stethoscope, at various times, upon the inferior part of the abdomen, I discovered the double pulsations, which were repeated one hundred and forty times a minute, while the pulse of the mother was only seventy-six. I could not hear the souffle ute'rin. " Her confinement took place in the following January. The child, which was perfectly developed, appeared not to have suffered the least during its gestation." Here, then, gentlemen, you have a case in which the double sound of the foetal heart was discovered one hundred days, or, three months and ten days after the fecundation had taken place; and in which the preg- nancy continued one hundred and seventy-four days after these foetal sounds were detected by Dr. De Paul; giving two hundred and seventy- four days for the duration of the gestation, assuming that the fecunda- tion took place upon the 20th of April, and two hundred and seventy- seven days, assuming that it took place upon the 17th of the month. It is clear that, in this case, it might have taken place on the 17th, 18th, 19th, or 20th. With regard to hearing the double sound of the foetal heart in auscul- tation of the uterus, though we may feel some surprise at the early de- tection of it in these cases, we cannot refuse to admit the exactness of the diagnosis, inasmuch as in both the cases we have statements of the rate of the mother's pulse. I examined this day, by auscultation, the uterine region of a young lady supposed to be three months gone with child; she has been very much reduced by a severe attack of the vomit- ing of pregnancy, accompanied with a hectical state of the circulation. There is nowhere to be discovered the least sign of the bruit de souffle, but a rapid double sound, coinciding with the double sounds of the heart, is heard whenever the ear is placed over the uterus; but these double sounds are those of the maternal heart, and not of the fcetal heart, for 504 DISORDERS OF PREGNANCY. they are perfectly coincident with her pulsations—but for this coinci- dence the diagnostic would be erroneous. I relate these cases as encouraging you to hope to be able in the course of your practice to discover these proofs of pregnancy as early as they have been detected by Dr. De Paul; yet I beg you to believe, that such an early discovery is more likely to be owing to a fortunate accident than to any general facility to be met with, and on which you might rely in expectation of being able to make so early a detection. Dr. Evory Kennedy, author of Observations on Obstetrical Ausculta- tion, etc., Dublin, 1833, lately master of the Dublin Lying-in Hospital, says, at page 101 of his work : " Although we have, in a few cases, detected this sound even before the end of the fourth month, it will not, in the majority, be possible until a later period; and in those cases where it can be detected about this time, it is sometimes so delicate and feeble as to render it necessary for the individual exploring to have an ear well trained to stethoscopic sounds. In general, therefore, we look upon this phenomenon as not to be detected until after the period of quickening, when the uterus has risen out of the pelvis, and allows of our coming more immediately in contact with the part of it in which the embryo is contained." Such is the opinion of one of the most practiced obstetrical auscul- tators now living. I beg you to remember this opinion, expressed by Dr. Kennedy; so that, when you come to make this obstetrical auscul- tation, you may feel no embarrassment, and exhibit none when you fail to detect the sound in those stages of gestation in which the sound cannot possibly be perceived. When the child has acquired a degree of development sufficient not only to render its motions perceptible to the mother, but sufficient also to render the sounds of its heart audible in auscultation, there is little difficulty; and the greater the progress of the pregnancy, the louder and more distinct the sounds; so that, from the sixth month to the conclusion of the full term, you will have just reason to expect to discover these sounds where they really exist; and not only to discover the sounds of the foetal heart, in cases of single pregnancy, but those of two distinct hearts in cases of twins, the sounds being heard in different regions of the uterine globe. I was going to say again, that I implore you never to pronounce definitively upon the existence of a pregnancy, unless you can clearly jnake out the sound of the foetal heart; or unless you can touch some part of the foetus in a vaginal examination; for you may be deceived by supposed motions, supposed resistances, supposed dimensions and forms, ascertained through the abdominal parietes. The two preceding methods, on which I recommend you to rely, can never deceive you. DISORDERS OF PREGNANCY. 505 How desirable is it that a physician shall not suffer himself to give an erroneous opinion. I assure you that I think nothing could tempt me to give an opinion in such cases, except I could deduce it from one of the two signs above mentioned. I may be ready to admit the extreme probability of the existence of a gestation ; I may not dissent from the opinion of the patient herself; but for my part, I will not pronounce until I shall know. This unalterable resolution has conducted me safely through many difficulties, nor has it ever exposed me, as far as I know, to the least inconvenience or disappointment. The obstetrical auscultation, as it is called, was really discovered by the distinguished physician, Mayor, of Geneva, though the credit of it is generally given to M. de Kergaradec. M. de Kergaradec read his communication upon the subject at the Royal Academy of Medicine, on the 26th of December, 1821, since which time great progress has been made as regards the precision of the results to be obtained by this method of diagnosis. While I am treating on this subject, it may be as well to say that the obstetrical auscultation of the foetal heart is highly useful to deter- mine questions as to the life or death of the foetus in utero, as well as questions relating to its health and safety, and the necessity of doing, or forbearing to do certain things in the conduct of a labor, as neces- sary for the conservation of the life of the child. The same art of obstetrical auscultation may be most usefully applied for the purpose of ascertaining the presentation of the foetus ; the ex- tremity of the stethoscope being placed in a situation the nearest pos- sible to the beating heart, will determine the place of the heart; which, being nearer the os uteri or the fundus uteri, will determine the pre- sentation. I am not writing a treatise upon midwifery, but I can very readily conceive that the general practitioner who undertakes to treat the dis- eases of females, irrespective of their lying-in management, might have frequent occasion to examine the health, condition, and the presentation of the foetus in utero; wherefore, I have proffered you these remarks. There is a sound to be discovered by obstetrical auscultation, which is called the placental souffle, the uterine souffle, or bruit de souffle uterin, as Dr. De Paul prefers it should be called. This is a sound which you hear with your stethoscope, or ear, applied over the globe of the uterus, in pregnant women. That is to say, it is a sound that is heard, provided the ear or the stethoscope be applied upon that part of the uterine globe immediately under which the cause of the sound exists; for it does not exist in all parts of the uterus, being mostly to be heard 506 DISORDERS OF PREGNANCY. upon the sides, and also in the immediate vicinity of the placental attachment. It is a blowing sound, and it often sounds like the rush of air issuing from the nozzle of a bellows when one is blowing the fire. Sometimes it is musical, and resembles very nearly the note of a dove cooing at some distance from the ear. It is in some instances like a faint breath- ing, and in others like a loud snore. It is unattended with any shock or suddenness. While you listen to it, and hear it with the utmost dis- tinctness, it often ceases to be heard, and then recommences, although, in the mean time, you have not removed the stethoscope from the spot where you heard it, and where you have continued to listen. It is pro- bably owing to the motion of the blood in its vessels, and is attributed to the escape of the blood from a narrower into a wider channel. For example, if the posterior lateral surface of the uterus should press heavily upon the primitive iliac, the external iliac, or the internal iliac vessels, so as to lessen, at the point of contact, the caliber of the tube, the fluid issuing into the uncompressed portion would probably occa- sion the sound of the placental souffle; just as the blood, issuing from the cylindrical portion of an artery, into an aneurismal dilatation of the same tube, gives out the aneurismal sound. Some authors have supposed that the sound is occasioned by the rush of blood into the great sinuses and veins of the uterus; or that it is oc- casioned by the rush of blood from the veins of the uterus into the so- called cells of the placenta; and a variety of explanations, that have been offered for it; but nothing appears to me more clear than the one which I have presented to you above. Dr. De Paul, whom I am willing to take as authority upon this point, thinks it is probable that the bruit de souffle exists for some time before it can be distinguished. I will allow myself in the criticism, that it would be better to say that the supposed causes of the bruit de souffle exist earlier than the bruit de souffle itself; for a sound that cannot be heard is not a sound. M. Kergaradec mentions a case, at page 276, in which he heard the bruit de souffle on the eighteenth day. M. Orfila refuses to regard this sound as a certain sign of preg- nancy. Dr. De Paul, at p. 206, says: " For my part, I do not hesitate to make the declaration, that the uterine souffle is not a certain sign of pregnancy." M. Jacquemier, of Paris, and M. Stoltz, of Strasburg, do not regard the bruit de souffle as a sign of pregnancy. You will find in the course of your surgical studies, that tumors in the abdomen, from their pressure upon the great vessels, which pressure DISORDERS OF PREGNANCY. 507 interrupts in a partial manner the course of the blood at the points compressed, produce sounds not to be distinguished from the bruit de souffle ute'rin. Neither is it to be doubted that the empty uterus, after labor, in many cases, yields the same sound. Now if this representa- tion be just and true, and I believe it to be so, what real value will you attach to the existence of this sound in any case of obstetric ausculta- tion ? It can have none at all; since it neither clearly proves the presence of the child, nor its life, nor its death. With these remarks, I shall trouble you no further with the placental souffle, which I advise you to entirely dismiss from the category of the signs of pregnancy. As pregnancy advances, the uterus becomes constantly augmented in size. In those primipara women in whom the abdominal muscles and tegumentary tissues have never before been weakened by the distension attending the gravid condition, the globe of the uterus is strongly re- sisted by those muscles and tissues in its ascent into the abdomen. This resistance presses it against the firm solid back part of the cavity. For the most part, the uterus is in a flaccid condition, growing hourly, daily, weekly larger under the compulsion exercised by the developing ovum; yet it is true that, from the beginning of pregnancy to its end, the contractility of the uterus is frequently exerted at uncertain inter- vals, and that in such a manner as temporarily to condense and harden its fleshy textures. When so condensed, the hand applied on the ex- terior of the abdomen meets with a firm solid ball, incompressible during the contraction, its outline clearly definable by passing the hand over it, and disappearing after from ten to thirty seconds, upon restoration of the flaccidity of the tissue. But, when the uterus is thoroughly flaccid, it is impossible to define its outline through the integuments, the whole belly presenting the appearance of a uniform, soft, compressible, fluctuating tumor. ' During these oft-repeated contractions of the uterus, and probably even while not in a state of condensation, the organ presses more or less heavily against the arteries and veins, as well as on the ab- sorbent branches in the lumbar region, and also upon the sides of the pelvis, just above the brim. This compression of the absorbents, and of the veins, temporarily interrupts the free course of the lymph and the venous blood in their ascent towards the upper parts of the body, and causes the feet to swell. A strong pressure could not fail, in like manner, to contravene the freedom of the flow of blood, in its downward course, through the arteries; for the pressure of the uterus produces an effect like that of a tourniquet-pad, though in a very slight degree. For the most part, you may venture to say that the swelling of the feet is not to be looked for until after the sixth month of 508 DISORDERS OF PREGNANCY. pregnancy. Yet I have met with frightful cases of infiltration as early as the sixth month, and even earlier than that. In December, 1847, a lady twenty-two years old, of a fine robust constitution, was five months gone with child. On Friday and Saturday, her face was so much bloated as to change her physiognomy completely; her feet were infiltrated and her hands quite swelled, and she had a distress- ing headache. On Sunday, she could not go to church, though her husband was the preacher, on account of the headache. On Monday, she had great pain in the head. On Tuesday, still suffering with headache, and affected with great infiltration of the legs, she rode to town, twenty-five miles, in a temperature of 20° Fahr. in a carriage open in front. At eleven, P. M,, she had a puerperal convulsion, and in twenty succeeding hours eleven other attacks of eclampsia; during seven of which hours she was absolutely comatose. She recovered her senses, and two days afterwards miscarried, and then recovered well. If she had been bled on the Friday, she would not have been ill on Sunday. "In a subsequent pregnancy, she lost her life from convulsion. The frequent interruption to the ascent of the lymph and the deten- tion of the blood is necessarily followed, at first, by an increase of the halitus in the cells of the cellular tela, depending on some diminution in the power of the absorbents, which should carry it away ; hence, by slow degrees, there is formed a collection of serous fluid in the cellular tissue of the lower extremities, which is manifested by an increase in the size of the ankle and foot, and which gives the lady a disposition to go about slipshod, or to take a larger pair of shoes. As the swelling increases, it becomes oedema. If the cause continue to act with a cer- tain degree of intensity, the cellular tissue of the legs and thighs be- coming thoroughly distended with fluid, they pit upon pressure, are incommodious from the weight, and not unfrequently painful from the distension. If the action of the absorbents is still more greatly con- travened by the pressure of the uterus, the amount of the halitus pro- duced must be pari passti, increased; and, as the infiltration goes on, the fluid in the upper part of the thigh passes into the cellular tela on the trunk of the body, where it infiltrates everything. It rises to the throat, which is enormously distended ; it fills the arms, and bloats the face ; so that the woman is, at last, afflicted with an enormous anasarca, which is the result of no disease, but dependent simply upon the acci- dental interruption to the action of the vector trunks in the lower ex- tremities. It is probable that you will meet with some cases of this kind, which will fill you with surprise on account of the enormous amount of infiltration. DISORDERS OF PREGNANCY. 509 As I have already spoken upon the subject of infiltration in my fifth letter, I do not deem it necessary to enter here into any considerable discussion on the subject; my principal design and desire in the present mention of the topic being to make you clearly understand that there is a great difference between an anasarca arising from a morbid condition of the constitution, and an anasarca more properly to be denominated cedema gravidarum, or infiltration, which, taking its commencement in the lower extremities, depends solely upon accidental pressure of the gravid uterus upon vessels, and vanishes, like snow before the sun, as soon as the pressure is taken off. It vanishes, I say, like snow before the sun, sometimes under greatly augmented discharges from the kid- neys, and sometimes without any perceptibly increased diuresis. A great diuresis would not be necessary, provided the cause of its pro- duction were entirely withdrawn ; for the production having entirely surceased, the power of elimination exercised at the ordinary rate might be expected soon to remove every excess. It is hardly worth your while, under these views, to trouble your patient, and compromise the health of her stomach and bowels by the administration of drugs ; for she is not sick, nor will your drugs have any other effect than to make her sick. She does not want a drug; she only requires that the pressure of the uterus should be taken off. The infiltration was an accidental result; the cause being removed, the effect is likewise re- moved. Don't give her physic for her accident! Pregnant women have a great tendency to become constipated and to overload the colon with unknown and unsuspected accumulations of stercoraceous matter. Such accumulations add to the power of the pressure already too great; and common sense dictates that they should be obviated or removed. Let the woman keep her bowels in a soluble state : give her two or three rhubarb pills twice or three times a week; but this is not so good treatment as to let her take a couple of Lady Webster's pills immediately after her dinner, when the stomach is full of food. But this is physic, and you can give her a pleasanter remedy than this. Let her infuse half an ounce of senna in a pint of boiling water for two hours ; let her strain the liquor over a pound of prunes in a saucepan, adding to the mixture a handful of loaf sugar; let the prunes stew until they become well cooked, soft, and pulpy; after which, they may be poured into a bowl or jar for use. Now, a prune cooked in this way tastes as pleasantly as if it had been cooked in spring water; it will amuse her to eat six or eight of them per diem; they will keep her bowels open without griping or purging, and assist very materially in obviating the tendency to an increase of her oedema gravidarum. 510 DISORDERS OF PREGNANCY. I have no doubt that in case of pressure exercised by the womb, the veins and absorbents, being the weaker vessels, suffer a greater degree of compression than the artery, which is endowed with an elastic coat for the tube through which the blood is impelled by the energy of the heart's contraction. The blood of the femoral vessels and of the popliteal may reach their distal extremities with a momentum so great, that, favored by the diminished power of the veins and the absorbents, it rapidly increases the effusion and the infiltration. Hence, where a primipara woman has cause to complain of the infiltration of the lower extremities, and the arterial pulse exhibits a strength and momentum above the. par of healthy action, it is highly reasonable, and sensibly conducive to her comfort and safety, to lessen the force of the blood's motion by opening a vein in the arm ; and this offers you an intelligible rationale of the common method, which is to bleed a woman whose legs are too much swollen. I repeat that I am not writing a treatise upon midwifery; and that though you may not become obstetricians, yet, as physicians, you will often have charge of the health of pregnant women. You have just considered the hindering effect of pressure upon blood returning from the extremities; I pray you now to ponder upon the effect which the same pressure would have in diminishing the flow of blood along the arteries below the bifurcation of the aorta, and the inevitable hyperaemia of the upper parts of the trunk and the members, coincident with such diminished flow downwards. If your patient, in an advanced stage of pregnancy, wakes in the morning with her face bloated, her hands and wrists so swollen that she can with difficulty flex and extend the fingers, and this accompanied with pricking sensations affecting the arm, as though the member had been asleep ; with sickness, pain in the head, or vertigo; you would at once refer such phenomena to their true cause, which is the polyaemic state of the upper part of the trunk and limbs. In the progress of the day, as she sits up and moves about upon her feet, the encephalic hyperaemia ceases, only to return upon taking the horizontal posture, and so, mani- fests itself again on the following morning, and so on from day to day. Such a woman ought to be bled, because, if this hyperaemic condition be allowed to be renewed from day to day, for weeks in succession, the vessels of the brain will become habitually surcharged, exposing her to no little risk of apoplexy during her pregnancy, and greatly aggravat- ing her liability to eclampsia at a time when, to the habitual hyperaemia, she comes to superadd the dangerous congestion that coincides with the excitement and the efforts of a first, hard, long, laborious labor. I shall now dismiss the subject of cedema gravidarum, satisfied that I have DISORDERS OF PREGNANCY. 511 laid before you all the explanations relative to it which seem to me proper in this place. The duration of a human pregnancy may be stated at two hundred and eighty days, so that, if you have occasion to calculate for your patient the probability as to the period of her confinement, you should inquire concerning the date of the disappearance of her last menstrua. It is most probable that when fecundation takes place, it will take place soon after the disparition—within from one to four or five days ; more likely on the first than on the fifth. The Jewish women, as I men- tioned in a former letter, do not return to the husband's bed until eight days after the disparition, and yet they conceive and bear children; which is a proof that the deposited ovulum still preserves its vitality at that late period—and possibly as late as the twelfth or thirteenth day. Hence, a Jewish woman, who is going to make her computation for two hundred and eighty days, would begin on the ninth day after her last menstruation ceased. Some persons do always allow eight days to elapse before they commence the computation, and then add two hundred and eighty. But for more than thirty years that I have been in the habit of making the computation, commencing from immediately after the recovery, and allowing two hundred and eighty days, I have had no reason to change the method. Professor Naegele always adds the eight days. Mr. G., a German Jew, informed me that his brother's wife—who observed the law—had twenty-seven children. She never gave suck. The same causes which produce the distressing infiltrations of which I have been treating, act on multitudes of women with such intensity as to establish for life a varicose condition of the veins of the lower extremities. I don't think that you will meet with a great many women who have repeatedly gone through the uterine gestation, in whom some of the veins of the lower limbs have not become permanently varicose; that is to say, enlarged, distended, tortuous, causing the appearance of dark venous stains in the tractus of the vessels. While not pregnant, and not sustaining the weight and pressure of the womb upon the vessels within the pelvis, these varices, although they exist, are not always troublesome ; but upon the re-establishment of the state of gestation, the interruption of the flow of blood exists to such a degree as to render them highly inconvenient and even painful. In proportion as a female approaches the term of her gestation, such a condition of the veins of her extremities become hourly more worthy of regard and attention ; for it is dangerous in the extreme to allow the disorder to go beyond a certain limit, the overpassing of which exposes the vessels to attacks of inflammation, which constitutes phlebitis. I 512 ANXEMIA GRAVIDARUM. have seen samples of frightful saphenal phlebitis supervening upon an unregarded varicose state of these vessels in pregnant women, and which resulted in death from pyogenic fever, evidently taking its origin from the points which I have just indicated. If there be in such a woman a condition warranting you to let blood, you ought to do so in fulfilment of a clear indication. Such a woman should be conscientiously in- structed and warned against the danger to which she would be exposed by being long in a standing position, and she should be earnestly ad- vised to observe a recumbent posture, not only during the night, but frequently during the daytime, with a view to allow the over-distension of the vessels to have some intermission. Inasmuch as, under these circumstances, the texture of the vein may be considered to have lost its tone, its contractility, its power of resist- ing the lateral pressure of the blood-column, you ought sedulously to provide some succedaneum for the lost tone, which you can only find in what the surgeons call position, or in the use of a laced stocking, gaiter, or roller bandage; by either of which methods, the dangerous distension of the tube is prevented, and the patient safely conducted to the term of her accouchement; when, the pressure being taken off, she will no longer be subject to the varix gravidas. I shall close this Letter here, with the expression of my sincere re- spect. C. D. M. LETTER XXXIX; ANEMIA GRAVIDARUM. Gentlemen: There are not a few persons who, in the pregnant state, become affected with seeming diseases of the heart, characterized by irregular action of that organ, such as palpitation, great augmenta- tion of the superficies of pulsation, dyspnoea, orthopnoea, paleness, con- vulsions, or sudden loss of sight and hearing, followed in the long run by oedema and true anasarca. I am speaking of persons who seem to labor under disease of the heart, and I speak, bearing in mind a vivid impression of divers cases that I ha\e had the charge of in the course of my practice. A pregnant woman ought to pass through the whole of her gestation without any feeling of disease ; and many women do, in fact, conceive, develop, and bear their children without any apparent change of their ANAEMIA GRAVIDARUM. 513 health or comfort. I have seen young women not far from term, skip up and down stairs as if they had not been married, preserving all their activity, agility, and appetite ; their good spirits, their color, and their temperature ; enjoying food; sleeping and waking, as if nothing was the matter with them. But there are some constitutions on which the influence of pregnancy is disastrous in the extreme ; constitutions in which the gestation seems to be a direful effort of the life-forces that they can scarcely carry out, which they are often indeed unable to per- fect, and which, in some instances, is perfected at the expense of the woman's health and life. A woman who develops her child requires an augmentation of her haematosic power; indeed, it is but fair to say that she requires an augmentation of the haematosic power for the uses of her own constitu- tion, applying it to the maintenance of her own developments which demand considerable reinforcements when the life-force is exerted with a preternatural energy. The reaper in a harvest field requires more drink and more food than the idler; the woman who maintains not only her own development, but also furnishes the materials for the develop- ment of the child, may, in respect to her wants, be compared to the reaper in the harvest field. But, an augmented development power is a power augmented at the expense of the nervous constitution or matter. There are some nervous constitutions that can furnish it without detri- ment, whereas others suffer the greatest detriment in doing so. If the nervous system becomes affected by these efforts, it may show the affection in some diminution of its power, and the diminution of its power will be most likely to manifest itself as to the specific tissues that are most immediately subservient to the supererogatory demands of the gestation. Inasmuch as all development takes place at the expense of the blood, of which the consumption and waste are very great in the progress of a gestation, it is not, I think, unphilosophical to suppose that the specific tissue most likely to suffer under these' circumstances, is the tissue which, in former letters, I have repeatedly mentioned under the title of the endangium of Mr. Burdach, or blobd^membrane, as I prefer to call it. But, if the blood-membrane, in consequence of exces- sive exertion of its faculties, becomes weakened, becomes diminished as to functional force, then we shall have an imperfect blood. The blood becomes imperfect in regard to the proportion of its solid constituents which are diminished while the watery part is abnormally increased, and that would constitute a state of hydraemia. But a condition of hydraemia in a constitution bound to carry on the great operations of gestation, is one likely to be attended with faulty innervation—faulty 33 514 AN.EMIA GRAVIDARUM. innervation, not only of the cerebellar and cerebro-spinal nerves, but of the whole ganglionic nervous system. The patient will in this case become more or less emaciated, while her cellular tissue is infiltrating with serum or halitus, giving her at first the appearance of an embonpoint very likely to deceive the incautious dia- gnosticator. The increased proportion of water in the blood will at length give to her superficies a character of pallor or chlorosis, and the diminution of the universal tone will extend even to the heart itself, which may become so flabby as apparently to increase in magnitude, and give rise to a great increase of its pulsative superficies in auscultation, misleading the inquirer, and causing him to believe in the existence of a disease of the heart, whereas the disease is essentially an anaemia, or an endangial malady only. These are most distressing cases; they generally become aggravated in proportion to the advances of the preg- nancy ; and not unfrequently allow of such extensive dropsical infiltra- tions, not only of the cellular tissues, but even of the serous cavities, particularly the thorax, as to bring the patient's life into the extremest peril. Yet these maladies are not diseases of the heart; they are sam- ples of anaemia, from which, often, the patient recovers with surprising rapidity, when the cause—videlicet, the gestation—has been brought to its term by the birth of the child. In cases of organic disease of the heart, I mean vast dilatation of its cavities, there is, in general, little reason to expect a rapid recovery, or perhaps a recovery under any circumstances. But the anaemical dilata- tion, or, if you permit me to use the term, the anaemical laxity of the heart's fibre, might well, and in fact does, for the most part, disappear under an appropriate treatment, when its provoking cause, to wit, the anaemia, has been removed. I am very desirous that you should give attention to this theory of the case, and that you should endeavor, when- ever you shall come to take charge of a pregnant woman affected with disease of the heart, to make a careful discrimination between the incu- rable organic lesions of that important organ, and the modifications of its density and contractility, that may be superinduced by a too feeble innervation of its tissues. The most extravagant deviations in the heart's action that can be produced by the anaemical state are commonly found to be lessened and even to disappear wholly, when the patient is placed in a recum- bent posture, and has had time enough to allow the accidental hurry and excitement which have been produced by exertion, motion, or emo- tion, to subside, and the rate of all the functional forces to come down to a condition conformable to the wants of the economy when in a state of profound repose. The anaemical disorder of the heart, under the sup- ANEMIA GRAVIDARUM. 515 posed condition of perfect repose, disappears in so far, at least, as it can be manifested by the respiration or by the circulation. This is not the case in the true organic disease of the heart, where, though the derangements of the heart's action, aggravated by exertion, are fright- ful, indeed, yet they do not wholly disappear even in a state of the most profound rest, but leave their physical signs so plainly discernible to the practised inquirer that he cannot be misled by them. The hy- pertrophic throb of a thickened ventricle, and the feeble imperfect action of a coincidently dilated auricle, can be detected by the ear, even after a long night's sleep. But the irregular, disordered, anoma- lous, feeble beat of the anaemic heart, often gives place to a perfect rhythm, impulse, and superficies, after such a repose has been had. I am very desirous that you should make a careful discrimination in the cases supposed, and that you should not mistake the sudden but feeble impulse of the anaemical heart for the stern, resolute, and dan- gerous injective force of the hypertrophied ventricle. In the one, you will be prompted to use the lancet as a means of diminishing the exces- sive general momentum of the arterial pulse; in the other, you would prescribe absolute recumbent rest to save the constitution from the effects of the disordered and convulsive beat which follows every effort. You would direct a nutritious and light diet, you would give wine and iron, you would direct well-ventilated rooms, you would prescribe the use of moderate anodynes and antispasmodics, to blunt the exaggerated sensibilities of a debilitated constitution; and in so doing, you would conduct the patient wisely, if not safely, to the term of her utero-ges- tation, which, being completed, and the cause being removed, they leave you afterwards nothing to do but to contend against the pathological causes of the simplest anaemia. But so much has already been said in these letters upon that subject, that I shall not offer any further observations here ; and I refer you to those letters, in the confident belief that the pathological principles there explained are founded in sober views of important practical truths. In the treatment of these anaemical cases, you will meet with pre- judices against the employment of ferruginous articles ; for the public in general, who believe that iron is endowed with what are called forcing properties, as regards the menstrua, are timorous as to the use of such therapeutical agents during gestation. They suppose that forcing articles have the power to produce abortion or premature labor, because they thoroughly believe that such forcing articles are capable of bring- ing on menstruation, in season or out of season. To you who have adopted the doctrines of the periodical ovulation and deposit, I need not say that the chalybeates have no such forcing power as is supposed, 516 ANEMIA GRAVIDARUM. and that the use of them during gestation is not less prudent and safe than that of any other tonic medicine whatever ; and I have not the least misgiving as to the propriety and safety of employing them for the cure of these endangial maladies in women pregnant, whether in the early or in the advanced stages of gestation. I attended here a few years since a young woman during the latter half of her utero-gestation, and during the labor in which it terminated —a case which was put in my hands by the advice of her medical at- tendant, on the ground that it was a very dangerous one, with which he was not disposed to charge himself. She presented all the appearances of great dilatation of both the auricles and ventricles of the heart—the impulse of which was percept- ible to the right of the middle of the sternum. The pulse, except when she was in a state of recumbent rest, was large, gaseous, unsteady, and very sudden. The face and the whole surface were pale and flabby; the cornea was nearly uncovered by the upper palpebra. The respiration was troubled, and became on the least motion or emotion, precipitate and difficult. At the end of the seventh month, the lower limbs became con- siderably infiltrated, and the power of muscular motion much curtailed in consequence of its being always attended with violent beating of the heart, breathlessness, and uneasy sensations in the head, as pain, ver- tigo, noises^ and dimness of sight. The progress of the pregnancy was accompanied with aggravation of all these appearances. On different occasions, she had attempted to walk in her house, and had fallen on the floor in a state of insensibility. Being hurriedly notified of such an accident, I arrived on one of the occasions, at the house, soon after she was taken up from the floor and laid upon the bed. I found her absolutely pale, scarcely able to speak, and completely blind. She knew my voice, and opened her eyes to look at me as I spoke: the eyes were bright, the pupils natural, but she was wholly without sight. She complained of some degree of fulness of the head. The pulse was still agitated. In a short time, the .sight returned and was perfect as before. I do not recollect how many times she actually fell in this manner, and with such following phenomena, but the acci- dent was repeated several times. In nearing the term, the swelling of the limbs from oedema was greatly augmented, so as to affect the thighs, and the buttocks, and labia; the pericardium became also the seat of a dropsical effusion, so that a complete orthopncea soon declared itself. My patient could not lie down day or night. If she sat up with a pillow against her back and shoulders, the oppression became so dread- ful she was obliged to throw them away; but, requiring some support, ANAEMIA GRAVIDARUM. 517 she placed her back against one of the posts at the foot of the bed : leaning on the slender cylindrical bedpost, she could find the needful support for rest without the oppression brought on by pillows or cushions. Here she sat day and night for many days, with very bad thin blood, which, of course, was imperfectly oxygenated, and so, greatly increased the disorders of the innervation. Her condition was truly deplorable, and it was difficult to imagine that the heart could ever recover its form, consistency, and power, should she even escape death in the im- pending conflict of labor. In fine, labor came on, and in due time I delivered her with the forceps, in order to save her from the necessity of exerting any voluntary force. Soon after the birth of the child, she began to sleep upon pillows, which she allowed to be made up lower and lower; and at the end of the month of her lying-in, it was no longer a question whether* she would recover. Her health soon became stronger, and now she is in consummate health. The heart presents no evidences of disease what- ever. I have met with several similar cases. I look upon it that all the distress and the peril of this young woman proceeded originally from an endangial malady, provoked into exagge- ration by the demands of the gestative state on the blood-membrane. The whole scene was a representation of the effects and complications of a simple anaemia. Anaemical girls—girls who have passed badly through their puberic age and crisis—are more liable than others to be affected in the manner above described, if they subsequently to marriage become the subjects of pregnancy. Women in pregnancy are liable to palpitation of the heart, especially dependent on anaemia. I advise you, whenever you encounter the case of a pregnant woman. who complains to you of sudden attacks of palpitation of the heart, to inquire carefully into the causes of such palpitations; more especially is it your duty to do so where the attacks of palpitation continue for a considerable length of time before the heart recovers its usual rhythm. A woman who, in her gestation, has an attack of palpitation that lasts from two to six hours, is absolutely in need of good advice; for not- withstanding I have seen cases of palpitation lasting from morning to night, and attended with the most distressing sensations, and the most complete disability of all the organs of relation, yet the patient, upon recovering the normal rhythm of the heart, seemed to be from that mo- ment perfectly well, save of a feeling of debility, and perhaps some pain in the extremities, which, however, soon vanished by the aid of a little rest. I have seen the heart beating more than two hundred and twenty times a minute for ten consecutive hours, and yet the patient who had 518 ANXEMIA GRAVIDARUM. been in such an apparently dangerous situation has evinced no consider- able signs of disorder a short time after the cessation of the palpita- tion. I confess to you, gentlemen, that notwithstanding the frequent ex- amples of perfect recovery from such extravagant palpitations, I can with difficulty imagine that the individual can be safe during the exist- ence of them; for the blood must reach the organs with a pressure, and with a momentum so different from those that attend a healthful state of the circulation, that the development force, one would think, could not fail to result in organic lesions in some of them. And truly, these wild irregular actions of the heart do, in some of these cases, give rise to organic changes, and the heart itself, which is the first organ served by the systemic circulation through its coronary vessels, is the one perhaps most likely to suffer. When it does suffer, through its own illness and imperfect functional power, it gives rise to a patible state of the brain, which, in consequence thereof, determines imperfectly its innervations to the organisms, and so the whole consti- tution is overthrown and made a wreck. What will you do with these palpitations, supposing that they are the result of pure anaemia ? Here I pray you to take into consideration the case that I proposed in a former letter, of persons breathing at a vast elevation on the side or summit of a mountain, where the pressure of the mercury in the barometer allows the column to stand as low as twenty or twenty-five inches, not for want of a given number of cubic inches of atmospheric air, but for want of a given number of cubic inches of atmospheric air of a certain density. Such persons, you may remember, are perfectly at ease while sitting down upon the snow, or on a projecting point of rock ; their pulses beating naturally, and their respiratory act being performed without any notable exaggeration; but, as soon as they begin to move, and call upon their innervative powers for extraordinary dotations of nerve force, the heart beats vehemently and irregularly, the diaphragm and respiratory muscles make the most vio- lent efforts to carry on the respiration in the lungs; the head aches and becomes dizzy, and the traveller, after taking some twenty paces, is obliged to stop, and give rest to his respiratory and circulatory organs, in order that they may recover their composure and gain time for the generation of an amount of nerve force conformable to the wants of the next succeed- ing efforts in ascending. Now your anaemical patient, as I stated in the letter alluded to, is in precisely the same condition as to the oxygenating power, as the travel- ler on the top of Mont Blanc or Yungfrau; and, if you permit her to continue to take exercise, or advise or compel her to do so, you act as ANAEMIA GRAVIDARUM. 519 unwisely as M. De Saussure would have done had he insisted upon the members of his party continuing to make continued efforts to ascend, instead of allowing them to rest and recover their powers of innervation. Continued exertion in an atmosphere so rare as that which is found at the highest altitude of mountains, is, perhaps, impossible; but if it were possible to urge the traveller onward without rest, he would doubt- less perish from apoplexy of the head, the lungs, or some other apo- plectic tissue. If your patient then continues to labor or to exercise under these conditions, there is great reason to fear that some of the important organs will be compelled utterly to give way; whereas if you treat the case wisely, there is little danger of any of the organs giving way, and your patient will go on to the full time of her pregnancy, experiencing, perhaps, occasional attacks of palpitation, but recovering from them well, and in a condition to meet at last the conflict of labor without risk, and without much suffering. When I meet with a case of palpitation from an ordinary anaemic cause, I feel that I shall not cure my patient, until I cure her by means of a trained exercise. I expect my patient daily to walk many miles, before her health can be completely established; but I do not allow her to begin the process of training, until first by a long rest, sometimes by a rest of a week or more in bed, I have prevented her from experiencing the abnormal innervation of the heart, which every imprudent or excessive attempt at exertion had not failed before to bring upon her. Send such a person to walk rapidly up a stairs, and you will find upon her return- ing that the most violent disorder of the circulation has been produced by the effort. Such excessive throbbings cannot but injure the texture of the heart by the experiment. Judge for yourselves whether, if such an experiment might be injurious when you wish to get the heart into good train in order to begin your cure, you ought to let the patient rest in bed, as I said, for a week or more, and then, commencing carefully, allow her to test the power of the heart by walking on a horizontal plane gently and slowly. If she can begin, she can go on day by day, further and further. During this preliminary rest, I take advantage of the occasion to prepare her for the training treatment, by getting the skin into a favor- able state, by procuring determination to the surface, favoring the operation of all the secretory organs, invigorating a little their tonicity by nutritious diet, by cordials and by tonics; and then when I begin to allow her to take exercise, I direct her to adjust the amount to her ability, increasing little by little, until I carry it up to the desired point. If such a caution is necessary in the conduct of the cases of palpita- 520 ANAEMIA GRAVIDARUM. tion, even in the anaemia of the virgin, how much more desirable is it that it should be applied to the cases of pregnant women ; since the sequelae of the palpitation are so distressing whenever there are super- added to them the constitutional excitement and the disturbance that must attend upon a violent or protracted labor. I find that, notwithstanding my intention in a former part of this letter to trouble you no more with observations on the subject of anaemia, I have not been able to overcome the disposition I felt to give the above explanation. But I hope you will accept the explanation now; for the necessity of rest is as applicable to the cases of palpitation derived from the thickening of the valves, their laxity, their granula- tion, dilatation of the cavity, hypertrophy, dilatation or weakness of the great vessels, or indeed whatever direct causes of palpitation of the heart, as it is for those that depend upon simple, pure, unmixed anaemia. In cases of pregnancy, accompanied with palpitation, and convulsive, or rather what you might prefer to call nervous action of the heart, among the very best resources of the materia medica is the digitalis purpurea. This is a pure narcotic, which, by its influence upon the nervous system, when properly administered, diminishes its excessive perceptivity, and in doing so is capable of lessening the manifest result, within the organs, of that excessive perceptivity which is always accom- panied with exaggerated action of the reflex innervation. Everybody, whether painter or poet, musician, agriculturist, or phy- sician, becomes more or less a routinist; that is to say, he acquires habits in his actions; whence it is, I suppose, that you find some physicians who never prescribe digitalis except in powder; others who confide in it only when used as the tincture of the plant; while some never permit themselves to employ it except prepared according to the formula of Withering's infusion. I am in the latter category, and I scarcely ever give digitalis unless in the form of Withering's infusion, except where I give it to young children, and then I always employ the tincture. In the class of patients of which we have just been speaking, I commonly prescribe, when I think the use is indicated, half an ounce of Wither- ing's infusion of foxglove, which I direct to be repeated once in eight hours. But I think it is necessary always to add a very clear and un- derstandable caution as to the repetition of the doses. No physician ought to trust himself to prescribe such a medicine unless he can in person, or by means of a confidential agent, note the progress of its therapeutical force in bringing about the desired control of the circula- tion. When the pulse begins to fall in frequency, the administration of the drug should be either wholly suspended, or lessened as to the doses, or as to the periods; because the collapse which follows the ex- ANAEMIA GRAVIDARUM. 521 cessive action of the medicine, being sudden, is a thing not to be thought of for a pregnant woman, for it is frightful enough for the non-gravid. " In morbis pectoris, per vias urinae ducendum est," is an ancient precept, and the digitalis purpurea, perhaps, of all the articles in the materia medica, is most highly endowed with the diuretic force, which renders it peculiarly appropriate in the affection under consideration. I need not lengthen this letter by specifying directions as to the pre- scriptions, and the formulae of prescriptions, which will be required in the course of the treatment. If you be really well founded in the know- ledge of anatomy and of physiology, you will be able, in contemplating the rate of the functions of the different parts of the body, so to direct your therapeutical prescriptions and your hygienical ordinances as to correct, if possible, the local derangement, and, by removing them, ab- solve the nervous system from the necessity of perpetually perceiving these local derangements, and perpetually contending against them by exciting what is called reaction. There is another distressing affection which accompanies pregnancy, and about which I am desirous to say a few words. I mean the incon- venience and pain resulting from a strain of the pelvic articulations. The symphysis pubis and the sacro-iliac junction ought to be firm ; the least motion of the pieces of bone that are bound together by these articulations is attended by a feeling of weakness, insecurity, and pain, in the highest degree annoying. I have seen a patient who could not take ten steps across her chamber without producing a sensible motion of the right and left ossa-pubis ; so that, when she would stand upon her right foot, the os pubis of the right side would be raised at least a quarter of an inch above the left one, and vice versd. But if you under- stand the nature of the auricular symphysis, you will perceive that the pubis cannot become a movable joint without involving more or less motion in the sacro-iliac junction, and that such motion must give a feeling of unsteadiness, insecurity, and debility, than which nothing can be more distressing : the woman feels as if she was going to fall to the ground between her thighs. Her inability is so great that she is obliged to call for assistance to turn in bed, or if not assisted, she first sits up in bed and then lies down on the opposite side. It is probable that the perpetual strain, the weight, and the pres- sure occasioned by the presence of the gravid womb within the cir- cumference of the superior strait, and the resistance of the abdominal muscles against the distending, growing uterus, all of which force, it must be admitted, is concentrated or expended upon the pelvic articula- tions, may determine a state of disease or abnormal vitality there, to be followed by infiltration and relaxation, or by partial softening of 522 ANXEMIA GRAVIDARUM. the fibrous material, the result of which is the articular relaxation in question. It is a vulgar opinion that the pelvic joints do naturally open to give escape to the child in labor; and among the common people it is by no means rare to find them making use of ointments and lotions for the purpose of promoting and softening the relaxation of the articulations. All such attempts are both unnecessary and futile. Whenever the re- laxation does take place, it arises from the causes which I have just stated—causes that are, perhaps, fortified by a rheumatic vice which has fallen upon the parts. The vitality of these low-lived tissues is so slow in its processes, that a great deal of time is required to effect any changes in their density ; and I believe you will make a great mistake, if, when a woman, after her child is born, complains to you of relaxation of the symphysis, you should admit, what she will probably suppose, that the relaxation was produced by the strain of the labor. A labor shall scarcely last long enough to effect such great modifications in the life of these half inor- ganic materials. I have met with a good many examples of this distressing accident in my clinical practice, some which have been perfectly cured in the course of a very few weeks, and some which have never recovered, and seem as if they were destined never to recover. The patient is so dis- tressed that she asks for a treatment; nay, she asks for a cure. Now what shall be the treatment, what shall be the method of cure ? Sup- pose you had a patient laboring under an inflammation of the hip, of the knee-joint, of the ankle, or of any other articulation, would you not treat it with a splint ? And why with a splint ? Would it not be that by means of the splint you might treat it by rest ? Now the word rest is the other expression for the word splint. An inflamed joint, like a broken bone, requires rest, as a general rule, although it may have more exceptions than the case of the broken bone; yet it has few exceptions; for even in the case of the broken bone it might happen that where a false joint is formed, or is about to be formed, the motion might deter- mine a cure by re-exciting the power of the periosteum, which is the bone-producing power. I don't see much use in giving drugs to a woman who complains of loosened articulations. You might, perhaps, reasonably resort to some anti-rheumatic medication in the cases which you should deem depend- ent on a rheumatic vice, existing either as the original cause of the relaxation, or continuing to prevent its cure, or else as supervening in a part weakened by the causes before indicated, and in that way inviting an attack. Consider these points, and act accordingly. ANiEMlA GRAVIDARUM. 523 I ought to have observed that Prof. Moreau, author of the Trait'e Pratique des Aceouehemens, at p. 47, vol. 1st of his admirable work, assigns pelvic relaxation as the cause of some of the slow and difficult labors that are occasionally met with. He says, the muscles that are auxiliary to the uterus, having no longer a firm insertion on the vacillat- ing bones of the pelvis, painfully affect the symphyses by their con- traction ; and that the woman, restrained by fear of the pain consequent upon the contraction, fails to bring into play these accessory powers : so that the uterus, left to the resources of its own energy alone, frees itself slowly, and with difficulty, from the products of conception. I am about to violate again a rule that I had laid down in the com- position of these letters, which was, to put in them very few quotations from authors ; but the disorders arising from the cause in question are in all respects so interesting to the practitioner that I will not resist the temptation I feel to lay before you a translation from the same Prof. Moreau's work, the reading of which will serve to throw an abundant light upon the subject; and as I have not met in my practice with any case so important, of our disorder, I think I shall do you a service in laying before you that of the learned Professor. The following are M. Moreau's words: " Mad. D., of Paris, aged thirty-three years, of an apparently sound constitution, had been weak and delicate during her childhood, and had also exhibited some signs of rickets, marked by slight tumefaction of the articular extremities of the long bones. She became regular at fourteen years and a half, and then grew rapidly. From this time up to the period of her marriage, she enjoyed perfect health, saving that there was always a little weakness of the ligaments. She was liable to slight sprains, and had very little strength in her wrists. She was married at the age of six-and-twenty years, and soon became pregnant. The first steps of this new condition evinced nothing extraordinary. At about the second month, an excur- sion of five leagues from Paris, which she made in the course of one day, brought on a general uneasiness, accompanied with sharp pains, that were thought to threaten an abortion. The physician had her bled in the arm, ordered her to rest, gave her tepid baths, and directed a light regimen. The pains which during the first eight days had been so sharp that the patient while in bed was incapable of the least motion, became quieted; at least, so that she could be placed upon a sofa. At the end of a month, she tried to walk, but though the attempt gave her no pain, she could not take a step without finding herself ill. " This inability to walk continued for some time : however, towards the end of pregnancy, the young lady gained strength, and was able to walk with a little less difficulty. 524 ANAEMIA GRAVIDARUM. " Labor pains came on in the night of the 16th of October, l^O, and had continued for twenty-four hours, when the forceps was employed to assist the delivery of a male child, in good health, whom the mother in vain attempted to suckle. " During the first fortnight of the lying-in, she had severe pains in the hips and the parts of generation, which were attributed to lacerations occasioned by the passage of the child's head and the use of the for- ceps. " After this, she made an attempt to get into an easy-chair, but fainted, and was again put to bed. " At the end of six weeks, the lady attempted to walk from her bed to the sofa, leaning on the shoulders of assistants ; but at every attempt she had sharp pains in the articulations of the pelvis, and felt as if her body would slide down between her legs. " Five months having elapsed, she went, by the advice of her physi- cian, to the country. There her hips being bound round by a bandage kept in place by understraps, she attempted to walk in the garden, but the attempts were always attended with suffering. Whenever the un- derstraps were loosened, she said she had a sort of bursting sensation, with a desire to sit down, or to lie down. " For ten months, she made use of gelatinous baths, baths of Bareges- water, and saline or astringent injections, but without any appreciable advantage. A consultation was then held between the accoucheur and MM. Magendie and Amussat. It was determined at the consultation that there was relaxation of the symphyses of the pelvis, the effect of which was, that when the patient was placed upon her feet and left to herself, she was incapable not only of maintaining such position, or of walking, but also of adducting the thighs. " Madame D. was now ordered to wear a belt better constructed, and stronger than the one which she had hitherto used. This belt embraced the hips, both trochanters, and the upper parts of the thighs, so as to approximate them, and maintain the approximation with great energy. "When supported in this manner, it is certain that Madame D. could begin to walk, not without difficulty, in her chamber, and sometimes in the street; but she could neither ascend nor descend a stair ; it was necessary to carry her, to enable her to get up four or five steps. Af- ter two years of care, and of a treatment in which sulphurous, gelatin- ous, and aromatic baths had been employed, her health improved ; she could walk better. At the end of 1832, she was able to take short walks, prolonged sometimes to the extent of five-and-twenty minutes ; still, however, she always had pain on the day following such an effort. " In the month of March, 1833, she became pregnant again. In the ANAEMIA GRAVIDARUM. 525 course of the first three months there was nothing peculiar, except that she experienced great difficulty in walking. At the end of three months, her sufferings increased ; at which time I was called in for my opinion in the case. In spite of her sufferings, and in hopes that the open air would give her strength, she continued until the fifth month to go to the gardens of the Luxembourg, a promenade from which she was separated only by the width of a street. " Towards the end of August, upon returning from a walk, she had such violent pains in the hips, thighs, and loins, that she was obliged to keep first her chair, and her sofa, and then her bed, for the remainder of her pregnancy. " On the first of December, 1833, at half-past four o'clock in the morning, after a labor of a few hours, which was neither tedious nor very painful, she gave birth, naturally, to a fine healthy boy. " Immediately after this second accouchement, Madame D. lost all power of motion. In bestowing upon her the cares required by her 'condition, it was necessary to move her legs one at a time ; but the limbs could never be moved without causing pain so violent that the patient could not or would not move, even to satisfy the most imperative wants. She groaned incessantly; cried out whenever she was touched; and if, in her uneasy sleep, she happened to change her position, she was immediately awakened by the pain, and unable, without assistance, to recover the position she had just quitted. Still, there was no fever, nor enlargement in the articulations of the pelvis, nor change in the color of the skin. The left leg was weaker than the other. The sur- face of the mons acquired such an extreme sensibility that the patient believed that the hair had become sensible, because the least touch or the least friction gave her pain. " Narcotic and emollient applications, without recourse to bleeding; diet, the use of diuretic and sedative drinks, and two slight doses of purgative medicine, coupled with the most perfect immobility, sufficed gradually to dissipate these sufferings, which, in the course of a month after her confinement, totally disappeared. " Nevertheless, the movements of the lower extremities became less and less free. One fact ought to be mentioned, in which the case dif- fered from her former confinement; she could not abduct her limbs. Whenever she wished to move them, she was obliged to move them both together to the same side ; to effect which, she was, and still is, obliged to flex the knees, by drawing up the feet towards the pelvis, and then incline both the limbs towards the right or the left, as in incipient paraplegia. " On several occasions, I expressed to the family my desire to be 526 ANXEMIA GRAVIDARUM. assisted by the advice of some of my brethren, and especially of those who had formerly had charge of the patient, and who still saw her from time to time. " Consequently, at the beginning of April, 1834, I met MM. Ma- gendie and Amussat. After an attentive examination, these gentlemen, who had observed the case during the first confinement, ascertained that there was an enormous increase of the mobility and separation of the symphyses. " It was agreed at the consultation, that, as a basis of treatment, the lady should be sent to the country, to a dry and elevated situation, where she should be exposed upon her bed to the influence of pure air and solar light; and that she should take saline, alkaline, sulphurous or aromatic baths; that she should make use of an animal diet, which should be tonic without being too stimulating ; and that, above all, she should return to the use of a mode of constriction of the pelvis, which should be strong, methodical, and permanent. " My colleague M. Amussat, who took charge of the treatment, and gave the most assiduous attention to the patient, was kind enough to see that the bandage should be prepared by a careful artist; a sort of mechanical girdle, which should embrace the hips, taking as its point d'appui the trochanters; the pressure to be regulated by means of screws. When the apparatus was applied, the patient could bear it only for a quarter of an hour at a time, although the buckles and the screws were not much tightened. The result did not answer the expectations that had been indulged, for, as soon as the machine was applied, she was attacked by slight fever, accompanied with very decided nervous spasms ; symptoms that were reproduced upon every repetition of the experi- ment. It was necessary to give up the means as too energetic, and to recur to the use of the simple bandage furnished with buckles and strong straps, which the patient could tighten at will. " Notwithstanding the most careful attention—in spite of the per- severance with which the above treatment has been carried out for two years ; in spite of the employment of other therapeutical means, which, with many other interesting details we shall omit to mention, the lady remains very nearly in the state in which she was in the month of April, 1834. " Having been called to her five or six weeks since, to take care of her in a new pregnancy, which began at the end of November, 1835, I find her in the following condition :— " In the course of the two years during which I had lost sight of her, she has grown thin; the digestive functions are torpid, and often per- formed with pain; the alvine and urinary excretions are voluntary and ANAEMIA GRAVIDARUM. 527 easy ; the sexual organs retain the free exercise of their functions ; the sensibility of the legs and thighs natural, but they have sensibly dimi- nished in size, are more flaccid, softer, and have almost entirely lost the power of motion ; flexion and extension are still difficult; it is impos- sible for her to lift up her limbs, and she cannot quit the horizontal posture. Upon exploring the symphysis of the pubis, either internally or externally, the bones are found more separate than in the ordinary condition. Upon lifting up one pubis, and pushing the other in the opposite direction, I thought I could perceive a vacillation of the bones, which the patient said she also could perceive." I have nowhere met with a more interesting detail of the effects of the relaxation of the symphysis of the pubis than the one which I have now laid before you. Nor have I seen one attended with so total a loss of power as this described by Prof. Moreau. I long had charge of the case of a lady, laboring under a strange susceptibility of the nervous system, accompanied with a loss of in- nervative power, so that, although she was at ease, and apparently well in a state of recumbent repose, a slight, even a very slight muscular effort was often observed to be followed by a severe attack of lypo- thymia. The digestive powers were not particularly affected, nor were the assimilative functions- much interrupted by these strange maladies. It seemed at times that she was greatly benefited by the pelvic bandage; and I doubt not that the motion of the lower extremities was much more possible, and much less painful, when the bones of the pelvis were held in firmer contact by the aid of the girdle. She has recovered and lost again, two or three times, the power of voluntary exercise ; she has given birth to several children, and is now in the possession of comfort- able health. I always supposed that her maladive condition had its radiating point in an affection of the pelvic symphyses, which came on during fatiguing journeys, while pregnant with a heavy male child. I could always produce pain in the symphysis pubis, by drawing the cristas of the ilia asunder with my two hands ; but I could never give any pain by pressing the pubes together by placing my hands on the exterior sides of the pelvis. I believe that such cases ought to be regarded as cases of rheumatism of these important articulations ; and whether they be rheumatic or not, in their incipiency, the sprain, and injury done to the joint by gestation and labor, are sufficient to invite attacks of rheumatism, which, having once effected a lodgment in the tissue, can be with diffi- culty only, or not at all displaced. In cases of relaxation of the pubic symphyses refusing to yield to a treatment consisting of absolute rest of the articulation effected through recumbency and bandaging, there will also, I think, be good reason to 528 ABORTION. accuse the part of rheumatism, provided we can exclude from the diag- nostic any possible condition of active inflammation tending to produce suppuration or caries of the joint. In the case that I cited at such length from Prof. Moreau, you see that the patient suffered for many consecutive years, and that the last note of the case left her still in very ill health. Do you think that such grave disorders of the health, and so great a persistence in them, could possibly depend upon mere relaxation of the fibro-cartilage that binds the ossa pubis together ? Do you not rather concur with me, in the opinion just now expressed, that there must be some disorder over and above the state of relaxation in which the articulations are known to be ! And is it not likely that the disorder is rheumatic? I should think that if you should come across a case such as that of Prof. Mo- reau, you would resort to an anti-rheumatic treatment; and that, for the subduction of the arthritic disorder, you would at least come to the conclusion that the use of a powerful counter-irritation and derivation, such as that of the seton, might assist to restore the patient's health. I imagine that such a seton as that of Dr. Grauiex would scarcely be ob- jected to by the patient herself, as it would afford some reasonable ground of hope to relieve a torturing and disabling disorder. I have proposed such a seton to a young lady at present under my care, who has suffered for years from manifest relaxation of the inter- pubic ligaments, whose general health, however, not having been deeply mined, leads her to decline the application of the remedy. C. D. M. LETTER XL. ABORTION. Gentlemen : Among the diseases and accidents of pregnancy, few are more common or more vexatious than those connected with miscarriage and abortion. The full term of pregnancy extends, as I have stated, to about the two hundred and eightieth day from the fecundation of the ovum. It is most prudent, in making the calculation for the term, to beo-in the computation from the day of the last catamenial show: two hundred and eighty days from this date, the woman ought to expel the child. It is in this manner that I have made the computation for my patients for many years past, and as yet have found no reason for changing my ABORTION. 529 method or habit. It is true that the Jewish women, as I mentioned in a former letter, begin their computation after the eighth day subsequent to the disappearance, and that they say the calculation serves them well; but the other method has also served me well. That very distinguished physician, Dr. Carl Franz Naegele, of Heid- elberg, is said to have long made the computation without failing to be correct, by adhering to the rule of commencing the count eight days after the menstrua, and not immediately after the cessation of the show. If Dr. Naegel& has been more fortunate than others, it may be that he was made acquainted with the customs of the Jewish women above re- ferred to, and that the most prudent course would be to commence the calculation at the end of eight days. For my part, I have always made it as I have stated, and shall not change my plan. Some years ago, there was a trial in England involving the question of the duration of pregnancy. It was called the Gardiner-Peerage Case, and was instituted for the purpose of settling the title of a claimant to that peerage. Many eminent medical men in England were examined on the occasion, and the result was that no absolute term of pregnancy was ascertained or assigned. Moved by the interest excited in that trial, Dr. Merriman, of London, took the greatest pains to ascertain in many women the duration of pregnancy, and succeeded in satisfying his mind of the great correctness of the computation as to one hundred and fourteen cases of mature children. The results of these inquiries he published in the Lond. Med.-Chir. Trans., vol. xviii. part ii., at p. 338. He gave a tabular statement as follows : There were born at 255 days, 1 14 in 39th week. 288 days, 5 256 " 1 274 days, 4 289 " 2 259 " 1 275 " 2 290 " 2 3 in 37th week. 276 " 4 292 " 4 262 days, 2 277 " 8 293 " 2 263 " 2 278 " 3 15 42d week. 264 " 4 279 " 3 295 days, 1 265 " 1 280 " 9 296 " 2 266 " 4 33 in 40th week. 297 " 2 13 in 38th week. 281 c lays, 5 298 " 4 267 days, 1 282 " 2 301 " 1 268 " 1 283 " 6 10 43d week. 269 " 4 284 " 1 303 days, 1 270 " 1 285 " 4 305 " 1 271 " 2 286 " 3 306 " 2 272 " 2 287 " 1 4 in 44th \? 273 " 3 22 41st week. 34 530 ABORTION. From the foregoing table, it appears that the term, or duration of a pregnancy, is not absolutely fixed, and that there is a considerable lati- tude as to the number of days the foetus may remain in utero ; some of them being rendered "mature" sooner, and some later, according to the amount of vital force they are endowed with : it is relative, perhaps, also to the strength and ability of the maternal constitution, and in some degree, probably, to the placental attachment and connection, as being more or less extensive and perfect. From the table, you may perceive.that Dr. Naegel&'s mode of making the calculation cannot possibly secure you from a liability to error, since, even if the fecundation cannot take place until the eighth day, the indeterminate and latitudinarian duration of a pregnancy must frequently disappoint you. I advise you to study with care the works relative to the duration of pregnancy, and among them the three volumes Sur les Naissanees Tardives, that were published in France in 1765, and which consist of tracts by the most eminent men of that period, some in favor of, and others in opposition to the doctrine of protracted gestations. Dr. Asdrubali, in his work on Obstetrics, devotes the whole of his last volume to show that a protracted pregnancy is possible, and has been so considered by the learned in all ages. But, while the natural term of a pregnancy is about two hundred and eighty days, such is the delicacy of the attachment by which the foetus is united to its parent, that many causes are found sufficient to separate it from the living surface before its time; while numerous dis- eases, to which its frail nature renders it liable, may serve to bring its life to a premature conclusion. By its death, the ovum becomes a foreign body, and it is expelled by the womb which it now irritates patho- logically, and thereby excites the contractile force of its muscles, so as to give rise to the pains or contractions of a miscarriage, as well as the bloody discharge that usually attends those contractions. It should be considered, that though the feetus is contained within the cavity of the womb, it is prevented from all direct contact with that organ, except by the placenta. It floats in the water of the amnios, and the interior of the womb is lined everywhere by the amnion and chorion. This placenta is properly to be esteemed as an expansion of the main trunk of the foetal aorta—just as the retina is an expansion of the optic nerve—inasmuch as the aorta of the embryo divides, above its pelvis, into two umbilical branches, which, as they pass down towards its brim give off the iliacs—and then reflecting themselves upwards on each side of the bladder, proceed through the umbilical ring and along the cord to the placenta, which is another name for their umbel- like divisions, expansions, or ramifications. When the aorta has thus ABORTION. 531 pushed its extremity against the living surface of the mother, hav- ing risen upwards on the growing allantois, it has succeeded in esta- blishing the utero-foetal union, and this is the only point at which that union exists; everywhere else the womb is protected against direct contact by the interposed membranes, as before observed. It might, without a violent stretch of the imagination, be conceived, that, in this case, the heart of the foetus has projected its vessels to a great distance and expanded them upon the vital surface of the mother, in order to obtain on that living surface certain parts of the oxygenated blood of the parent; and we can discover an analogy in the case, to what happens in the brain, which, in order that it may receive the im- pressions of light, projects from its substance the optic nerves, extends them beyond the walls of the cranium, and expands them as retina on the choroid coat, in order that a larger surface may be exposed to the radiation. Or again, just in the same design, the trunk of the pulmo- nary artery divides itself into innumerable arteries, arterioles, and capil- laries, in order thereby to expose a given quantity of blood on a vast superficies, to the action of the oxygen of the atmosphere. This point of attachment of the embryo to the womb has been lately called its mesenteric attachment, and it must be easy to conceive that, whatever may have power to destroy that mesenteric union, has equal power to arrest the progress of the foetal life; for if that attachment be partially destroyed, the foetus will slowly or suddenly perish; or possibly recover, if the injury be not too extensive. For the most part, the union betwixt the placenta and the womb is very slight; it may be overcome by a blow on the woman's abdomen, acting directly on the place of union. Contractions of the womb, af- fecting that part of the superficies of the organ on which the afterbirth sits, may detach it. Sudden and violent augmentations of the mo- mentum of the blood's motion in the maternal vessels are sometimes sufficient to break the union; and this happens in consequence of the impulse causing some drops to escape from the womb, and lodging be- twixt it and the placenta—thus peeling or dissecting it off, little by little, until a sufficient superficies is removed to destroy the life of- the embryo. Sudden and violent muscular motions of the mother, as in recovering from falls, in stooping, in lifting heavy weights, in ascending stairs, in running, dancing, leaping, &c; in riding over rough roads in a carriage, or riding on horseback; all these are sufficient, on certain occasions, to break the connection of the afterbirth with the womb. Emetics—by the relaxing influence of nausea, followed by the intense 532 ABORTION. efforts of the muscles in vomiting—also serve to detach the placenta in some individuals. The violent and drastic operation of cathartic drugs, as aloetics, senna, &c, by the great tenesmic action they introduce, and by the affluxion and heat which they determine to the pelvic organs, are also sufficient causes of abortion. The action of blisters, and the internal use of cantharides and certain essential oils, may also, by the irritation of the neck of the bladder, involve the adjacent and connected womb in great irritation, and so serve as causes of abortion. Ergot is doubtless sometimes employed for the purpose of procuring criminal abortion. I am aware, however, of only one case in which it was used for that object. A woman, a widow, about forty years of age, in full, vigorous health, after an illicit intercourse, found herself preg- nant. She had a large family of children, and fearing the consequences of her fault, procured from an apothecary, a portion of ergot, which she took with a view to cause the expulsion of the ovum, at about the fourth month. The ergot made her very sick, and as the vomiting alarmed her for her safety, she sent for me in great fear of the conse- quences, and confided to me her painful secret. I warned her against the enormity of her crime, and seeing that the attempt to excite the womb's action was happily a failure, advised her to leave town for some months, which she did, in order to be confined at Boston. I have men- tioned this case, the only one within my personal knowledge, of the use of ergot in a healthful gestation, for the purpose of exciting the uterine contractions. In this case it signally failed ; and I am strongly inclined to believe that, although the power of ergot to excite the mus- cular action of the womb in labor is undeniable, it is not certain that it Can excite those motions ab origine. It very certainly often does fail to set the womb in motion when given to facilitate miscarriages already in progress, but going on too slowly. Dr. Robert Lee's Clinical Mid- wifery, at page 82, contains a very interesting case of attempt to bring on premature labor by the use of ergot—which signally failed of the expected success. If we consider for a moment the extreme tenuity of the membranes and vessels of the early embryo, we ought -rather to be surprised at the power it has to live on to term, than at the occasional cessa- tion of its existence in the early stages of its intra-uterine life. The least obstruction of the delicate umbilical vessels, or of its omphalo- mesenteric apparatus, would destroy it. The least rupture, perhaps, of the hyaloid membranes of its reticulated magma would cause its death— and an error loci of its blood-globules, as they proceed to mark out the ABORTION. 533 tracks of its bloodvessels, might cause an inevitable cessation of its existence. Pray observe that the early ovum resides in the fundus and cor- pus and not in the cylindrical cervix uteri; the cervix being the re- tainer while the fundus and corpus are the containers of the ovum. An unceasing conflict of expulsive and retentive antagonism is waged be- tween the cervix and the fundus from the beginning to the end of every pregnancy. The fundus always endeavors to deploy the cylinder of the neck into a cone, and then to convert it into a large cylinder, through the cavity of which it may expel or thrust forth the embryo. If a woman have a feeble cervix it will yield and will dilate and allow the fruit to fall; if she have, on the other hand, a fundus that is too strong and too resisting, but a natural strength of the cervix, the latter must yield and lose the fruit of the conception. So that either of these two causes may lead to the abortion. Hence, you may not infer that those women who always miscarry always do so because they have a feeble cervix uteri. See to it, and learn to ascertain your duty of strengthening by curing the neck, or else of reducing the abnormal energy of the other segments of the womb. It is probable that a major part of the abortions met with in practice are the results of a failure in the vital forces and arrangements of the embryo, and not of a faulty action of the womb itself, or some accident or emotion of the woman ; some imprudent step, gesture, or posture. If the embryo dies in utero, the ovum commonly soon ceases to pos- sess any vital property, and then the womb, by some sort of organic perception; by ceasing to grow or expand ; by the irritation of a pre- sent foreign body, comes to a full stop or arrest of those living and progressive developments under which it has been acting since the com- mencement of the gestation—a new principle of activity is awakened in its organism; its muscular fibres begin to constringe themselves; the superficial content of the uterine cavity grows less and less under these contractions, and the embryo and the ovum are thrust through its orifice into the vagina, from which they are soon pressed forth or fall away by their own weight. Although the death of the embryo involves a certain cessation of the projection of its blood to the vessels of the placenta, and notwithstand- ing this cessation is generally very soon followed by the expulsive action of the womb, it is not always soon followed by the latter effect. A lady conceived, about the 20th of April, 1842, and consequently made ar- rangements for her accouchement for the 20th of January, 1843. The pregnancy went on well until about the 5th or 10th of August, when she had a very slight show, and there was a complete arrest of the 534 ABORTION. usual developments. She was at various times affected with slight ap- pearances of her catamenia, as she supposed, but without any flooding, until the 3d of January, 1343, when she sent for me, saying she had suffered extreme pain, like the pains of labor, for some hours, but was now easy, though she thought something was escaping from the vagina. Upon examining the patient, I detected the ovum, partly in the vagina and partly embraced within the cervix, and removed it with the index finger; and, upon carefully examining it, found that it was the unbroken ovum of a foetus of three and a half months, apparently. The ovum itself contained a sort of granular brown and thick fluid, while the foetus, also of a mummy color, retained its lineaments, although consider- ably macerated by its long residence in the waters. The placental portion of the ovum was red and fresh-looking, and had evidently re- tained more or less vitality up to the period of its separation from the womb. I think I can safely assert that, in the course of my practice, I have met with near twenty cases of the protracted residence of the ovum in the womb, after the death of the embryo. I have had under my care several cases where it has certainly remained five months after its death. Nor, indeed, is there any reason for surprise at this, if we reflect that numerous examples have been met with, in which, in twin pregnancies, one of the foetuses has perished at the third or fourth month, and yet remained in utero until the other twin had gone to the full term of utero-gestation, become fully developed, and been safely delivered at the same time with the abortive twin. A miscarriage is not always painful. Women sometimes exclude the ovum, when at an early stage, by such gentle and easy contractions, and by so ready a dilatation of the os uteri, that they are hardly sensible even of a degree of uneasiness. In general, however, it happens that, when the womb does begin to contract for the expulsion of its contents, it does so with very great vigor, and the contractions are both lon» and frequently repeated. If they are violent, they press the ruined ovum into the narrow canal of the cervix uteri, which, by the resistance of its sphinctorian fibres, opposes with great energy the distending or dilating effort of the advancing ovum. This resistance causes pain, often of the most acute kind, so that women, now and then, have in- formed me that they have suffered much more distressing pangs in this way than in their labors at full term. This is not surprising if we reflect upon the length of the canal of the cervix, and the thickness and density of its walls thus hastily pressed open, by a sort of direct violence or force. Let it be again observed here, that, in the early stages of pregnancy, ABORTION. 535 the ovum inhabits the body and fundus of the womb, and that it has not hitherto appropriated any part of the structure of the cervix as its cavity or habitation. Hence it happens, that, though the body and fundus may have pressed and pushed the ovum quite out of their cavity, which is now nearly empty and unoccupied, they are unable to force it quite out of the canal or cavity of the cervix. This tubular or acutely conical canal now grasps it firmly, and will not let it go, keeping up a constant irritation and disturbance of the organ, that maintains the hemorrhagic nisus, if there be any, or excites and produces it, if it do not already exist. The inference from this fact is that, in such cases, if the physician remove the half-expelled ovum, or after-birth, from the grasp or gripe of the cervix and os uteri, he will thereby remove the cause of distension, and, by allowing the womb to contract perfectly, bring about an instant cessation of the hemorrhage. It will, therefore, be his duty, in all cases depending on such cause, to ascertain its exist- ence and operation, and take the proper measures for its obviation. I have observed numerous cases, in which the ovum has been thus detained many hours, and even many days, keeping up, as before re- marked, a constant irritation, with hemorrhage sometimes of frightful violence, that always ceased as soon as I could take away the mass in question. The great and very important principle that, in order to the suppres- sion of uterine hemorrhage connected with gestation, it is necessary to empty the womb, ought to be more universally known or admitted than it seems to be even among certain medical persons of considerable ex- perience. When called to a married woman who is flooding, the first question should be directed to the ascertaining if she be pregnant or not. If she say she is not enceinte, and yet is of that age, and in those circum- stances that expose her to a liability to be pregnant, I am reluctant to act upon her responsibility. If she say, "I was pregnant, but I miscar- ried yesterday, or last week, or a month ago, and yet I am suffering hemorrhage at the present moment," I should always suppose her opin- ion, or that of any other person, not worth taking, until I should have learned for myself, by my own sense of touch, that she was not misin- formed—for what should cause a woman of the childbearing age, and in good health—what, I ask, should cause her to flood ? If permitted to make the examination by touching, I could satisfy my own judgment on the question. Such is the course I take, always, where the exigency of the symptoms of hemorrhage calls for it—and I must say that, in the larger proportion of cases, when there has been pain, and where hemor- rhage has continued after the pain is gone, I have, upon touching, found 536 ABORTION. the ovum grasped in the cervix, and upon dislodging it thence have found the hemorrhage to cease at once. It appears to me to be inexcusable to permit a woman to lose pint after pint of her blood, rather than take this disagreeable mode of learning what our duty in the case may be. Such losses of blood are followed, in certain cases, by long years of broken health, and by weakness which is never fully recovered from. It is better, therefore, to determine with accuracy what the indica- tion of treatment is, and having got that, the path of duty lies plain before you. I have the less reluctance to speak to Students in this manner, because I have so many times been called upon in consulta- tion where the patient had already lost a large quantity of blood, the medical attendant being persuaded either that there had been no pregnancy, or that the pregnancy had already terminated some time before. Within three clays, a friend has sent me the uterus of a patient brought into one of the public institutions dying—who was said to have miscarried several days before. This uterus, which was in a state of sphacelation, contained the placenta of a foetus of four months. It was partially detached from the placental superficies—a separation that had occasioned a hemorrhage of forty-eight hours' duration. From the situation and size of it, I suppose it could have been removed with a placenta hook or a small pince a faux-germe, without risk or difficulty. It is evident that the person who had the case under treatment was not aware that the placenta was not delivered. True it is, that, in some cases of abortion, it is not within the com- petency of the medical attendant to extract the placenta. The long cylindrical canal of the cervix closes soon after the expulsion of the waters and embryo; the womb sometimes ceases to contract, and the finger cannot gain access to the uterine cavity; and even if it can, it is not always possible to remove the placenta, which occasionally adheres with abnormal pertinacity. Attempts with a proper small forceps, with the placenta hook, by means of ergotism and other means, should always be carried as far as a sound discretion will permit; but all rude and forcible attempts to procure extraction should be regarded as equally dangerous as the continued stay of the after-birth in the cavity. I have many times preferred to leave the remains of the abortive ovum to mace- rate and putrefy in utero, to the dangerous risk of provoking inflamma- tion of the organ by forcibly tearing it from the womb. In my own practice, I had never occasion to regret my decision. Yet I saw, in consultation, a lady, some two years ago, in whom the placenta of a four months' foetus was never extracted, and who lost her life by me- tritis some days afterwards. The case of the uterus, recently presented ABORTION. 537 to me, and of which I just now spoke, is another one which ought to induce any medical man to pause and consider carefully the indications of duty, before he should either decide to act, or refrain from inter- fering. To a young practitioner, or to the general practitioner unaccustomed to the treatment of the disorders of pregnancy, a call to a case of abor- tion is a source of discomfort, embarrassment, and even of dread. I doubt not, my young friends, that in the commencement of your career you will often have occasion to experience the pangs of doubt, and the consciousness of incapacity, which the want of a familiarity with such scenes will inevitably produce. But, as I often told you in the lectures, your principles of medicine should guide you and protect you against any uncertainty, disquietude, or alarm. In the present case, the principle chiefly concerned is that of the contractility of the womb. You, I presume, understand the principle well, and you will confidently depend upon its power to save your pa- tient in the wildest and most frightful effusion of blood, because you will always know how to incite and invigorate the uterine innerva- tion, where it may be possible to do so, and so stay the effusion of the blood. But, wherever the means within your reach prove incompetent to rouse the languid, exhausted or expiring forces of the organ, I cannot well conceive how it should be that the youngest and most inexperienced member of the Class could suffer himself to be at fault for a moment in deciding upon the points of his duty. That duty will depend, in the first instance, upon the actual state of the constitution of the patient, and upon the views he may take as to the propriety of preserving, or the necessity there may be of disregarding or sacrificing the ovum. If the woman be not evidently exhausted from the losses she has already sustained, it is easy to perceive that little danger will attend some ad- ditional loss. Or, if she be already much reduced in strength—the condition to be discovered by inspection of her countenance; by inquir- ies as to the force of her muscular apparatus ; the color of the surface as to paleness or the reverse; the circulation, as indicated by the arte- rial pulse; the respiration, from observing its frequency and its degree; the intellect, to be inquired into by eliciting from her some intellectual expression—he will at once resolve to interfere for the immediate rescue of the female, or he will determine to let it go on. I can see that a medical man, under such circumstances, has no right, in the exercise of his professional avocations, to do any act or thing which will insure the destruction of the young embryo, unless the ne- cessity of the case be so apparent and so urgent as to exclude entirely all 538 ABORTION. idea of exposing his patient to further risks with a view merely to the con- servation of the delicate creature within. For example, if you are called to a patient who is flooding in the third month of utero-gestation, you would, perhaps, immediately make the reflection that you have at hand a means of suppressing the hemorrhage as sure as the surgeon's ligature, or Petit's tourniquet—I mean the tampon or plug—which, filling the vagina, is capable of preventing the further escape of blood, by detain- ing between the tampon and the cervix uteri a quantity sufficient to form a coagulum extending through the canal of the cervix uteri into its cavity, and presenting a complete bar to the further issue of fluid from the bleeding vessels of the womb. But, if a woman be flooding, not dangerously; and if there be any hope that the flow of blood may be restrained by haemastatic remedies, or other therapeutic procedures, and so save the embryo, it will be unallowable practice in you to employ the tampon; since its use would inevitably destroy the mesenteric attach- ment of the ovum to so great an extent, as to insure its final destruc- tion. The force with which the blood, under a strong hemorrhagic nisus, is expelled from the interior of the bleeding vessels, is a force far superior to that by which the ovum is attached to the womb; and the presence of a tampon, which prevents the escape of the outflowing blood, cannot restrain the effusion until the ovum, and often the whole placenta, become detached from the gestative wall, and entirely encompassed by a co- agulum, from which it is possible, after the expulsion of the object, to pick out the unbroken membranes, as you would take the yolk of an egg from the midst of the white. Here then, gentlemen, you perceive a great point of duty to be de- termined upon by you in settling your indications of treatment. I repeat, that you have no right to destroy the pregnancy, unless the woman's condition clearly points out the necessity for so doing; and I freely declare my opinion, that the tampon in the flooding of abortion must as effectually destroy the child, as a rupture of the membranes or the plunge of a stilette into its body. I am anxious to put you upon your guard upon this point; I trust you will always act up to the principle that you must not do evil that good may come. Wherever a clear indication for the sacrifice of the tender embryo exists, no evil is done in procuring the greater good of the mother; on the contrary, the act by which it is destroyed is an act in morals as purely good as the saving of a man's life. The lesser, in morals, must yield to the greater ; the lesser is always included in the greater. It is out of my power, gentlemen, to say how far you shall allow the ABORTION. 539 hemorrhage to proceed, before interfering by means of the tampon. This is a point which is to be determined in every special case; it can- not be determined from any book written by any man. It cannot be determined, because no man can say to what extent a uterine hemor- rhage may proceed without endangering the life of the woman. As a general rule, if a woman not advanced beyond the fourth month loses a teaspoonful of blood, it is probable that she will miscarry; and yet, not unfrequently, exceptions are met with of persons who, pre- vious to the fourth month, lose many ounces, so much in fact as to pro- duce paleness and lipothymia; and yet, after the cessation of the hemorrhage, the pregnancy goes on as pleasantly and as regularly as if no such accident had happened. It is not your province to decide from mere probabilities. You can- not know in any case of early abortion whether the embryo be living or dead at the time of your arrival. You cannot determine this point, for the double sound of the foetal heart, your only ground as to a knowledge of its state, cannot be heard so early. You need feel no embarrassment on account of this uncertainty, since the principle which should guide you must be this, namely, that not knowing it to be de- prived of life, you are always to consider it as still existing, and as claiming your conservative protection, as long as the mother's interest and safety permit its claims to be heard. An attack of uterine hemorrhage in the early stages of pregnancy invariably excites considerable trepidation and alarm, and the physician is sent for with the most urgent appeals for speedy attendance. Upon arriving at the scene of such occasions, the first object is to get rid of all the moral excitement of the patient, which is effected by your calm, dispassionate, intelligent conduct—the nervous system becoming free to play its part among the organs when the excitement and disturbance which have become developed in it, by powerful moral causes, shall have been allayed. In general, it is not difficult to convince the patient, how- ever ill, that the physician has power over the case to control it—to handle it at will. I have sometimes said to persons whom I have found frightened half to death, "Are you frightened?" and when the reply has been in the affirmative, I have continued : " Well, then, look in my face—look right into my two eyes. Do you see me ? and do you think that if I were presiding over a case in which a life so important as yours was in danger, I should be so utterly unconcerned as you see me ? Or, will you not take my assurance that it is within the power of any intelligent phy- sician to put a definite stop to this loss as soon as it shall, in his judg- ment, become expedient to do so ? Or, will you believe me a person 540 ABORTION. ignorant of my art, and on that account distrust me ? Be calm. Be tranquil. Be obedient. Be still, and I shall take good care of you. Do you understand me ?" " Yes, sir." " Do you believe me?" "I do indeed !" Having disposed of all the alarm and trepidation, the next thing to be done is to determine, if possible, the amount of blood that has been lost; to which end you should ask the nurse or attendant for an oppor- tunity to examine the napkins, sheets, &c, that may have been soiled; besides ascertaining by inquiry the amount of what has been thrown away. Don't take anybody's word on these occasions, if it be in your power to depend upon your own observation. I am very sure that I allowed a poor woman, many years ago, to lose her life, because I ne- glected this rule; having trusted to the report of an ignorant nurse— and there are few nurses that are not ignorant on these subjects. If the flooding is still in progress, ascertain its rate. Touch, in order to know if the vagina be full of clot or no. Take a clean napkin, and having crushed it in your hand, in order to take out the hardening, let it be applied to the external genitalia; taking good care not to allow it to be soaked in a pool of blood which has, perhaps, been already effused. Leaving it some ten minutes, more or less, in situ, cause it again to be presented to you, so that you may judge of the amount of the stain. Should the nurse have dipped it in a pool of blood, she will present it to you thoroughly soaked, though the woman have in the mean time not lost a drop, and thus you may form a determination fatal to the life of the young embryo. I beg you, then, not to neglect this not trifling caution. See that the woman be properly placed. If the day is warm, and the bed situated quite out of the draught of the windows, or in the angle of the two walls, let it be conveyed into the centre of the apartment, where it is accessible on all sides, and where the woman will respire a purer air. I have opened all the windows and allowed the snow and sleet of a violent winter tempest to pass freely into the apartment of a woman flooding in abortion—so as to be obliged to shake the snow off her bedclothes. She must have air. If she be weak, don't allow her head and shoulders to rest upon pillows ; if she be very weak, don't let her have any pillows at all under her shoulders, and if her strength be exceedingly reduced, take the pillows from under her head, even if she should lie upon an absolute horizontal plane. A hemorrhage that would go on ad deliquium will often cease by taking all the pillows away, for the momentum of the blood in the vessels from which it es- capes is highly favored by its gravitating power. Sometimes, in ex- cessively dangerous debility from hemorrhage, you should not only take ABORTION. 541 away the pillows, allowing the head to lie upon the mattress, but the feet of the bedstead should be elevated four or five inches, by placing some books or blocks under the lower bedposts. You have thus all the advantages derivable from position, a term in surgery of which you doubtless comprehend the meaning and import. Muscular contraction is promoted by the influence of cold; and the womb, when contracted by the tonic action of its muscular fibres, will not bleed so freely as if it remain in a relaxed condition. Apply cold, then, to the hypogastric region, to the groins, to the external genitalia, and to the inner surfaces of the thighs. Cold spring or well water, or iced water, should be mixed with a portion of vinegar, which is always at hand in every house; or with some spirituous liquor. A large nap- kin, carefully and strongly wrung out of the cold liquid, should be spread over the parts just mentioned; and above it a piece of oiled silk, or a square of flannel, to prevent it from wetting the bedclothes or night dress of the patient. It should be often changed. She will probably be very thirsty if she have lost a considerable quantity of blood, and should, therefore, be provided with very cold lemonade; or she should take from ten to fifteen drops of Elixir of Vitriol, in a wineglassful of water or a wineglassful of filtered infusion of roses, made as cold as possible ; the dose to be repeated every hour, or even every half hour, pro re natd, as long as the indication for its employment continues. Or, we should take some of the alum-and-nutmeg powder which I mentioned in a former letter; say five grains of alum with three grains of nutmeg, mixed in honey, or syrup, or any convenient vehicle ; the dose to be repeated every hour, or half hour, according to circum- stances. Or, you may resort to the haemostatic power of opium, which, by its influence over the nervous system, whether in the brain or the distal fibril, may have power to quell the nisus haemorrhagicus. Or, you may give your patient two, three, or even five grains of ace- tate of lead, mixed with one-fourth, one-half, or even a whole grain of opium, the dose to be repeated from time to time, perhaps not oftener than once in two hours. Beware, however, of the sugar of lead; there is no little danger of determining by its use the most obstinate vomit- ing, or of establishing the whole series of morbid actions denominated colica pictonum. A physician is scarcely pardonable, who, in a considerable case of uterine hemorrhage, fails to explore the condition of the os and cervix uteri. Such an exploration reveals to him the fact of the dilatation, or non-dilatation, or the disposition to dilatation of the part. If the os uteri be dilated already, the question as to the ovum is already decided 542 ABORTION. —it must be lost, and it is no longer deserving of our respect. Such a dilatation now indicates the use of the tampon, if anything be indicated, beyond mere hygienic interposition. It is far preferable to any the- rapia, because it does not and cannot do any harm ; whereas all the other procedures which I have above indicated are to a certain extent harmful, saving only the position, and the directions about drinks. More than half of the physicians of the United States, probably, have the most incorrect notions of the uses of the tampon. I have seen those among them whom I esteemed excellent accoucheurs, make use of a bit of sponge no bigger than your thumb, and which abso- lutely floated free in the midst of a vagina dilated to the size of an immense fist; for in all these hemorrhages, although the sphincter vaginae may close the ostium, the inner or uterine portion of the tube is found to be extraordinarily relaxed, and its walls vastly extended by the pressure and distension of the coagula, which they have at some stage contained. Please, gentlemen, to look at the letter, number XXXIIL, in which I have already given my opinion of the choice of the material and the administration of this useful chirurgical means. There is one point which is deserving of your careful remembrance, and that is, the importance, nay the absolute necessity of great care to obtain all the proofs that a miscarriage has taken place. A woman does not always recover as soon as the ovum is discharged; on the contrary, the irritation of her constitution occasionally becomes still greater after the womb has become emptied, and if you shouldn't know that it has become emptied, you would be entirely at a loss for the means of diagnosis. Don't you perceive that, if the diagnosis should be that the womb still contains the ovum, or a rest of the ovum, your treatment will be founded upon that very presence ? Whereas, if the diagnosis should prove to be that of an emptied womb, your treatment would necessarily take some other form? Some of the most dreadful miscarriages that I have ever met with have been those of very early ova. But, if the ovum should not be larger than a black walnut, and be contained in the cavity of a uterus with an undilated cervix, it is inaccessible to any knowledge except what is derivable from rational inference. As long as it remains there, it is fair to regard it as the cause of the mischief, but it cannot be so deemed when it has come away. Now, if your nurse or the patient herself, upon discovering the dis- charged ovum, should throw it away, how are you to tell whether it has been thrown away or not, since, out of one thousand women, you will ABORTION. 543 not find two and a half that could tell the difference between an early ovum and a clot of blood. I have had clots of blood sent to me from very good doctors, for dis- section and for preparation for my museum, under the supposition that they were the organized products of a regular fecundation. I have had a patient who had been be-deviled for three months by an eminent practitioner, under the supposition that she was laboring under menor- rhagia, whereas nothing was the matter with her, but a dead and undis- charged ovum. I have told you before, and I tell you now again, that the product of conception may carry on its development for two, three, or four months and then die and remain in the womb without exciting the least apparent tendency to contraction, for three, four, yes even for six months. Of course, you will not be surprised to find that where the muscular irritability of the womb is not excited by its presence there may be, nevertheless, irritation produced, and the most probable form that the irritation will assume will be that of the nisus menor- rhagicus. Let me advise you again, never to take a woman's report as to the organic character of the substances discharged in an abortion or mis- carriage, but let it be an invariable rule in your art to institute careful inquiries as soon as you take charge of the case, as to all such appear- ances as may have been antecedently noticed, and give the most par- ticular and even solemn cautions, as to not removing or throwing away any such as may afterwards appear during your administration of the case. A man who has charge of a case of abortion, in which he cannot decide whether the abortion has taken place or not, is at sea without oars or sails—he does not know what to do; in fact, he is like a bull in a china shop. I admit that he might back out without breaking the crockery, but he can scarcely turn without doing mischief. You see I speak feelingly upon this point; and I do speak feelingly, for I bear in my memory the recollection of a case I attended here a few years since, in which I exhausted all the means of diagnosis without being able to come to a conclusion, while the patient was visibly draw- ing nearer and nearer to the brink of the precipice. She did not go over, gentlemen, but she recovered her health, and I have never yet been able to find out what became of the ovum, or why she continued after its discharge—if it was discharged—to have the same symptoms as those have in whom it has not been discharged. You should, therefore, claim the privilege, which is justly yours, of inspecting with your own eyes all the uterine products, whether liquids, 544 ABORTION. coagula, shreds, or solid substances. It is very clear, that when you have got a whole ovum unruptured in your hand, it is out of the wo- man's womb: and no doubt can then rest on your mind. If she con- tinues sick after this, the diagnosis has lost all its difficulty. But, with a perfect diagnosis, what can you want more ! If the process of throwing off the ovum has gone to a certain extent, you will find it in the cervix, and perhaps with a large portion of it protruding below the os uteri, but still firmly held in the grasp of the tube, and keeping on foot those irritations of the whole nervous consti- tution, that serve to sustain the vigor of the hemorrhagic effort. If you make such an examination and find the ovum protruding, you should place the patient with her shoulders upon the same plane with her hips. Direct the nurse so to arrange her dress that there may be but one, and that the thinnest, of her garments, interposed between your hand and her hypogastrium. Let her be upon the right side of the bed, near the edge, lying on the back. Then, standing on her right side, press the palm of your left hand upon the hypogastric region, so as to push the integuments gradually and strongly down upon the plane of the superior strait, which will bring the os uteri as near as may be to the ostium vaginae. And now let her draw up both her feet close to the body. If, while so situated, you carry the index finger of the right hand to the os uteri, it will not recede from the pressure, being maintained in situ by the pressure of your left hand upon the hypogastrium. The index can now be gently insinuated betwixt the protruding ovum and the wall of the canal of the cervix, and carried high enough in some cases completely to command the product; for if the finger be a little flexed at its last phalanx, the ovum may be caught upon it, as upon a hook, and turned out of its bed. If, upon examining, there be reason to suppose that nothing has been left in the womb, you may tell your patient it is probable that she will have no further trou- ble; or you may go so far as to say that she is well already. I said so to a lady this morning, April 18, 1854. Where you cannot command it with the finger, you may sometimes succeed in extracting the ovum, or its rest, by means of Dr. Dewees's placenta-hook, or by Mad. Boivin's pince a faux-germe, or by my friend Dr. Henry Bond's placenta forceps, which you can get here, as manufactured by Messrs. Rorer, Schively, and other surgery Cutlers. I advise you, though, to be well upon your guard against the use of instruments in these cases. If you get hold of such a body with an instrument, you will be tempted not to let it go again ; and if you pull too hard, you do so at the expense of uterine tissues that are already in trouble, and will not kindly submit to any rude handling. I have ABORTION. 545 seen a patient severely hurt by the violent extractive force that was applied by means of a wretched placental forceps for the extraction of a dead ovum. It is even better to wait and trust to the maceration, and the discharge in solution or fragments, of the ovum, than to wound or tear the organs. I have so waited in cases where I had failed in any reasonable ex- tractive effort; and have found the product to be wholly discharged as it macerated, without any other inconvenience than that occasioned by the tedious confinement, and the offensiveness of the odor. I have just concluded such a case to-day, October 23, 1850. I have no idea that the patient is exposed to considerable hazard by this expectant mode of treatment, which leaves you with the daily, nay, hourly hope that the uterus will at last wake up to a sense of its condition, and free itself from its burden by the exercise of its expulsive power. At any rate, an examination, repeated from time to time, will make you acquainted with any progress that may be had in the expulsive action of the womb ; so that you may have the satisfaction at last of taking it from the cervix, conscious that you are doing no injury. I had a patient who, in two successive pregnancies, allowed the ovum to die between the third and fourth month. In one of them, it lingered for several months within the cavity of the womb before the organ be- came irritated to its expulsion. In the other, I was employed in the treatment, and having satisfied myself that there was a dead ovum in the uterus—notwithstanding the woman had neither hemorrhage, nor pain, nor any discharge, indeed—I determined to try the power of ergot in the case. I gave her a drachm of the powder mixed in six fluidounces of cinnamon water, with directions to take a tablespoonful three times a day. Before she had finished the quantity, the uterine contractions were established, and the ovum expelled without accident, or any consequent disorder. Ergot will sometimes excite the contractions of the uterus in the early stages of gestation, but it is often found utterly to fail in the exertion of its peculiar therapeutic powers. But, as no inconvenience is to be apprehended to the health from its administration, you should consider yourselves at liberty to employ it in fulfilment of a clear indication. The wine of secale given in teaspoonful doses and repeated from time to time, according to the exigency of the circumstances, will be found a convenient and often an effective administration ; and I presume you would not, in any case of serious hemorrhage or protracted retention of the product, fail to put into play its extraordinary power over the muscular organ of the womb. A woman who has miscarried, if no accident follow the event, will. 35 546 ABORTION. be likely to get rid of her lochial discharge in the course of a few days. It often disappears on the third day, but sometimes continues to the tenth, or twentieth, or even longer. When the woman seems recovered, she too soon thinks she ought to have the privilege to get up and take charge of her affairs, or give herself up to her pleasures; but she will be highly imprudent to do so; nor will you fulfil your duty as medical counsel, if you advise or allow her thus to expose her health. She should be kept very quiet for many days, during the greater portion of which she should be in a recumbent pos- ture, either in bed, or on the sofa or couch; nor should she be permit- ted to go about until all signs of miscarriage have entirely disappeared. A miscarriage within the first four months is not followed by secretion of milk from the mammary gland; but, should it go to five months and a half, before she loses the ovum, the woman is very likely to have an abundant secretion of milk. I attended a poor woman some years ago in Tenth Street, who miscarried at five months and a half, soon after which she became a wet nurse, at my request; having a supply of milk sufficient to support a strong healthy child. A woman who has suffered one abortion is probably more liable to a similar accident in subsequent pregnancies than she who has not suf- fered in this way. There are many persons who suffer repeated miscarriages, and whose health is injured by the irritation and loss of blood accompanying those accidents ; moreover, the disappointment experienced in regard to the hopes of offspring, occasions great disquietude ; so that it is extremely desirable to discover some method of obviating such an evil tendency. I have no doubt, as I before said, that in these cases the mensual effort is often at the foundation of such distressing occurrences ; for women are more apt to miscarry at stated periods than at irregular times. Many of the early embryos that I have met with have been so fresh and so firm in their texture, that I could not but suppose them cast off while still endowed with vital properties. Under such circumstances, I could not but suppose that the accident of the casting off of the uterine product was the result of a status of the womb itself, and not of the ovum. In such a case, I suppose that the ovary might have discharged a mature ovulum, notwithstanding the pregnancy, and that the uterus, obedient as usual to the provocative of sanguine affluxion, became, as usual, mensually engorged. Such engorgement tends to result in the effusion of mensual blood at the expense of the attachments of the em- bryo, which begins immediately to be cast off, and thus comes into my hand, whole, firm, and recent, as above mentioned. ABORTION. 547 It is true that many causes of abortion besides this mensual cause do exist—a blow, a violent succussiori or shock; an irritation of the womb consensual with intestinal irritation ; some deep emotion of soul, modifying the relation of the innervative forces of the whole constitu- tion, followed by sudden reaction in the force of the arterial injection, may well determine an instant hyperaemia of the uterus, to be relieved only by an effusion of blood from its internal wall, at the expense of the mesenteric attachments of the embryo that are torn asunder by the gush. I had some time since a very perfect specimen of an ovum of two months and a half, which came off enveloped in the decidua. Having opened it, and placed the little embryo on the field under a Wollaston doublet, in order to inquire into its condition, I found that it had suf- fered from an apoplexy of its cord, for one of the omphalo-mesenteric arteries had given way and filled the tissue with extravasated blood. Pro- bably myriads of young embryos thus perish from the delicacy of their organism and the feebleness of their vital forces. For, notwithstanding they are so carefully and perfectly protected by the admirable nidus in which they reside, which nidus itself is supported as it were upon the most elastic springs, well devised to save it from shocks and violent succussions, they must be deemed liable to the hazard of multitudinous derangements of their circulation and innervation, calculated to lead to their destruction. There are also many women to be met with who cannot carry the gestation out beyond a certain time, not absolutely fixed, but yet far short of full term. Their children always die ; and they know that the child is dead, in the first place, from the absence of all spontaneous motion, and from shrinking of the before well-developed breast, and secondly, from a certain sense of heaviness, or sluggishness, or strange ponderosity within. The womb, moreover, seems to fall from right to left, or from left to right, as the woman happens to turn from either of these positions. I have at this moment a woman under my care at the Pennsylvania Hospital, who has lost many children at about the sixth month. These children were always born dead, putrid, having remained from four to six weeks in the womb after the cessation of their existence. She applied to me for admission, informing me that the child was dead as usual—an opinion in which I concurred after careful auscultation, and which was confirmed by the expulsion of the child, after it had re- mained a month dead in the womb. If you ask me, my young friends, why it is that these women lose their children in utero so repeatedly, I feel that I shall be compelled to say that I cannot give you any explanation of this strange occurrence. 548 ABORTION. They do not, so far as I know, appear to suffer from rigidity of the uterine texture, contravening its natural expansibility under the grow- ing force of the ovum ; nor have I discovered in them any signs of general or topical ill health, save the one in question, if indeed that be one. It is most likely, I think, that the fault exists in the ovum itself, for I think it is not unphilosophical to suppose that a woman may be possessed of all the signs of competent health in her own person, whereas the ova which she produces may be weak and unendowed with the usual amount of vital force. But it is vain to form or utter hypo- theses ; it is better to say, on such occasions, we do not know, we do not understand. Sometimes, we may observe that the foetus had developed too small a placenta. The placenta of a child at term ought to be as large as a dinner-plate. If it be no bigger than the mouth of a teacup, how could such a placenta serve for the development of a well-grown foetus? You will often be able to explain that the child perished because its after- birth was too small to support it. I had such a case at the seventh month, on the 21st of October, 1850. A lady under my care gave birth to a son at full term; after which, she was sixteen times pregnant in vain; sometimes going to the seventh month and giving birth to the child dead, putrid; and sometimes going to the fifth, fourth, or third, and always suffering so great an amount of constitutional disturbance during pregnancy, and also sustaining so great a loss of blood during the abortion, as to leave her at the last in a state of wretched health, consisting mainly in disorders arising from repeated excessive anaemia from hemorrhage. When, for the first time, she came under my care, after the sixteenth pregnancy, I gave her directions which she carefully followed, and carried the child a little beyond the eighth month, when it was safely born. Another pregnancy, within two years, was followed by the birth of another son. When this child was between two and three years old, she died instantly of apoplexy while seated at her dinner table. These abortions had ruined her health. Doubtless, miscarriages often depend upon irritability of the womb, which refuses to dilate under the pressure of the growing ovum. The Hallerian irritability of the womb, or its muscular contractility, may be so great as to oppose the advance of the ovum in growth. If you had such an ovum growing inside of a metallic sphere, it would neces- sarily die, because it is indispensable for the embryo not only to live, but to grow, for its life does not consist in living but in augmenting itself. But if the womb won't let it develop itself, will it not die ? and hence, don't you perceive that an unyielding, rigid uterus may cause ABORTION. 549 the woman to miscarry again and again; whereas, if you cure the rigidity and unyieldingness of the womb, you may allow the woman to go out to the full term of utero-gestation ? Suppose you were treating a case, taking such views as these as to the cause of the miscarriage, what could you do to give the uterus a kindlier disposition ? Could you not obtund its organic sensibility, and at the same time diminish the vital force of its motor nerves, by bring- ing it occasionally, at proper intervals, under the sedative influences of opium, and under the relaxing influences of venesection, of the warm bath, and of a cool and light regimen ? Would you not give to such a patient at bedtime five-and-forty drops of tincture of opium mixed with a wineglassful of thin boiled starch, to be used as an injection into the bowel ? I have done so for a great many people for a great many years past, when I have deemed the cause of the disposition to miscarry a cause connected with the status of the womb itself. I shall probably, as long as I continue to practise, frequently employ this method, as I have every reason to believe that a great many persons have thereby been preserved from miscarrying, who had repeatedly done so under every other mode of treatment. I have occasionally directed such an administration to be repeated both night and morning ; and it is as a sort of general rule with me, in giving such a direction, to counsel the woman to use the anodyne enema daily, until after the quickening of the child takes place. I know of no objection to such a mode of procedure, having never found the least in- convenience to result from it as regards the patient's health. Taking it all in all, as a methodus medendi, it is the most commendable one that I am acquainted with; it was Doctor Physick's, and I learned it from his lips. Dr. Physick had very few methods that were not to be depended upon; and the sanction of his opinion alone would, in my estimation, make it worthy of the highest confidence. If a woman is likely to miscarry from her menstrual cause, she should be confined to her bed at the menstrual period; a little before, during, and for a few days afterwards. Her bowels should be kept free by gentle aperient medicine, or by enemata, which are least objectionable, as causing less disturbance. She ought to be bled, not too much, but moderately, at the arm, with a view to counteract the monthly engorge- ment of the uterine and spermatic branches; an intention which will be well sustained by the daily use of the anodyne enema as before men- tioned. A woman might be supposed to miscarry in consequence of debility; in such a case, the use of proper tonics, with nutritious wholesome diet, should be carefully prescribed. 550 ABORTION. Don't give a pregnant woman purgative medicines, if you can possibly avoid it; since violent action of the bowels, particularly of the lower bowels, is extremely apt to bring the womb into sympathetic disturb- ance. Women have the toothache in pregnancy, and will come to you to ask permission to have the tooth taken out. You should always decline to give your consent to this operation ; an operation which cannot be performed, I think, without producing a dangerous shock to the nervous system, and violent succussive contractions of the diaphragm and abdo- minal muscles, quite as apt to disturb the connection of the ovum with the womb as a fall, a blow, riding in a carriage, or any of those causes that physicians are so careful to guard their patients against. If a woman have in her pregnancy an insufferable toothache, you will often cure it by putting a couple of leeches on the gum, opposite the alveole, or by filling the carious cavity, if there be one, with opium ; or it will get well after a few days, if she will but have patience with it. I will not deny that a toothache may be so insupportably painful as to war- rant the patient in having it extracted, and warrant you in giving your consent thereto; but let me advise you never to do so when you can find any reasonable ground for avoiding it. Some physicians, when a woman applies for counsel for this habitual abortion, always advise her to go to bed and stay there, under the idea that motion or exertion is apt to provoke the abortion in those who are predisposed to it. It may be that a woman is safer in her bed or on her couch, than walking about town, or riding in her carriage, or engaging in domestic affairs; and it is palpably true that one who perceives some present threatenings of miscarriage ought to go to bed, and be still. I cannot but think, however, that sending a woman to bed with the purpose to keep her there until the end of her pregnancy, not to be completed until the lapse of six, five, or even four months, is altogether preposterous; since I cannot well conceive that a patient could, for so long a time, be de- prived of exercise, of fresh air, and of solar light, without inducing modifications of her nerve force, and of her nutrition, that would be more likely to lead to a miscarriage than the very exercise that is so much dreaded. I am quite certain I have never been guilty of giving so preposterous an order as this, and that I have known many instances in which the practice has signally failed. I believe, indeed, that it would be better for a woman to miscarry than lie down for six months. If a man break his thigh bone in the midst of the most consummate health, and if he be taken to his house and laid upon his bed, and ABORTION. 551 treated with Dessault's apparatus, or any other apparatus for the treat- ment of fracture of the thigh, then he will not have his bowels moved for the first eight days, unless he take some eccoprotic article. His bowels do not become confined because he has broken his leg, but they are constipated for want of the perpetual succussion which it is de- signed they should receive from the abdominal muscles which encase them. The man with Dessault's splint is like the woman whom you put to bed for six months; neither of them has the least occasion to use the abdominal muscles in progression, nor in daily exercise; and the alimentary tube, deprived of this usual provocative to its excitement, lies torpid, its muscular fibres scarcely, or with reluctance, performing their office of provoking motion in the canal. In order to obviate this evil, you are compelled to give drugs ; but a pregnant woman ought not to take drugs if there be any means to avoid it; and I think you will find, upon a studied experience, which you will have, that it is best not to place her in a condition where your drugs will become necessary. To allow her to become costive is to disturb the whole of her splanch- nic innervation. She gets a foul breath, a foul tongue, and restless nights ; her appetite is mawkish, she loses the bright tint of her skin, and masses of the circulation tend inwards, producing engorgement of the greater trunks ; so that, if you succeed in carrying her to the end of her term—an improbable expectation—you will deliver her of a child, after you shall have ruined her health. I mentioned, at page 548, the case of a lady who had been sixteen times pregnant in vain, but who, after taking my directions, gave birth to two children in succession. I said, there, that when she came under my care, after the sixteenth pregnancy, I gave her directions, which she carefully followed, and carried the child to the eighth month, when it was safely born. She had been repeatedly confined to the sofa, or the couch, during several consecutive months. Several of the gesta- tions were conducted under the counsel of the late Professor Dewees, who had great confidence in protracted repose for the conservation of the gestation ; but, as in all the other cases, she had continued to meet with disappointment. When she came under my care, and related the distresses of which she had been the victim, I made known to her my aversion to this treatment by rest. I said to her : " My dear madam, you place me in a very disagreeable predicament by appealing to me on this occasion. In all probability, seeing your present age and your present health, this will be the last of your gestations; you have here- tofore been under the care and the counsel of the most distinguished practitioners of my art, in this country and in Europe, and it has, per- 552 ABORTION. haps, become a principle with you to treat all such cases by profound and protracted rest. If I, who am opposed to such a method, should advise a contrary course, and the case should result in an abortion, as usual, you might hereafter accuse me of great imprudence in departing from a method so recommended, and never becoming pregnant again, charge me with depriving you of the last chance of having offspring. Nevertheless, I shall guide you according to my judgment and my conscience. I believe that the best health that you can obtain is the securest health for your pregnancy, and that health can only be had by exercise, sub dio, in the open air. Pray, then, take my advice, to walk out, or to ride out, daily; to receive and return visits; to go to the party and the ball, and try to forget that you are pregnant, acting, indeed, as if you were not. Be always, however, a little careful of using violent muscular effort, or awkward positions of the body ; and, above all things, do not tumble down stairs. Take an anodyne injec- tion every night before you go to bed, and let it consist of forty-five drops of laudanum, in half a wineglassful of thin clear starch." She did follow my directions implicitly, saving only the exception that she did tumble down stairs twice, and yet I had the pleasure of delivering her of a child, as mentioned at page 548. When I was an apprentice to my late master, Dr. Thomas Hanson Marshall Fendal, of Augusta, in the State of Georgia, I was acquainted with the circumstances of a case of abortion under his care. The lady in question, whose name I am bound to withhold, expelled an ovum containing a foetus of about three months, yet six months afterwards she gave birth to a male child at term ; so that it is possible for a woman pregnant with twins, to discharge an entire ovum of one of the twins without destroying the mesenteric attachment of the other, which goes on to the full term. Such a case is one so rare, that probably if you live a long medical life you will never meet with one like it. It is well, however, to know that such things are in rerum natura. I have seen one case in which a woman giving birth to a child at full term, afterwards discharged a placenta, attached to which was a foetus of four months and a half, completely mummified and pressed as flat as a bit of deal. Some stupid people, upon such a sight, would lift up their hands, and exclaim " Superfoetation !" Superfcetation has nothing to do with it; it is a case of abortion, with retention of the foetus four months and a half after its death. You will find a beautiful drawing representing a precisely similar case, in the tenth plate of the Atlas to Mr. Pouchet's Theorie Posi- tive de V Ovulation Spontanee. The account of the case is related at ABORTION. 553 page 436 of his text: the child, as in the case which I saw, was com- pressed, its head being mashed flat by the pressure of the living ovum against the side of the uterus. I think, gentlemen, that for the present I have nothing further to say upon abortion; but I have now a few remarks to offer you on the subject of moles or false conceptions, which will suffice for the present, to close this subject. In ancient times, the doctors were accustomed to have very curious notions on the subject of what are called moles; and some of their superstitions about them are very queer and amusing. There is a vague notion that lurks in the female mind even to the present day, that renders the production of a mole a subject of much talk and wonderment. They are called, by most people in this quarter, false conceptions, and are rarely met with without giving rise to much examination and cross-questioning, addressed to the medical attendant. They who have had a false conception, or a mole, are anxious to know why and how such a thing happens. Not only have I found the female worried about such an event, but I have also discovered that the hus- band is not without some uneasiness and self-condemnation. It hap- pens in this way. When such a woman conceives in the womb, she goes on in her preg- nancy for some weeks, or for two months perhaps, perfectly well and naturally—the embryo then perishes, and, floating in the amniotic waters, undergoes a process of maceration and solution ; so that it soon disappears completely, leaving a brownish dirty liquor still inclosed within the amnios. The spongy or tufted chorion, having in the mean time established a mesenteric connection with the uterus, a sort of vitality continues to exist within it, provided the womb does not cast it out by contracting its walls. Under this low rate of life, the mass of the mole slowly in- creases in size, and becomes more and more solid and heavy. The mass continues to grow more or less rapidly, until the womb, no longer able to tolerate its presence, contracts, and expels it. Such a mole is but a diseased and altered ovum, and the woman who is distressed with the notion that she has some peculiarity of nature that concerns her, the subject of such a misfortune, ought to be relieved of the false impression, which might render her unhappy. Sometimes the ovum, instead of being converted into a firm, hard, and fleshy substance, becomes the seat of what is called hydatids of the womb. In this case, every part of it is occupied by numerous vesicles of various sizes, from the bigness of a mustard-seed to that of a large Malaga grape. These vesicles are filled with pellucid fluid—and they 554 ABORTION. continue to be formed and to increase in magnitude until the womb ac- quires the dimensions of the gravid uterus of the seventh month. Or the womb, irritated by the pressure of such a foreign body, refuses any more to distend, whereupon, contractions setting in, the whole heterologue product comes away, in quantity, sometimes, sufficient to half fill a wash-basin. It is asserted by some writers, that the graye-like vesicles are really independent animals—acephalocysts, endowed with great powers of production ; but I am by no means of that opinion. They are, far more probably, derived from the distension of the altered spongioles and cellules of the placenta, which, by some endosmosic act, become filled with water, and thus dissect, so to speak, the whole mass of the mole or altered placenta. Now and then, you will meet with cases where, the child being even born in good health, the placenta exhibits numerous specimens of these bullae. If very numerous, they could not fail to destroy the embryo, by destroying more or less completely its branchial organ, the placenta. A case is not, in general, early suspected of being a false conception, and it is not until it is cast off that the truth is known—still, when the pregnancy proceeds at a more rapid, or at a less rapid rate of develop- ment than natural, and when the woman is troubled with the frequent slight markings and discharges of blood per vaginam, she may be held as suspected. The rapidity with which a bunch of hydatids may grow is very great. I have, for example, now under treatment a young lady, married about a year ago, who became pregnant about the 20th July, 1847. On the 23d October, 1847, she discharged a large quantity, near a pint mea- sure, of hydatids and altered placental structure. Pending the gestation, she was sick for twelve weeks, during a major part of which time she vomited daily, and many times a day. She became rapidly and excessively emaciated, and had for a long time a pulse above 120 per minute. The womb was always of a doughy feel, except when condensed by its muscular contraction, which was often the case during the process. My fears were greatly excited by her condition, until her pains coming on, the whole diseased mass was driven out of the uterine cavity —whereupon she immediately began to recover, and is now, Nov. 6, 1847, in pretty good health, although still weak and pallid. Previously to the expulsive effort, the fundus uteri had risen nigh to the umbilicus, and yet she was only three months gone, at which period the fundus ought not to have jutted much above the plane of the superior strait. ABORTION. 555 This ought not to surprise you—when you reflect that her womb ex- panded at such an unnatural and even fearful rate. It was rather like a process of bursting than deploying the tissues of the uterus. No constitution could patiently tolerate such a bursting process. It must feel the irritation. If, therefore, you should take charge of a patient, pregnant, sick, suffering occasional attacks of uterine hemorrhage, with great consti- tutional irritation, evinced by frequency of pulse, emaciation, and other signs of suffering—and if coincidently with such signs there should be a too rapid development of the womb—you might very confidently make the diagnosis of hydatids. Because, in true pregnancy, the rate of development is decided by a generic law—peculiar to each genus of animals—or to each species rather. If the rate of growth is non-ge- neric, the product will be non-generic likewise, and leave you clearly at liberty to take measures for the cure. In such a case, you cannot bring on premature labor—but you can bring on labor. There can be no prematureness for a thing that has no generic term of development. You might provoke contractions of the womb by doses of ergot, or if that should fail, by the use of sponge tent carefully placed in the canal of the cervix uteri. A sponge tent could hardly expand in the canal without causing the fundus to enter into active contractions. There are some women, in whom the womb, during menstruation, be- comes filled with a small coagulum. A coagulum of blood as large as a walnut, in the non-gravid uterus, would be subject to a firm pressure; the serum escaping, might leave the more solid parts within the cavity, which might remain therein undisturbed during a whole intermensual period. New coagulations taking place at the return of the menses, the mass becomes increased in size, and at last, exciting contractions, is expelled with the sharpest grinding and dilating pains. I have seen a lump of fibrine larger than a black walnut, exceed- ingly solid, and of a whitish-yellow color, produced in this way. It is not a false conception—but a lump of fibrine out of which all the serum and corpuscles have been squeezed, and which, may lie a longer or shorter time in the womb without exciting its expulsive power —and at last come off with very violent grinding pains—so great, in- deed, as to make the woman suffer as much as in the most painful mis- carriage. I wish you to take notice that I have above stated that in menorrhagic cases, a coagulum of blood as large as a walnut may be formed in the womb. Now, whenever in these cases you shall observe that coagula as large as your hand are expelled, you are to remember that they have been formed in the vagina and not in the womb. The 556 PUERPERAL DISEASES. sphincter vaginae muscle closes the canal so completely as to retain within the passage the blood that issues from the os uteri—it there becomes congealed, and is forced out whenever the accumulation becomes very considerable, or when the patient coughs, or suddenly changes her position. I shall here close this letter, with the expression of my sincere respect. C. D. M. LETTER XLI. PUERPERAL DISEASES. Gentlemen: I am about to address you to-day upon a subject of the extremest importance in any consideration of female complaints. I mean the diseases of the Lying-in. A treatise on midwifery might be, perhaps, more appropriately selected for such a discussion—but inasmuch as the general practitioner is liable to be called upon for counsel in many of the purely puerperal affections, he ought to be as well prepared as the Accoucheur himself to treat them properly. Among the earliest and most serious of the disorders of the puerperal woman, we should enumerate fainting and flooding. They generally go together—so much so, indeed, that when a woman faints away shortly after the birth of her child, she should be immediately held suspected of flooding—whether there be any visible hemorrhage or no. It is true, that a woman may faint immediately after the delivery of the child, and yet not be the subject of any considerable hemorrhagic discharge. This accident is most likely to occur to women in whom the womb has been excessively distended, either from a twin pregnancy, or the accumulation of a great quantity of the amniotic liquor. Such a person, having a very rapid labor, and a speedy discharge of the after- birth, is likely to faint for want of a due amount of pressure upon the abdominal viscera. The same thing happens to those who are relieved, by tapping, of a large ascitic collection. I was present a few years ago, when the late Dr. Jacob Randolph, Surgeon, of this city, tapped for me a young woman who had a vast ovarian cyst. A broad bandage, or binder, was put, as usual, around the abdomen, to be drawn tighter, in proportion as the water of the dropsy should run off through the canula. When rather more than half of the fluid had escaped, and the abdominal walls had lost much of PUERPERAL DISEASES. 557 their tension, I purposely relaxed the pressure of the binder, which I had taken by its ends in my hands. As soon as I left her solely to the pressure and support of her own abdominal integuments, she grew faint, but immediately recovered upon my tightening the bandage again. This experiment I repeated several times during the progress of the operation, with a view to satisfy my mind as to the relation between this lypothymia and the relaxation of tegumentary tension. A woman whose abdomen becomes very suddenly and greatly reduced in size by the escape of a full-sized child—a great quantity of waters, and an after-birth of more than a pound in weight, suffers, then, the same sudden withdrawal of abdominal tension as the patient under paracen- tesis, and requires, like that patient, the support of a bandage, or binder, adjusted to the abdomen. I published in the Philadelphia Praet. of Med., 2d ed., p. 204, a case, which is related in the following words:— I attended Mrs. J. A. S., confined with her fifth child, in a labor that was perfectly natural relatively to the birth of the child, the de- livery of the placenta, and the symptoms that immediately ensued in the parturient state. Having waited about half an hour, I took leave of the patient near two o'clock in the morning, and had proceeded a good way towards my house, when I was overtaken by the husband, who entreated me to hasten back to the lady, as she seemed to be dying. Upon returning to the house, I found my patient without pulse ; the face of an extreme paleness, and her whole state expressive of the last degree of sinking or prostration. The idea that became immediately obvious was, that she must have had a large effusion of blood; but, upon placing the hand upon the uterine region, the organ was found to be well condensed; while, upon a careful examination of the bed, no very considerable extravasation of blood was detected. I found that the abdominal parietes were remarkably flaccid; to such a degree, as to strike me forcibly, as affording incompetent support to the viscera within. Indeed, the contractility of the abdominal muscles was so very slight, that it appeared to me the bowels could receive almost no sup- port from their pressure. After exhibiting such restoratives as were at hand, I folded two large towels into squares, and placing them upon the abdomen, as compresses, secured them by a bandage, which retained them in situ and afforded such a decree of support to the contained viscera as I deemed sufficient to obviate the sinking and fainting tendencies that always ensue from a loss of this support or pressure. I enjoined rest in a horizontal position, removed the pillows from under her head, and found, when the forces of the constitution had rallied, there was no further alarm or distress. It 558 PUERPERAL DISEASES. has happened to me many times to meet with this syncopal state, after delivery unaccompanied with hemorrhage, either external or internal ; and in all parturient persons who are enormously distended, or who are prone to such faintings after delivery, I take the precautions suggested by the above case in good time; and I can safely say that such pre- cautions generally result in success. Fainting is caused by diminished tension of the bloodvessels of the encephalon, suddenly produced, whether d pathemate mentis, or from hemorrhage or other causes. There can be no such thing as fainting with the vessels of the brain full and tense. If you suddenly take away the support—I mean the extrinsic support that the great arterial and venous trunks, as well as the arterioles and venules and capillaries of the belly receive from the muscular and other integuments, you suffer those vessels to yield to the lateral pressure of the blood-columns—to become excessively distended, and thus to draw off the circulation from the superior parts of the economy, especially if the patient be permitted to sit up, or to lie too highly inclined. See to it, then, that the danger be obviated by early substituting the bandage pressure for the lost pres- sure of the abdominal walls—and that the patient be not allowed to sit up, or even to have pillows, where the case requires such a precaution. If through your oversight or ignorance the whole of the abdominal ves- sels be allowed thus to become engorged, your patient will be exposed to unnecessary risk—for how shall you be assured that the engorgement shall ever be removed, or that it shall not become the basis of incurable sanguine stasis, and so of mortal inflammation ! I ought to put you on guard against a mistake into which you might fall, were you to be governed in some cases by opinions like those just * expressed. You must not believe that the newly-delivered woman faints from withdrawal of pressure and tension of the integuments when, in reality, she faints from loss of blood. A woman may lose a quantity sufficient to cause an alarming and very dangerous deliquium, without any visible signs of flooding upon the napkins or clothing about her person—and that, even when the globe of the womb appears to be well contracted. Do not, therefore trust to the very faithless diagnostic drawn from the application of your hand to the hypogaster—it will not always give a true report. On a great multitude of occasions, I have found women to faint after delivery—say in half an hour, and sometimes in an hour, or even as late as an hour and a half subsequent to the expulsion of the after- birth. I have had the napkin immediately presented to me for examin- ation, and found it scarcely stained. Upon placing my hand on the uterine globe, too, I have found it well reduced in size, and firm and PUERPERAL DISEASES. 559 so small, as evidently to contain no considerable quantity of blood. Were one to trust to such a diagnosis as this, he would, in many in- stances, make a great mistake, supposing that the fainting does not depend on flooding—and this is the very error against which you should most vigilantly guard yourself. Let me explain. A woman, after the delivery of the placenta, shall have a good con- traction of the uterus. She shall have a napkin applied firmly against the privities—and suppose herself to be quite well and safe. In the course of half an hour, or an hour and a half, she shall ask to be fan- ned, or for some drink, or for the volatile salts, and say she is faint. Her pulse will be very small, and feeble, and frequent—or it may be, undiscernible. The attendant at once places his hand upon the hypo- gaster to discover the state of the uterus, which he finds small and sufficiently firm. He ascertains that there is no visible hemorrhage, and is apt thence to conclude that there is no hemorrhage at all. But if he trusts to restoratives and cordials, et id genus omne, he may lose his patient—for the vagina is filled with coagula in quantity sufficient to make her faint away, and even to put her life at risk. The vagina is extremely distensible always, but immediately subse- quent to delivery it remains so dilatable that the slightest pressure against its walls makes them yield. It has lately been expanded in the labor to a dimension sufficiently great to contain the trunk of a child's body, which is very large. If the nurse, upon her delivery, should clap a large napkin against the exterior genitals, and the patient, in order to keep it there, should strongly adduct the thighs, the issue of the lochia would be impeded, or prevented entirely—but, even the con- densed womb bleeds, more or less; and the blood that it sheds, passing into the vagina, and finding no issue at the ostium, becomes coagulated. The whole tube of the vagina becomes enormously distended with co- agula, making a mass as large as the trunk of a child's body, and though the woman faints for the loss of her blood, yet, the hand on the hypo- gaster does not discover this fact. The napkin outside acts as an obtu- rator—and the clot inside as a tampon. The lochia cannot find issue— and the quantity lost is considerable enough to produce fainting. But I have long been convinced that another principle, in addition to that mere one of the loss of blood, is concerned in the production of the phenomena. I mean to say that the woman will faint for the loss of the blood, and continue to faint again and again, provided the coagula are not removed from the vagina and cervix uteri—but, she will imme- diately recover from her deliquium, upon their removal. There is some influence of a disturbing nature, as to the nerve power, that is connected 560 PUERPERAL DISEASES. with the presence of a large quantity of clots in the vagina—probably that influence may proceed from the distension of the walls, and their pressure on parts in relation to them exteriorly, and on a nervous im- pression which they thereby suffer. Be this as it may ; it is quite cer- tain that, if you should press two fingers of the right hand into the canal of the vagina, and with them break the clots to pieces, while, with the other hand upon the hypogastrium, you press the globe of the womb downwards into the excavation of the pelvis, exhorting the woman, meanwhile, to bear down, the coagula will all be expelled, the vagina will contract its tube, and the woman will at once be relieved, and scarce fail to express her satisfaction with much energy and emphasis. To take out the coagula, or turn out the clot, as I used to say to you, does not give the woman any more blood, nor replenish her veins, and yet hundreds, yes, many hundreds of times have I seen women instantly recover from the most depressing feelings of faintness and prostration, upon turning out the clots from the vagina. Hence, I repeat, that to turn out the clot is to relieve the patient of her deliquium. But, gen- tlemen, suppose you do not turn out the coagula ! why, then, you leave a tampon of clotted blood in the vagina! No sensible man would ever think of such wicked folly as that. Every sensible well-instructed medical man knows that where the womb is firmly contracted there is no flooding, but only lochia—and that where it is relaxed or uncondensed it will bleed, and that the blood it sheds, provided it be retained, will fill its cavity, and distend it more and more in proportion as the blood flows—and not only so, but the larger it becomes the more rapid is the effusion. But the womb, after labor, is alternately contracted, and soft or relaxed. If you leave a tampon in the vagina, the womb whenever it becomes relaxed will fill, and the contraction is often not strong enough to expel the coagulated blood. The patency of the hemorrhagic orifices on the inner superficies of the uterus augments at a certain ratio with the augmentation of the superficies. To leave an immense tampon of coagulated blood in the vagina, even while the womb feels well con- densed, is a great error in practice. If nothing can be more prepos- terous than to place a tampon in the vagina of a newly-delivered woman, nothing can be more careless than to leave there one that nature may have adjusted there in the shape of a clot of blood. From all the foregoing, it results that a woman may faint from hemorrhage after delivery notwithstanding you can discover no great distension of the womb, and though there may be no external visible signs of a flooding—and the precept that arises out of it is this—viz. when you go into an apartment where a woman just confined is in a fainting state, your first act of duty is to place your hand on the hypo- PUERPERAL DISEASES. 561 gastrium in order to learn whether the womb is any larger than it ought to be ;—second, to make a careful investigation as to the quantity of blood contained in the cloths and bedclothes about her person;—and third, when the womb is well down and the clothes quite unstained, to pass two fingers of the right hand into the vagina and turn out the clots if any be there ; and if there be none there, nor in the womb, have a clear diagnostic of deliquium from some cause unconnected with flooding. But, a woman shall flood very dangerously, without discharging any blood upon the napkins or bedclothing about her, and when you come to put the hand upon the abdomen in order to inquire into the condition of the uterus—you shall find that the womb has become very large again, and has risen up, so that its fundus reaches as high as the navel. This is a case in which, not the vagina only, but the uterus also is filled with blood. Whenever I wish to learn whether the womb is just as large as it ought to be, I proceed as follows: Standing near the pa- tient's right side, I apply the thumb of my left hand to the anterior superior spinous process of the right ilium, and, stretching the point of the little finger towards the left anterior superior spinous process, I learn whether the fundus uteri rises above the ulnar edge of my hand ; if it rises but a little higher than that edge, the womb is not well con- tracted ; if it is lower than that edge, it is perfectly well condensed. It is worthy of remark that the clot in the womb in this case always feels very solid; so much so, in some of the samples, as to tempt to the belief that it is not clot, but a large portion of placenta. The woman's life is in danger until the clot shall be discharged; and there is no time to be lost, therefore, in taking it away. This is to be done by compressing the uterine globe with the palm and fingers of the left hand, while with the index and medius of the right or sometimes with half the hand passed beyond the sphincter vaginae, you are enabled to break to pieces the solid coagulum in the womb itself with one or with two fingers. After having first got out those that may be detained in the vagina, exhort the woman to bear down. If she makes a proper effort, while you at the same time continue to break up the masses that come within reach of your fingers—the whole will be found suddenly to gush forth—the womb will again become hard, condensed, solid, and very small—and that is the end of the flooding for the present. As soon as the uterus has become thus quite empty, you should endeavor to secure a good permanent contraction of its muscular fibres, by gently pressing or kneading it with the palps of the fingers of the left hand on the hypogaster—and this you should do for a considerable length of time. You know that not the muscular fibres of the womb only, but also those of the bowels may be excited to contraction by frictions, 36 562 PUERPERAL DISEASES. which serve to arouse and stimulate their irritable nature. These fric- tions, then, are very powerful means of keeping the texture of the womb hard and firm; but if the texture of the womb is thus kept hard and firm, don't you perceive that there can be no flooding ?—since, in that firm and contracted condition, the vessels of the womb are crimped and constringed, and their lights, in many instances, almost put out. Surely you recognize the truth that the great veins and sinuses of the womb, that are seen in it when at full term, are invisible in the non- gravid organ. Well, then, when you want to make those great veins and sinuses and arteries as small as possible, so that they may carry as little blood as possible, you will do all you can do to make the womb approach, as near as possible, to its non-gravid magnitude by contract- ing and condensing its muscular tissue. Let me put you on your guard, however, against too much confidence in the conservative power of this treatment. You are not to suppose, because you may have dextrously relieved the patient in compelling the uterus to contract, that she is, therefore, absolutely safe. It is true, as I said, you have arrested the flooding for the present; and it may not begin again : it is, however, still truer, that in most of these cases, the muscular irritability of the womb is below par, and that the effusion of the lochial blood, going on, however moderately, and clotting as fast as it exudes, it tends to fill up and again distend the cavity of the womb, which, the larger it grows, the more rapidly it bleeds, and so repro- duces the feeling of faintness, with diminution or loss of pulse, anxiety, jactitation, and all the signs that attend excessive sanguine effusion. Your most vigilant care is required to meet these symptoms in their very inception. You will discover them early, if you be really panop- tical in your vigilance—and you will put an end to the second and to the third attacks as easily as you did to the first; and by the same method. I believe, indeed, I ought here to tell you, that in a majority of the cases in which you shall hereafter turn out the clot, you will be obliged to do it a second time, and in many instances a third. I don't remember that I have ever done so four successive times in the same case. A strong compress, laid on the hypogaster, and confined there by a binder, consisting of a long towel or pillow-case, will aid you to keep the womb from expanding again and again. As to a compress and binder, let me tell you that 1 have at different times been teased by them when the tendency to repetitions of the he- morrhagic attacks was very strong—for, the abdomen being concealed beneath compresses and bandages, I found that I could not so perfectly observe the state of the uterus, which would steal a march on me by PUERPERAL DISEASES. 563 filling itself with a quantity large enough to make my patient ill before I could discover it. Much vexatious experience of this sort has taught me, long ago, that the best compress is a folded napkin held down by my own hand, for it has the advantage of being not merely a compress, but my hand is an intelligent or perceptive one, one that is capable of telling me—" Sir, the womb is filling again. Take care lest it should hurt her." As soon as you can feel satisfied that the disposition to be hemor- rhagic is over, you should adjust the compress over the uterine globe, and secure it there with a bandage round the body. I advise you to do this with your own hands in all serious cases of the sort, because you can better trust yourself than any nurse whatever. At least, your mind will be at ease, as you will know what you have done ; but you cannot so well know what another has done under your di- rection. There is another point that is worthy of your most especial regard in such cases. I mean the position of the patient. She must not sit up—she must not even be inclined upwards, if she be really ill—she must have her head in the same plane as her hips— or, if she be very ill, you must, you must make her head lower than the hips, by putting some books, blocks, or bricks under the foot-posts of the bed, which will elevate the legs and hips, and depress the trunk and head. I have already said that fainting results from diminution of the tension of the vessels of the encephalon. Suppose a person to stand up and be bled at both arms—he would faint for twelve or sixteen ouncets—but suppose him to be bled while lying down, he would bear the loss of twenty ounces ; and if he were to be held with his head downwards, you might take four times as much, probably without causing deliquium. When the head is down, the blood does not quit the brain so readily; but, as long as the encephalic tension is kept up by means of a due fulness of the vessels, there cannot be such a thing as a fainting fit. If there should be no fainting, there would be no suspension of the somatic innervation. If she faints badly, the woman's heart scarcely beats, and that so slowly and at such long intervals that the blood is apt to coagulate within the resting auricle and ventricle. Suppose your patient to have her right auricle and ventricle and pulmonary artery instantly filled with a single coagulum ! What will you do for her ? The precept then is, in all cases of faintness from flooding, to get the head down as low as may be. Therefore, take away the pillows and bolsters —and refuse to restore them until all danger is clearly over. This precept is so clear, so plain, and the reasons for it so understandable, 564 PUERPERAL DISEASES. that I have oftentimes, when called in consultations, been amazed to find a medical brother, in good practice, and of considerable expe- rience, neglecting it. I have seen such an one alarmed as to the state of his patient, and using all means to arrest the fainting, save the first and best—namely, the getting of the patient's head down. It was but the other day that I was called, in consultation, to a case of desperate flooding from placenta praevia. I found the woman's head well raised on pillows. These pillows I not only took away, but I elevated the lower end of the bed, and bringing the head over the edge of the bed, allowed it to hang or droop down over the side with a view to keep the vessels of the encephalon full, for I know that as long as the encephalon is kept duly distended by vessels full of blood, so long will the brain generate and radiate its nerve force, its biotic force to the organisms— but if the brain cannot produce and send forth the nerve force, where- with shall we carry on life in the organs ? The heart will not beat, nor the diaphragm move, nor the par vagum do their office—and she will surely die. When a person lies in deep deliquium animi from loss of blood, the pulse is not to be felt at the wrist, and the sounds of the heart are not plainly discerned in auscultation. Under such circumstances, the cavities of the heart, I repeat it, fill so slowly that there may almost be said to exist a stasis of the blood in the auricles and ventricles. It is very certain that when blood ceases to move, it tends to coagulate; and it is very true that blood coagulates more readily in those who have already suffered great loss by hemorrhage than in such as are not anaemical. From the above remarks, you will perceive that if your patient should faint very badly, she will be liable to perish suddenly, or fall into in- curable ill health by the formation of a clot in the auricle—or even in both the cavities as well as in the tube of the pulmonary artery. I am very sure that I have seen some women perish in this manner; cases in which I made the diagnosis of heart-clot formed during a deliquium, and a prognosis of speedy dissolution, having been verified by dissection after the fatal result. See my article on the Heart-Clot, in the Med. Examiner. I beg you to consider briefly the effects to be produced by a mass of fibrinous remainder of a clot suddenly formed within, and moulded bv the right cavity or cavities of the heart. Inasmuch as the venous blood can only get back to the arterial side by passing through the pulmonic heart—such a clot, if of large size, must either wholly or venr greatly hinder the return of the venous blood. In fact, it would be equal to a partial ligation of the cava, superior or inferior. Death is likely to follow the occurrence either immediately, or within a few hours. I have PUERPERAL DISEASES. 565 observed it to occur within eighteen hours—in thirty-six hours—in eigh- teen days. If you reflect upon the danger of giving rise to the formation of a heart-clot, I am sure you will see the necessity of obviating for your exhausted patients every inducement to deliquium animi. You will not permit such persons to sit up before the circulation shall have acquired a degree of vigor that insures you against the risk of bringing about a syncopal state, that may prove instantly fatal. Here is another point. It should be a rule to ask for information as to the habits of a patient, who may be placed under your care, in labor. Has she always had fainting, and floodings, when confined ? If she has always suffered in this way, there is reason to think she will do so again, if something be not done to prevent it. Whenever I am informed, as to a patient about to enter upon her lying-in, that she faints and floods in labor, I invariably make arrange- ments to be provided with half a drachm of ergot. Let it be procured, and kept with the brandy, the laudanum, and the other preparations usually made for the exigencies of a labor. See that the ergot is of a reliable quality. If a woman, who is within some ten or fifteen minutes of the con- clusion of her labor, should swallow ten or fifteen grains of ergot mixed in water, the ergotism could not be developed until after the child's de- liverance ; but, within ten or twenty minutes subsequent thereto, it would begin to excite the nerves of the womb, and force them to com- pel the uterine muscles to contract and remain contracted. The power of ergot over the uterine nerves, and through them, over the muscles of the organ, is so great, that I always confidently expect a woman, who has invariably flooded before, will not now suffer at all in that way if she take ergot. I say, I confidently expect it, but I must admit that an occasional disappointment is to be met with; occa- sional, I say, but those occasions are so rare that, I repeat, I confidently expect to obviate them. I suspect that on certain occasions such dis- appointment has arisen from my having had an effete drug, instead of a good one. As an ounce of prevention is worth more than a pound of cure, I hope, when you come to practice, you will prevent hemorrhages in this way. Yet, if a flooding has not been expected, and comes suddenly upon your patient, you will have good reason to expect a tonic contrac- tion of the womb to follow a good dose—say fifteen to thirty grains— of the secale ; give it, therefore, for there is no danger or inconvenience, since it cannot hurt the child, who is already born, nor will it do any evil to the mother. 566 PUERPERAL DISEASES. Do not be afraid of opium. Opium has a salutary power over the hemorrhages, for it has a vast control over the innervative forces, and quells a hemorrhagic nisus as it quells a spasm of the stomach, or a toothache. I shall not dwell on the therapia of floodings any further. I have but one principle of guiding importance on the subject, and that is, to insure by all the means in my power, the condensation or contraction of the uterine texture; all other views and treatment are to be held subordinate to these views, and the treatment that, under them, tends to bring about and secure this desirable end. If you understand this, and understand it fully, you cannot go wrong, nor can you act wrongly in your methodus medendi for such cases. After-Pains.—A woman who is confined for the first time is not to be expected to suffer from after-pains. A first gestation is, in general, insufficient wholly to deprive the uterus of its tone ; but if a woman have gone through gestation and labor a second, a third, or a fourth time, the tonicity of the organ will be found to be less than it was after her first confinement; and although the nervous force may be sent to it energetically, yet it will not be sent into it in the steady, equable manner which characterizes the condensing power of the uterus not already exhausted by antecedent pregnancies, and the throes of reiter- ated parturition. There are some females, however, who preserve throughout life, and after repeated gestations, the same steady force as to the uterus, which characterizes that of the primipara. I have at this moment, under my care, a woman confined, now five days since, with her sixth child, and who has not had since the birth of it, and who never has had after the birth of any of her children, a single after-pain. This woman always recovers progressively and steadily from the gravid condition, without hemorrhage, without protracted lochial discharge, or any unusual symp- tom. Her uterus, which at the commencement of her labor, is ten or eleven inches in length, by eight or nine in width, and which would probably weigh, immediately after the delivery of the after-birth, a pound and a half, goes steadily on, reducing itself to its non-gravid con- dition, wherein it would not weigh over two ounces and a half. She has this good fortune, in consequence of retaining the same uterine tonicity, the same contractile force, that she had in her early youth— and one meets in practice with a sufficient number of examples of the sort to convince him that the case is not a very rare one. You will find in your intercourse with the world, as practitioners of midwifery, that women, in general, are acquainted with this difference between the primipara and the multipara female; for they will say to PUERPERAL DISEASES. 567 you—of the woman in labor—that, of course, she is not to have after- pains, because this is her first confinement; or of another, of course, she is to have after-pains, because this is her second, her fifth, or her tenth labor. What is an after-pain ? The pain of a labor consists chiefly, not solely, in the pain felt at the cervix uteri, and is the result of violence done to the texture of the cervix and os by the overpowering contractile force of the fundus and body. The pain is at the resisting part; it is not suffered by the compelling organs. If a man strikes you a blow with his fist and knocks you down, he hurts you and not himself; in the same way the fundus and corpus uteri, when they strike to rive open, and overcome the resistance of the cervix and os uteri, hurt them, excite pain in them, and sometimes even tear them to pieces, but do not them- selves experience any pain; there are hundreds of women in whom the circle of the os uteri is torn in labor; which is the reason why, in the examination of women who have borne children, you may find fissures in the anterior or posterior lip, or at the right or left angles of the lip, where the os is most likely to give way. I ask you again: what is an after-pain ? An after-pain is not de- signed to expel anything, unless there be a clot to be expelled. When there is in the womb a hard clot that will not break to pieces, and when the os uteri, immediately after the expulsion of the after-birth, has shut itself up like a steel trap, as it often does, the clot which cannot get out until the os uteri is again dilated, will excite pain by dilating it as the child did by dilating it. But there are thousands of examples where there is no clot to be expelled. When there is no clot to be expelled, the after-pains cannot depend upon the resistance of the cervix uteri to the contractions of the body and fundus. A woman who has an after- pain designed to expel nothing, will have the pain in the whole womb, not in the cervix, as in the labor pain; but pain in the whole womb in labor is a dangerous thing ; it is a pain which proves the existence of rheumatism in the uterus, or of a tendency to laceration of the organ. So that you see there is a difference between the true after-pain and the pain of labor. A woman in labor does not complain of pain and sore- ness if you press your hand upon the globe of the uterus, whereas, when she has just been delivered, she shrinks from the pressure, saying, " Sir, you hurt me—that is very painful." The whole womb is more sensible of pain, intolerant of pressure ; the function of its sensitive cords is exalted after labor. Now, during the moments of relaxation, while the sensitive fibres are not compressed in the tissues among which they are distributed, the woman feels no pain; but as soon as the motor cords begin again to excite the muscular tissues, the passive tissues among 568 PUERPERAL DISEASES. which the sensitive cords are also distributed, feel that pressure, and the woman feels the pain arising therefrom ; just as she feels the pain arising from the rude contact of your hand. This is an after-pain. I take it for granted that the after-pain is designed for a useful purpose of some sort, and I submit it to you whether by the contractions of the organ, the blood in the vessels of it, whether they be large or whether capillary vessels, is not pressed or chased out into the correlative vessels, thus allowing the uterus to grow smaller and smaller and pro- voking the more vigorous action of the absorbents. Such is the process by means of which the womb recovers, after forty days, its non-gravid volume and form. An after-pain, therefore, is a good thing, and a natural. You ought not to make haste to stop, or even lessen it, except it become too violent. In a former letter, I spoke of the frequent occurrence of rheumatism as seated in the uterus; and I have no doubt that many of the violent after-pains which we meet with are cases aggravated by a rheumatic condition of the organ ; for, a woman who has suffered from rheuma- tismus uteri for weeks before the birth of her child, I have always found more prone than another to agonize with these after-pains. I speak with regard to their intensity, and their rebelliousness against the usual modes of treatment. An ordinary after-pain will be relieved by an opium pill weighing one or two grains, or by two or three such pills; or, it disappears after a few doses of laudanum, consisting of twenty-five or thirty drops each. A dose less than thirty drops it is hardly worth while to give. A woman may take an opium pill of a grain, or thirty drops of laudanum, every hour, until she has taken two or three such doses; and it is rare to hear her complain of after-pains after taking the second, or more es- pecially the third such dose. Camphor, also, has a very special power to take away the distress occasioned by after-pains. Our good Dr. Physick was accustomed to say that camphor seemed to have been made for women, with whom it always agrees, while it always disagrees with men. As a general rule, opium as a medicine is preferable to camphor, for it is less heating and less stimulating to the whole economy; but inasmuch as there are idiosyncrasies which, under the use of opium, render it distressing or intolerable for certain persons, you should pre- fer for such patients the camphor medication. Here is a good formula. R.—Camphor 3ss ; Pulv. gum. acacise Sij ; Sacch. alb. 9ij ; Aq. cinnam. Siij. M. ft. Mist. S.—The dose is a tablespoonful. PUERPERAL DISEASES. 569 This will give you six doses, each containing five grains of the drug. You may give the second dose in half an hour after the first; or in an hour or an hour and a half; the other doses may be repeated at longer intervals, pro re natd. In some instances, it is proper to add a portion of laudanum to each dose, say 10 or 20 drops. Don't follow the old fashion, which commanded us always to send an eight ounce mixture to the patient; a fashion good for the apothecary, but very bad for the patient; for the nurse might make her sick by giving her the whole drachm, whereas she could not do her any mortal injury by giving her half a drachm of camphor. Drugs and medicines are a sort of edged tools ; and nurses and unlearned people, generally, are not to be permitted to use them, a discretion, as a French tavern- keeper says of the wine on his table. After-pains irritate; violent after-pains, frequently repeated, may irritate the whole constitution so far as to develop strong febrile phe- nomena. Where they are accompanied with fever, or frequent pulse, how can you discriminate between the phenomena so arising, and those attendant upon the most mortal attacks of metritis or puerperal peri- tonitis ? I pity you, gentlemen, from the bottom of my heart, for the distress and embarrassment you are destined, inevitably, to encounter from the difficulty, nay, the almost impossibility of making a correct diagnosis in such cases. I think one of the most distressing nights of my pro- fessional life was passed in the apartment of a lady of the greatest worth, and of the highest social standing, who, after a long attack of rheumatismus uteri, preceding her accouchement, gave birth to a feeble child which died a few days after it was born. The expulsion of the placenta was followed by severe after-pains, that deprived her of sleep during the night, and which, continuing in an aggravated form, during the following day, brought on a reaction of the heart and arteries, during which the pulse beat from one hundred and twenty to one hundred and thirty strokes per minute, and this, accompanied with the most intense pain of the abdomen as well as of the head. She was a person of great dignity of character, and the utmost propriety of conduct; hence, the loud complaints she made convinced me, from my knowledge of her character, that her suffering was nearly intolerable. I knew that she had had rheumatism of the womb before the birth of the child, and that the rheumatic condition had modified the muscular power of the uterus; interfering with, and retarding the normal progress of the labor. But, when I discovered, six-and-thirty hours after the accouchement, that she had a pulse of one hundred and twenty, with a hot skin, and the most acute pain of the abdomen, I could not but hold her life to be 570 PUERPERAL DISEASES. seriously threatened. I passed the whole night, as I have said, in her apartment, agitated by the most conflicting opinions. Certain motives induced me to refrain from letting blood in the case; and yet, when her groans and cries prompted me to come to her bedside, to examine with the most minute care the state of the pulse, of the respiration, of the calorific power, of the tension and sensibility of the abdomen, as well as the sensibility of the vaginal cervix as ascertained by the Touch, I always returned to my seat, comforted with the conviction that I was treating a rheumatic neuralgia of the uterus and the splanchnic branches of the great sympathetic. The diagnosis was, in my opinion, undenia- ble ; yet, in half an hour, her cries and groans recalled me to her bed- side to renew my diagnosis of rheumatism, and to go again and again through the same sea of troubles, of doubt, and misgiving as to the correctness of my judgment. For I said : If I judge wrong as to the diagnosis of the case, and if I lose this patient, I shall never again feel perfectly contented in this world. Happily for me, the morning brought a remission to the intense distress. My patient recovered from her lying-in, and has continued ever since, now these many years, to suffer from distressing rheumatic neuralgia in many parts of her person. I should in vain endeavor to put down upon paper the discriminating signs by which you are to ascertain that your patient is laboring under rheumatismus uteri, or neuralgia of the womb, and not under some acute inflammation of that viscus. It is idle to write such a relation; a picture cannot be written; it must be painted—nature must paint it for you—and you will find the picture in the clinique of your prac- tice. Perhaps, if you and I were standing by the bedside of a patient laboring under this disorder, I might be able to point out certain signs—discoverable in the physiognomical expression, in the tone of the voice, in the frequency, quickness, and volume of the pulse, in the respiratory acts, in the ability to move the limbs; in the patient's tolerance or intolerance of palpation, whether abdominal or vaginal; in the discharge from the uterus, and in the state of ^he urinary bladder and the bowels—that should show you why the case should be called neuralgia, and not metritis, or metro-peritonitis. I could indicate, and you could see these things ; but how can I write them down ! Y"ou know I cannot; nor no man else. If }'ou have studied your profession well, so that you have made yourselves masters of guiding principles in diagnosis, you will be able to find your way through these devious paths, and I must leave you to your own resources in the matter. I will not dismiss the subject, however, without first repeating that there is not a more difficult task to be performed by the physician than PUERPERAL DISEASES. 571 to make the diagnosis in such cases. An antecedent rheumatic state of the womb may serve to lighten up the path of the observer, but, let him beware, oh! let him beware! that even rheumatismus uteri may pass into metritis or metro-peritonitis; in which case, an error in judgment costs a human life; costs the disruption of the bonds of the family compact, the overthrow of the family altar, and the suppression of the most grateful incense that can rise to Heaven—the smoke of the in- cense that ascends to declare the happiness of parents and of children, in the holy and sacred temple which is called Home. The vessels in the interior of the uterus, that open upon the late placental superficies, continue to bleed after the delivery has taken place. In a womb recently emptied, there is a considerable number of patent orifices, of which you may see a very pretty drawing in Dr. Robert Lee's Treatise on some of the Diseases of Females, which repre- sents the orifices arranged in such a fashion as to furnish them with a species of valve. Noortwyck's drawing is also a very good one. The blood discharged from the vessels is called the lochia; to. \oXta ■ %oXn* is the Greek word from which it is taken. It is called in German, kindbettreinigung, and is called lochies in French. The discharge con- tinues for several days. Between the third and fourth days, the abund- ance is less ; probably because the forces are employed in determining the new movements towards the mammary glands, which now become centres of fluxion, whereby the granules of the gland are evolved, in order to the secretion of the nutriment of the new-born child. When the milk has been fairly secreted, the lochial discharge increases again; and on the sixth, seventh, eighth, and ninth days, it becomes more abund- ant than on the fourth and fifth; so that, when your patients complain to you on the third and fourth days of the diminution and almost dis- parition of the lochial discharge, you should not be disconcerted, nor allow them to become so; seeing that it is not a morbid but a natural phenomenon. In from eight to twelve days from the birth of the child, the red-colored lochia has given place to a greenish or yellowish-green fluid, possessing a peculiar and often most offensive odor, powerful enough to fill the whole of a large apartment; and so intense, that no scrupulous cares on the part of the monthly nurse can keep the patient's person and bedclothes free from the disagreeable effluvium. The odor sometimes approaches that of substances in a state of putrefaction and maceration, and the inexperienced practitioner can scarcely avoid a feeling of doubt and distress as to the safety of the patient, considering the mtenseness of the stench. But I believe that I can truly say, the woman whose lochia is so disagreeable as above expressed, is scarcely more liable to 572 PUERPERAL DISEASES. attacks of disease than she from whom no offensive exhalation can be perceived. I say this, founding myself upon much observation, for I have often experienced this great distrust on such occasions, when, it seems, I had no reason to do so ; nor can I remember that the attacks of disease that I have met with in my lying-in patients have commonly been characterized by an antecedent unusual lochial odor. There are some women in whom the discharge continues until the end of the month ; and it is by no means rare to meet with persons in whom it does not cease until the end of the sixth week. The greenish discharge, with its peculiar odor, gradually gives place to a colorless and bland mucus, which, for such women as have great powers of reco- very, is gone entirely by the twenty-first day. This discharge is very like thin albumen-ovi—and comes from the crypts of the canal of the cervix. In the early stages of a labor, when the os is opening, those cryptae send out a profusion of this albumen; and when the cervix is recovering after the fifteenth day, the excretion becomes again abund- ant, and is not of bad omen. I have seen a case in which the womb has apparently recovered its non-gravid magnitude in three weeks from the birth of the child ; and I have seen a case in which the uterus, filled with coagulated blood, extended nearly up to the umbilicus of the woman on the eighteenth day after the child was born. A womb that remains very large is more likely to give rise to a protracted lochial excretion than one that firmly condenses itself, and approaches the state of the non-gravid uterus. You will have, then, a prognosis that is favorable or unfavorable, ac- cording as the womb is large or small. If the womb grows small ra- pidly, and puts an early end to the excretion, in consequence of its healthful condensing power, the woman is not likely to suffer danger from the cessation of the discharge ; but if a womb remain large, and heavy, and doughy, and the discharge cease too early, or too suddenly, the diagnostic will be that of a pathological condition of the organ, and the prognosis will flow out of that; for an inflammatory condition of the organ could not but modify its power of excretion. In one case, you may be called on to interfere therapeutically; in the other, you do mischief by your intervention. When complaints are made to you on occasions like these, you should give them careful attention, and institute such inquiries as to the state of the sick organ, as may suffice to discover the truth as to whether it be morbidly deprived of its excretive power, or whether it be physio- logically deprived thereof. You will find, in the world, a foolish prejudice, especially among the less informed classes of the population, which induces them to allow the PUERPERAL DISEASES. 573 accumulated products of the foul excretions of the uterus to rest and putrefy upon the external genitals, from an ignorant fear they have of checking a discharge deemed essential to their safety. I hope you will always endeavor to dissipate all false notions in relation to this matter; and you will not find it difficult to do so, if you should take the trouble to explain to the patient or to the nurse, that putrid exhalations arising from the accumulated blood and mucus at the orifice of the vagina, or within its canal, expose the woman to the dangers of putrid infection; and you should direct the nurse, in all cases under your care, to keep the woman scrupulously clean by ablutions of warm water and soap, to which should be added some spirits or wine. For persons whose cir- cumstances will warrant such expense, I generally direct my nurses to make ablutions with red wine and water. I find that some of the brethren, and even some of the monthly nurses, in this quarter, are in the habit of ordering the vaginal injection. The circumstances would be very peculiar that could induce me to make such a prescription ; for I conceive if the napkins that receive the discharge are changed several times a day ; and if a sponge, squeezed out in warm soap and w.ater, or wine and water, be used as a detergent, the contractility of the tis- sues within will always emulge them sufficiently. I am not quite satis- fied that it is the dictate of prudence or caution to fill the patient's womb with soap and water, or any other material of injection. In cold weather, and in the variable seasons of spring and autumn, the woman should be carefully protected against the danger of taking cold by undue exposure of these parts. Let me advise you to caution the patient against going, even after the lapse of the month, to the privy, the exhalations and the damp and cold of which render her very liable to repercussion of the fluxional movements, which should be most sedulously avoided. Some women have their lochia too profusely, from getting up too soon : when they are thus profuse, one of the most reasonable remedies will be found in ordering them to take again a recumbent or horizontal posture. Such a position, taking off the strain from the distal branches of the vessels, is alone, in many cases, sufficient to put an end to the morbid momentum of the blood in its uterine and spermatic branches. When recumbency fails to cure, the question might present itself of the propriety of bleeding from a vein, in order to take off a portion of the injecting power of the systemic ventricle ; or, if such a procedure is not to bethought of, and if the excess be justly attributable to an en- feebled or atonic condition of the uterus, one should direct the patient to take some astringent infusion ; such as infusion of red roses acidu- lated with aromatic sulphuric acid; or infusion of cinchona and cas- 574 PUERPERAL DISEASES. carilla; or quassia, or chamomile; or infusion of krameria, or diluted tincture of catechu or kino ; or some doses of opium ; or the saccharum saturni; or alum-and-nutmeg powders so often mentioned in these pages ; or more than all, the vinum secale cornuti, or the secale 'in powder mixed with water, or one-grain pills of ergotin; the doses to be repeated once in an hour or more. I shall take advantage of the present occasion to refer you to the 220th page of that charming volume, entitled: Leetures on the Theory and Practice of Midwifery, delivered in the Theatre of St. George's Hospital, by Robert Lee, F. R. S., &c. &c. : London, 1844, 8vo., a book which I could desire to be in the hands of every one of my pupils, as I look upon its author as the ablest man in all England, in this department of science and practice. I told him, in 1845, that he might safely die now. " WThy die ?" said he.—" Because you are already ineffaceably inscribed on the roll of Fame.'' " How's that ? how's that ?" said he.—" It is thus, my dear doctor : first, you are the man who has made the profession know the true nature of phlegmasia-alba-dolens; it is you who have taught us the malady is crural phlebitis; secondly, you are indissolubly united with that company of men who have established the spontaneous ovulation as a cause of menstruation. Nothing can separate your fame from that of Negrier, Gendrin, Pouchet, Purkinje, Von Baer, Rudolph Wagner, &c; thirdly, you have just now shown me your last and greatest discovery, that of the largest ganglion in the human body, to wit, the cervical ganglion of the womb. I don't see anything left for you to discover, and therefore, I say, you may die now ; nothing can prevent you from being immortal." Dr. Lee replied : " I'll no die yet! I'll no die yet!"—and I am very glad to learn that he is still living and in excellent health. Such people ought to die of old age, and nothing else, as we say in America. But to return to his 220th page ; he says: " This discharge from the uterus after delivery, called the lochial discharge, does not usually cease altogether, until the uterus has contracted greatly, and become much reduced in volume by the absorption of its coats, bloodvessels and nerves. The uterus is much more rapidly absorbed in some women than in others, and this chiefly depends on the previous state of the patient's health, and the nature of the labor." I cannot agree with Dr. Lee in the opinion that the uterus is absorbed • because I look upon the virgin uterus as a gravid uterus in potentia • a uterus possessing every organ and part of an organ that is necessary to enter into the composition of the gravid womb; which when it returns to its non-gravid condition, does so doubtless by the aid of much ab- PUERPERAL DISEASES. 575 sorption, but not by the " absorption of its coats, bloodvessels, and nerves ;" for I conceive them never to be absorbed. Dr. Lee might as well say that the granules of the female breast are absorbed after the weaning of the child, or that they do not exist in the virgin; but he knows that Sir Astley Cooper has demonstrated them to exist even in the male gland. I offer this little criticism on the 220th page of my excellent friend's work, because, although, " aliquando bonus dormitat Homerus," Homer himself ought to be waked up when he does nod. It is customary to put a binder around the abdomen of a woman just confined; a precaution rarely neglected in this country; but the neglect of which is usually assigned as the cause of much after suffering and ill health that the patient causelessly attributes to the ignorance and carelessness of her monthly nurse, or her medical attendant, should she happen not to have a good getting-up. It is necessary that you should be cautious in the use of the bandage ; for if the bandage be worn too strictly and with a heavy compress be- between it and the abdomen, it cannot but happen that the globe of the womb, which for a few days after delivery is as large as a cricket- ball, will be thrust down into the excavation, pushing the vagina before it, thus shortening that tube, on the upper extremity of which the uterus rests, and which, in fact, furnishes to the uterus nearly its whole support amidst the bones of the pelvis. Suppose you were to fix one of the utero-abdominal supporters, as they are called, upon the hypo- gastrium of a woman just confined, and compel her to wear it for the forty days ensuing, or until the uterus had recovered its non-gravid magnitude and weight, would not your patient be sure to recover with a prolapsus uteri? Messrs. M'Clintock & Hardy, in Practical Ob- servations on Midwifery, Dublin, 1848, 8vo., at page 6, inform us that at the Dublin Lying-in Hospital, where they made the "Observations," the binder is regarded as a most essential article in the Lying-in ward, that Dr. Joshson looks upon it as one of the most important means of securing a good detachment and expulsion of the placenta; and they even attribute to its universal use in the house the fact that only one case of hour-glass contraction, requiring the introduction of the hand, had occurred there for five years. Should you meet with the work above cited, be not, I pray, misled by their statement, for experience and reflection will come to show that hour-glass contraction is caused by adherence of the placenta to the womb, an adhesion so firm that the strongest contraction of the womb cannot displace it. In such an event, the placenta serves as a splint to distend the fundus, whereas the corpus and cervix, finding no opposition, contract and shut the placenta up in the superior cell. Their explanation is an error. 576 PUERPERAL DISEASES. You will find, at page 208 of Prof. Asdrubali's work, Tratalo Gtnerale di Ostetricia, Teoretiea e Pratica, vol. 2d, some excellent observations on the evils and abuse of bandages ; and inasmuch as, throughout the United States, the most incorrect and harmful notions exist on the subject, I think I shall do you no disservice if I translate the whole passage from that most learned and admirable author. " The habit of binding up the abdomen of women in childbed was in use among all the ancients. Yet Peu and Mauriceau have declaimed against the abuse of it, though they did not admit that it should be wholly proscribed. Many of the moderns still advocate its employ- ment, but with great precaution ; as if in doubt whether it might do most good or most harm ; but the majority of them have condemned the custom. Buchan looks upon it as absurd, and Gorter as mischievous, and as the occasion, almost always, of serious disorders. " Among the motives that have prevailed among some to recommend the binder, the principal one was to furnish the patient with the same sort of aid as it is customary to give the patient in dropsy, after the operation for paracentesis, with a view to prevent attacks of lipothymia and syncope, likely to ensue upon the sudden and great evacuation of the abdominal cavity. Another motive was, to restore to the abdomen its non-gravid size and form. " It is not to be doubted that the cavity of the abdomen, when com- pressed by the binder, will find as much assistance for the compression of the viscera and bloodvessels as it ,had previously received from the gravid uterus. But, inasmuch as, for the obtaining of this effect, the abdomen must be firmly bound, and as there is no other motive for it, the constriction, no doubt, is often sufficient to produce suppression of the lochia, whence may arise suffocation and pain, which are the begin- nings of terrible maladies. How some recommend it without clear motives, and others reject it altogether, is demonstrated by daily ob- servation ; for it is observed that no evils befall those who make no use of the binder, but leave the abdomen perfectly free: they pass through the puerperal state without the least untoward circumstance. Why should we resort to a method from which, as Dionis observes, there pro- ceeds more mischief than good ? In order to avoid deliquium and syn- cope, it is only necessary that the woman, as soon as she is confined, should preserve a horizontal posture ; and if, unexpectedly, or by acci- dent, deliquium should occur, certainly we ought to make use of remedies equal to the removal of the evil, and prompt in their action, and not trust to a mere bandage. If a woman should have an extraordinarily flaccid abdomen, it might certainly be advisable to contract it by a bandage made moderately tight, and kept so, for a few days. PUERPERAL DISEASES. 577 " The second motive for recommending a bandage is, as expressed in § 282, to reduce the size of the abdomen of the puerperal woman. But experience shows that the restoration of its shape depends upon nature, and not upon any art whatever. The abdomen, as soon as it is relieved from its distension by the gravid uterus, recovers such form and size as it is susceptible of, under the contraction of its muscles and teguments: it would not, certainly, be susceptible of a corrugation be- yond the natural degree, by any restraint afforded by a linen bandage. How true this is, may be observed in many women, who, after repeated labors, find the abdomen relaxed and flaccid, notwithstanding their ex- travagant sacrifices to the dictates of fashion in dress. They look to the physician for this happy restoration ; they suppose that he, by means of his bandage, ought to restore the abdomen to its primitive condition ; never reflecting, that they wear their corsets without obtain- ing the least advantage ; and that the support they require for too flaccid an abdomen is to be obtained only from the ordinary corsets and busks, which they.can tighten at will, and to which they can give any form, adapted to their necessities or caprices." Professor Asdrubali concludes his article with a considerable quotation from Lemoine, which I shall not cite to you for the present. I have already, in a former letter, offered you some remarks upon the use of the bandage, as a means of suppressing the tendency of the uterus to expand soon after labor, and receive, and contain the products of what is called a concealed hemorrhage, for which I refer you to Letter XL. I likewise expressed the opinion that certain women, after sudden deliveries, having had the womb enormously distended before, suffer from violent lipothymia and deliquium for want of some abdominal tension, or for want of a bandage. For such exigencies, I hold the bandage to be laudable, and the use of it not to be pretermitted; but as for the rest, I here fully give my approbation to the sensible, reasonable remarks of Professor Asdrubali. It is very probable that much of the prevalence of prolapsus uteri in this country is due to the improper use of the binder. Pray attend to this point. There is one point in the management of women newly delivered to which I must now advert. It is a very common occurrence to find the woman recently put to bed, affected with retention of urine : the occur- rence is so common, that it is a rule of duty in the physician who has charge of the case to make inquiry into the matter. It cannot but be inconvenient, and not a little dangerous, to allow the products of the renal secretion to accumulate in the bladder to a great amount. But that organ has been so much distressed, so much compressed, and, per- haps, so much contused in the transit of the foetus through the pelvis, 37 578 PUERPERAL DISEASES. that it must be. and, in fact, it is an exceedingly trite occurrence to find the woman allowing from thirty to forty ounces of fluid to accumulate in the bladder of urine. This puts the cystic tissue dangerously on the stretch, compressing the uterus and thrusting it too far backwards, or even overturning it; exciting pain, urinary and rectal tenesmus, and fever, which it would be easy to guard against by a simple precaution. It is considered by accoucheurs, therefore, an invariable point of duty to inquire, within'a few hours after the birth of the child, whether the bladder of urine has been relieved. If you, who read this letter, be not, and do not intend to become an accoucheur, you might nevertheless adopt the custom of the accoucheur in such cases. An accoucheur would not think, I suppose, of giving medicine to provoke a discharge of the urine in such a case An ac- coucheur does not like his patient to be disturbed by a dose of physic, or even by a common aperient enema, in the first two days at least of the lying-in. He knows that drugs are of no avail for this kind of re- tention, and he resorts at once to a remedy which cannot fail, which is not inconvenient, and in nowise painful: I mean the introduction of the catheter. If the woman should not be relieved in the course of from eight to twelve hours, the catheter should be introduced, and so on from day to day, until the power of the urinary organ be quite re- established. I pray you remember, that you might make a false diagnosis in the matter, if you be not careful. I have seen this false diagnosis made a hundred times by the nurses and by patients themselves; they supposing the distress to arise from what is called after-pains, while, in fact, it depended solely upon retention of urine and extraordinary distension of the bladder of urine. If, for a woman complaining of after-pains, you should explore the case, by pressing your hand upon the hypogastrium, and find there a well-defined, resisting, orbicular mass, nothing would be easier than to mistake it for the uterus. Sometimes I have had a difficulty in making the discrimination, by trusting merely to my sense of touch. The difficulty of diagnosis has vanished from me always, however, upon ascertaining—first, that the woman has had no urinary evacuation for a number of hours; and, secondly, by saying to her, "Listen to me; attend. I am pressing my hand upon a lump which I find here at the lower part of the stomach. I am going to press harder, in order to give you some increase of pain. Please give your attention to the sort of pain" which I shall produce;—and tell me whether or not the pain you now feel may be truly called a. urinary pain. Is it a pain to make water?" "Yes, sir, it is !" PUERPERAL DISEASES. 579 " Very well.—I understand the case now." After such an answer, a doctor would be very stupid if he should not propose the use of the catheter. After severe labors, the bladder is occasionally found to refuse to re- sume its function of expelling the urine for three, eight, ten, and some- times fifteen or twenty days. As long as it refuses to do its duty, the medical man should remove the urine twice a day, or, what is far better, leave a proper catheter in the hands of the patient; first instructing her to apply it for her own relief. There are many persons who can be trusted to do this little operation themselves, which is a saving both to their own feelings and those of the medical attendant, for there is scarcely a more disagreeable operation to be performed than that of catheterism of the female ; an operation which, I should think, every gentleman would be glad to commit to other hands than his own. It does no mischief, I suppose, in such cases, to give a little sweet spirits of nitre ; to give a little weak solution of nitre; to allow your patient to take infusion of watermelon seed ; of parsley root, of horseradish, or of juniper berries ; which do little harm, and less good. If the patient will have a placebo, let her have the most innoxious one you can devise. After all, there is nothing for retention of urine like a good catheter. It is not good practice to excite perturbations in the economy of a woman who has just gone through the pain and excitement of a labor. Such a person requires a long and profound repose of the organs and organisms, as well as of the spirit itself; for which all sorts of compla- cencies ought to be provided. A dose of cathartic medicine, admin- istered within twenty-four hours, is sufficient, in some instances, to call up movements, whether nervous or vascular, that it would be far wiser to leave uncalled. Wake not the sleeping lion ! Attacks of engorge- ment and inflammation have, I am sure, followed the intempestive exhibition of purgative medicines by imprudent and presuming nurses. It is time enough, under all ordinary circumstances, to cause the bowels to be moved once or twice, after the lapse of from sixty to seventy-two hours; and the woman ought not to be disturbed with any kind of physic for at least this length of time after her delivery. When the time does arrive for giving some medicine, an aperient ought to be se- lected, and not a purgative. The patient is not sick; she does not want physic ; her bowels are lazy, and merely require to be roused a little ; the woman ought to have one or two alvine dejections, and not more, unless she be really sick. To procure this desirable end, pray select some article that you can depend upon. Can you depend upon mag- nesia, or upon the common combination of magnesia and Epsom salt ? No. A dose of magnesia will operate either not at all, or once, or 580 PUERPERAL DISEASES. eight or ten times. Will senna or rhubarb answer your purpose ? Un- faithfully ; because they bring on purging, if you give a sufficient dose; and if you give a moderate dose, you will be disappointed in the ope- ration. What is the medicine that does not disappoint you ? Castor oil. The dose of this medicine ought to be, as a medium, about half a tablespoonful. In ten cases of women just confined, a dessertspoonful of castor oil will be sufficient for nine of them, and the tenth one can repeat it after five or six hours, if she chooses. I advise you to follow this method; and I confidently advise you in this way, because " haud inexpertus loquor." Neither my friend Dr. Samuel Jackson, nor I, would consent to give a woman a tablespoonful of castor oil under such circumstances, because we know that half a tablespoonful is a better dose for her. Dr. Jackson is a good authority in matters of therapeu- tics. I wish there were more like him in the country. The diet of the woman is worthy of some consideration : many women are left by labor with their bloodvessels in a state of convul- sion, so to speak ; the tempest and whirlwind of their passion do not subside, for many of them at least, for hours after the provoking cause has been taken away. i If the woman has not lost a great quantity of blood by the detach- ment of the placenta; or if the lochial discharge should prove to be not very abundant, the materials for development left within her blood- vessels ought not to be deemed to require much refection for two or three days. She is about to have a new cause of constitutional disturb- ance set up within her: both the mammary glands are destined to sudden, I was going to say, bursting development. They are both about to become suddenly instinct with life ; an operation attended, in the majority of cases, if not with fever, at least with a quasi febrile paroxysm. These considerations render it expedient that her diet should consist of very light, digestible, and sufficiently nutritious materials. I pre- sume that in different parts of the country there are different modes of treating the lying-in woman as to her diet; but as for us in Philadelphia, a time-honored custom which is universally adhered to, commands the nurse to provide for her patient a diet of gruel made with oatmeal. Many of the nurses boil it into a thick porridge, and give it to the pa- tient sweetened with sugar, after having made a very slender addition of salt; it is deemed aperient, agreeable to the patient, and satisfies well the cravings of the stomach. The woman is also allowed a cup of tea, and some dry toast or baked rusks; or any simple preparation of bread. Tea and toast, oatmeal gruel and cold water are a lying-in woman's allowance until after the PUERPERAL DISEASES. 581 milk comes, in Philadelphia. Hot tiff, or brandy and water; soups, meats, eggs; all animal substances ought to be proscribed. As to the diet of oatmeal gruel, I have on many occasions observed that women taking oatmeal gruel have become tympanitic ; and that it is a less wholesome food than is generally supposed. You will be amused if not instructed by the following paragraph from Rainald's Byrth of Mankynde :— " And here it is worthy to be noted, that whereas it is a common usage to geve often to women in theyr chyld-bed cawdels of otemele, thynking and saying therby the woman to be scoured: whereas in deede the sayde otemele is a notable bynder and dryer; therefore ye shall understand that the ryght use therof is to geve it to such as have alreadye ben well and sufficiently scoured and clensed from their birth, and other thynges to be looked for in this tyme and case; but if the woman be not sufficiently purged already, then give her no otemele cawdels, ne other thynges that may bynde." I have said above that all animal substances ought to be proscribed for the woman recently delivered. I ought to qualify this statement for the cases in which great debility might seem to demand a more generous diet. The good old author whom I have just now evoked from his grave that he might speak to you about otemele cawdel, was far more liberal than the moderns in his allowance of food to women in travail. At the 70th page, speaking of cases of retained placenta, he saith:— " If retention of it comes by weakenes of the labourer, through long trauyle, then must she be recomforted and strengthed with good com- fortable meates and drinkes, whiche may enhart her, as broath made of the yolcke of egges, or with good olde wyne, and good fat and tidie fleshe of byrdes, hennes flesh, capons, partrige, pigins and such like." I hope you will sometimes remember and perpend the good fat "tidie fleshe, byrdes, hennes fleshe, pigins, and so forth," that might have been the happy allotment of Queen Catharine Parr had her hopes of a baby not been doomed to a sad disappointment, at the time when her pregnancy, like Mrs. Commodore Trunnion's, tenues in auras evadebat. Pray never forget that excellent old English parlance of his, nor for- get to enhart her when your patient has come too low after her wasting hemorrhages, or exhausting efforts in childbearing. A woman ought to keep her bed for the first nine or ten days after her accouchement: if she gets up, the womb descends lower into the ex- cavation than the place it ought to occupy. The womb will get well, notwithstanding such imprudence ; but the vagina may be ruined, and 582 PUERPERAL DISEASES. the woman's health may be forever after disturbed by a prolapsion, which always coincides with a shortening of the vagina. Prolapsus uteri means, and is nothing else than shortening of the vagina; and you have nothing to cure in prolapsus uteri but a shortening of the vagina; and when it is cured, the woman is cured, and you have nothing else to do with it. There is another motive why a woman should not soon get up, arising from her extraordinary nervous susceptibility after labor. She may take cold; she may be seized with a rigor; and the rigor may give her an attack of weed in the breast; or the force of the reaction may fall upon the womb, or upon the peritoneum ; so that she shall pay for her imprudent early rising with a mammary abscess, or by loss of her life in a childbed fever. I verily believe that one-half of the vexations I have experienced in the course of my life, from such occurrences, have been the fruit of untimely, imprudent exposure as to diet, or as to too early rising from the bed. I tell my young lady-patients that if they keep the bed until they are cured, childbearing will not make them break—as it is called. A squaw with two pappooses is nothing but a squaw. She might have been a very pretty woman still, if she had had a good nurse, and kept her bed until after the ninth day. She who gets up too soon will have wrinkles, and grow sallow and ugly before she is twenty-five. After the ninth day has elapsed, if nothing has happened, the woman may be taken up for an hour in the morning, and again as long in the afternoon ; prolonging from day to day her leave of absence from the couch, until her strength being gradually restored, there shall seem no longer need for any restriction whatever. I shall refrain from offering remarks here on the coming of the milk, and the management of the breast, as I intend to devote a separate letter to that consideration. As to riding out, it will depend upon the state of the patient's health; it is well, however, to have a rule. My rule is to say, you may ride out on the twenty-first day, if you be well enough, and the weather be inviting. An hour's ride is long enough for the first sortie. But, if the lochia are not gone, it is better to stay at home. No woman ought to consider herself recovered from the effects of her accouchement until after the lapse of an entire month. The Jews, who inhabited a very warm climate, were considered, by their Lawgiver, unclean for forty days after the birth of the child. Christian women are purified in thirty days, and I am afraid that some of them think themselves so earlier than that. I wish that the brethren could lend their influence to reinstate the Mosaic doctrine on this point. But some PUERPERAL FEVER. 583 people will not believe Moses nor the prophets either; nor would they believe, though one should rise from the dead to tell them, they are not well, if they but feel well. Pregnant women ought not to be vaccinated. This is a rule that I advise you not to depart from even on the most urgent occasion. If a woman have been once vaccinated, and appeal to you to revaccinate her because there is a present variolous epidemic, I hope you will refuse to accede to her request. Smallpox is exceedingly and peculiarly per- nicious to pregnant women. She who has it, and miscarries—or who is brought to bed at term, generally dies. It is, in my opinion, inex- cusable to expose her to so great a risk—a risk far greater than that from accidental contagion, or that of the epidemy. But the vaccine is identical with the variolous animal poison, saving some lessened inten- sity of its malignant form derived from its having been modified by the nature of another mammal. To inoculate a cow with smallpox virus, is to give her the vaccine disease, with the lymph of which you can vac- cinate, but cannot reproduce unmodified smallpox. Keep your preg- nant patients clear of smallpox in all its forms, whether modified or unmodified. Do not vaccinate them. I have been the witness of dreadful distress from the operation. Eschew it, I entreat you. C. D. M. LETTER XLII. PUERPERAL FEVER. Gentlemen: There is a "word of fear" that I shall pronounce when I utter the name of Puerperal fever; for there is almost no acute dis- ease that is more terrible than this—even smallpox, which reduces the fairest form of humanity to a mass of breathing corruption, cannot be looked upon with greater awe. Childbed fever, like an inexorable Atropos, cuts the thread of life for those to whom Clotho and Lachesis would give the longest span. There is something so touching in the death of a woman who has recently given birth to her child; something so mournful in the disap- pointment of cherished hopes ; something so pitiful in the deserted con- dition of the new-born helpless creature, forever deprived of those tender cares and caresses that are necessary for it—that the hardest heart is sensible to the catastrophe. It is a sort of desecration for an 584 PUERPERAL FEVER. accouchee to die. Pliny, in his letter xxi. lib. iv., speaking of two sisters of Helvidius who each died in childbed, says: " Ita mihi luctuo- sum videtur, quod puellas honestissimas in flore primo foccunditas ab- stulit. Angor infantium sorte, quae sunt parentibus statim et dum nascuntur, orbatae. Angor optimorum maritorum, angor etiam meo nomine." The disease in question acquires, from its liability to assume the character of a devastating epidemic, an importance far greater than would appertain to it, were it limited to the occasional fatalities of its sporadic or accidental forms—inasmuch as when it does prevail as an epidemic, it sometimes ranges over a great extent of country, or through- out certain districts, and lays not aside its destroying wrath, not for weeks only, or months, but even for a series of years; carrying in its train fear, expectation of death, and the overthrow and desolation of the domestic altar for hundreds of families. The maladies comprised under the denomination of puerperal fever are several in number, and are so insidious in their approach, so sudden and violent in the attack, so rapid in their progress, and so dangerous always, and the fatal boundaries not unfrequently so far overpassed be- fore assistance is sought for from the hands of the physician, or danger even suspected, that it is clearly your duty to make yourselves accurately acquainted with their nature and treatment. Puerperal fever, or child- bed fever, as it is also called, is a disorder very apt to mislead you, to confound your judgment, to terrify and drive you from the path of your therapeutical duty in the case, or tempt you to the commission of the greatest errors in the conduct of it. I shall, therefore, in the present letter, endeavor to lay before you such views upon the subject as I have been able to obtain from no little clinical observation of cases, from re- flection upon what I have myself seen, and from conversation and read- ing. I should deeply regret to hear that any one of you, after begin- ning to attain to some degree of success in the practice of your Art, should have the misfortune to encounter an epidemic of this sort, for I am sure the troubles it would bring upon you, if not fully prepared and armed with a true knowledge of your duty, might well lead you to think it were happier for you had you never been born. I shall, therefore, try to tell you the whole truth about it. This I shall do, not as arrogating to myself a degree of knowledge and discrimination superior to those of other men and brethren of mine, but as feeling that I have a solemn duty to discharge towards you, as your teacher, as well as towards the public, who are to be advantaged or injured by your conduct as physicians towards those who may have the misfortune to suffer these terrible maladies. PUERPERAL FEVER. 585 Puerperal fever, denominated, by the public, Childbed fever, is also called Peritoneal fever, Puerperal peritonitis, Metritis, Metro-peritonitis, Uterine phlebitis, and lastly, Pyogenic fever: it is a disease consisting of inflammation of the serous coat of the abdomen, or of some portion of it—inflammation of the ovaries—one or both of them; of the womb, with or without coincident inflammation of the peritoneum; of the veins of the womb ; or of the absorbent vessels of that organ. If this is a true statement of its nature, it is clear that the disease is not a fever, but a phlegmasia, and that the fever is an accident, and not the essential disease. It is probable that a major part of the cases consist of serous inflam- mation only—cases in which the sub-serous textures have little partici- pation in the inflammatory modifications of the peritoneum proper. Many of these very samples of peritonitis, however, coincide with violent inflammation of one or both of the ovaria—of the ligamenta lata, and of the internal superficial tissues of the pelvis. In pure samples of metritis—or uterine phlebitis, the inflammatory modification of the tissues may not, on the one hand, or on the other may extend to, and involve the serous lining of the womb, and spread far and wide throughout the various folds and reflections of the whole peritoneum. You will find in a subsequent page that Tonnelle* has shown how often the malady assumes the form of uterine phlebitis, he having found pus in the veins of 90 out of 224 cases he dissected. You might be disposed to ask why it is that a function so natural as that of parturition should be followed by this disastrous disease. Leav- ing out of consideration the nature of the recondite causes that operate upon the economy to develop the various puerperal inflammations, such as an epidemic or an endemial influence; or a poison conveyed in the clothing or persons of physicians and nurses, one would seem to perceive sufficient provocatives to the attack of inflammation, in the state of any parturient woman's constitution, and in the events of the labor by which she may have been brought to bed. Indeed, there is room for surprise, that the examples of violent inflammation of the tissues concerned in parturition are not far more numerous than they are in fact found to be. It is always rare to let blood for a patient pregnant and nigh to her term, without discovering the proofs of an inflammatory tendency, in the sizy and cupped appearance of the blood, when left awhile to rest. I beg you to take notice, in your future practice, of this point. But if the blood be sizy in nearly all pregnant women, then all such women are, to say the least, in a state of proneness to inflammatory attacks—since that siziness of the blood indicates an excessive predomi- 586 PUERPERAL FEVER. nance of the fibrinous element. Allow me here to repeat, that in 1,000 grains of healthy blood, there should be found not more than 3.5 of fibrin—but, if you bleed a pregnant female far advanced in the gesta- tion, you will discover size enough in the coagulum to lead to the supposition that instead of 3.5 there must be not less than .10, or perhaps .15 of the plastic material. Pregnancy, for most women, is carried on at the cost of an exalted general vital force—for many of them, the latter weeks of gestation are weeks of feverishness; and when, upon such a basis of dyscrasy of the blood as I have above mentioned, we come to superadd all the san- guine and nervous exaltations of the conflict of labor, which is usually attended with greatly increased action of the heart and arteries, we may well believe that the blood is generally left in a highly pathologi- cal condition after the delivery. The nervous system, too, in most cases of hard labor, becomes ex- hausted, and is rendered thereby extremely impressionable by all mor- bific causes: all the causes of inflammation must act with redoubled intensity upon it; and inflammation, once begun, may, with difficulty only, be prevented from extending far and wide beyond its radiating point. As to the serous lining of the abdomen, there is scarcely any portion of it that is not affected, in pregnancy, either by the vast extension of the peritoneal superficies of the womb and the abdominal integuments, or by the pressure effected upon them. The birth of the child takes off this pressure—leaves much of the peritoneum in a state of relaxation or flaccidity—and thus brings it into an atonic condition, inviting the approach and onset of disease. The repeated, protracted, and vehement contractions of the abdo- minal muscles cannot but have a tendency to effect contusions in the opposite peritoneal surfaces that are so violently jammed or ground together during the labor throes ; while the lower portions of the mem- brane or the cervical portion of the uterus, containing within it the foetal presentation, are thrust with an incalculable force down below the plane of the superior strait, and oftentimes held for hours against some part of the osseous structure of the pelvis; so that one is amazed to find these tissues escaping wholly from disease, when it was so probable they could not escape absolute destruction. Consider also the state of the textures composing the womb itself; and reflecting that the power of the womb is resident only in its mus- cular fibres—see what and how great must be the mechanical violence done to the remaining elementary structures of the organ during the protracted and agonizing contractions of those muscles—contractions PUERPERAL FEVER. 587 that seem, in some instances, to make every sensitive cord feel the vio- lence that is directed and occasioned by the motor cords. The labor, too, is not the end of the scene, for the womb and the vagina, with their whole cortege of arteries, veins, capillaries, nerves, and absorbents, as well as the muscles and cellular tela, are passing, during forty days after the birth, back again into the non-gravid state; a transition-period, full of hazard, and open to the attack of inflamma- tion. There are new determinations of blood to be established. The tor- rents that have poured for months, and in increasing volumes, along the uterine and spermatic branches, are suddenly cut off in a measure by the closure or quasi obliteration of their accustomed channels ; and great veins and sinuses, as big as a little finger, must allow their walls to collapse, compelling their endangium to re-enter the state of non- gravid abeyance from which the pregnancy had forced them to issue. Upon the interior surface of the uterus is left the cotyledynous superficies, with the patulous orifices of the lochial vessels that were uncovered by the detachment of the placenta. Those mouths are often bathed with fluids of the most putrid and offensive and even acrid character, provoking inflammatory exaltation in the capillary and nervous textures, and the endangial tissue of the veins. Finally, the new life-force in the breasts must begin; and the firm tension of the mammary glands, and galactophorous tubes develops fever, which is akin to inflammation. In addition to all the causes above enumerated, it is proper to take into consideration the state of the skin. There are few women who go through a labor without violent perspiration, which issues from the head and thorax, and flows in copious streams. Such a condition of the cutaneous exhalants leaves the delicate vascular and nervous appa- ratus of the skin in a highly susceptible or impressionable attitude, so that cold and damp operate with peculiar intensity in causing disease. There are, besides, many labors that are interfered with by the offi- cious intermeddling practitioner, whether male or female, who happens not to have been well instructed in the duties of the obstetrician. In- struments are not unfrequent causes of contusion, as well as of laceration of greater or less moment; so that multitudinous provocatives and causes of disease are to be discovered, even in the most simple healthful case of parturition. There are, moreover, epidemic causes of puerperal fever. I cannot tell you what is an epidemic cause, since it is uncognoscible, recondite, and beyond the scope of the human understanding. We can know that it exists, and we can witness the efficacy of its awful causation, in the 588 PUERPERAL FEVER. frightful devastation of hospitals, towns, villages, and even large and extensive districts of country. Dr. Sydenham showed long ago that a constitution of the atmosphere may exert modifying influences upon the nature of diseases, and that, as the constitution changes from time to time, so will the characteristic qualities of any disease undergo conformable modifications from year to year. He showed that there may reign influences to render pre- vailing maladies either synochous or typhous, so that the fiercest attack of pleuritis shall participate in the nature of the most atonic form of the typhus fever, and that, upon some unknown or some meteorological mutation of the qualities of the ambient air, the serous inflammations shall recover all their activity and redhot intenseness. No eudiometrical researches have hitherto succeeded in wresting from nature her direful secret as to the essence of epidemic causation. The poisonous exhalations from the bogs of the Valteline, or the marshes of the Campagna, in the eudiometer betray no combinations of the air different from those that rest on the pinnacle of the Shreckhorn, or the Faulhorn; no additional infusion of carbonic acid, no supersaturation of oxygen, nor excessive nitrogenous dilution. Hypotheses and conjec- tures, however specious and plausible, are all that we have to rest upon in the arduous and anxious exploration. In the case of the confessedly contagious disorders, we seem to come at something like approximation to the truth. We can, in the case of smallpox, visibly and palpably demonstrate, if not the essence of the contagion, at least the contagious virus or material in which it exists. We can take it from one, and transfer it a thousand leagues to another, and plant, as it were, its seeds to spring up like a vast Upas, over- shadowing with its arms of death the whole area of a city or a county. Perhaps there are other maladies, as scarlatina, rubeola, pertussis, &c, that may be placed in the same category of contagious power. Yet, if we be compelled to admit that they are propagated by contagious force, we cannot deny that they are also extended among a population by epidemic causations. Willis, in his Tractatus de Febribus, in some ob- servations on contagious and epidemic smallpox, discourses very sensibly where he says, Peculiaris quaedam aeris dispositio variolas insigniter producit; hinc saepissime popularis evadit, ac per totas regiones, urbes, vicosque passim desaevit; hinc etiam vere et autumno crebrior existit, &c. How are we to explain this epidemical power of a purely con- tagious malady, if we deny that there is a means of its evolution, utterly independent of all personal sources of its production? Is it to be believed that a material so subtle as that which causes smallpox, and which is undeniably produced by the living body—which is peculiar— PUERPERAL FEVER. 589 producing one, and only one form of diseased action—can we reasonably suppose that it has many various sources of its origin ? We are bound to conclude that epidemical influences may tend to favor the production of the material in living bodies, not that they cause its evolution in other sources. In the great example, the Asiatic Cholera, we have seen that the epidemic causation has risen into activity in various latitudes and longi- tudes of the globe, commencing in the Delta of the Ganges, and spread- ing eastward to China, and westward to Persia; northward, to the shores of the Caspian at Astracan, and to those of the Mediterranean, at Latakie; ascending the Russian rivers to Moscow, and then invading Western and Southern Europe, and the countries of both North and South America. In the disastrous spread of this great epidemic, which has probably cut short the span of life for more than fifty-five millions of our race, how many thousands of the strongest proofs have been observed of its contagious power, and yet it is probably not more contagious than rheumatism, or gout, or ordinary ague and fever. As to the contagiousness of smallpox, I cannot deny it, since I can- not deny the contagiousness of any inoculable malady. But the con- tagious nature of puerperal fever, though asserted by so many of the brethren, entitled to my respect for their learning, judgment, and hu- manity, I cannot for a moment admit. Its epidemic or its accidental origin is for me a sufficient explanation of all the asserted examples of its communication by direct contagion. Sydenham, as I have said, made us acquainted more exactly with the important fact that changes occur in what he calls the constitution of the air, by which he means certain unexplained cosmic forces or principles present in the air, and capable of modifying the intenseness of our vital sensibility and irritability. Those same influences exerted in space, whether vast or minute, may serve to explain how it happens that in a dis- trict of country where a case of puerperal fever had been unknown in the memory of the oldest inhabitant, a major part of the puerperal women shall, for a series of months or years, become the subjects, and many the victims of it. An epidemic influence, be it what it may, can place the constitution in a predicament that renders it prone to be affected by the inflammations that I have, in the beginning of this letter, denominated the textural lesions of our disease; and to the end of conceiving of such epidemical influence, it is not necessary to imagine any fermentative, sporiferous or ovular element of propagation, nor any poisonous exhala- tion, material, or gas escaping from substances in putrefaction—since the smallest change in the atmospherical mixt, or constitution, can give 590 PUERPERAL FEVER. the utmost vigor to the vital forces, or take them away, or reduce them to the minimum of power. It is, in my opinion, not to be reasonably denied, however, that telluric emanations, or modifications of the atmo- spheric mixt may take place in regions of country more or less vast, and that such alterations may produce more or less disturbance of the public health. The gigantic ferns that lie buried beneath the ruins of the antedilu- vian world, and the inexhaustible deposits of carbon in the coal fields and in some of the rocky strata, have been presented by the geologist as proofs of a former different combination or mixture of the atmosphere, as to its carbonaceous portion. But, if the geologist has a real founda- tion for such an hypothesis, we shall not do violence to the spirit of philosophy in supposing that atmospheric combinations and mixtures, excluding the idea of poisons, may reign in hospitals, cities, counties, districts or states, to the production of epidemic maladies. If a disease be contagious, it must be so by virtue of a material, or essence produced in and evolved from the person of an individual; and it is averred that A and B may propagate that cause from house to house, while C, D, and E are admitted to have no such power of trans- mission. A physician has even been called a walking pestilence, be- cause he has met with numerous examples of puerperal fever in his practice, while his brethren have had no such trying occurrences to lament. He has been tracked, it is said, by the victims of a contagion transmitted by his person. And it is quite true that we occasionally meet with inexplicable instances of the existence of the disease among the patients of a single practitioner, or of two or more medical people of a city or village, while the other brethren who continue their prac- tice in obstetricy encounter no untoward lying-in cases. It is a matter of great moment to determine the question of the contagion, or the non-contagiousness of puerperal fever. But it is a subject most difficult to investigate, and like the question of the contagiousness of plague, of cholera Asiatica, of yellow fever, likely long to remain unsettled, after useless discussions and inquiries. It would, perhaps, be wrong to say useless, since such inquiries lead, in the long run, to the establishment of the truth. But, how shall we settle it ? Certainly not by proving that I happen to encounter fifty or a hundred cases of puerperal fever among my patients, while my neighbor who has a larger practice than I, meets with no examples of the kind in the course of his business. Having practised midwifery a great many years, and having been concerned in the visitation of the sick laboring under puerperal fever whether sporadic or epidemic—visiting the same cases with those who have so cruelly been abused, as performing the part of a walking pesti- PUERPERAL FEVER. 591 lence, and scattering death and desolation where they desired only to do good—and seeing that I could never convict myself of being the means of spreading the contagion, I remain incredulous as to the con- tagiousness of the malady. I have gone from the dissection of the bodies of women dying at the hospital or in private practice with symptoms of the most violent puerperal peritonitis prevailing epide- mically there, and have never communicated it to those whom I soon afterwards delivered in their labors. I have visited the patients of those, among whose patients the disease seemed to extend because they were the attending physicians, yet I did not eonvey the malady into my own clinical practice, while they were loudly accused of so doing. One of these gentlemen has had the kindness to furnish me with a note, in which he relates that he has carefully examined his memoranda of cases of puerperal fever, and finds the whole number that he attended amounted to ninety-five, of which there occurred— In 1841, .... 3 " 1842, .... 9 " 1843, .... 45 " 1844, .... 25 " 1845, .... 6 " 1846, .... 7 making in all, ninety-five. The first case was on the 6th of September, 1841, and the last on the 6th of June, 1846. Seventy-seven recovered, and eighteen of the cases terminated fatally; of which, two were cases of twins, and three were cases of presentation of the arm. In eight of the cases, the child was born before the gentleman entered the chamber; and in four the delivery of the placenta had taken place previous to his arrival. Dr. Rutter, of this city, to whom I am obliged for the note in ques- tion, was engaged at that time in a most laborious midwifery practice ; a practice for which he is eminently qualified, by his knowledge, skill, and temper. The result of his practice during a disastrous epidemic might be taken as proof of his ability, for he lost only eighteen out of ninety-five patients, or one in five and a half; and that, in a class of cases that were characterized by the utmost intensity of violence, as I can bear witness, having seen some of them along with him. During the prevalence of the same epidemic at the Dublin Lying-in Hospital, while the distinguished Dr. Robert Collins was Master of the hospital, eighty-eight cases occurred. Of these eighty-eight cases, fifty-six proved fatal, which is equal to the loss of two out of every three cases, and that, too, under the watchful care of the most scrupulous and conscientious assistants, directed by a person of such high medical ability. 592 PUERPERAL FEVER. Gordon, up to the time of changing his mode of treatment, lost one in two of his patients; and the younger Hey, of Leeds, had a success not so good as this, until after he had discovered the Gordonian theory of the treatment of puerperal fever ; for up to that time, he lost eight out of ten. My friend Dr. Rutter informs me, that to one of the cases, he was summoned on the night of his return to the city, after an absence from it of ten days, at a distance of thirty-five miles. Previous to visiting the patient, he entered a warm bath, had his head shaved, put on a new wig, new hat, new boots, took a new handkerchief, and every article of his dress was bought new for the occasion ; leaving at home even his watch and pencil, and taking care, after the bath, not to touch a single article of the clothing he had previously worn. The patient whom he attended was immediately seized with the symptoms of puerperal fever. I was called to see her along with him, and attended her up to the period of her death, which took place on the eleventh day after the birth of the child. Two years later, in 1846, he resorted to the same precautionary means, before taking charge of the case, which being seized with the disease, likewise terminated fatally. Eleven of the children born in the ninety-five births died with erysi- pelas, commencing at the umbilicus, after the mother had succumbed to the malady; and four others perished in the same way, while the mother recovered from the attack. If the malady, which many of my brethren in this city supposed to have been propagated by the gentleman in question, had really been transmitted through his person, how shall we account for its attacking those women whose labor terminated previous to his arrival; or how shall we explain the exemption not only of many of his own patients, but of mine also, and those of other physicians called by him in con- sultation, from the influence of a contagion so direful. Would it not be more philosophical to say that one of those strange fatalities that are often found to occur, had brought him into contact with the cases of women ill, whereas his neighbors and fellow-practitioners, more fortu- nate than he, met only with the ordinary phenomena accompanying the lying-in state. I shall now relate a case that ought, I think, to convince you of the injustice of accusing an individual of so terrible a power as that of poisoning, by his presence or infectious contact, the bodies of patients intrusted to his care. A gentleman, a friend of mine here, who, during the prevalence of the same epidemic above referred to, unfortunately met with numerous PUERPERAL FEVER. 593 violent and fatal cases, was also supposed by many persons to have carried the poison about his person. On one occasion, he invited me to see an individual laboring under the malady, in the district of Kensing- ton. She was moribund at the time of my visit; and while deploring the event, he pointed out to me a house at no great distance, in which he was about losing a patient laboring under the same malady. He informed me that the person in question, whom he was accustomed to attend in her confinements, had engaged him to be present at her expected accouchement; but having been rendered anxious by the late sad events of his practice, and hearing nothing from her at the time proposed, he had called at her door to ask after her health. He was informed that she had been confined two days previously, but so sud- denly, and with so little difficulty, that they had not thought it neces- sary to notify him, or give him the trouble to call. He was told she was now indisposed, and invited to see her ; whereupon he entered her chamber, and found that the case, one of puerperal fever, had gone be- yond the curable stages. So that she must be added to the catalogue of the victims of this walking pestilence. You see how unjust it is, in making up the list of fatalities in the doctor's practice in the epidemic, to put down such a case as this among the victims of contagion. When did she take the poison ? Where did his other patients find it ? Does the doctor generate and distil the poison, or merely transfer it. If he transfers it, why don't I also diffuse it ?—we are equally men, equally clothed. No, gentlemen, you do not carry the poison ; you are merely unhappy in meeting with such accidents through God's providence. Dr. Collins, at page 387 of The Practical Treatise on Midwifery, in- forms us that in 1829, when he was Master of the Dublin Lying-in Hospital, puerperal fever, which, for several months previous had pre- vailed there, increased much in intensity. Upon consulting with the medical committee, it was recommended that no patient, except the absolutely destitute, be admitted ; but that assistance be afforded at their own homes. He then had all the wards, in rotation, filled with very condensed chlorine gas for forty-eight hours; the windows and all openings being carefully closed. The floor and wood work were then covered with chloride of lime of the consistence of cream, left on forty- eight hours ; after this, the wood work was painted, and the walls and ceiling washed with fresh lime. The blankets, &c. were scoured, and all stoved in a temperature of from 120c to 130°. From this time until the termination of his Mastership, in November 1833—that is, a period of fifty-seven months—he did not lose a single patient by the disease. 38 594 PUERPERAL FEVER. These facts are strongly calculated even to prove that the fever de- rived its origin from some local cause, and not from anything noxious in the atmosphere. To this, Dr. Collins says he should assent, was not the evidence equally strong of its existence in the houses of the rich. The prize work by the younger Baudelocque, entitled Traite de la Peritonite Puerperale, a work of the greatest, value, contains, at page 127, Dr. Baudelocque's observations of the subject of the contagiousness of the malady. He speaks of the difficulty of discriminating the epi- demic from the contagious character of a disease, which is as true of epidemic puerperal fever as of any other epidemic ; and thinks, in the present state of our knowledge, it is impossible to decide as to the contagiousness of our malady. But notwithstanding the sentiments of the English physicians, Joseph and John Clarke, he inclines to the opinion of the non-contagionists; and cites Mr. DugC's, who states that he has never known a case in which an Eleve-sage-femme, charged with the cases of women confined in the hospital, had carried the disease from a sick to a healthy woman: nor has he ever known the disease to be propagated from bed to bed in the ranges of wards appropriated to healthy women. M. Baudeloeque looks upon these facts as opposed to the doctrine of contagion, yet as not settling the question; and it would be presump- tuous, he thinks, to affirm that there is no contagiousness ; and that, disbelieving in contagion, he should nevertheless hold himself bound to act in any case as if contagion were possible. Dr. Robert Lee, at page 492 of his Lectures on the Theory and Practice of Midwifery, expresses the opinion that it is our duty to act, in all cases, as if the contagious nature of the disease had been com- pletely demonstrated. You ought to read Dr. Lee's thirty-ninth lecture, beginning at page 487, which is an excellent examination of the causes of inflammation of the uterus and its appendages in puerperal women. While I fear that the cases he has recited may tend to establish in your mind the doctrine of the contagiousness of the malady, I assure you nothing has yet served to convince me that it is transmitted by a physician or nurse; yet, notwithstanding such an opinion, I cannot wholly divest myself of an obligation to take the most especial care not to be the agent of its transmission, under the supposition that the contagionists possibly are right, and the non-contagionists possibly in error. It is an incontestable fact, whether the disease be contagious or not, that one midwifery practitioner is liable to meet with numerous cases in his practice, while his brethren, equally engaged in the same streets, villages, towns, or districts, shall meet with no cases at all. This was PUERPERAL FEVER. 595 remarkably proved in the epidemic at Aberdeen, the history of which is related by Alexander Gordon. Dr. Armstrong also tells us that forty out of fifty-three cases observed in Sunderland, occurred in the practice of one surgeon and his assistant. Gordon looked upon it as contagious; and he considered that every person who had been with a patient in puerperal fever became imbued with an atmosphere of infection, which was communicated to such preg- nant women as happened to come within its sphere.— Vide, page 51, of the Philadelphia ed., 1842. If you insist upon it, that the cases, like those of my friend Dr. Rutter, and those referred to by Dr. Armstrong, were communicated by contagion, you will be compelled to say, that either the constitution or the clothing of one individual has some peculiarity which enables him to carry the fomites wherever he goes ; while those of another person, apparently in the same state of health, and with a similar dress, is wholly incapable of transmitting it. This is a fact, and I conceive it to be an unanswerable one. I have proved it in my own case, over and over again, since I have gone from the houses of persons laboring under the most malignant forms of the disease, and from par- ticipating in necroscopic examinations, without carrying the malady with me. If you should assert that a medical man may generate or receive the fomites of our disease in his own constitution, without being at the same time subject to any manifest signs of the malady himself, you will arrive at a conclusion quite as probable as that of the contagiousness of this, generally speaking, serous malady. To the admission of its contagiousness, I find an insuperable objec- tion in the serous character of the malady, since the contagious mala- dies are, all of them, either mucous or dermal affections. It is true that some of the cases of gangrenous metritis that we meet with affect the mucous surface of the womb, if it hath one, which is still a subject of dispute among authors. But even admitting that the cause of puer- peral fever is to be communicated by contagion to the womb itself, you are to consider that metritis is only one of the several forms of puer- peral fever, many of which occur without at all interesting the internal structure of the uterus. I am more inclined then every day to reject the doctrine of the contagiousness of these maladies; and to look upon the occurrences that have gone so far to establish, in some men's minds, the opinion of its personal transmissibility, as to be explained upon the doctrine of accidents. It is a fact, that accidents happen in groups : very frequently railroad accidents happen in groups; numer- ous accidents at saw-mills happen in groups; accidents or murders from 596 PUERPERAL FEVER. firearms occur in groups; fractures of the limbs occur in groups, with- out any known connection between places or the number of individuals who suffer or the occasions which bring about the results. An insuper- able objection t<5 admit the contagiousness seems to me to exist in the fact, that the poison can affect only the parturient, and yet that poison, if there be one, must be more active than smallpox, or arsenic, or nico- tine—for in many of the cases it proves fatal in twenty-four hours, and not only so, but it acts without any period of incubation, some of the women being seized within four or six hours after the delivery. How can you reconcile this amazing virulence with the total innocuousness of the poison, as to doctors, nurses, children, and all other persons, save the parturient alone! From all the foregoing, you will perceive, my young friends, that 1 assert my disbelief in the contagiousness of the various forms of dis- ease that are grouped together under the title of puerperal or childbed fever • and you will have noticed at the same time that, notwithstanding my plenary assertion of this disbelief, I am not able to fly in the face of the assertions, and opinions, and sentiments of many of my medical brethren, worthy of my highest respect; so that, in fact, I do not feel at liberty to disobey their injunctions, as to taking all proper precau- tions against propagating by my person a malady so fatal in its nature. And I therefore most explicitly declare, and I beg you to bear in mind that I now make this declaration, that I think it will always be your duty, whether you may believe in the contagiousness or not, of a malady, to avoid, as far as it may be in your power, all occasion to transmit, if it can be transmitted, an epidemical or endemical disorder. Perhaps you could not do better in a way to settle your doubts on this point than by stating the proposition as follows: Women in child- bed are liable to several different' diseases, that are alike known as childbed fever; and that, whether the disorder be simple peritonitis, metritis, metro-peritonitis, uterine phlebitis, &c. It is asserted that the diseases thus denominated are contagious, and that the nurse in attend- ance on one case may carry the contagion to a considerable distance, and communicate it to a second and a third woman whom she may visit and assist; and also that the physician in any one such case may con- vey it with him to the several patients whom he may attend. Neither the nurse nor the physician is liable to be affected by the malady—nor can they convey it to the husband or mother or sister or child of the lying-in woman, nor to any other being than the lying-in woman. The doctrine of the contagionist thus declares that none but a lying-in woman can be affected with the subtle poison or contagion ; a dogma this, PUERPERAL FEVER. 597 which maintains that the lying-in woman is different in susceptibility from all other persons of the human race; whereas, all persons are un- deniably liable to be attacked with peritonitis, and also with phlebitis. If puerperal fever is the inflammatory disorder I have supposed, then to say that only a lying-in woman can be affected with the causes of this inflammation is, at most, to go very far in dogmatizing. It has often been observed that cases of puerperal fever have been particularly rife at the same time that there has been a considerable prevalence of erysipelatous diseases; and you will often hear in con- versation, and you will observe sometimes in your reading, that there is some connection asserted to exist between the nature of erysipelas and that of puerperal fever; and further, that there is an identity in the causes which produce them. In the Lying-in wards of our Pennsylvania Hospital, where puerperal fever has been repeatedly prevalent, it has been noticed, that numerous individuals laboring under wounds, whether from accidents or from sur- gical operations, have at the same period of time been laboring under erysipelas ; and it has become a sort of custom of the house to fear the outbreak of puerperal fever in our lying-in wards, whenever a remark- able rifeness of erysipelatous disease is observed in the Surgery. Never- theless, it is absolutely true that erysipelas frequently prevails in the Surgery when there is no puerperal fever among the women confined in the establishment. Erysipelas is a disease of the skin. I have no doubt that erysipelas is always an inflammation of the capillaries of the skin—it is always an endangitis; and although it is occasionally found to descend into the tissues lying beneath the skin, converting itself into what is called oedematous erysipelas, perpetrating the most direful mischief in the cel- lular and adipose structures there, it is essentially a dermal disease, and primarily can only affect the dermal structure. You might as well say that a woman has an iritis of her pylorus, which would be absolute non- sense, since no such tissue exists there, as to say that she has an erysi- pelas of the serous lining of her belly. It might be perfectly true that she has erysipelas of her vagina, or an erysipelas of the lining membrane of her womb—if she has one—a question still subjudice—because, a mu- cous tissue is nothing more or less than a true skin turned inwards: mu- cous textures and dermal are convertible terms; skin may be converted into mucous membrane, and mucous membrane may be converted into skin, in one instance by bathing it in fluids, in the other by exposing it to the drying influence of the atmosphere. You will find the proof of this in the cases of chronic prolapsus uteri, or inversion of the vagina, met with in practice. 598 PUERPERAL FEVER. There is not, and cannot be any identity between erysipelas, a dermal disease, and the deadly inflammation of the peritoneum observed in lying-in women; notwithstanding there may be some coincidence in the causes which, in the first case, render surgical patients liable to erysipe- las, or in the other, lying-in women to attacks of childbed fever. The fallacy in the case arises from this, that both erysipelas and pe- ritoneal and pleuritic inflammation are membranous maladies, not in general extending beneath the subcutaneous and subserous textures; and people have supposed, because they are membranous maladies, and alike liable to spread along the surface of membranes, that they are alike erysipelatous. If you choose to say, gentlemen, that every dis- ease that spreads far and wide over a membrane is erysipelatous, I have no objection to your calling it so. But I beg you to observe, that in that case the duty will devolve upon you of furnishing some new theory of the pathological lesions in our malady, which in some of the most deplorable instances exhibits no signs whatever of membranous disease, but proceeds to destroy the patient at once, by a process o* sphacelation, or ramollissement of the newly-delivered uterus, reducing it, in the space of six-and-thirty or eight-and-forty hours, to a condition of softness so complete, that a man's finger may be thrust through it as through a pudding. You had better say, therefore, that the disease is not erysipelatous ; but that, when erysipelas is epidemic, or endemical, the persons who are to be confined ought to take special care of themselves, since any in- temperies of the air giving a tendency to erysipelatous inflammation, exposes the accoucbe'e to attacks of puerperal inflammation. This is not less true of the prevalence of typhus, of smallpox, or other great epidemic maladies, whose domination is so universal, that they compel all manner of diseases and diseased propensities to come beneath their sway. At Aberdeen, in Scotland, there formerly lived a gentleman by the name of Alexander Gordon, whose name I have already mentioned in this letter, and who enjoyed an extensive practice there, and in the country round about, and was a man of distinguished ability, probity, and consideration. Dr. Gordon encountered an epidemic of puerperal fever, in and about Aberdeen, in the end of December, 1789, which continued to prevail epidemically in that region until the month of October, 1792. In this epidemic, he attended seventy-seven persons, of whom there died twenty- eight, according to his Table, which you will find at page 36 of his book, entitled A Treatise on the Epidemic Puerperal Fever of Aberdeen, &c. " It prevailed," he says, " principally among the lower classes of PUERPERAL FEVER. 599 women," and, on account of his public office, and his extensive practice of midwifery, most of the cases came under his care. The disease, at the time of its onset, was new and unknown at Aberdeen. Dr. Gordon was unacquainted with its real nature ; and out of the first twenty per- sons that he attended, from December, 1789, to October, 1790, he lost eleven, more than one-half of the cases; because he treated those cases without energy, and without intelligence. Having been taught, by woful experience, the inadequacy of his method ; and having enlightened his mind by the dissection of a few of the early victims, he adopted a more energetic practice, founded upon the substantial proofs of phlogistic action, revealed by the necroscopic inquiries. Dr. Gordon's volume is a small, unobtrusive book, written without arrogance or pretension: it is a plain, round, unvarnished tale ; being a history of his concern with the epidemic ; and carries so convincing and truthful an air into every page and line, that I cannot imagine anything better fitted to impress the mind of the reader with the warm and intense convictions of the writer. Half a century has elapsed since it appeared, and it is always quoted or referred to in treatises on the same subject, and never loses its good and solid reputation. Every medical practitioner, whether accoucheur or not, ought to read it with care; and I am almost ready to say that its perusal is indispensable to a right understanding of the history, nature, and treatment of puerperal peritonitis—not that I intend to declare that Dr. Gordon's observations, whether therapeutical or necroscopical, were sufficient to make plain the whole nature of the malady; but that, if a man take up the modern books only, there will be, in his notions of the subject, a void as to its literary history, and the history of its treatment, that no other book than Gordon's can fill. Whatever critics may please to say of Dr. Gordon's performance, however wofully they may have erred in their theory and practice in our malady, Gordon must ever be regarded as the reformer of our the- rapeutics in childbed fever: nor can it be denied that since his publi- cation there is universally diffused a more perfect and sensible conviction of the inflammatory character of the disorder, and, what is of far greater consequence, the little regard that need be paid to the state of the pulse in making up one's mind as to the necessity of treating it boldly in its curative stages. I say this even in view of Tonnelle"s celebrated papers. Gordon had neither leisure nor privilege to make numerous or elaborate dissections ; that task has been well fulfilled, eminently well, by Robert Lee, of London, in his Treatise on Puerperal Fever and Crural Phlebitis, which you will find at the 21st page of Barrington 600 PUERPERAL FEVER. and Haswell's edition before cited. The task has also been admirably performed by Tonnelle, and others. All the researches since his time have but added strength to the pathological explanations, that are first to be sought for in Gordon's volume. The newer and more minute essays, which proceed so much further than Gordon had gone, ought to be studied by every one of you ; for I do not believe that the writings of Hey, of the younger Baudelocque, of Armstrong, of Mackintosh and Lee, of Legouais, or Collins, combined together, could carry such a weight of conviction to the mind of the reader as the perusal of them after the study of Gordon's would do. Gordon is the first of the series, and the others wait on him, and honor themselves by illustrating him and their subject in confessing their obligations to the practitioner of Aberdeen. If it were in my power, gentlemen, to put into the hands of every member of the class a copy of Barrington and Haswell's volume, I would not take the trouble to write this letter ; for I believe that a study of that volume alone—I don't say merely the reading of it, but a careful study and a conscientious examination of that volume alone—is almost enough for a man's education on the subject of childbed fever, whether sporadic or epidemic. It cannot be too often repeated that the pregnant woman approach- ing the time of utero-gestation, generally undergoes many modifica- tions as to the crasis of her blood, and suffers no inconsiderable changes in regard to the recrementitial absorptions of her body; since the pres- sure, intrusion, and distension of important textures cannot fail signally to interfere at many points with the innervative, assimilative, secretory, and absorbing functions. I think it would not be extravagant to say, that few women march up to the termination of pregnancy without falling into a state deserving to be called pathological. When the child has been born—often after the most cruel sufferings and the most pro- tracted exertion ; amidst the most convulsive efforts of the will; amidst doubt, anxiety, and fear—the uterus, returning upon itself, hastens to recover its non-gravid form and dimensions, leaving the constitution under the necessity of disposing of the surplus fluids and solid parts, which the pregnancy had called into existence. Tissues have been pressed together, subjected to contusions, and often to slight and unsus- pected ruptures, or lacerations; the placental orifices of the uterine sinuses are left bleeding and inflaming ; so that thousands and thou- sands of provocations to sanguine engorgement and acute inflammation always exist as to them. You will find a picture strongly drawn at the 475th page of Archives GenSrales, t. 22, 1830, by Tonnelle', in which it is asserted that gestation and parturition produce in the constitution PUERPERAL FEVER. 601 effects not very dissimilar from those developed by the causes of typhus fever. It is justly to be regarded as a matter of wonder that so many thou- sands of women escape unharmed the operation of these unfavorable influences ; nor should we be surprised when we meet with persons in whom violent disease has been developed by the operation of such causes. In particular, ought we to feel no astonishment, if an aerial cause, having the potency of an epidemic principle, come to add its force to the personal ones just enumerated. We ought, then, to regard a newly-delivered woman as by no means freed from the- perils of childbirth, because her child has just been born. In fact, so few women die in labor, or in consequence of injury done to the tissues in labor, that it might almost be said to be not at all dangerous to go through that process. The childbed mortality is a post-parturient mortality, consisting mainly in the results of inflamma- tory action attacking the reproductive tissues, and the parts directly connected with them. A woman shall now and then be found to perish from hemorrhage, convulsions, or inflammation of the lungs ; from a cerebritis; from an attack of diarrhoea; from a bilious or typhus fever, or some chronic ailment of the intestinal tube, forced into destructive activity by the parturient circumstances ; but, it is almost true to say, that when a woman dies within some eight or ten days after delivery, she has perished with puerperal fever, since so few of them are known to perish from other causes. There is sufficient evidence of the fact that occult causes, whether atmospheric or local, are capable of so impressing the human economy as to give it a tendency, when affected by known morbific powers, to exhibit the effects of such forces, under sthenic on the one hand, and on the other under asthenic forms. Thus, for a series of years, the lancet, and the most powerful antiphlogistic methods are generally adopted by the profession; whereas, another series shall succeed, during which such methods come to be proscribed, and generally, at least, abandoned by our people. If, then, puerperal fever be a true inflam- mation, that inflammation may be a very different sort of malady when occurring in a constitution prone to typhoid forms of disease, from the same inflammation attacking an individual in a highly phlogistic and reactive condition of life, each suffering according to the nature of the epidemic constitution of the air. Local disorders always take their tendencies from the state of the whole nerve-force; and an inflammation of the womb or of the peritoneum, may be either in the highest degree vigorous, or to the last degree typhous in its nature. The inflamma- tion, however, always remains essentially the same malady, regarded as 002 PUERPERAL FEVER. local—the constitutional disturbances flowing out of it are widely differ- ent, in the two opposite, or s}Tnochous and typhous formulas. All the necroscopic examinations concur to show, that puerperal fever ia a febrile condition developed in the system from certain radiating points of local inflammation of the reproductive organs. A puerperal fever that proves fatal, and leaves no trace of inflammation demonstrable by the necroscopic inquiry, ceases on that account to have, in my opinion, the value of puerperal fever ; it is something else. I do not mean to say that if you examine the body of a female who has died, as you sup- pose, of puerperal fever, and find no gangrene or softening of the uterus, no inflammation or deposits within the belly, you are, therefore, to sup- pose that you have been mistaken in your diagnostic; you will find in the pathological records abundance of examples of the absence of these traces. But these very cases, being those of persons who have perished with all the constant signs of our malady, are cases of endangial dis- ease, attacking the vessels of the uterus and parts in its vicinity: en- dangial disease, running early to the extent of pus-production or the pyogenic stage, may rapidly destroy the patient from purulent infection of the whole mass of the blood. I have no doubt that some of M. Ton- nelle" s cases were of this very kind. The attack of puerperal fever generally begins previous to the fourth day after delivery of the child. Not a few examples are recorded, in which it began previous to the labor. I have seen such a case myself. For the most part, the dangerous day is the third day, for that is the period at which the new fluxional movement towards the mammary glands begins to take place. If the occasional causes of the disease have been in action, this fluxional movement, itself alone, might become sufficient to act as the exciting cause; laying the foundation, perhaps, in a few moments of active operation, of an inflammation that shall spread with frightful rapidity throughout the most important textures. It rarely happens that an attack of puerperal fever comes on, in the absence of the physician, without its being mistaken for an after-pain ; and, in fact, the pain at the commencement is accompanied with alter- nations of increased and lessening distress, which is likely to mislead in the diagnostic. If the irritation is intense at the commencement, its constitutional influence is manifested by rigors, that may be simply moderate rigors, or that may rise to the height of the most violent ague-fit. The chill may last twenty minutes, or two hours, or more, and is followed by febrile reaction more or less open and free, according as the powers of the nervous system shall be exerted with a greater or less energy at the sources of the circulation. The chill of puerperal fever is found, in PUERPERAL FEVER. 603 some instances, to precede the attack of pain; from which you are not to conclude that the chill is the real cause of the attack. The chill is but a sign, not a cause of the commencement of inflammation. A woman who is to be attacked with puerperal fever is a woman in health, or rather in a state of quasi health: she has neither smallpox, nor Syrian plague, nor yellow fever, though she may have a proneness to fall ill with what you call childbed fever. If you fire a bullet through her womb, or tear it, or contuse it with a pair of forceps or a sharp crotchet, and she die of the inflammation resulting from the accident, she will die of puerperal fever. And so if from the intense irritation endured by the organ under after-pains; if from the impetuous mo- mentum of torrents of blood determined upon its tissue during a rigor or an ague consequent upon swallowing a tumbler of iced water, or of getting out of bed while in a state of perspiration ; or of the intempest- ive action of a drastic purgative dose; or if, from whatsoever cause, the bloodvessel system of the uterus becomes the seat of a local inflam- mation, that inflammation will determine in her the onset of childbed fever, which you shall denominate uterine phlebitis, metro-peritonitis, ovaritis, simple peritonitis, or inflammation of the lymphatics of the uterus, according as the phenomena clearly made manifest during the life of the patient, or upon examination after death, shall determine you to call it. Don't you see, my dear friends, how impossible it is for me, after writing the above paragraph, to admit the possibility of a specific contagion as the cause of this malady; a contagion which, if it does really exist, must in a thousand instances act without the interven- tion of the shortest imaginable incubative stage. Sometimes the pain, which at the onset of puerperal fever is felt in the hypogastric region, is too intense to be borne by any human pa- tience ; and no exhortation or recommendation can prevent the woman from crying out aloud, or even screaming in her agony. I have seen patients who not only appeared to suffer intolerable pain, but in whose minds that pain appeared to excite the most unspeakable terror. I think I have seen women who appeared to be awe-struck with the dread- ful force of their distress, as you might imagine an ancient Roman matron to be who might suppose such a pain to be inflicted by an ictus Jovis, the anger of the Gods. The pain, however, soon loses a portion of its intensity, and no doubt much of the earliest and sharpest pain is neuralgic, since it is not in the nature of mere inflammation to occasion such great sufferings. The paroxysmal character of the pain in metritis must be deemed to be occasioned by a convulsive or spasmodic constriction of the inflamed tissues, under the irregular activity of the muscular fibres of the organ, 604 PUERPERAL FEVER. which soon ceases, allowing the pain to become more settled, steady, and bearable. If there be a chill, there will be found, as in all chills, increased frequency of the heart's action: the systole comes in a very short time to be repeated at the rate of 120 or even 160 beats per minute. This is necessarily accompanied with congenerous modification of the action of the respiratory muscles ; and there is no part of the whole economy of the creature throughout which the blood is not driven with an im- petuous haste and force. But the brain cannot receive such modified injections of the blood, and of the oxygen of the blood, upon which depends its power to evolve neurosity, without irradiating its nerve power morbidly to every part and parcel of the tissues of the woman. So that you see, gentlemen, there is no occasion to be surprised or astonished, when, after having left your patient at ten o'clock in the evening comfortable, and apparently without any untoward symptom or accident, you find her at six in the morning a prey to the most un- speakable disorders of the innervation, the respiration, and the circu- lation. The foregoing is sufficient to set forth my opinion as to the nature and beginning of the attack of childbed fever. To show you what may be the organs involved in the ravages of a disease thus commencing, I shall cite for you some passages from TonneMs paper, op citat., page 482. This author, in the great epidemic which he witnessed at the Ma- ternite in Paris, when he acted as resident student there, under the guidance of the celebrated Prof. Desormeaux, had the extraordinary opportunity, but still more wonderful industry, to dissect the bodies of two hundred and twenty-four women who died under his care—more than perished at Contreras, Churubusco, or Chapultepec. He gives the following tables showing the tissues affected:— 193 gave peritonitis. 197 gave disease apparently of the womb. 4 represents the excess of the uterine cases over the cases of peritonitis. One hundred and ninety cases gave— 79 of simple peritonitis. 29 of superficial ramollissement of the womb. 20 of deep-seated ramollissement of the womb. 58 of inflammation of the ovaries. 4 of inflammation of the ovaries, with abscess. 90 cases gave pus in the veins. 32 " gave pus in the lymphatics. PUERPERAL FEVER. 605 3 cases gave pus in the thoracic duct. 9 " gave inflammation and suppuration of the lumbar, in- guinal, and other glands. The whole epidemic was characterized by three formulas of puerperal fever, as follows :— Inflammatory or simple inflamma- f The peritoneum, the womb and its ap- tion of different organs. «- pendages. f 5 3 J _ . ... „ ,, Consecutive suppuration of the veins; ' Typhoid form, or from alterations . , * i or accompanying putrescence or ramol- j lissement. I Ataxic form, or lesions of the innervation. Now, this is sufficient to set forth in a clear manner, as far as it goes, the doctrines you ought to adopt as to the pathological seats of our disease ; and let us therefore proceed to trace the character of it. Let us suppose that it is one of the peritoneal cases; a case in which the peritoneal surface of the womb, of one or both of the broad liga- ments, or of an ovarium is the radiant point, the first red-specked point of inflammation. Suppose the inflammation to extend upon the intes- tines, to attack the meso-rectum, the peritoneum covering the iliacus internus, the mesentery, the whole peritoneal coat of the smaller intes- tines and the omentum—the mesocolon and the colon—the stomach, the peritoneal coat of the liver, and the entire lining of the diaphragm, as well as of the kidneys and spleen ; and then you will have an idea of a woman laboring in the lying-in state under a universal peritoneal inflammation. Consider now that she has passed through the whole of the evolutions of a nine-months' gestation; through the convulsions, intellectual, phy- sical, and moral—of the conflict of labor ; and, to a certain extent, through the mutations of her constitution consequent upon delivery ; her blood deranged as to its crasis : her neurine exhausted by protracted exertion of its functional power, and her whole endangium in a condi- tion in which it is highly prone to take on, if it have not already fallen into a real pathological state. What is the condition of your patient ? Has she not hepatitis ? Has not she a pure hepatitis, the whole peritoneal surface of whose liver is inflamed ? If the whole outer superficies of your stomach is in a state of incandescent inflammation, have you not a gastritis ? But suppose her mesocolon, her mesentery, her meso-rectum, her ligamenta lata all burning, like a prairie on fire; are not all these parts in a state of inflammation ? And if they be, what wonder have you to find her whole nervous system shocked, overwhelmed, staggering, as under a 606 PUERPERAL FEVER. concussion, and crushed to death by a load of diseased perceptions and vascular and textural obstructions impossible to be borne ? This is a picture, not at all exaggerated, of some of the forms of pu- erperal fever. That individual is very tenacious of life who fails to succumb under the earlier stages of the mortal developments of such inflammation. There are multitudes who die before it can come to the stage of effusion or sphacelation; but death must come to many of those whose peritoneal cavity contains pints or quarts of serum in which float masses of coagulated albumen. The uterus and intestines and perito- neal surfaces are tied together by a complete magma of coagulable lymph, beneath which are to be found softening of the tissues, and other results of the most intense inflammatory action. Inflammation is inflammation; it is not weakness or debility ; it is development force violently exaggerated in the tissue which is the subject of that force. I pray you, young gentlemen, do me the favor to turn back to Letter XXL, and you will find, on the 296th page, my quotation of several paragraphs from M. Serres's Anatomie Transcendente. If you mean to read my letter on puerperal fever, I am very desirous that you should really appreciate my meaning and intent, and the reading of M. Serres's extract will be a good preparation therefor. It will show you that the products of inflammation are the products of a force acting in pro- gression, and not in retreat, and that inflammation is the result of an increased action of the development force, tearing or bursting to pieces the organs in which it revels. Let us take another case. Let us suppose a case in which the endan- gial membrane of the uterine veins begins to be inflamed at their orifices, which are patulous in the now denuded placental surface, and, pro- gressing rapidly along the membrane, involves the whole vascular system of the uterine sinuses and veins in its embrace. Look at it now. Can't you see it with the eye of faith ? What is faith ? The Bible tells you that faith is the evidence of things not seen. Have you not that evidence ? Look at Tonnelle" s paper, op. citat., page 483. His table is as follows : In ninety autopsies, 32 had suppuration of the veins, with purulent degeneration of the uterus. 11 had ramollescence or putrescence of the womb. 5 had metritis and ramollescence combined. 34 had peritonitis without other alteration. 8 had suppuration alone. Here is the evidence, which your faith ought to see, of the state of PUERPERAL FEVER. 607 suppuration of the veins—a result of inflammation of the endangial tissues. Thirty-two out of ninety cases ! Look at it again. Don't you see two vast uterine arteries, coming off from the internal iliac or the ischiadic ? And don't you see, also, two powerful branches, which we call the spermatic, the sum of whose transverse areas or lights is a vast sum, through which is pouring, under the convulsive and disordered action of the systole, a torrent of blood to fill up the capillary circulation of the uterus, and which shall find no other way of escaping out of the womb than through the thickened, swollen, obstructed, and often totally obliterated vein tubes, of which I spoke ? If you would read M. Raciborski's admirable Treatise on the Veins, you would learn from it that a vein, when it enters a viscus, leaves all its accessory coats at the entrance, and carries in with it nothing but its endangium, or what Bichat calls its membrane commune. If this be the case in the vein-distribution within the womb, then you cannot doubt that uterine phlebitis will always be coincident with metritis— that is, with inflammation of some part of the substance of the uterine texture. Raciborski's paper on the veins, in the 9th vol. of the Memoirs of the Royal Acad, of Med. for Dec. 1840, contains an assertion that a woman cannot recover from the accouchement without adhesive phlebitis of the womb; and that every case of what is called milk fever is a case of true' phlebitis. " La fievre de lait n'est done pour nous que la fievre traumatique, occasionne'e par le travail de l'accouchement, modified plus ou moins par les circonstances particulieres au milieu desquelles se trouve une femme qui vient d'accoucher. C'est la fievre puerpe'rale Cphemere, d'apr^s Doublet."—p. 621. Look again—with your eye of faith—I say, and inquire how the volumes and torrents of blood that are becoming more and more packed and jammed into the capillary body of the organ are to flow off and let the organ recover by Mr. John Hunter's process of resolution. Suppose it cannot flow off as fast as it arrives—will not the womb die?—will not the inflammation reach that height and intenseness that must, as Dr. Physick used to tell us, transcend the power of recovery, and must therefore end in the destruction or disorganization of the tissue! It will be destroyed, it will be disorganized—it will perish by gangrene, or by ramollissement, which virtually is the same thing expressed in different words. The womb will die, and the woman will die in conse- quence ; for she cannot continue to live while her nervous system suffers the shock or the irritation attending upon such an intolerable 608 PUERPERAL FEVER. organic perception as that. She will die; and it will not unfrequently happen that she shall die within thirty-six or forty-eight hours from the onset of the malady, and some cases terminate fatally even in eight hours. She may die with this very malady alone; and when you come to explore the pathological lesions, you will find, perhaps as in the ninety cases reported by Tonnelle, that eight of them exhibit no com- plication or extension of diseased action. You must cure these diseases. They are, however, to be cured promptly, or not at all. Such a malady as this hurries with hot and furious haste to a term beyond which there is not, and cannot be any useful Therapia. But it is time, gentlemen, to return to the consideration of some of the phenomena that accompany the malady when it is complicated with or consists solely of peritoneal inflammation. The disorder attacks, in general, before the end of the fourth day. The womb remains, up to that period, very large ; its fundus jutting far above the plane of the superior strait. Upon each side of the organ rests a psoas muscle, which overhangs, by its inner margin, the side of the brim of the pelvis. When this muscle is contracted, which is always done in the act of drawing up the knees, the belly of the muscle swells, and presses upon the side of the womb; the pressure gives pain, and the woman knows it. She therefore dislikes to draw up the knees often, for fear of the hurt. When once drawn up, however, by the contractile effort of the psoas, the foot rests planted on the bed, and the psoas relaxes—so that it hurts her less when drawn up than when extended. She soon in- stinctively draws up her knees, therefore, but she keeps them up. When you go into a lying-in chamber, and find the patient in this attitude, you ought to inquire why she prefers it. She may prefer it because the uterus is less compressed by the psoas ; and also, because the peritoneal covering of the psoae being inflamed, is relaxed by the relaxation of the muscles. For many years past, I have perhaps never called upon one of my accouchC'es, within four or five days after the delivery, without asking her to show me whether she could draw up her knees without pain. If she can do so, I am always content. The iliacus internus muscle that lies upon the fossa or venter of the ilium, gives pain if contracted, when the peritoneum that invests it is inflamed. Hence, I cause my patient to rotate the lower extremity, in order to inquire whether the action of the muscle produces pain, and, if it does not, I cannot deem it covered by an inflamed peritoneum. In all cases of a suspicious character, you ought to direct the monthly nurse to remove the binder for you, and then, covering the patient's ab- PUERPERAL FEVER. 609 domen only with the thinnest dress, give you an opportunity to make a careful exploratory palpation of the belly. By means of palpation and percussion, you may come with great certainty and confidence also, to a firm conclusion that the pain is, or is not peritoneal or metritic, or ovaric. * You cannot make any useful researches if one or two petticoats, and other garments be interposed between the hand and the belly. It is very difficult sometimes to say clearly that it is inflammation, and not after-pain; or that it is, or is not rheumatism, or neuralgia, or colic. Suppose the peritonitis to seize on the serous coat of the large and small intestines ! Tympanitis will commence very soon after the inva- sion. The muscles of the bowels are found torpified and refraining, under a sort of teleological sense, to act, while their peritoneal invest- ment is inflamed. The gases that are now extricated in great volumes from the ingesta fill up and distend the alimentary tube, and the abdo- men becomes as large as previous to the labor. This is the tympanitis. I saw a case, and more than one, in which it became inflated in the course of a very few hours after the attacking chill had come on—and be- coming hard and resisting, though highly sonorous on percussion, refused to yield to any kind of aperient or purgative means, as completely as if the peristaltic muscles were in perfect paralysis—the patient perishing within thirty-six hours. Pray, my young friends, do not allow this ballooning of the belly to become too great, under some idle fear of the effect of purgatives. A patient often more urgently requires to purge off the intestinal gases than the bilious or acid saburra that plagues her. Whoever objects to the use of purgative doses upon some hypothesis of their being injurious in puerperal fever, must be a person of little reflection and less judgment. An extreme degree of tympany implies an extreme inflation of large portions of the intestinal tractus, in which case the coats of the bowel become stretched like a drum-head, and are, under percussion, as sono- rous as a tambourine. Reflect for a moment on the effects of such distension upon the play of several important functions. For example : Reflect upon the capil- lary circulation in the intestinal textures while stretched to bursting: can there be a resolution obtained, without previous detente, of the bowel?—Again. Here is a great mass of inflamed intestines, and other organs that fill up and enormously distend the belly—they even thrust the diaphragm upwards as they push the abdominal muscles and tegu- mentary tissues outwards to the size of the gravid abdomen at term, and even further out than that. 39 610 PUERPERAL FEVER. Can the diaphragm descend in the aspiration without crushing down- wards before it, this inflamed and highly sensitive mass ? No! Every breath gives pain—to make a long aspiration is impossible; and to cough or to sneeze is to be agonized. The diaphragm works with short strokes then, for the respiratory piston descends only half-way down the cylinder of the trunk, and it works like a steam piston cut off at half stroke. In the mean time, the oxygen of the respiration is indispens- able—and if a certain quantity cannot be supplied by the half-stroke, that stroke must be repeated twice, or thrice for once. Here, then, we have a new source of disorders in the redoubled and trebled frequency of the respiratory acts. So much oxygen—or death—that is the alterna- tive; and, if the breathings must be repeated at half-strokes, or at quarter-strokes, at the rate of sixty respirations per minute, the me- dulla oblongata must furnish the nervous material. What an exhaust- ing operation! Here, then, you get the hurried, singultiform, staccato respiration of your puerperal fever cases. When this respiratory difficulty rises to a certain height—and the nervous supply grows feebler and feebler from the exhaustion of the neurine—the blood commences to be less perfectly decarbonized, or less completely oxygenated. The oxygeniferous streams in the brain are changed for carboniferous streams, and, pari passu, with their increase the innervations lessen; they cease; and the life is fled at the moment of that cessation. Such are the evils arising from the tympany of childbed fever. All the medicines that excite the peristaltic muscles of the bowels, to expel this gas, are purgatives or laxatives. Is it true, then, that purgative medicines are contra-indicated in our malady ? What stupid misapprehension to say so ! Is it not easy to perceive that one of the most inconvenient and dangerous of the ac- cidents that can happen to a female attacked with puerperal peritonitis, is this very inflation of the alimentary tube; and that the means of obviating it are among the most important that can be sought for as securities for the cure of the essential malady—by which I mean the actual inflammation? We shall now, if you please, advert to the state of the heart in puerperal fever:— " The nervous filaments that animate the heart come from the pneu- mogastric and the great sympathetic." These words I have cited from Longet's Anatomie et Physiologie du Systeme Nerveux Sec. torn ii page 526. I do not ask you, however to adopt any other opinion as to the source of the heart's motion than this, viz: that it depends unon the neurosity determined into it, or generated within it—and that this same neurosity is the result of the presence and combination of oxygen PUERPERAL FEVER. 611 and neurine. I have no doubt, in my own mind, as to the power of the pneumogastric and the sympathetic to modify, and, to a certain extent, co-ordinate the movements of the several parts of the heart. I am not at all surprised, then, to find when the organic and intellectual per- ceptivity of the woman are brought to feel the impressions made by an inflammation, whether metritis or metro-peritonitis, that, the reflex power of the nervous centres directed upon the heart, should rapidly and greatly augment its rate of action. A thought, a sentiment, a shock can set the heart off at full speed. The profound impression of a great viscus in danger can equally excite its forces. The heart, then, in puerperal fever, beats with redoubled frequency, and we expect to find the pulses at the wrist rise to 120, or even 150 beats per minute. Along with this great acceleration of the circulation, there will be an increased extrication of animal heat, and a coincident mischief to the constitution of the blood, whose normal rate of movement is expressed by a radial pulse of a certain volume, beating only seventy times a minute. See what great disorders are introduced into the actions of the economy—see what you ought to do for your patient! You ought to keep down the frequency of the pulse, in order to lessen the call on the sources of the heart's motion at the origin of the vagus and in the sympathetic arches. You ought to lessen the evolution of animal heat by lessening the intensity of the respiration and circulation. In short, you should look on all the phenomena exhibited by the constitution as the signs and results of a topical lesion—videl. the metritic, or the metro-peritonitic lesion—and you should use all the means within your control to guard the constitution against the irritating and disordering influences of that metritis, phlebitis, or peritonitis. I am far from denying that a status of the constitution, a status ante febrim, may rule and modify the march of the malady; it would be as unreasonable to deny it as it would be to deny that one individual is weak, and an- other strong—one prone to violent, and another to mere passive or ataxic forms of disease. But I contend that the disease is one and the same, everywhere, always; sporadic or endemial; in private practice, or in the hospital clinic. It is essentially inflammation, and though not always to be approached by the same precise remedies, yet always on the same principles. As to the mode of treatment for our disease, it is clear that your intentions of cure must flow out of your views of the whole of the phenomena, seen in the light in which they may be presented to your minds at the bedside. If you imbibe the idea that they depend upon a typhous state of the constitution, you will scarcely fail to treat it as 612 PUERPERAL FEVER. typhus. M. Tonnelle' remarks upon the fact that almost every observer selects and advocates a method, one of his own, to the exclusion of all others; one person proclaiming the success of general bleeding—an- other of topical bloodletting; one of mercurials, and another of ipe- cacuanha, or purgatives. It seems to me that all this uncertainty arises from the imperfect etiology of the case as deemed of by the proneurs of each particular practical mode. I have myself been condemned in some of the foreign journals as extremely sanguinary, as it is called, in my sentiments as to the treat- ment of the cases ; and if by sanguinary is meant that I look upon venesection as the remedy, I am willing so to be held. But let us proceed, now, my friends, to inquire calmly and dispassionately, if we can, into the claims of the different methods of cure. Let us try to divest ourselves of all feelings like party feelings in the case, and in- vestigate the subject with a heartfelt desire to discover the truth, that we may enjoy the benefits of the truth in going about doing good in our vocation. For my own part, I hope that there is in me no wish to cause any particular theory to flourish, since, whether it flourish or fall, I am not interested, as I am no founder of systems, but rather a mere humble imitator and grateful admirer of those good writers who have taught me my art, and to whom I am willing still to be nothing more than a docile Pupil and humble Student of Medicine. In a former part of this letter, I said that I considered Alexander Gordon, of Aberdeen, as the real informer of our therapy in childbed fever. Now, I propose to inquire further as to his claims to be so regarded. If I should retrace the history of our disease, I should write a whole volume, and not a letter; I cannot, therefore, entertain you with a retrospective review of childbed fever. It is enough to know that before Gordon's time, it was excessively mortal—and is so still, wherever his book is not read or felt. Dr. Wil- liam Hunter lost thirty-one out of thirty-two cases of it. In Paris there was an epidemic, in 1750, which killed every patient. Denman, Leake, and others, were afraid to treat it as it required to be treated; and Gordon, a man of sense, says that the "disease, when left to nature or improperly treated, generally proves fatal," and he very correctly ac- cuses Leake of advising prompt, copious bleedings, while in practice lie took away only eight or ten ounces. I have already said that Gordon lost nineteen out of thirty-eight of the first cases that he encountered in his epidemic. It was the thirty- eighth case that afforded him the materials for dissection, and he makes at the end of the account of that case, the following remarks after PUERPERAL FEVER. 613 having given a statement of the inflammatory results disclosed in the autopsy. "If," says he, " either the quantity of blood taken away at the two bleedings had been taken away at the first bleeding, or the purging been continued, which was exchanged for sweating, I am thoroughly convinced that we should have been able completely to over- come the disease. This was the opinion which I formed from the dis- section, and its truth was confirmed by my success in all the succeeding cases to which I was called. Thus, the loss of this patient was the means of saving many others." He subsequently attended thirty-nine cases of the disease, of which he lost only ten, and saved twenty-nine; so that, of his whole epidemic, forty-nine patients recovered and twenty- eight died. He says: " We are directed by Drs. Milne and Leake to form our judgment from the pulse. But I assert, in the most PEREMPTORY MANNER, THAT IF PRACTITIONERS 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." " The Conduct of practitioners must be governed by the stage of the disease and not by the state of the pulse." Dr. Gordon, at page 47, says: " Of those of these patients who got wine and cordials, under the idea that the disease was putrid, none re- covered," which he considers as evidence that the puerperal fever is an inflammation. He admits that it frequently puts on a putrid appear- ance in its progress, which he most judiciously explains as the effect of the uncured, violent inflammation; and he asserts, that when the dis- ease is properly treated at the commencement of the inflammatory stage, no symptoms of putridity appear. Omitting any notice of the intervening chapters, I shall refer you to his sixth chapter, on the cure of the malady. At the 55th page, you will find these words: " When I took away only ten or twelve ounces of blood from my patient, she always died; but when I had courage to take away twenty or twenty-four ounces at one bleeding, in the begin- ning of the disease, she never failed to recover." He insists upon it, that the practitioner should never take away less than twenty or twenty-four ounces at one bleeding; and that, other- wise, he will fail in curing the patient. At page 56, it appears he had felt the prejudice against bleeding in full force, for he lost every patient from whom he took not more than twelve, fourteen, or even sixteen ounces. Please to observe that Dr. Gordon says, " This abstraction of blood must be made within six or eight hours after the attack, or it will fail;" and adds that he declined using the lancet at a later period, 614 PUERPERAL FEVER. because he knew that it would fail, and he would not bring that remedy into discredit. Let me cite for you from the 60th page. This, it may be said, con- tains the summary of his precepts as to venesection; and although the period at which he would still bleed is fixed rather later after the attack, I am disposed to take it as the last satisfactory result of all his experi- ence. It is as follows:— " After much experience in the disease, and after mature deliberation concerning the conduct which ought to be pursued in my peculiar situa- tion, I came to the following resolution: If called to a case within twelve hours after the attack, I insisted on bleeding the patient, and promised for its success; but, if at a later period, viz., from twelve to twenty-four hours after the attack, in this case, like Sydenham with the same remedy in smallpox, I thought it incumbent on me to propose it as the only effectual remedy; but I neither insisted upon it, nor pro- mised for its success." Mr. William Hey, Junior, practitioner at Leeds, a man of talent and candor, who encountered epidemic puerperal fever in 1809-12, gives us the account of thirty of his cases. The disease was first seen by him December 9, 1809, and, up to the time of his ninth case, in June 1810, Mr. Hey had not seen Gordon's treatise. His attention being then called to Gordon's doctrines, he adopted that author's recom- mendations, and went through the remainder of the same epidemic with the most brilliant and happy success. You will find the same good fortune as to Dr. Armstrong's practice in the Sunderland epidemic and the fine practice of Dr. Robert Lee of London. Hey does not inform us how many cases he had during the whole prevalence of the epidemic. He merely says a great number of them came under his observation. Of the thirty cases published in detail, the following is a tabular view of the dates, the treatment by venesec- tion or otherwise, and the results. Case 1, 1819, December 9, 2, a no date, 3, a December 27, 4, a no date, 5, 1810, January 26, 6, u 26, 7, u February 5, 8, u 7, 9, a June 18, 10, a July 5, Not bled bled died. recovered. died. cured. PUERPERAL FEVER. 615 Here, then, is a table showing, that of ten cases from December 9, 1809, to July 19, 1810, in which two recovered and eight died, only the last, or No. 10, was really bled; since the other, No. 9, was bled but seven ounces twice, and three ounces at other times, which had no effect on the disease. Mr. Hey having fearfully and timidly bled his patient No. 9, and having at that time, January 18, six months after the breaking out of the disease, become acquainted with Gordon's writings, followed his plan in case 10, which was promptly cured, and gave a fortunate turn to the direction of his views. After stating the first acquaintance he got with Gordon's work, which opened his eyes to the truth (see page 107, op citat.), he uses these words, at page 111: " The next case that occurred was the first of three, which were all that proved unsuccessful *in my practice, out of a great number—after the change of treatment adopted in the preceding case (No. 10), and I hope we shall be able to show that the method of cure we now employ had not a fair trial in any of them ; and consequently that they cannot be justly considered as instances of its failure." It is to be regretted that we do not know how many cases he had subsequent to July 30, 1810 ; he says, " a great number ;" and you perceive, by his own showing, that the first examples under his care were very fatal, being eight out of ten. There is an admirable paper, entitled Reflexions et Observations sur Vemploi des Saignies et des Purgatifs, dans le Traitement de la Peri- tonite PuerpSrale, by Legouais. Dr. Legouais was resident physician at the Maternite', at Paris, where he had large opportunities of studying the malady in question. At page 21, he insists, like Gordon, upon one of the conditions of success in the use of bloodletting, which is, that the evacuation must be effect- ive__in an abundance suitable to the gravity and extent of the in- flammation. "Experience," he says, at page 22, "has confirmed me in the belief that bloodletting is never truly useful except when it is able to destroy the malady at a blow, and blot it out—so to speak—at its very origin." It appeared to him that this is the very case to apply the " jugulare febrim," so celebrated as a mot of Galen. He says that it is like the fabled Hydra, which cannot be conquered but by cutting off all the heads at one blow; if a single one be left, it has sufficient vital force speedily to reproduce the monster, in a form more terrible than before. But I am in danger of making out of this single letter a whole book, and perhaps of expressing myself with the warmth of a partisan, which I sincerely desire to avoid. I ought, therefore, to make no more cita- 616 PUERPERAL FEVER. tions : not even from the prize essay of the younger Baudelocque, in favor of the use of the lancet in the treatment of our malady ; nor from Mackintosh—nor from West—nor from David D. Davis—nor from Denman himself, after he had recovered his senses upon the subject. But you must excuse me if I advert to the reports of cases under that distinguished author, Dr. Robert Collins, of Dublin; and I do so the more willingly because I ought not to show you only the side that is favorable to my own views. I should think that no work upon mid- wifery that has appeared since the beginning of the present century has acquired greater reputation for its author than the Practical Trea- tise on 3Iidwifery, $c. by Dr. Robert Collins, and it certainly is one of the most important contributions that has been recently made to the Obstetric art and science. It is replete with the most judicious direc- tions, and impressed with the characteristics one might expect to find in the writings of an able and conscientious observer; besides which, it contains the statistical results, most ably set forth, of 16,414 births, under his superintendence, at the great Lying-in Hospital of the Irish metropolis. You will at once acknowledge how great must be his experience in midwifery. I am sure, gentlemen, that while no person interested in the advance- ment of our particular department of Medicine and Surgery, who reads that book, can fail to acknowledge its very great merit, one may never- theless, have a just right to examine, and even disapprove, of certain parts of the doctrine—not without the profoundest sense of obligation to the author for all the useful information he has communicated. If you will turn to Dr. Collins (page 396), you will find the following remarks on bloodletting in our disease :— " The result of my observations upon the treatment of puerperal fever is that general bleeding, except where there is a strong, full pulse, and the symptoms are of a highly inflammatory character, is injurious," &c.—Dr. Collins prefers leeching, followed by the warm bath, stuping, calomel and ipecacuanha with opium, mercurial fric- tions, &c. Dr. Collins asserts, very broadly, that his experience teaches him the above rule or principles of action. I beg you, however, to observe on what basis this opinion is founded. There occurred, under his administration of the house ( Vid. p. 391), eighty-eight cases ; of which fifty-six died and thirty-two recovered. " In fifteen only of the eighty-eight did we deem it advisable to bleed generally; seven of the fifteen recovered." In the whole of the epi- demic, therefore, fifteen were bled, and seventy-three were not bled. PUERPERAL FEVER. 617 Fifty-six died—of whom only eight were bled, and forty-eight were not bled. Does not the question here arise: Why did forty-eight persons die who were not bled, while only eight perished that had been subjected to the treatment of Gordon, and seven others recovered ? Is the inference a just one that the eight died because they were bled, while forty-eight died though they were not bled ? If you will read Dr. Collins's article, you will find that he leeched his patients very freely, and thus bled them from the skin, while he did not approve of the loss of blood from a large vein. Pray attend to the meaning of the word bleeding, which here means venesection. You should observe that Dr. C. used leeches freely—but I wish to fix your regard on the Gordon method of cure, which was by venesection and not by topical bleeding. It appears to me that this simple statement ought to suffice to show you that Dr. Collins's objections to the use of the lancet are of less moment than they would seem to be upon a simple reference to his broad assertion of its inapplicability, and to his acknowledged reputa- tion ; since it appears that his experiment of the venesection was incon- clusive from being early discontinued. It is true that he refers to a former experience, when he was assistant, in 1823, and when bleeding was used by the then Master. But we have no data, on which to form an opinion as to whether those venesections were in accordance with the Gordonian rule or no. Dr. Robert Lee, in his " Lectures," &c, before cited, gives, at p. 457, et seq., a tabular statement of 160 cases of severe inflammation of the uterus and its appendages, observed by him in London, from 1827 to the end of April, 1838. The table is presented in five columns—of which the first one contains the number of the case; the second, names, residence, and delivery; the third, date of attack, and symptoms ; the fourth, treatment; the fifth, result, and morbid appear- ances. This constitutes one of the most complete and accurate tables I have seen, and offers a good conspectus of the cases and modes of treatment. I have carefully analyzed Dr. Lee's table for you, and have divided it into— 1st, those who were bled and who died, &c, &c, as follows :— 72 who were bled; recovered. 15 who were not bled; recovered. 34 who were bled; died. 34 who were not bled; died. 5 no account of treatment. 160 cases. 618 PUERPERAL FEVER. Two-thirds, or 106 of Dr. Lee's cases were treated by venesection, of which 72 recovered and 34 died; whereas 49 of the cases were treated without the lancet, of which 34 died, and 15 were cured : a difference in result from those obtained by Dr. Collins that is very striking; 87 of Dr. Lee's people having been cured, while 68 died, he making a bold and daring use of the lancet—whereas Dr. Collins lost 56 out of 88 cases in which he used the lancet very sparingly, and not at all according to Gordon's precepts. But a truce to statistics, which ought never to be the physician's guide. I am no admirer of medical statistics, as I have already stated in an early letter. I would, however, cite the above to show you that Gordon's precept does not kill. You will, by this time, perceive that I am an advocate for the use of the lancet in puerperal fever: my clinical experience concurs with my pathological views to render me so. I have not been deterred by the reports of typhous forms of the malady, from viewing it as inflam- mation. Professor Moreau, who kindly showed me the whole establish- ment called La Maternite, at Paris, in 1845, pointed out, on the occa- sion of my visit to that great hospital, several cases then under treat- ment. He was of opinion that in many cases venesection is the remedy, but that seasons occur wherein the patient will not tolerate the loss of blood. He is a person of great experience and wisdom. M. Ca- zeaux, who was on duty at the Clinique d'Accouchement, gave me the same opinion; as did also Professor Retzius, of Copenhagen, whom I had the pleasure to see there while visiting M. Cazeau's wards. All that I saw on those occasions, and all that I have myself witnessed before and since, confirm me in my admiration of Dr. Gordon's pre- cepts ; and I adhere to, and adopt, and I desire as your Professor of Midwifery, to lead you also to adopt Dr. Gordon's views. Do you ask me if I expect to cure my patients by venesection, and whether they never die under that treatment ? I answer, that the malady is able, in many cases, to resist all sublunary power ; and that numerous instances must continue to occur in which the curable stages are overpassed before any open manifestation of the disease can be discovered. But, where the disease is curable, it is more curable by the lancet than by all other means besides, and is in fact generally curable by its means; while every patient is exposed to increased danger- ous risks whose life is confided to any other single anchor of hope and safety. I look upon it as child's play, to attempt the cure of these great inflammations by doses of ipecacuanha—by calomel—by cathar- tics—by opium—by turpentine. I think that even the miserable far niente of the Homoeopathist is likely to cure the cases that are curable PUERPERAL FEVER. 619 without the lancet; and that his ordinary and professional nichts thun will allow a patient to get well whose constitutional force is equal to the overcoming, by resolution, of a metritic or peritoneal inflammation. What can calomel do in one of these great cases of peritonitis ? Let me show you how inadequate is the remedy. Open your eyes to the reasonable representation—lay aside your prejudice, and think as a man ought to think. I mean to say, think for yourself. See, now! The alimentary canal alone is not less than forty feet in length from the cardia to the rectum. If divided with the enterotome, and laid out on its mucous surface, it would average a breadth of four inches by a length of forty feet. If you reduce this into square feet, you have fourteen square feet of peritoneal surface, even leaving out of the com- putation the rest of the serous membrane of the abdominal cavity. I entertain no doubt of having seen many individuals, in whom the whole serous portion of this vast superficies was in a state of inflammation. But the pain of a panaris, or the iritation of four or five square inches of erysipelas, will often suffice to disorder the whole constitution : what shall we think, then, of the disturbing power of a universal peritonitis in a woman just out of her gestation, and just escaped from the pains of her travail? And for such a case as this you propose to put—what?—what is it you are going to do with that solemn air?—you are going to put two, or ten, or twelve grains of calomel upon the mucous membrane of the stomach, to cure fourteen square feet of redhot serous tissue! Does it not seem preposterous ? Why what a Snob the man must be! Pray do not reply that you are going to get the alterative effect, or that you are relying on the aplastic power of the calomel. Read Gordon. Learn to make your diagnostic of childbed fever ; and then freeing your spirit from the shackles of the schools, dare to act upon the promptings of your reason and judgment. Do not suffer yourself to be governed by a symptom. Be governed, rather, by a clear, dispassionate, perspicuous observation of the state of the whole creature, and her wants. Do not rest your diagnostication on the pulse only. Believe me, my dear friends, that there are many cases of grave constitutional disorders, in which the pulse is not at all to be held a fitting guide to the physician; and that if you be but pulse-feelers, and nothing else, as long as you live you will barely rise above the height of the Chinese doctor, who founds his diagnosis, prognosis, and thera- peutical course, upon a judgment of the pulse of a lady, which is thrust through a hole in the door, for his opinion as to her health and require- ments. I am very sure I have been many times able, jugulare febrim in puerperal fever, by a Gordon venesection, that I should not have dared 620 PUERPERAL FEVER. to make had I been led only by the perception derived from my fingers. Are not a man's senses more than one ? and shall one sense carry all the others away captive, and bind in chains the contrary judgment aris- ing out of their combined perceptions ? Don't let your fingers deceive and mislead you, when you have eyes, hearing, reason, and judgment, to proclaim that they are traitors to you, and only hide the truth. In these great circumstances, neither you nor any man should trust for his guidance to the radial pulse alone. You should, examine the brachial, the carotid, the temporal arteries, and know them all. You should go to the fountain-head of the circulation, and by a careful, pro- longed auscultation of the heart, confirm or correct the more imperfect notions of the state of the sanguiferous system derivable from touching the radial pulse alone. I repeat it—read Gordon; learn how many hours are fled ; and judge, whether the progress of the malady may have carried the victim beyond the curable stage; for there is, there must be a curable stage. Is the woman past hope before her sickness is begun ? Is she foreor- dained to this particular death ? Having now laid before you, perhaps at too great length, my opinion of the indispensable necessity for venesection in our malady; its safety, and its superiority over all other means, I need not say anything fur- ther on the subject, except to warn you not to trust this operation to other hands than your own. You should always be present; the light should be good, in order that you may clearly observe the changes in physiognomical expression that attend the outflowing from the vein; the apartment should be in order; no noise, no movement, ought to be allowed. The patient's position should be carefully directed ; neither allowing her to be raised too much, nor to be on pillows too low. A man who is about to bleed in a puerperal fever should be solemnized ; there should be a mit hiilfe (Bkrttes sentiment about him ; for, on his operation hangs a human life. Death, widowhood, orphanage, are often the questions that are suspended upon this eventful ministry. Many doctors prefer leeches in the treatment. You may see what a very free use of them was made by Dr. Collins—and you may see, also, that the success could not have been much more unsatisfactory. Lee is no leecher; he is a good Gordonian bleeder in our case, and owes his brilliant success to that. Desormeaux was a leecher and mercurial- izer. You will find it so if you will read Tonnelle', who tells you he lost 240 patients with it at the Maternite'. Chaussier was a good bleeder; see what his intelligent eleve Legouais says about it. I never could understand well the motives of those, who, though they are more frightened at the click of a spring-lancet than is " a hurt fowl PUERPERAL FEVER. 621 or a struck wild duck" at the report of a caliver, yet find nothing at all distressing in the noiseless absorptions of two or three hundred leeches. They dread Dr. Gordon's direction to take twenty ounces at a bleeding, but they are not in the least alarmed at the abstraction of forty or fifty ounces by 300 .leeches; not put on all at once, it is true, but in the course of a very few days. For my part, I am afraid of leechings. I am not afraid to bleed with my lancet, with a good light on the patient's face, and my fingers on the pulse; for I can always feel satisfied that the flow is enough— not too little, and not too much. I can stop the jet with the dossil of lint—I can interrupt, or arrest, or recommence the bleeding in an in- stant—I can auscult the heart while it goes on, and feel that I am guiding a powerful, but docile servant of my ministry. In leeching, I always procure fatigue, pain, damp, and often exhaustion for my patient. In puerperal peritonitis, the inflammation is in the intestinal perito- neum. All the blood of that inflammation is blood from the digestive arteries—the celiac, and the two mesenteries. What reason have I to expect to control the action of their distal and capillary branches by leeches placed on the skin of the abdomen ? Would it not be as rea- sonable to leech the calf of the leg as to leech the belly for the cure of childbed inflammation ? In childbed inflammation it is the intestinal not the parietal peritoneum, that is sick. I shall not deny that I have, on occasions, applied leeches to the abdomen ; but I have ever done so in doubt, and shall, probably, continue so to use them, and even less frequently than heretofore. Great stress is laid upon the power of calomel to cure the disease, and many physicians regard it as the sheet-anchor of hope and safety. I have no doubt that its aplastic therapeutical force is great, especially when given in large doses, and when its cathartic influence is lessened by combination with opium. A woman who has been attacked, and who has been bled, ought to take some ten grains of calomel with a grain of opium: a dose that should be repeated in the course of some four or six hours, provided the first one be not followed by alvine dejections. I would give this medicine, because a dose of the mild chloride of mercury almost invariably produces a sensible degree of qualm, or nausea, which has a checking influence on the intenseness of the cir- culation, thereby moderating the threshing power of the heart and the vessels, so much as to hinder the increase of the fibrinous element in the blood.—Remember, that the fibrinous element is expressed by 3.5; calomel assists to prevent its figure from going up to fifteen, or even twenty. But if you bring about the inflaming effects of mercury, as in salivation or stomatitis, then it is not aplastic, but the very opposite! 622 PUERPERAL FEVER. Calomel excites the secretory offices within the alimentary tube. As a general rule, the more abundant those secretions, the more com- pletely are the remote branches of the digestive arteries disengorged. All those branches furnish secretions for the bowels, or for the liver; they go nowhere else. Calomel, then, is a good and reasonable, nay, a precious drug for the occasion. But to trust to it alone, is to lean on a broken reed that pierces the hand. Calomel is one of the leading juvantia in the cure, and nothing more. So rapid is the rush of the attack and conquest, that " cita mors venit, aut Iseta victoria," as Gordon quotes the lines from Horace. It is not a case in which a prudent man dare wait for the alterative influences of a mercurial ptyalism. If those influences could be set up in time, they would perhaps often prove the effectual bar against the destructive ad- vance or continuance of the malady. But they are rarely to be got up. Many a life may be saved, in the course of a long medical career, by means of the supporting consolations, and the recovering exhorta- tions, that fall from the lips of a medical man who is known to be worthy of confidence and trust. I hope that you will not believe, be- cause you have got your Diploma in your hand, and because you have just been told in the College the names and the doses of the various articles of the Materia Medica, that all you have to do in this world, in your vocation, consists in meting out those drugs and medicines. I hope you will live long enough to know that the function of the phy- sician goes beyond the exhibition of his doses, and that the power of his presence, of his deportment, of his opinion, and his decision, is a real power over the mind and the body of the patient, more true, and more useful than the pretended Mesmeric force. An eloquent man can control the wildest mob, or sway the opinion of the gravest senators. Eloquence, however, is not found only in the harangue; you may see it in the gesture; it is heard in the whisper; its most potent spell often breathes in that still small voice of the Physician, which, amidst terror and doubt and anxiety, gives assurance of protection and restoration. In the conduct of cases of puerperal fever, it will be a matter of no inconsiderable moment to determine the precise seat and degree of the lesion ; and, for this purpose, it is not sufficient for you to go into the patient's apartment and ask half a dozen questions as to the state of the bowels—feel the pulse, and ascertain the state of the tongue. You should examine your patient carefully. If she, for instance, lie in bed covered up with two blankets and a counterpane, it won't do for you to examine the state of her abdomen through the bedclothes, petticoats and all as I have seen people do. Her life is at stake ; and it will be lost if you do not understand how it is at stake, how much so, and how to save it. PUERPERAL FEVER. 623 She should be visited often—many times a day. A careful note should be taken of the state of her pulse; you should set down, on a sheet of paper, the rate of her respirations, and insert memoranda of all the great points—the doses of medicine, and the sensible effects produced by them should be recorded. Remember, that when you feel the pulse, you do so for the purpose of knowing what the heart is doing, and that you have no other motive to touch it—absolutely no other; and that you will not always be able to ascertain what the heart is about by touching the pulse alone; there- fore, whenever you pay a visit, examine the heart carefully; note the impulse, the force, the area, and by comparing the impressions made upon your mind through your fingers by the radial artery, with those conveyed by the heart itself, through the ear, endeavor to get a true and correct notion as to the general momentum and effect of the arte- rial circulation. The arterial system, by injecting oxygen, develops in the brain, and the whole nervous system, the flash of life : where its injecting force is greater, the life is greater; where it is less, the life is feebler. Nearly the whole of your power to modify the rate of life in the organs and parts are powers exercised upon this very force of the circulation; and the physician never knows so perfectly the state of the life-force in his patient as when he gathers that knowledge from a perfect knowledge of the state of the circulation of the blood. Study the pulse, and let it be a constant study; it has been admitted of all times that a good pulse- feeler is, quoad hoc, a good physician, and that it is one of the greatest accomplishments of the medical station to know the pulse well; and why ? Because, a knowledge of the state of the pulse reveals the state of the life-forces. To know the pulse may almost be said to constitute the (Brtmbkraft of the medical ability. But, take heed that you be not pulse-feelers only. You will suppose that your patient is doing well, if she has a mode- rate perspiration, occupying the whole superficies of the body; and particularly, if the perspiration have an unctuous feel. A very thin and watery perspiration is not so favorable; for, when it is unctuous it shows not only that the pores are free, but that the sebaceous follicles also are in a state of activity. Your patient will be better, if the pulse is becoming less frequent, and at the same time losing its volume, after having been too large; or, if it is recovering its volume, and becoming less frequent, after having been too small. Your patient is becoming no better, if the pulse be- comes more and more frequent; for its increasing frequency indicates an increased distress of the whole constitution. 624 PUERPERAL FEVER. Let me relate a curious case of the malady:— Wednesday, May 26,1852. Last Friday (21st of May), at 10 o'clock A. M., Mrs. D., aet. 24, primipara, had a convulsion, which was preceded by violent headache, for which the Doctor bled her twice before the eclampsia came on. He delivered with forceps; soon after which she had a second convulsion, and then no more—what, with venesection and leeches, he took sixty-five ounces of blood. The pulse was rapid all day; Friday and Saturday, Sunday and Monday, another physician attended with him, and on Monday I was called. Pulse 135 to 140; had been 160. Belly very tympanitic, resisting, sonorous, and painful; sensitive; respiration good; skin hot, wet, and pale; tongue clean; physiognomy good. I did not expect her to survive until 12 o'clock to-day; but at 9 P. M., she is, in all respects, better, save that the pulse is 140. Let us see whether a woman, with a pulse 140, on the sixth day of a childbed fever, shall live or die! Thursday, 27th. 9 o'clock A. M. Pulse 140; pain in hypogastric and right iliac fossa; meteoration less, seems in many respects better; but, the seventh day of a 140 pulse is upon her, can she recover ? Friday, 28th. 9 o'clock A. M. Pulse 128. Tympany still great; but mostly in the small intestine: she seems much better; took, on the 27th, 12 grs. of sulph. quinia; very sore to touch in the lower belly; had a small blister on the right lower belly yesterday which filled well. Saturday, 29th. Pulse 116; better in many regards ; still has hypo- gastric pain. Sunday, 30th. Pulse 112 ; very great soreness of the hypogaster; tympany. Monday, 31st. Pulse, at 7 P. M., 120; seems in many respects better; but has a hard and very resisting body in the left iliac fossa, rising some four inches above plane of strait and extending to right of linea alba. This cannot be even gently touched, without great care, as even the lightest percussions give a positive pain. Is it flatus, or is it depot ? We shall see. Friday, 4th of June. The pulse, at 7 P. M., is 120. She is in all respects much better, except for this accelerated pulse, a very great ballonnement of the belly, and a hard and excessively painful lump, swelling, or distended gut that lies on the left anterior quadrant of the plane of superior strait. It is very sonorous on percussion, and the slightest tap hurts like the apple of the eye. This lump has not varied or changed one iota for nearly a week. I do suppose it is one of Puzos's depots. June 5th. Seven o'clock P. M. Pulse 128; belly very tumid, pain and depot unchanged. Monday, 7th, seven P. M. I did not see her yesterday. Dr.____said PUERPERAL FEVER. 625 her pulse was 120 yesterday; now it is 116. The belly very much distended with gas; though soft and not painful, yet the hard swelling in the left side of the belly, near the brim, is exquisitely tender ; the part is sonorous, but quite hard; it does not interfere with flexion and extension of the thigh. She has no abnormal heat; has appetite ; very little milk, the breasts being quite flaccid. I presume she may get well by the resolution of the inflammation. As she seems to be better, I have retired from the call; but I have in vain persuaded my colleagues to give an aperient for many days. When I saw her first on Wednes- day, June 26, I prevailed to give an aperient; but could not convince them that oil and syrup of rhubarb was proper, as Chaussier used it. They gave 47 grs. of rhubarb. I believe that since that time no dose has been given, except an occasional enema of soap-water, &c, &c. I have attended for thirteen days ! ! ! Surely the poor woman would have had some more considerable relief by this time, if she had been purged with moderation—even now, on the eighteenth day, the pulse is 116. I had retired from this case, but was recalled on the 12th. June 15th. Pulse 116; belly tumid; the swelling in the left iliac fossa the same, but not quite so tender to touch; great tympanitic sonorousness; could not prevail on them to give the aperient. They had given 4 grs. calo- mel and some castor-oil, which, they said, gave one watery stool. I am sure she" has overloaded bowels, and that she is kept sick and in danger by that cause. She had, however, a pulse 92 this afternoon, and, I suppose, she may now recover, with or without doctors. This patient at length recovered her health. I have related the case to show you its particulars, of which you can judge, and now proceed with my text. If the woman's respiration become slower, deep, and long, and more equable, she will be better ; if it be saccadSe, jerking, requiring the aid of the accessory muscles, the sign is almost to be held fatal. If the urine is abundant, the sign is good. If the tympanitic distension of the bowels is growing less, giving to the integuments of the belly, relaxed after parturition, their usual soft fluctuating feel, instead of the hard, elastic, and swollen appearance which they before presented, it is favorable. If the abdomen become more and more distended, hard, intolerant of contact, the sign is bad. Nobody is better in a fever in whom the hypochondria are tumid. Here is one of the aphorisms of Hippocrates: " Febricitantibus, quibus hypo- chondriae tument malum." Here is another : " Febricitantibus, quibus hypochondriae non tument bonum." This aphorism was written four hundred years before the advent of the Saviour ; it expressed the truth then, ever since, and now. 40 626 PUERPERAL FEVER. If the thirst diminish, it is good ; if it become more and more in- satiable, the sign is unfavorable. If the sensibility of the abdomen, as tested by pressure, grows gradually, and not suddenly less, the sign is good. But if the patient, having been extremely sore, ceases suddenly to complain, it is probable that she is nigh unto death ; for, the cessa- tion of the pain depends upon the sudden cessation of the disease: the disease was inflammation, and the inflammation having rapidly come to its last term by effusion, a copious effusion of lymph and serum and albumen into the belly has cured the disease—but the patient is about to die. The tension of the vessels of the brain, which gives the most intense pain, is relieved by the extravasation of the blood, which con- verts a headache into a fatal apoplexy: in our case the people will say that mortification has taken place. Why, a woman won't live in this malady until mortification takes place ! She has not time for mortification to take place; she could not resist a state even approaching to it; therefore, in your autopsy, you will not find mortification. In order to show you a prognostication upon the sudden cessation of the pain in puerperal fever, I am going to quote a case for you, which is enough to make one feel something like awe in the reading of it. It is the first case related by Gordon, that of Andrew Low's wife—No. 15 in his table. It is at the 37th page of Barrington & Haswell's edition. " Case I. John Low's wife, No. 15 in the Table.—In the afternoon of the 19th of August, 1790, John Low, miller at Justice-mills, came to my house, requesting me to go immediately to his wife, ' who,' he said, ' had swooned after delivery, and was in great danger.' I accord- ingly went, and found her in a dangerous situation ; she complained of an acute pain in the lower part of the abdomen, attended with a very great degree of fever, the velocity of the pulse being at the rate of 140 strokes in a minute. " The disorder commenced with a violent rigor at six o'clock in the morning,"being about thirty-six hours after delivery. " I had no difficulty in ascertaining the patient's disorder, having had previous opportunities of seeing it both in London and in the course of my practice in Aberdeen, for this was the fifteenth case I had attended since the epidemic began, though the first of which I kept a journal. And, in every respect, the disease answered the description of that known to practitioners by the appellation of the puerperal fever, a dis- temper which so frequently proves fatal to women in childbed, baffling the skill of the most eminent physicians. As, therefore, I had so often seen the disease, I could not be puzzled in regard to the proper method of treatment; though, at the same time, I was well aware that I could by no means promise success. PUERPERAL FEVER. 627 " I accordingly ordered bleeding to the quantity of sixteen ounces, the abdomen to be fomented, and a glyster to be given; and, at the same time, I ordered large quantities of diluting drink. I likewise directed an anodyne diaphoretic draught to be given at night, and a cooling laxative the ensuing morning. " On the 20th, when I visited the patient, I found the velocity of the pulse somewhat diminished, but no abatement of the other symp- toms (the pain and tension of the abdomen remaining as before). " The laxative given in the morning had the desired effect; the blood drawn exhibited a very thick inflammatory crust; the lochia were sup- pressed ; the urine was scanty, and voided with pain ; when recent, it was high colored, but when allowed to stand for a short time, it became exceedingly turbid. " The fomentations were continued, and an opiate given in the evening. " On the 21st, when I visited her in the morning, I was happy to find that she had been pretty easy throughout the night, and had en- joyed some hours' sleep. The pulse was 136. She was in a profuse sweat, which, I hoped, would prove critical, and, therefore, endeavored to promote it by small doses of tartar emetic in the saline mixture. But I was sorry to find that I was disappointed in my expectation; for, when I returned in the afternoon, I found that the sweat had disap- peared, being succeeded by a diarrhoea. " The patient now complained of very great pain, and the swelling of the abdomen seemed to increase. I ordered an opiate in a large dose, and applied a blister to the abdomen. " On the 22d, I was sorry to find that the disease was making rapid progress, in spite of all the remedies employed ; and, as I perceived that the diarrhoea was not proving critical (for the pain and tension were extended over the whole of the abdomen), and that the patient's strength was sinking, all hopes of recovery were now totally abandoned. " The patient's agony was now extremely great, and called loudly for relief: I therefore thought proper to administer opium both exter- nally and internally, on purpose to mitigate pain, if possible, to procure rest. " I went early in the morning of the 23^ to visit my distressed pa- tient, and found that the storm was lulled into a calm. The friends received me with transports of joy, vainly thinking that the danger was over. " The patient, supposing herself perfectly well, asked my permission to rise; for she seemed to feel no pain, and suffered me to touch and press the abdomen, without showing any signs of uneasiness ; a proof 628 PUERPERAL FEVER. that the parts were in a state of gangrene: for this sudden cessation of pain in the puerperal fever is a fatal symptom, which announces the approach of death, and denotes that a mortification has taken place. The friends, ignorant of this circumstance, were quite overjoyed to see the patient so composed, after such excruciating pain. However, not- withstanding this composure and apparent ease, it was evident, from the ghastly appearance of the countenance, from the tumefaction of the abdomen with the absence of pain, from the sunk state of her pulse, and from the coldness of the extremities, that death was not far off. Accord- ingly, in a few hours, the scene was closed." Can one imagine a more distressing scene than this ? How perfectly, how naturally, he paints it. I have looked upon such as it many times. It goes to the heart. You will see that Gordon speaks of diarrhoea. I have not very often seen diarrhoea in patients affected with puerperal fever. I have, how- ever, met with it occasionally, and have been surprised to discover the power of the bowels to transmit liquids—for these stools are always fluid ones, while several cubic feet of gases, contained in the alimentary tube, were obstinately retained there, keeping up the enormous disten- sion and rendering the cure hopeless as long as it continued. If, when a patient has had a diarrhoea, it gives place to a more healthy character of the alvine dejections and a disappearance of the tympany, the sign will be good; but an increase in the frequency of the alvine dejections, and, above all, their occurrence without the patient's consciousness of the circumstance being excited, are signs the most disastrous; particularly where the belly remains much distended. When a patient is going to die of this malady, it happens some time before the fatal event—some hours, or a day, or even two days before- hand—that she begins to have eructations. If these eructations are accompanied with a sound like hiccough—if they are singultiform you need scarcely entertain the hope to rescue the patient from an impend- ing fate. The eructations become more and more frequent; the fluid discharged may be at first whitish; it acquires at length a greenish tint and everybody supposes she is bringing up bile; it comes at length to be a slight vomiting; she brings up a spoonful at a time—a wineglass- ful, a teacup full: it next becomes brown, and looks like fine coffee grounds; it becomes perfectly black—it is black-vomit. It is the black- vomit that accompanies the fatal serous inflammations of the abdomen: you will find it in almost all persons perishing from intussusception from strangulated hernia, and various forms of enteritis. I have no doubt that when it begins, the serous coat of the stomach has begun to be inflamed; and that the inflammation, increasing in intensity coin- PUERPERAL FEVER. 629 cides with the change of color, and quantities, of this ejected fluid. So that, at the last, that is to say, when she is bringing up half a basinful at a time of this vomito, her stomach is already half dead. How painful it is to a physician to stand by at the commencement of these vomitings, and look through the dark vista along which the patient is seen by him to move; while the friends and acquaintances are filled with the cheering hopes of health speedily to be restored. Mrs. Low's friends received Gordon with " transports of joy." If she has had an abundant secretion of milk, the secretion will be suppressed if she be violently ill with puerperal fever; and the aban- donment of its duty by the lactiferous gland is a dangerous symptom, expressive of extraordinary constitutional disorder. The maintenance of the power of the milk gland is always to be held as of good augury in the case. The total suppression of the lochial discharge is pernicious in its in- fluence, and discouraging as a sign ; the restoration of the discharge is hailed as a new attempt at recovery. And now I have a few last words to say before I close this letter. You should never take your leave of a patient who has been confined, without giving the clearest, the most impressive directions as to circum- stances that might render your recall necessary. The majority of these diseases come on in the night time, and many people are unwilling to awaken the physician, or even to call him at a very early hour in the morning; either because it is inconvenient to themselves to send, or that they dislike to give him the trouble to pay an extra visit. They will expect him to look after his accoucbe'e, and are very apt to wait until the expected hour of his call; as to which, they may be subjected to disappointment, since his assistance, in person, may be required else- where, and since, having left his patient Avell at the last visit, he is apt to consider her still so upon receiving no communications. You know Gordon says, that if you don't cure puerperal fever within the first six or twelve hours, you have little chance to effect a cure, and that the nearer you are to the time of the attack, the greater of course will be your expectation of success. I think I scarcely ever leave a patient, after she is put to bed, without addressing myself especially to her, and explaining to her the impropriety of taking anybody's advice as to her case, except that of her regular medical attendant. I tell her, that it is even very difficult for the physician to discriminate be- tween the various forms of disease in their attacking stages, and that it is quite impossible for unlearned persons to do so. I endeavor to make her understand, that some of the forms of disease that affect lying-in women, perfectly curable, if treated promptly, may, in the course of 630 PUERPERAL FEVER. from six to ten hours, if neglected, pass entirely beyond the hope of re- covery ; and I say, " If you are sick during my absence, see to it that I be instantly notified of it. Don't consult with anybody as to the pro- priety of letting me know that you are indisposed. You have placed your safety in my keeping; it will be the last degree of injustice to me, should you be taken sick in the intervals of my visits, not to inform me thereof, but to take instead of mine, the opinion of a nurse, or of some acquaintance. I charge you, therefore, that you let me know, as speedily as possible, if anything should happen to derange your health." I give similar directions to the monthly nurse, and, if I have the oppor- tunity, I ask the husband of the lady to watch over her, in order that I might receive the earliest information of any indisposition. This course I have pursued for years, and yet, up to this hour, I am unac- quainted with a single household or an individual in whom I can trust on such occasions. If the lady is taken sick, the nurse, or the grand- mother, or she herself, will explain it as after-pains, or as headache, or as rheumatism; though if the curable stage has been gone through be- fore your visit, such signal disobedience of express directions, such enormous stupidity is apt to be followed by the loss of the patient; a loss so great, that there are no words in which I can set forth the men- tal distress it occasions. Please to understand, that if you scrupulously adopt the plan which I have above recommended, and should practice midwifery for half a century, you will scarcely find ten occasions in your whole life in which a prompt information will be communicated to you; and this it is that makes the life of an accoucheur more painful than that of any surgeon or mere general practitioner. It is very singular, but it is very true, that physician accoucheurs are peculiarly subject to these constant anxieties and mortifications. A woman will send a break-neck message after you, and call you out in night and storm and tempest, because her baby has had a belly-ache, or possibly a green stool; but she will not send for you, perhaps, if she herself is standing on the very brink of the grave, as every woman is who is even threatened with this direful disease. She will ask the nurse to do something to cure her. Be not discouraged, however ; the fault will not be yours, provided you should have taken all the precau- tions in your power; whereas, a heavy charge would lie upon your con- science should a patient be lost in consequence of inattention, on your part, in issuing the needful precautionary directions. After the death of a charming lady here a few years ago, I sent to her husband a copy of Gordon's treatise. She fell a victim to the imprudence and stupidity of her nurse, who allowed her to pass through the curable stage of an epidemic puerperal fever, declaring that it was CRURAL PHLEBITIS. 631 only after-pains, which she understood as well as the doctor, and that she would not have the doctor sent for. " Haven't I nursed," said she, " for thirty years and more, and must I have a doctor put on me be- cause you've got an after-pain ? Nonsense !" And so, when her physi- cian, who had left her well a few hours before, was at length requested to visit her, he found the lady far gone—past all hope of recovery. The gentleman read Gordon, and when he returned me the volume, "Oh, sir !" said he, "why is it that this book is not to be found in every house ? If I had read these pages sooner, I should not, perhaps, now mourn over my irreparable loss." I could relate to you many histories, setting forth the importance of early information in this case. But it is time to close this letter, in which I have endeavored to give you what I regard as sound and whole- some views upon the subject of which it treats. If you will take my advice, you will buy Barrington and Haswell's book, and read it with the greatest care. And when you shall have read Gordon, Hey, Arm- strong, and Robert Lee, if you will practice with ipecac, and calomel, and nothing else, I cannot be responsible for you, though I shall be very sorry for you. C. D. M. LETTER XLIII. PHLEGMASIA DOLENS; CRURAL PHLEBITIS. Gentlemen: There is a disease of which I have not yet spoken, and which is vulgarly known by the term Milk-leg. It has been called by the writers plegmasia alba dolens puerperarum, or the paintul white swelling of the lying-in woman. Some of the Frenchmen still call it Lait repandu, which is a translation of the English word milk- le._a word employed to express the sense that the milk of the woman ha&s fallen into her leg, and inflamed and swelled it. And I suppose indeed, that in this nineteenth century, half gone as it is, you will have plenty of trouble to convince your patients that it will not be your duty always to get the milk out of the leg, or so to regulate your pre- scriptions as to provide against the effusion of more milk mo th cellular tissue of the limb; particularly, if you should persist to call the disorder by the name of Milk-leg. It would be wise of you to de- nominate it crural phlebitis, which is its real name. I suppose you will laugh, gentlemen, at the idea of having milk in a woman s leg, for you 632 CRURAL PHLEBITIS. know milk is made in the breast, and not in the leg; it is pretty much like saying that a man has a salivation of his liver, or a diarrhoea of his kidney ; in fact, it is sheer nonsense. There are a great many doctors in this country—those who don't read at all—who, while they don't suppose that it is milk in the leg, yet persist in believing that it is inflammation of the cellular tissue : though no man ever saw one produce suppuration or sloughing of the cellular-tela, and though every man knows that when cellular tissue inflames, it is almost sure to suppurate or slough. I should like to see a woman get well of an inflammation of the cellular tissue of the whole limb from the crista of the ilium to the os calcis, and from the pubis to the metatarsal bone of the great toe!—one whose thigh is bigger than a man's body, and her leg swollen to the size of that of an ele- phant !—that is to say, get well without a suppuration, or indeed, in any way. Some persons have suppossd that the swelling is produced by a disease of the absorbents of the limb; and, in fact, nothing was known about it until Robert Lee—the same Robert Lee of whom I have spoken so many times in these letters—made the discovery of it, and clearly demonstrated its true pathological nature; showing that the lesion in the disease is a lesion of the veins of the limb, whence he gave to it the name of Crural Phlebitis, the name by which it is now called by all physicians who know anything about it: it is called milk-leg only by those who know nothing about it. The old areolar doctrine of milk-leg is still taught by persons in high places. Dr. Lee, in his Essay on Crural Phlebitis (Barrington and Haswell's ed., page 314), after having given a literary history of crural phlebitis in puerperal women, says : " It is a remarkable circumstance in the history of crural phlebitis, that nearly a century and a half should have elapsed, after it was first clearly pointed out by Mauriceau, before an opportunity was presented of ascertaining by dissection the precise nature of the disease. There had been opportunities, as I have shown, to determine the accuracy of the different hypotheses that had been advanced, but these were neglected, and the real nature of the disease, and its commencement in the uterus, were imperfectly understood, until I ascertained, by dissection, the true nature of the complaint." Dr. Lee's account of this dissection is in the Medico-Chirurgical Trans- actions, vol. xv., 1839. The disease under consideration commences in the endangium of the crural vessels, and is the same malady which most frequently carries off the chirurgical patient who has been subjected to amputation of the limb. It is the same thing that happens to every bloodvessel, whether artery CRURAL PHLEBITIS. 633 r vein, around which you cast a ligature, and tie it for the suppression of hemorrhage. Fortunately, the application of your simple ligature develops only a sufficient amount of inflammation to effect the union of the disrupted endangium, and constitute a plug of lymph, fit to become a bond of union for the opposing walls of the vessel, and thus restrain the hemorrhage after the ligature shall have fallen off. Crural phlebitis may begin before the termination of the gestation: I have met with several cases in which it occurred six weeks before the child was born. It may commence soon after the ending of the labor, or not until the woman has begun to move about her chamber ; she is liable to it at any period within the lying-in month. A man is liable to it; so is a child ;—it is by no means peculiar to the gentler sex. Many of the cases of swollen limbs that are looked upon by the Doc- tors as oedema, coming on at the close of great chronic visceral diseases of the belly, such as enormous enlargements of the liver or spleen, or great heterologue glands, that are developed there ; or cancer of the stomach—many of these swellings, I say, are not cedema, as the Doc- tors suppose, but they are crural phlebitis. I have known them to be so at the beginning, and have proved them to be so after death ; for I have found the great crural veins and internal iliacs filled with lymph and pus, and coagulated blood, and in some instances totally obstructed. Dr. Lee has found some puerperal cases in which the great crural vein, in returning into the body has been lost, like an African river in the sands, no trace of the vessels being left by the ravages of disease, which had extended from the endangial lining into the circumvolved tissues within the abdomen. Now, gentlemen, see a limb supplied by a great femoral artery and profunda, with its anterior and posterior tibials, and all the other branches : imagine these arteries healthy, strong, perfect in structure and volume ; and see a current of blood, driven into them by the con- traction of the heart under the powerful injection-force of a great fever; and then imagine the femoral vein or the saphena obstructed by thick- ening of its endangium ; by quantities of plastic lymph which has ex- uded from the inner wall; by strong, firm coagula of blood, which have been arrested on its now irregular surfaces; by a quantity of serum exuded between the outer or fibrous coat of the vein and the cellular sheath in which it runs, so as to give you the feeling, when you pass your finger from Poupart's ligament down the limb to where the vessel pierces the triceps muscle, as if the finger were pressing upon a body as large as a man's thumb, and as hard as a stick. Now, tell me, what is to become of all the blood thrust into the limb by the injec- tion-force of an infuriated systemic ventricle; and how is it to get out? 634 CRURAL PHLEBITIS. How is the woman to avoid the great swelling of the limb, which you call phlegmasia alba, or milk-leg, but which you would better call crural phlebitis ? Is a vein anything more than an efferent duct ? It is impossible to suppose such a condition of the vessels without conformable swelling;; for the vein which carries blood from the limb is virtually compressed, as if you had tied it up with a ligature prepa- ratory to bleeding it. The vein is as if you had put the pad of Petit's tourniquet upon it, leaving the artery perfectly free and unobstructed. But it is not the crural vein alone that suffers in these cases ; the in- flammation not unfrequently extends into numerous superficial branches, which become extraordinarily sensible to the touch, and hard; evidently containing within their cavities quantities of coagulated blood. But, the disease is called phlegmasia alba dolens. What makes the pain ? Don't you know that the femoral artery, the crural vein, and the great crural nerve, constitute a fasciculus, and that they are bound up in a common sheath or theca, until they reach the point where they perforate the triceps to get into the ham? Well, then, the inflammation of the endangium of the crural vessels dips through the fibrous coat, and causes the infiltration I spoke of into the common sheath of the fas- ciculus ; producing the long, hard, cord-like swelling extending from Poupart's ligament even into the ham. The whole crural nerve is thus compressed, gentlemen; but if you compress the crural nerve, won't the woman have pain ? Won't she have neuralgia ? Well, the sensi- bility that the woman has, and the pain that she suffers in crural phle- bitis, are essentially neuralgia from pressure on the crural nerve. The veins in the interior of the body are, for a long time, compressed by the gravid uterus; and sometimes, compressed with great force, which is increased enormously in the throes of labor. They are not only compressed, so as in some instances absolutely to suffer contusion, but the whole of the veins of the lower extremities are, in many women, for a long time distended by the pressure of the womb, causing cedema gravidarum, and that very common occurrence, varix gravidas. Such a constant, long-continued pressure upon the vessels might well be sup- posed to have, in many instances, the effect of developing an inflamma- tory state there; this would be endangitis. But the endangitis is more likely to affect the veins below than those above the point of pressure. There are many cases in which inflammation, commencing in the branches of the uterine veins, and spreading along the endangium to the internal iliacs, passes out beneath Poupart's ligament, along the external iliac to the femoral, and thence to all the veins which become subject to it in the leg. It will be first suspected by pain felt at the groin, or in the calf of the leg. I am very sure that, in many of the cases I have met CRURAL PHLEBITIS. 635 with, my first detection of the existence of the malady was made in consequence of complaints as to pain in the calf of the leg. When a woman who has been confined, or who is pregnant, tells me she has a pain in the calf of her leg, I put a thumb upon the spine of the tibia, and the fingers upon the calf, and then suddenly compress the gastroc- nemii and soleus against the bone: if the woman shrinks from the pressure, and makes an outcry, I next ask permission to examine the groin; and if I feel the swollen ridge of the theca of the vessels, I know that my patient labors under crural phlebitis. I then examine the external iliac, by putting my hand on the same side of the hypo- gaster, and pressing the teguments against the brim or strait of the pelvis as far as I can push them—when I am very sure to detect the evidence of inflammation extending up into the body, if it goes so far inwards. The calf of the leg will be found hard. Let the woman lie upon her back, and be directed to draw both of the knees up in the bed until the tibiae become nearly vertical: if you now take hold of the calf of the leg, lightly from behind, and endeavor to shake it from side to side, you will find you can't shake it, for the whole mass seems attached to the bone, or packed against it. If you shake the other calf, it will be per- fectly flabby and movable in your hand; the result of this comparison will settle the diagnostic. As you will have to treat the case, you ought to be able to make comparison of its progress from day to day; to which end, take a piece of broad tape, cast it around the thickest part of the calf of the leg, measure it accurately, making a mark with a pen or pencil upon the tape, to show the exact circumference, with the date inscribed. Let this tape be carefully kept by the nurse for future reference; and let this measurement be repeated from day to day. If you detect the disease in its formative stage, or in its earlier stages, you will find it before there has been much swelling, particu- larly of the thigh; and you should announce that the thigh will become enormously swollen, provided your treatment should not succeed in as- suaging it. There will also necessarily be fever, or the expression of constitutional distress, from so great and so painful a malady. And now, gentlemen, as for the treatment. It is rarely proper to bleed for this disease; because the disease is seldom detected until one of the terminations of inflammation has been reached. I say one of the terminations of inflammation, for the termination of an inflammation is reached, first, by resolution—second, by effusion—third, by suppuration __fourth, by adhesion—fifth, by sphacelation and mortification. But, when you find this great ridge, extending down from the groin, it is 636 CRURAL PHLEBITIS. because effusion has taken place already; and, therefore, the bleeding stage has passed by. It may be useful to apply some leeches along the course of the swollen theca, because a topical depletion tends to prevent the further exterior or circumferential progress of the malady ; yet it will have very little influence on the essential or endangial disease. But, perhaps, gentlemen, the best and most efficacious of all remedies is position, used in the chirurgical sense—I ought, perhaps, to say rest and position. The patient is to be absolutely confined in a dorsal de- cubitus ; the whole limb to be placed upon pillows, or upon a bolster, so arranged as to incline the leg upwards at an angle, not above 7° or 10°. She should be told : " Now, madam, if you dare to put the foot upon the floor, even after you shall be almost cured of this disease, you will scarce fail to reproduce it with all it* intenseness: the peril and the pain will be yours. Look to it, that you incur them not." Is not it very clear that if she puts her foot to the floor, and stands upon it, she will have to lift the whole column of blood in the veins, from the sole of the foot to the cardiac extremity of the vena cava, at the ex- pense of the most enormous strain upon the sides of the sick vessels ? It would be the grossest malpractice to allow the woman even to sit up on a sofa until the limb is safe. Our great and learned surgeon, Dr. Physick, used to be proud of the certainty with which he treated cases of phlebitis by HIS method. Dr. Physick's method was to apply a blister, covering the whole dis- eased tractus of vein, a little wider than that tractus. If you will take my advice, you will not neglect it; for of Dr Physick's practice it may be said, "Nil tetigit quod non ornavit." Well, what is the next thing to be done ? The limb is to be stuped, which should be done in this way : procure an old flannel petticoat— there is always a petticoat to be found where there is a woman—cut off the gathers and the hem; dip the flannel petticoat—the whole of it— into a large basin filled with equal quantities of vinegar and boiling water. The liquor should be very hot. Let the petticoat be wrung out, as hard as four strong hands can possibly wring it, and with it let the whole member be carefully enveloped. To prevent the moisture of the fomentation from wetting the bedclothes, a piece of blanket, or some oiled silk, should be spread beneath it. A blanket is better, for the blanket can be rolled over the whole stupe, keeping up its tempera- ture and its moisture for a long time. My custom is to keep up the stuping for six consecutive hours; after which, as the woman becomes tired of it, I cause the member to be gently bathed with a mixture of warm sweet oil and laudanum, care- fully wrapping it up afterwards in fine flannel; and after leaving it so, PUERPERAL CONVULSIONS. 637 about four hours, the stuping is recommenced, and continued for five or six hours; and so, I alternate the stuping, and the inunction with the oil and laudanum, until the swelling has abated, or until I can shake the calf of the leg. After which, I inclose the limb in a common roller bandage, for the purpose of facilitating and hastening the absorp- tions. When the woman has got well, I let her walk about; but I always make it a rule to tell her that her vein is reduced in size, and that it is no longer capable of carrying off from the limb, with the same facility as formerly, all the blood thrown into it by the arteries; that if she will throw into it excessive quantities, by walking about too soon, or too much, she will have a swelled leg. Sometimes the leg continues swelled for thirty years ; I have seen it so. Why should it not ? The caliber of its vein is diminished, and in some instances destroyed. Where it is totally destroyed, the woman can never expect to have the limb as small as it was before the malady—she has lost the principal vas efferens of the leg—she should be thankful to God for her escape with existence. No prudent man would lay aside the charge of such a case without directing his patient to wear a gaiter—to come up above the knee—for several months after the cure. C. D. M. LETTER XLIV. PUERPERAL CONVULSIONS. Gentlemen: Among the numerous sources of that anxiety to which the practitioner of midwifery is exposed, is the dread that he often feels lest his pregnant or parturient patient should be attacked with eclampsia or puerperal convulsions. I say the practitioner of mid- wifery—for I presume that it will be found in general true, that he who has much professional business in the line of those maladies that are called Diseases of. Women, will be also an Obstetrician. Puerperal convulsions, or eclampsia, from «*xo/i*nto, a flash, is a con- vulsion affecting a woman advanced in pregnancy, or in labor; or one in the first days of the lying-in. It is a malady that is not met with every day—but it is one so hor- rible in appearance, so deadly in its tendency, so embarrassing some- 638 PUERPERAL CONVULSIONS. times in its treatment, that, although, as I said, it is not met with every day, it is solicitously looked for, and probably obviated in many a case which, but for such careful supervision, would swell its propor- tions in the statistical tables. To show you the relative frequency of the attacks, in a given num- ber of labors, I refer you to Dr. Collins's Midwifery. Among the whole number, 16,414 labors, under his care, there were thirty cases of puerperal convulsions—of which twenty-five recovered, and five died. This shows you that one woman out of every 547 was attacked with the disease. How many others were guarded against the threatened attack cannot be known ; since many of them may have been menaced whose cases, having ended happily by being averted, do not appear in the statistical result. Out of 20,357 labors, under the care of the late Madame Boivin, at the Maternite', at Paris, the number of patients affected with eclampsia was nineteen. So that, out of every thousand women in the Maternite', one was seized with the disease. Dr. Churchill (Midioifery, p. 447) has collected tables of 96,903 labors, in which 159 cases of convulsions occurred; giving one in 609. These results, if you depend upon them, will mislead you in practice. They do not at all represent the risks that women run from this cause; for in fact, if you become wise, sagacious, and prudent practitioners of midwifery, you will avert the attack in a very large majority of the instances that would, but for the precautions made use of under your administration of them, add to the ratio in the tables. I have met with a good many samples of eclampsia in the course of my obstetrical practice, but I am very sure that I have prevented a far greater number of attacks than I have witnessed. Some of those that have fallen under my observations were wholly unexpected; sudden as a flash. Others came on after a long and anxious expectation of them, or after the careful and persevering employment of all the prophylactic means within my reach. Those means, in a far greater number of cases, have been employed where I had good reason to expect convulsions; but where no convulsions occurred. I did suppose that the remedies had hindered the attacks, and I still believe that they did so. Perhaps, however, I have many times indulged vain fears for the safety of my wards, and subjected them to treatment that was unnecessary. Upon consulting my case-books, and taxing my memory, I find that I have observed twenty-nine instances of puerperal convulsions ; and my colleague, Dr. Huston, your Professor of Therapeutics and Materia Medica, informed me in 1844 that he had observed thirteen cases. Of those under my observation, twenty-four recovered, and five died. Dr. Huston's cases show eleven recoveries, and two deaths. PUERPERAL CONVULSIONS. 639 Primipara women are most liable to eclampsia; but all parturient women are liable to the invasion. Of eighty-five cases that are mentioned in the work of Collins, seventy- three were observed in primipara women. Women with short necks ; those who are fat; those who possess con- siderable muscular strength ; those whose tissues are firm, solid, hard, and unyielding; those that are of a sanguine-nervous temperament; those who have swollen feet and hands, and such as, upon waking in the morning, complain of numbness in the hands and bloating of the features; those who are affected with a feeling of great weakness, or with loss of sensation in one side of the face, or in one of the members ; those who have suddenly lost their hearing ; those who have vertigo, cephalalgia, muscse volitantes, flashing of light within the eyes, dimness of sight, double vision, or half sight; those who have sudden loud noises in the ears, and such as feel as if a violent blow had been re- ceived upon the head ; those, furthermore, who labor under intense anaemia, with distension of the bloodvessels and heart—all such are to be held liable and should be closely observed and protected. Puerperal convulsions consist of violent, irregular, non-spontaneous innervation of the voluntary muscles, characterized by strong rotation of the head to the right or left, and backwards, with violent jerking contractions of the muscles of the upper and lower extremities, the back, and the abdomen. Spasmodic action of the diaphragm and muscles of expression, very rapidly repeated, always attends it. The lips and teeth are firmly closed and opened by turns, so that the rapid and violent breathing produces a loud, peculiar hissing sound. The tongue, which assumes a very dark livid color, and is almost in every case thrust for- ward between the teeth and jaws during the paroxysm, is often found to be severely bitten. The wounds of the tongue permit the saliva, and mucus of the mouth and throat, to be tinted with blood, which flies to a considerable distance through the compressed lips, staining the patient's face, her dress and pillows, and adding to the horror of the spectacle. The rapid convulsive movement of the diaphragm, being accompanied with spasm of the glottis, the blood of the lungs does not receive the benefit of a true and loyal respiration. It does not get its full dose of oxygen, but is hurried off imperfectly decarbonated to the systemic auricle and ventricle, whence it is injected black into the brain and the whole system. The darkening hue of the countenance; the deep venous tint of the tongue, and the blueness of the hands and feet, show that the patient is passing into a state of asphyxia ; and she does blacken her blood more and more, until the brain, no longer receiving oxygen suffi- 640 PUERPERAL CONVULSIONS. cient to extricate the nerve stream, the convulsive innervation ceases from want of the means to extricate any longer the nerve-force, or neu- rosity, as Dr. Cerise calls it. During this extraordinary scene, one in which the organs that are innervated by the pneumogastric nerves chiefly suffer, the powers of the hemispheres and tubercula quadrigemina experience a temporary aboli- tion, or rather, suspension of power. And it is a curious reflection, that those important parts of the brain should be quelled into a sort of temporary death or oblivion, while the spinal cord and the cerebel- lum, which are the sources and directors of the motions, and also the medulla oblongata which gives origin to the respiratory nerves, should be the seats of that intense though irregular evolution of power, whose effects we witness in the writhings, and contortions, and agonies of the eclampsia. It is also a curious circumstance, and one well worthy of your atten- tion, that the blackening of the blood, or its conversion into venous blood by the interruption of the respiratory or oxygenating function, should be the means provided and designed by Providence for the cure of the paroxysm. When the whole sanguine mass has become carbon- ated, the brain and the spinal cord must cease to innervate the muscles convulsively ; and the speedy relaxation of every rigid muscle permits the restoration to the lungs of their oxygenating power ; for while ever the muscular system is convulsed in the spasm, the movement of the mass of the blood is greatly modified by the alternate violent contrac- tion, and the relaxation of the muscles, a modification that ceases as soon as the muscles come to a state of rest—so that, in a few moments after the countenance has been black and deformed in every feature, you have the pleasure to see it recover its whiteness, though ghastly pale ; while the brain, I mean the whole brain, wakes up to the renewed perform- ance of its organic as well as its intellectual offices. When, therefore, in looking upon these frightful scenes, you see the face of your patient growing darker and darker, you will discover in that very circumstance the hopeful announcement of a speedy close of the distressing exhibition. I think that, in a majority of the cases, you may expect to find the whole brain recover soon after the ceasing of the convulsive innerva- tions ; but this is not always the case; for, in some patients, I have noticed a profound coma to succeed the convulsions; the hemispheres, the cerebellum, and the tubercula quadrigemina, remaining oppressed and extinct, as to power, while the medulla oblongata and the spinal cord had resumed a quasi regular exercise of their forces. In a case that fell under my care in this city a few years since the lady had convulsions, which occupied the hours from about 11 o'clock PUERPERAL CONVULSIONS. 641 A. M. till near 5 P. M. During these convulsions she gave birth to a dead foetus of seven months ; remaining wholly unconscious during the process. I say unconscious, though she moaned a little, during the labor-pains, like a person disturbed by some distressing dream, or like one under the influence of ether in a surgical operation. Some hours after the last convulsive attack, and after she had been lying profoundly still, as if asleep, she moved with spontaneous or voluntary motion, showing that the cerebellum was aroused to its true office of directing or co-ordinating the power extricated in the brain and spinal cord. She soon afterwards spoke and recognized the voices of friends, and was perfectly reasonable ; showing that her hemispheres had waked up to their office of intellectual perception and combination. After having for some time spoken, and spoken well, she said : " How dark it is— why do you keep it so dark?" " It is not dark," replied I, "do you not see the candle ?" " Oh no, there is no candle here." " Yes, dear Mrs.-----, here is the candle—see, I hold it just before your face." Her beautiful eyes were open, and she turned them at will, to look for the light which shone into their large dark pupils. " Do you not see the light ?" said I again. " Oh no, doctor ; why do you say so ? I'm sure there's no light here." She was totally blind : that is to say, her tubercula quadrigemina were still oppressed, while the rest of her brain had recovered, being liberated from the thraldom of the congestion. After some time, the dawning light of day having considerably increased, she perceived it, and cried out: "Why, it's daylight!" and I then knew that the tubercula quadrigemina had also recovered. There is a useful moral in this statement—it is that we should look to it, in the conduct of all such cases of disease, that all the parts of the brain recover—and that in so far as our measures may have efficacy, we fail not to employ them to«the entire subduction of even the last ves- tiges of morbid action, or oppressed or suspended power. These vestiges of disease we may clearly discern in the intellection, and in the muscu- lar innervations. The successive recovery of the different parts of the brain in this case is interesting, as it is analogous to the incidents observable under etherization. When a patient is subjected to the inhalation of ether, the different parts of the brain are affected in succession; but not al- ways in the same succession. The sensitive cords of the cerebro-spinal axis are, in etherization, plunged into a state of insensibility—leaving the hemispheres capable to perceive and understand what the quadrige- minal tubercles see of any operation that the surgeon is performing. Or, the motor fibres are put asleep, yet the sensitive ones communicate 41 642 PUERPERAL CONVULSIONS. to the conscious mind the painful impressions made on the nervous mass —which it forgets, however, as it forgets a painful dream. If the etherization go very far, the hemispheres, the cerebellum, the tubercles, and the motor and sensitive cords are all hushed in a state of profound aperception, including both the direct and the reflex influences or impressions: the medulla oblongata alone continues to do its work of irradiating the parts that are under the control of the pneumogastric. If the ether be given long enough, and in quantity sufficiently great to quell its force of innervation also, the patient dies. Hence the me- dulla oblongata is called by M. Flourens the life tie—the vital knot— le noeud-vital. The oxygenating power depends upon it, and without oxygen—no neurosity. Take away the ether in good time ; admit the pure atmosphere to the lungs, and the functions of the whole brain are revived—so, in our eclampsia, as soon as the abnormal state of the en- cephalic circulation gives place to a normal, or, one more nearly normal, the brain wakes up to its duties again, and the patient sees, hears, speaks, and acts with the most perfect co-ordination of all those vital forces that are dependent on the brain and cord. If, in etherization, you press the administration of the drug to the point of quelling the vital-tie of the medulla oblongata, the patient will die, and you will find no necroscopic lesions in the encephalon. So, like- wise, in the speedy dissolution under eclampsia puerperalis, the autop- sia discloses no lesion of any part of the brain. Are you surprised that the woman should die without perceptible physical lesions of the brain ? You are not at all surprised if she disclose none such when destroyed by ether-inhalation. May not the brain perish under the influence of carbon as well as under the ether, and yet, dying, leave no sign? In eclampsia, there is always abolition, for the moment, of the power of the hemi- spheres, always of the tubercula quadrigemina, and always (perhaps !) of the cerebellum. All these revive, and are extinguished again and again, as the paroxysms are repeated or suspended by turns. When the case has come to its close, and the patient is restored, where are the lesions ? No trace of them remains. But—and here is the ex- planation—if the medulla oblongata be affected equally with the other members of the encephalon, the patient dies outright; because the sources of the respiration are then cut off. There are many circumstances, the concurrence of which tends to the development of the eclampsic convulsions of pregnant, puerperal and lying-in women. For many women, the whole state of gestation, from conception to labor, is a state of nervous excitement or hyperes- thesia, which renders the subject specially obnoxious, under the appli- cation of exciting causes, to convulsive or irregular non-conformable PUERPERAL CONVULSIONS. 643 innervation. Whether this too susceptible nature depends upon an altered crasis of the neurine, or whether it arises from modifications of the blood developed during the gravidity, remains to be ascertained; and the subject contains questions full of interest to the pathologist and the therapeutist. The sensorial system does certainly, in many pregnancies, suffer from the intrusion, pressure, and displacement that coincide with the immense augmentation of the volume of the uterus, which thus offers a perpetual provocation to what is termed irritation. The globe of the womb, when it has attained a certain volume, presses by its weight and mass (and is by the abdominal muscles pressed) against the ventral aspect of the spinal column, as Deventer proposed. But the great vascular trunks that lie along the front of the vertebrae suffer compression by this vast womb; and in the primipara woman, whose abdomen resists the extension of its walls, the uterus is pressed strongly against the aorta and the cava; more strongly than in those who have been many times pregnant. But if, in labor, the patient in order to assist in the expulsive efforts of the womb, should bear down by con- tracting her obliquus, rectus, and transversalis abdominis muscles, while the womb is at the same time hardened by the contraction or pain, those great sanguiferous trunks must be so much compressed as greatly to lessen their caliber, and so diminish the flow of the blood through them. This effect is demonstrated in the swelled or infiltrated limbs that we meet with in the last stages of pregnancy, the oedema gravidarum, of which I shall here say nothing more, having given a full explanation of its causes in my letter to you, No. XXXVIIL, to which I refer you. Now, if to the habitual over-distension of the encephalic blood- vessels we superadd the immense determination to the brain caused by the straining efforts to bear down; by the hope ; by the expectation ; by the disappointment; by the stings and agonies of the labor pains ; by the heated and quasi febrile condition of the whole mass of the blood; by its augmented momentum and velocity; what wonder is it to find that the nerves of the spinal cord, both motors and sensorials ; that the par vagum, and the phrenic ; in short that the cerebro-spinal axis, overstrained, overheated, overstimulated, overcharged with blood, should yield to the coincident action of so many causes, and manifest its distress in the convulsive innervation of the muscular system, and in the temporary suspension of the perceptive faculties ? and further, that the paroxysm being overpassed, the patient should speedily feel as if nothing had happened ? Or what need have we for surprise if the patient having perished in the attack, we can discover in some 646 PUERPERAL CONVULSIONS. Perhaps some of you may be inclined to adopt the opinion that in the management of a labor in which, by the physician, fear is entertained of eclampsic seizure, there is danger of its being brought on and not averted by the use of the lancet, agreeably to the reasons set forth by that able and distinguished physician, Dr. Henry Holland, in his Medical Notes and Reflections. Dr. Holland, at p. 52 says: " The use of the lancet is easy, and gives a show of activity in the practitioner, at moments when there appears peculiar need of this promptitude ; current opinions and prejudices are wholly on the side of bleeding ; and the complexity and danger of the cases tend to obscure the results of the treatment pursued. The physician needs all his firmness to decline a practice thus called for; when the event is so doubtful, and where death may be charged upon his presumed feebleness, or neglect." Dr. Holland, while making these remarks, nevertheless recognizes, " in the fullest sense, the value and need of this remedy promptly and vigorously used, in various cerebral diseases, or in prevention of such, where well- marked symptoms lead to their anticipation." Should you admit any apprehension as to the liability to invite, in- stead of preventing the epileptiform convulsion of labor, by venesection, I trust you would take into consideration the very peculiar condition of the parturient patient, who is rarely found able to disembarrass her- self of the fruit of the womb, without a most intense application of voluntary tenesmic force in addition to the mere normal uterine power; and, that the exercise of that voluntary force is invariably attended with the signs of augmented encephalic determination. The sound and philosophical cautions of Dr. Holland, therefore, cannot apply to the instances of epileptiform attacks or menaces for the parturient woman, however earnestly they ought to be inculcated for some, nay, many of the extra-gestative cases. M. Flourens's experiments on the brain have thrown so clear a light on the symptoms that attend the encephalic disorders, that the path of the therapeutist is made straight for his successors. To show you clearly what is the nature, and what the appropriate treatment of our disorder, I ought, perhaps, to present you an abstract of his results. But, in fact, I have already done that for you, in placing within your reach M. Flourens's little tractate, called Phrenology Examined, a book which you could not read (and one may read it through in an hour), without finding much of the difficulty both of comprehending and treat- ing puerperal convulsion obviated, or indeed nullified. M. Flourens's results, then, can be applied to the diagnostication of the state of the brain and its several parts; and when you see the co- ordinating brain (the cerebellum), exerting its force abnormally, while PUERPERAL CONVULSIONS. 645 or soon after or before it, without at once making this reflection. Oc- casionally, upon hearing such complaints, I have been induced by motives which at the time I deemed paramount, to abstain from very direct interference, and I have almost invariably had cause to rue such determination. And I venture here to predict that, if you, in like manner should, without regard, pass by similar complaints made by your patients, you will have abundant cause for regret. It may be that, upon hearing a woman in labor complain of headache, I may, on a very few occasions, have had no cause subsequently to lament that I disregarded it. However, the impression upon my mind at this moment is, that whenever I have so disregarded the complaint I have had to treat a case of convulsions, that I might readily, perhaps, have postponed, or wholly averted by giving to it the attention it really demanded at my hands. Within a year, I sat at the bedside of a lady in labor, which was making a perfectly satisfactory progress. After a pain that she had, she said to me, " Oh! how my head aches, doctor." I imme- diately rose, and examined her pulse—for in her preceding confinement she had a frightful attack of eclampsia, on account of which I had bled her to a very large amount. Her health had never been very good since, whether in consequence of the derangement of her nervous system that expressed itself under the form of convulsion, or whether on ac- count of the large abstractions of blood. As she approached the term of the present gestation, she had repeatedly complained of headaches; flashings of light; tinnitus aurium; suffusions of the face and fore- head ; on which account I had dieted and bled her, so as to have placed her, as I supposed, in a condition favorable enough, as regarded the expected conflict of labor. When she now complained of this headache, I inquired as to its degree, place, &c, and as it very soon went off, I was averse to order- ing the further loss of blood, the more particularly as the child was quite near being born. I did not bleed her. She had two or three consecutive pains, after each of which the headache returned, but it was slighter. I resumed my seat, in order to take care of her at the moment of the delivery. A pain came on, and with it a short, quick, loud, hissing sound from her lips ; her head rolled strongly in extension to the left; her hands, arms, lower extremities, and indeed all the voluntary muscles, as well as the diaphragm, were in the most intense convulsions. I am as sure as that I am now recording these events, that she would not have had the convulsions, had I bled her ad deli- quium, when she first said: " Oh ! how my head aches, doctor !" The convulsions were repeated, so that she lost her life, to my great and lasting regret. 646 PUERPERAL CONVULSIONS. Perhaps some of you may be inclined to adopt the opinion that in the management of a labor in which, by the physician, fear is entertained of eclampsic seizure, there is danger of its being brought on and not averted by the use of the lancet, agreeably to the reasons set forth by that able and distinguished physician, Dr. Henry Holland, in his Medical Notes and Reflections. Dr. Holland, at p. 52 says: " The use of the lancet is easy, and gives a show of activity in the practitioner, at moments when there appears peculiar need of this promptitude ; current opinions and prejudices are wholly on the side of bleeding ; and the complexity and danger of the cases tend to obscure the results of the treatment pursued. The physician needs all his firmness to decline a practice thus called for; when the event is so doubtful, and where death may be charged upon his presumed feebleness, or neglect." Dr. Holland, while making these remarks, nevertheless recognizes, " in the fullest sense, the value and need of this remedy promptly and vigorously used, in various cerebral diseases, or in prevention of such, where well- marked symptoms lead to their anticipation." Should you admit any apprehension as to the liability to invite, in- stead of preventing the epileptiform convulsion of labor, by venesection, I trust you would take into consideration the very peculiar condition of the parturient patient, who is rarely found able to disembarrass her- self of the fruit of the womb, without a most intense application of voluntary tenesmic force in addition to the mere normal uterine power; and, that the exercise of that voluntary force is invariably attended with the signs of augmented encephalic determination. The sound and philosophical cautions of Dr. Holland, therefore, cannot apply to the instances of epileptiform attacks or menaces for the parturient woman, however earnestly they ought to be inculcated for some, nay, many of the extra-gestative cases. M. Flourens's experiments on the brain have thrown so clear a light on the symptoms that attend the encephalic disorders, that the path of the therapeutist is made straight for his successors. To show you clearly what is the nature, and what the appropriate treatment of our disorder, I ought, perhaps, to present you an abstract of his results. But, in fact, I have already done that for you, in placing within your reach M. Flourens's little tractate, called Phrenology Examined, a book which you could not read (and one may read it through in an hour), without finding much of the difficulty both of comprehending and treat- ing puerperal convulsion obviated, or indeed nullified. M. Flourens's results, then, can be applied to the diagnostication of the state of the brain and its several parts; and when you see the co- ordinating brain (the cerebellum), exerting its force abnormally, while PUERPERAL CONVULSIONS. 647 the reasoning brain (the hemispheres) is either in a natural state, or stupefied with coma—and so of the other parts of the brain—you will readily decide as to whether the signs demand, or forbid, the use of the lancet. If I were treating a woman in labor, seized with the true puerperal convulsion, I should certainly bleed her—provided the convulsion did not cease before I could effect my purpose—and should I, in any such case, open the vein, I should surely allow the stream to flow as long as any convulsive innervations were left unquelled. Provided the convul- sion should return again, I should bleed her a second time, and allow the blood to flow until the spasmodic and convulsive phenomena should have again disappeared. I do not say I should do so a third time, and a fourth, though I have done so heretofore. I should act thus, because I cannot conceive of such a convulsion in a person who has been sufficiently exhausted by venesection—since in such a person, the brain would be left incapable of issuing a sufficient amount of nerve- force to give rise to the eclampsic phenomena. In November 1849, a lady about twenty-four years of age, six months gone with child, and who had been convulsed in a pregnancy at seven months, about thirteen months before, went out to walk in the forenoon. At one o'clock, she stepped into a shop to make a purchase. She com- plained of the heat of the apartment, and took a seat; in a few mo- ments she was seized with eclampsia. Being placed on a sofa, she had four other convulsions, and did not recover the least sensibility in the intervals. I saw her more than two hours after the first seizure—she was then pulseless, cold, breathing very feebly and like one dying—the fingers of a dark purple hue, and the face deadly pale. She had been cupped on the head, and had sinapisms freely applied. In a few min- utes the pulse began to beat again, and the respiration to re-establish itself. As the pulse got up, I perceived that the circulation might soon become so impetuous as again to bring on the eclampsia, and was about to say so and to propose to bleed her from the arm, when she went into a violent fit, which was the sixth of the series. This attack terminated after some minutes; but not until the medulla oblongata had nearly ceased to exert its power over the respiration. Indeed, I felt convinced that she would not breathe half a dozen times more, so near was she apparently to the moment of her dissolution. I was surprised to find the pulse, however, beginning again to creep in the wrist—the breathing to improve in force, and in some six or ten minutes after I had deemed her to be drawing her last breath, to begin to breathe actively. I now proposed to take blood, which was agreed to by my medical friends, and the loss of some eight or nine ounces, pleno rivo, 648 PUERPERAL CONVULSIONS. quelled the dangerous arterial reaction. She had no more convulsions. At 10 P. M. she spoke for the first time, having a confused perception of the presence of her friends. Many days afterwards she was delivered of a premature child, which was dead. I have mentioned this case, in order that you should not be discou- raged even in very advanced stages of this dreadful disorder, from making use of the lancet wherever you can discover the indications for controlling the excessive momentum of the blood in the arteries. After bleeding the patient, I should deem it, in almost every instance, proper to procure a copious alvine dejection, by means of an enema— one, or more. The article most suitable, because it is the most conve- nient, is common salt dissolved in warm water: two large tablespoon- fuls of salt, dissolved in a pint of water, should be thrown into the rec- tum. This is so very powerful an excitant of the bowel that it may be expected to operate within a few minutes, but it should soon be repeated if the first dose fails. Upon the operation of the enema, a judgment may be formed as to any further necessity in the way of procuring alvine dejections ; and whenever it is ascertained that enough has been effected, advantage ought to be taken of the counter-irritant and revulsive power of the sinapism—accordingly, two large sinapisms, one to each leg, ought to be applied, and left in situ for some thirty minutes—not longer. The next step should be to administer the opium. Everybody now gives opium in puerperal convulsions, as soon as the depletion has been carried sufficiently far and the bowels have been relieved by the enema. A good dose ought to be given, say forty drops of laudanum or twenty of the black drop ; or two grains of powdered opium ; or fifty drops of laudanum as an injection—fifty drops of laudanum mixed in a fluidounce of clear-starch is the proper mixture. If the coma, with stertor, continues, the question will arise as to cups or leeches to the temples: let that question be settled by careful inquiry as to the state of the circulation in the brain. Such applications are often useful. The head should be kept cool. This cannot be properly done if the patient have a great quantity of hair. The hair, then, ought to be sacrificed. It should always be removed in eclampsia; and an objec- tion will never be made when the physician speaks with the proper tone and authority. To cut off the hair, and cover the head with an ice- bladder, or with cloths strongly wrung out of cold water, is indis- pensable. The cloths should be frequently changed. The doses of opium ought to be repeated from time to time, as long THE BREAST. 649 as the mind of the patient, and her muscular actions, continue to exhibit the direct influence of the paroxysm. But, when the reason returns, and the intelligence is re-established—and when the convulsive inner- vations of the muscles are at an end, there may be no further occasion to repeat the doses of opium—or at least, no reason for continuing them at the same rate. I am not writing a book on Obstetricy, and I shall therefore not speak of the delivery, except so far as to say that the woman ought to be delivered as soon as possible ; because, the child being taken away, one great cause of, and provocation to the eclampsia, will be removed along with it. By the words " soon as possible," I mean as soon as it can possibly be done with propriety. Of that propriety the accoucheur must be the judge—yet no one can be held excusable who absolutely forces the os and cervix uteri. This is a doctrine on which Dr. Dewees used to dwell with great emphasis. The os uteri is never to be forced. But there is a wide difference between forcing it and persuading it to yield. It may be prevailed against by means of the relaxing influence of belladonna ointment applied to its surface, aided by gentle dilatation with the hand. But I am lapsing into a discussion in Obstetricy, and shall therefore cut it short by bidding you farewell. C. D. M. LETTER XLV. THE BREAST. MAMMARY ABSCESS. Gentlemen: I found her lying in bed, and looking dull and dis- pirited when I entered the apartment; whereas, I had parted from her two days before in excellent spirits, proposing to get up on the morrow; for by that time, her ninth day, the dies nondinae would be complete. The child was in health ; she had had an excellent labor ; the flow of milk was abundant; and not the slightest untoward event had occurred up to the end of the eighth day. " I am sorry to find you have been obliged to send for me, my dear Mrs._______. I left you so well the day before yesterday, that, being much occupied, I thought I might lay aside my daily habit of coming to make you a salaam in the morning; you know that I have had nothing else to do here since the birth of the infant. You were cheerful and happy when I saw you last; but now you look downcast and apparently sick. What can be the matter with you ?" 650 THE BREAST. " I have been quite sick, doctor, since yesterday afternoon." " What! quite sick, and I not notified of it ? Did you not say, did not this nurse say, did not Mr. B------say that if, at any time in the whole course of the month, you should be seized with any symptom whatever, great or small, I should immediately receive a note, inform- ing me of it ? Here now, you've been sick almost twenty hours before I am made aware of it. Was this just to me? Was it just to yourself and your friends ? However, I suppose it will always be so with everybody, since I have found it so with everybody for forty-five years!" " But the Doctor will please to observe that we did not like to trouble him. It was thought that the indisposition might readily pass away ; and, indeed, I do feel a little better now than I have done in the night, or the early part of the morning." " But what has been the matter with you ? What have you com- plained of since yesterday afternoon ?" " I was taken with a chill, sir, at two o'clock, and I could not get warm for near two hours. This was accompanied and followed with pain in the head, in the back of the neck, and in the limbs, that I could hardly endure, after which I became so warm that I was obliged to throw off some of the coverings." " Have you any pain in the stomach or bowels ?" " No sir, not the least." " Can you draw up and extend the lower extremities without pain ? Try it; does it hurt you ?" "No, sir." " Cough—I wish to know whether, if you cough, it will give you any pain in the lower part of the bowels. There! that will do. Does that hurt you ?" " No, sir, it does not." "Make a great aspiration of air for me. Breathe hard. Any pain ?" " Not the least, sir." "Which of the breasts hurts you?—the right or the left one?" " My breast doesn't hurt me, doctor." " Yes, it does." " No, doctor !" " But, I am sure that it does; and that the cause of your chill, and of the heat that you have had all night, and that you still have—for your pulse is quick—is seated in one or more of the branches of the milk tubes. Will you let me touch the breast ?" " Yes, sir." THE BREAST. 651 " There, now, it hurts you at this point, does it not ?" " Ouch ! Oh, yes, sir, very much indeed ! Why, I did not know that I had anything the matter with the breast!" " But I did, you see." " Yes, I see that you did. It is very strange that you should know that I had a pain, when I myself didn't know that I had it!" " No, it is not at all strange; it is very easy to know that; because it is very easy to perceive in the rate of your pulse, your breathing, your heart; in the tint of your complexion; in your physiognomical expression ; in your gesture and attitude; in the absence of pain in the abdomen; in the state of your intellect, evinced by your answers to my questions, that nothing else could be the matter with you. In fact, as soon as you said, * I had a chill yesterday afternoon,' I knew that you had an attack of what the ladies and nurses call the weed. You have got a milk-fever, my dear." This conversation happened yesterday morning, Nov. 20th, 1847. To-day the patient is very well again, for the weed has disappeared; that is to say, the milk which had accumulated in excessive quantities in the lactiferous ducts of the mammary gland, or rather in certain of them, has been carefully drawn out; and the tension, pressure, irrita- tion, intension, affluxion, heat, sensibility, redness, and swelling, all disappeared upon its evacuation. I have been practicing my art now for a great many years, and I must have seen some hundreds of persons lying sick as this lady was ; some of them with intense fever, cracking headache, intolerable pain of the nucha, back, and limbs; not unfrequently with nausea and vomiting; and all this mixed up with distressing flying rigors—to whom I have said at once, " You have got a lump in your breast;" to which it has often been replied : " No, I have not." " Yes, you have." " No, indeed I have not." " Indeed you have." Whereupon the nurse rejoins: " Oh no ! there is not any at,all, for I examined the breast very carefully but just now." " Let me examine it. There now, does that hurt you ?" " No, not at all." " Does not that ?" " Oh ! dreadfully, dreadfully indeed!" " I told you so. It could not be otherwise. How should it be that I should not understand my business ? I could tell you had the weed in your breast, if you were in the moon, and I were looking at you with a spy-glass." 652 THE BREAST. If you are going to practice midwifery, my young friends, you will have to submit to the aid of what are called nurses; and suppose you should meet, during your career, with a thousand different ones, you will not find more than two or three of them that ever saw a gathered breast. A man would as soon acknowledge that he had stolen a sheep as a nurse confess, in general, that such an accident had ever befallen one of her patients. I saw a little darling of a woman here, about two months ago, more patient than St. Anthony—who had been about two weeks confined. I had not seen her for four or five days. Upon re- ceiving a summons, I repaired to her house, and found her complaining of pain on giving suck to her child;—pain in the nipple, extending back over the breast, towards its upper and exterior circumference. I took the breast between my thumb and four fingers, so as to compress the gland in the direction of its latitude or breadth, and found that gentle pressure gave her very severe pain. Upon touching it perpen- dicularly, I discovered a mass of solidified texture, about two inches and a half in width, by three and a half in length ; and, when I learned that she had had uneasiness in the breast for four or five days, I said to the nurse : " Did I not charge you to inform me if anything should be the matter with my patient ? telling you to watch her in my absence, in order that I might have the earliest intimation of any accident or dis- order that might affect her ? Your disobedience has brought her in danger of a mammary abscess, which may make her ill for three, or even for six weeks, during which she will experience much pain and constitutional irritation. You have done very wrong ; you have failed entirely in your duty to this person, who employed you to take care of her;—you have not taken care of her. I am afraid that she'll have a gathered breast, notwithstanding everything I can now do to pre- vent it." "Not she, doctor!" replied the nurse, "not she, indeed! I have nursed for twenty years, and I have never had a gathered breast yet, in anybody that J took care of." " Very well, Mrs. Nurse ; you are about to extend the area of your experience, in this very case ; for I think it is very likely that you will have two ; and I wash my hands of them ; for the blame is yours, and nobody else's. The right breast is gone so far that I have no hope of curing it, short of a suppuration. The left one is inflamed, and the fever that your patient is going to have will cause it also to suppurate, or I am very much mistaken." This poor lady had two of the most detestable mammary abscesses that I have seen for the last four or five years. Now, I have related this story to you for this purpose, namely, as an THE BREAST. 653 introduction to the precept, watch your patient yourself; for you cannot get anybody, for love or for money, to do your work as it ought to be done. You may lay down the most definite, clear, precise direc- tions as to the management of the breast, and you will be sure to be disobeyed. If the breast will take care of itself, and not get into dis- order, it is well; but, it is very apt indeed not to take care of itself, and to subject you to the mortification of an attendance upon a mam- mary abscess—always the source of displeasure, disappointment, and irritation in the family; and, to a certain extent, of blame to the physi- cian. It touches the nurse in a point of honor to suppose that her pa- tient could have a gathered breast, because she considers that her official function consists in taking care of the breast! and you might as well tell a physician that he does* not understand the Harveian circulation, as to express any doubt as to the competency of the monthly nurse to the entire charge of all the circumstances connected with lactation. I should in vain endeavor—devoting many pages of this letter to the purpose—to express the thousandth part of the vexations and mortifica- tions that I have experienced for more than thirty years, from the igno- rance, carelessness, and presumption of those in whom I have been obliged to put my trust. There are happily some nurses one can trust; but their name is not legion. But, I began this letter, designing to speak of the management of the female breast; let us proceed, therefore, to inquire what the breast is, its condition in gestation, and in the lying-in state; and what are the cares that it demands at the hands of the medical attendant; and the first thing you have to do in the matter, if you will be an accoucheur, is to purchase or borrow a copy of Sir Astley Cooper's Treatise on the Female Breast, which, though it costs about twenty dollars, is worth a thousand to a man who is to be engaged in this line of practice. That book will show you that beneath the skin on the front of the chest there lies—one on each side—a fascia, which sends up fibrous and cellular digit- ations to attach it to the inner surface of the derm. Between these fre- quent digitations exist many adipose cells, that often are found to contain great quantities of fat, so that, between the external surface of the fascia and the internal surface of the derm, is a chosen seat for the deposit of the adeps that gives to the breast its beautiful hemispherical form, its smoothness and softness. Within this fascia, of which I just now spoke, are to be found fifteen, and in some instances as many as twenty- one efferent ducts of the granules of the milk gland, or mammary gland. Each of these ducts, called milk-vessels, passes out of the gland through the skin at the extremity of the nipple. The nipple is, in fact, a fasciculus of milk tubes, or galactophorous tubes, which are 654 THE BREAST. gathered up into a bundle, and protected amidst a number of blood- vessels, some cellular tela, nerve fibrils and absorbents, within a very delicate derm, and a cuticle that should rather be called an epithelium. There is also a good supply of apparatus of sebaceous secretion, by means of which the delicate surface of the nipple is kept in a soft and unctuous state. Each one of the milk tubes contained within the fascia of the gland runs right and left, or obliquely or perpendicularly upwards, or downwards as it divides into numerous branches, becoming finer as they go inwards from the nipple, and successively dividing, until each of the minute tubuli terminates in a spherical hollow granule, big as a white mustard seed, from the inner surface of which the milk is secreted; for that is the secreting surface of the milk. Fifty, one -hundred, or any given num- ber of these granules are appropriated to the supply of a quantity of milk sufficient to fill up and distend its own galactophorous tube, whose issue is found upon the extremity of the nipple. If you had a syringe filled with delicate size colored with vermilion; and if you should introduce the point of the syringe into one of the milk pores upon the end of the nipple, you might inject the milk tube, and distend it so much as to make it swell out to the size of a large swan quill, or, in some instances, to the size of your little finger. If the material of the injection should run inwards into every branch of the galactophorous tube, so as to fill each granule at the extremity of its branch, you would make a beautiful injection of that part of the lactife- rous apparatus. If you should afterwards fill the syringe with other colors, green, black, blue, yellow, orange, violet, indigo, or any of them, you might inject, in succession, each of the fifteen or twenty-one porules at the end of the nipple, with a different colored mixture, and thus fill up the breast completely with various colored injections; each of which would run off to the branches of its own particular galactophorous tube, and nowhere else; so that you might say, as in boxing the compass, this one runs north, this one north by east, northeast, southwest, south and by east, northwest, west, and so on, until you have indicated the direction of each tube separate and distinct. Such is the anatomy of the breast. It is explained by Sir Astley Cooper in his delightful work on that subject. Now, these galactophorous tubes are supplied with the force for secreting an immense quantity of milk, consisting of a mixture of water, albumen in solution, casein, and oil which you call cream. I have seen a woman, using a common breast tube, draw out two large tumblerfuls from one breast, at one sitting; not that she had two large tumblerfuls in the breast when she began to draw it, but that she began to form, THE BREAST. 655 and continued to pour out this peculiar compound which we call milk, until the power of the gland to produce it being exhausted, it at length gave up the last drops; demanding rest for half an hour or an hour, until recovering its secretory power, it was ready to give up as much more. A good cow has an udder, which, if you could cut it off, you could readily put it into a very small pail; yet this same cow is capable of giving sixteen quarts at a drawing, which may serve to show you the rapidity with which these extraordinary organs are capable of pouring out the material that serves for the nutrition of her young. It must be clear to your minds that such a great functional force cannot exist independently of a vast supply both of blood and of nerve. Accordingly, numerous arteries come from within the axilla, and from the internal mammary artery; and a great variety of nerve fibrils, some of which are connected with the sympathetic, pass from within the chest, while others connected with the axillary branches, ally it to the cerebro- spinal system of innervation, serving to connect the mammary gland with the whole nervous constitution of the woman, and render it in the highest degree liable to those development-movements that result in sanguine engorgement and inflammation. At the period of puberty, among the first signs of the change about to be effected in the constitution of the young girl, those that take place in the breast are observable: the granules of the gland, and its efferent ducts the galactophorous tubes, acquire a more positive devel- opment ; and the hemisphere of the mamma begins to rise from the general surface of the bosom. But it becomes protuberant, rather from an in- creased amount of the deposit of adipose matter among the cellulo- fibrous digitations of the gland, than from actual development of the substance of the glandular matter itself, although that does, as I have said, increase a little. The nipple, at this period, is very small and is seated in the centre of the aureole, which is a. reddish or rosaceous area, extending from the base of the nipple a certain distance on the organ, in general not more than, half an inch from the nipple, in every direction. Observe, that it is of a rosaceous hue, deeper or paler, ac- cording to a sanguine, or lymphatic, or nervous temperament of the subject. As the young girl becomes more and more perfectly developed, the breast becomes more and more augmented in size; so that you should expect a person of eighteen or twenty to have a larger one than a girl who has just changed. The breast is, in general, possessed only of such sensibility as ap- pertains to the tactile power of the skin everywhere; but, upon par- ticular occasions, it is different. For example, many young persons at the approach of, or during the mensual period, find the breasts a little 656 THE BREAST. larger and fuller, and more sensitive, and affected with sharp pains and aching, disappear when the catamenia begin to flow freely, and reappear at the next mensual epoch. When a woman becomes pregnant, the breast very speedily begins to grow larger ; the fat deposited upon it is sensibly increased in quan- tity, and if the gland be taken between the thumb and four fingers, it is found that the fascia which incloses the material of the gland is fuller, rather tense, and has a more granular feel than usual: in many, it feels as if it were full of strings or ridges, giving in some instances a sensation as if one were touching hard earth-worms beneath the skin. At the time this process of augmentation within begins, the aureole increases its area, and what is very singular and worthy of your observation, the corpus mucosum of the skin beneath the aureole acquires the power of excreting pigmentum nigrum; just as if the corpus mucosum had now become endowed with a pigmentary membrane like that that lies beneath the skin of a Negro, a Malay, or an American Indian, but which does not exist beneath the skin in the Caucasian races. In some women, the breast grows fat at such a rate that the skin is pushed off further and further from the fascia which incloses the gland; and the milk tubes within, whose termini are upon the nipple, fail to stretch or elongate themselves pari pass-it with the rise of the skin. The nippple in this case seems to be drawn inwards, so that, instead of its being a prominent mammilla upon the breast, there appears a depression like that which the carpenters call a countersink. This countersink of the nipple is produced in the same way as the pit, is produced in the navel of the young growing child; for as the navel is held in, accord- ing to Billard's description, by the remains of the two umbilical arteries and the umbilical vein, so the countersunk nipple of the female breast is detained within by the unyielding galactophorous tubes, which refuse to be elongated while the rest of the tissue is being stretched. I sup- pose, gentlemen, that if our American ladies were in the habit of sup- porting their bosoms with the pretty Greek strophium, or the Roman fasciola, which women were accustomed to wear in the olden time, there would be less occasion to deplore the frequency of this troublesome retraction of the nipple. If the breast were left free to grow in all its parts, it is likely that the nipple would be produced, along with the rest of the tissues, but the wearing of corsets and busks must neces- sarily interfere with the development of the organ, and lend a mate- rial aid to the nipple in its refusal to come forward along with the rest of the structures. A young married woman, who should become pregnant, and who should find that her nipple is becoming countersunk in this way, ought THE BREAST. 657 to apply to the point of the breast a concave disk of very thin ham- mered silver, three inches in diameter, with' an opening sufficiently large to allow the nipple to pass freely through it, and having a cylinder, a quarter of an inch in length, soldered upon the edge of the opening. The concave of the disk would adapt itself to the form of the areola of the breast, and the nipple projecting through the opening, and protected by the cylinder, would have a constant tendency to come forward, and draw with it its whole fasciculus of galactophorous tubes; so that, at the termination of the gestation, the nipple might be found in a fit condi- tion to be seized by the lips of the child, instead of both vexing it and tormenting its parent with vain attempts to get it into the mouth. I have seen several women who could not nurse at all on account of this shortness of the nipple. All such are liable to irritation, and even to suppuration, in consequence of the impossibility of expressing the milk, formed in abundance by the granules of the gland; and from abrasions and cracks of the nipple, produced by repeated and pro- tracted attempts made with breast-tubes and pumps and various appa- ratus for what is called drawing the breast. After the above expla- nation, should you be consulted beforehand as to the treatment of the affection, I should think you will have no difficulty in giving directions conformable to the wants of the patient. Ladies will sometimes ask you whether it is advisable to hav.e the nipple drawn by a young puppy, or by the mouth of a friend or servant. Let your answer be, that God is all wise; that he could not make a mistake ; and that if it was necessary to have the nipple drawn before the child was born, he would have had the child born before its birth. All the laws of life are generic laws ; they cannot err; and it is per- fectly ridiculous for a mere human reason to dare to be superior to the will of God, as it is expressed in the simple words, " the laws of nature." Tell her to let it alone; it is just as reasonable to draw the nipple beforehand as it is to give ether to put a stop to the natural pains of labor. Let her know, that after her child shall be born, she will, after the third day, or earlier, put it to the breast; and that the moment the child begins to irritate it with the tongue and lips, she will begin to feel an after-pain—that is a contraction of the womb—for there is surely a connection between the breast and the uterus which affects them both interchangeably. To draw the breast, therefore, is to ex- pose herself to the risk of exciting the action of the womb before the time. Surely, to draw the breast is to risk exciting the womb into muscular activity. Somewhere between the first and the seventy-second hour after the birth 42 658 THE BREAST. of the child, the fluxional movement towards the mammary gland begins to take effect; and the determination of the developing-force proceeds in the direction of the secretory offices of the granules, manifesting it- self by the production of the milk. The fluid when secreted flows into the great tubes of the breast, making it hard, voluminous, hot, weighty, and painful. The whole of the gland being contained within its fascia, and being now greatly increased in weight, hangs suspended upon the skin on the front of the thorax. From its weight it prolapses, stretch- ing the skin, and often increasing the pain of the gland in consequence of the unequal tension of the several parts of it, caused by the descent. On this account the breast should always be held up; it should never be allowed to hang by its own tissue. You would not think of treating an orchitis without a suspensory; nor should you think, in like manner, to take good chirurgical care of an overfilled breast without providing good means for its support. A Greek or a Roman girl always supported her breast by means of the strophium or the fasciola, which passed beneath it —you should provide a strophium for your patient. The most conveni- ent one that can possibly be devised is, in my opinion, a linen strip of adhesive plaster, half an inch wide and ten inches long. Place it upon the skin behind the breast on the side: it should then be attached to the hemisphere, which is to be held properly upwards, and the upper ex- tremity being next carried upwards near the clavicle, should be adapted in such a way as to assist the corium to hold up the heavy breast, which is surcharged with fat, and granules, and bundles of milk tubes. Some- times, one adhesive strip suffices, though I occasionally put on two or even three, in order to give a perfect support. This is far better than all the jackets, and corsets, and pocket-handkerchiefs that can be de- vised—I mean for the early stages of the lactative breast. The adhe- sive strip should be reapplied every second or third day. Hold up the breast, then, with the adhesive strip or fasciola. In most cases, you would think a suspensory a sufficient remedy for an orchitis; in like manner, you will find that an adhesive strophium is a sufficient remedy for the slighter irritations of the female breast. You may apply it so as not only to support, but gently and favorably to compress the whole organ. When the breast becomes overfilled, its sensibility is so greatly in- creased that the woman does not willingly suffer it to be touched. You will often find it incompressible, and actually shining from the polish of its tension. It has now a power to irritate the nervous and vascular sys- tems equal to the power of an immense imposthume or abscess ; and the constitution will be found to react upon it, and the woman will have a fever ushered in with rigors, or even with a severe ague. These rigors THE BREAST. 659 and this fever, like those of an ordinary intermittent or remittent, termi- nate in copious perspiration. The fever is not a tertian, it is an ephemera; it terminates after a course of nineteen hours from the beginning of the cold to the end of the hot stage: this is its natural course. But still, a milk-fever, though so short-lived, is never a matter of indifference; because, a milk-fever attacks the constitution of a woman already greatly modified by gesta- tion and labor and the puerperal state; and if the violence of the vas- cular movement happen to be very considerable, or, if there have been any topical lesion, or any accident that may have happened in the course of the labor, it is apt to invite the fluxional movement upon itself, and thus become a new radiant point, whence inflammation may extend into the depths of the tissues, or along their surfaces. Don't say, therefore, "it is only a milk-fever, and requires no special care ;" but give it the attention it may deserve. If the milk-fever should be progressing favorably, and manifest a tendency to run out its natural course and terminate at its ordinary term of nineteen hours, your only duty would be to watch it, and take heed that it do no mischief within the bounds of the economy. Remember, the milk-fever is a constitutional irritation developed from a radiating point, videl., the over-sensitive, over-tense tissue of the mammary gland; and see, in this reflection, that one in- dication of treatment is to deprive the breast of this pathogenic power. Well, but to deprive it of this power which depends on the tension, you must make the tissues as flaccid as possible. How? What is it that chiefly renders it tense? It is the twenty-one milk tubes whose trunks and branches are all distended to the extremest degree of tension, be- cause they contain at one time eight or ten ounces of milk, constituting, perhaps, one-third of the whole weight of the organ. Take the milk out, and the breast that you could not indent with the palps of your fingers will be left perfectly flaccid, completely cool, and admitting of the freest palpation and handling, without the woman making any complaint. Tell the nurse to put the child to the breast often. How often ? As often as it is necessary. How often is that ? As often as the breast becomes hard. For thirty years past, I have told my monthly nurses these things ; perhaps in these very words ; nevertheless, I cannot, to this very hour, go into a lying-in room, where I find a breast in a state of tension, and the constitution in a state of fever, without being told, " I did draw the breast, doctor ; the child took it this morning." " How long ago, nurse ?" "Why, at seven o'clock." " What o'clock is it now ? twelve, is it not ?" 660 TnE BREAST. " Yes, it is twelve o'clock." " So you drew the breast five hours ago, did you ?" " I drew it at seven o'clock, sir." " And it has been as hard as a paving stone ever since. Can't you see that if you let the breast remain hard it will inflame ? This fever will increase and not lessen, and you will expose your patient to the risk of having a mammary abscess, or gathered breast, as you call it." " Oh ! never do you mind, doctor ; I never had a gathered breast in my life. Do you think I ever allowed a patient to have a gathered breast ?" Excuse me, gentlemen, for writing in this style, for I have at this moment under my care, two mammary abscesses produced by the faults of two most excellent monthly nurses. I am sure that you will be able to appreciate the importance there is of keeping down this mammary tension; for, if it is not kept down, the tissues must inflame; and inflaming under such circumstances of great constitutional fluxion, you will not be able to avert the mischief of the threatened suppuration, except at the expense of the most vigor- ous antiphlogistic means. To draw the breast now, and not by and by, is to save the patient from venesection, from leeching, from cathartics, from a disgusting series of poultices, and all the pain and exhaustion of protracted and difficult mammary suppuration. Take heed of it, then : see if you shall be able hereafter to be more successful than I, in making the patient herself, or those that attend on her, comprehend the true influences of mammary tension. If I could give you in this letter but a just notion of the meaning of the words mammary tension, I should think you were well rewarded for the perusal of the whole volume, though you got not another useful hint out of it. W7hen you find that the tension of the breast produces a constitutional reaction of great violence, and that the fever is accompanied with head- ache, pain in the back and loins, aching of the limbs, and frequent rigors, you should look upon it as a serious matter.; which, though it be nothing more than a milk-fever, exposes the woman to the risk of dangerous local engorgements and inflammations. You should lessen this constitutional reaction by opening a vein in the arm; by the exhibition of a cathartic medicine, whether saline or other; by proper doses of the neutral mixture, and by insisting upon the free use of demulcent and diluent drinks. If you allow the fever to rise to too high a grade, it may be feared that, instead of coming to its term in nineteen hours, it will become a continued fever, which will have an inflammatory character, and which may plague you for a week THE BREAST. 661 or ten days ; involving you in the constant necessity of watching over the patient, and exposing her to the greatest risks. Sometimes the breast becomes so hard, so rebellious, that it is found impossible to extract the milk from its tubes ; they crowd each other, acting as compressors upon each other; making it impossible to remove the accumulation. Under these circumstances, the nipple is apt to become irritated and even inflamed. The frequent sucking of the nip- ple by the child, or by various instruments invented for the purpose, produces cracks and abrasions of the surfaces, and then you have an ulceration established upon an inflamed base. Were the ulceration seated upon a non-inflamed base, it would cure itself: but you will no more cure the nipple-sore while the whole mass of the nipple itself is in a state of inflammation, than you will cure a cancer-sore while the ulcer is seated upon a carcinoma. I do not mean that it is incurable as the cancer-sore is, for the nipple will at last get well, having in it no heterologue character; the cancer will not get well, for it rests upon a heterologue base. You can have, at present, no idea of the vexations that women en- dure in nursing their children in the month from sore nipples ; a com- plaint so common, that I am surprised when I hear one of my patients say she does not suffer from it. The sore-nipple most frequently consists in a long, narrow ulcer, wide as a horsehair, and a sixteenth or sometimes an eighth of an inch long, situated on the side of the nipple. This ulcer is so small, that it requires a good light to see it; and even then it often cannot be detected, except by bending the nipple over to the opposite side, which discloses it. The ulcer is, at most, a narrow line of painful granula- tions ; and it hurts the woman so very much as to render her un- willing to suckle the child as often as it should be done; which ex- poses her to the risk of having an overfull breast. I think it very probable that many cases of mammary abscess owe their origin to the reluctance of the mother to encounter the pangs of suckling the in- fant while these fissures or cracks of the nipple are uncured. When one of them occurs in a nipple, the whole substance of which has be- come inflamed and hardened, it is very difficult to cure it; and it is even difficult to prevent it from increasing both in length and breadth, since as often as the child takes the nipple into its mouth to stretch and to pull it, so often is the sore liable to be augmented. The pain is repre- sented to be of the most intolerable kind; and it must be, indeed, most insufferable, if one may judge from the appearance of the mother, from whose eyes tears are seen to stream as she submits to the pain. I have often imagined the pain to be, in intensity, very similar to that which 662 THE BREAST. one feels who has received a bit of sharp angular sand in the eye, and which vellicates the lids of the globe, whenever they are moved, pro- ducing a pain and irritation that are truly intolerable. The sore would disappear I presume, in forty-eight hours, were it not for the necessity of drawing the breast. In treating such a sore, I generally avail myself of the antiphlogistic and anodyne power of the nitrate of silver, the contact of which is, in some instances, sufficient to make a speedy cure, where the massive in- flammation of the nipple will admit of the cicatrization of the sore. It is a matter of great consequence to touch only the granulations, and not the skin itself. To this end I take a fine camel-hair pencil, and, dipping it in a solution of the nitrate, I carefully pencil the granu- lations only; for I find it easy, with the delicate point of the pencil, to make the application exactly to the points I desire to touch. A solution of twenty grains to an ounce is strong enough. You will find, in many instances, that the extreme sensibility of the sore is lessened so much by one contact of the nitrate as immediately to enable the woman to give suck to the child with much greater comfort. Mrs. De Groot, a monthly nurse here, a most sensible woman, in whose prudence and knowledge of her business I can confide, tells me that the nipple rarely becomes sore under her method of managing it. As soon as the child has left the nipple, Mrs. De Groot invariably cleanses it with a bit of moistened linen. She dries it perfectly, and then, taking the mamilla between the thumb and two fingers, gently compresses it, with a view to assist it in disengorging its capillary ves- sels that are turgid from the suction. As soon as she has rendered it soft and flexible again, she covers it thick with fine arrowroot powder, and keeps it in that way perfectly dry. I do not remember that the ladies she has nursed for me have, any of them, suffered from this an- noying disorder. Dr. Physick taught me to cure a very bad nipple-sore in a patient he attended with me. He prepared a very delicate adhesive strip by spreading adhesive plaster on a narrow ribbon, called by the shop- keepers taste. " These gaping ulcers," said he, " are like gaping incised wounds. Their edges are separated too much ; they will therefore require a far greater quantity of granulations to heal them than if the edges should be approximated—bring them together then with the delicate strips of adhesive plaster, and keep them so—they will get well much sooner." This advice was followed, and the effect was soon perceived in the amendment of the lady. Most of the French physicians use, for the treatment, an ointment THE BREAST. 663 made out of the juice of cucumbers—the pommdde de eoncombres—and it certainly is one of the most emollient of the ointments. A good deal of it is employed here. In order to be useful, it should be freely applied. Borax, dissolved in mucilage of slippery elm, is a very pleasant wash. It should be put into a salt-mouth phial, the throat of which is large enough to receive the nipple. Let the phial be turned up on the nipple as soon as the child leaves it. If held thus to the nipple a few moments, the whole surface is effectually moistened by the wash. Dr. Vanderpool of Albany, New York, who formerly attended my lectures in the college, writes lately that he has very little trouble in healing the sore nipple, whereas formerly he had experienced much difficulty in curing his patients. The method he uses is, to smear the aureole frequently with an extract of stramonium.—If carefully wiped off before giving suck it does no harm to the child, while it speedily relieves the mother. Where the nipple has been greatly inflamed and swollen, I have on many occasions directed a number of leeches, six to ten, to be applied just outside of the areola. For this end, I cut a disk of linen, or of diachylon-plaster to fit the areola, leaving a fenester for the nipple. The leeches cannot puncture the areola itself, if this precaution be taken—but their bites are all made beyond the circumference of the disk. You should not allow them to wound the aureole, because it renders the act of sucking more painful, and because the erythema that always attacks the leech-bite would pass on to the nipple and aggravate, instead of diminishing, its inflammation. It is very bad when the end of the nipple becomes abraded and in- flamed, for then the inflammation runs along the milk tube deep into the substance of the mammary gland; and when it does so, a great difficulty is encountered in effecting a cure, short of the process of sup- puration. When the end of the nipple, therefore, is abraded and ulce- rated, you should give it a most careful attention, with a view to prevent so great a misfortune. Inflammation of the mammary gland, tending to abscess, is a warrant to order a venesection for a woman who is strong enough to bear the loss of blood, and there are few who are not strong enough, since those who are not, will, in general, not be found prone to these inflammations. You ought not then to hesitate to bleed for an inflammation of the gland, when the disorder threatens to be severe. 3 Leeches freely applied, if they be not set upon an inflamed portion of skin, are very laudable. Many a hard nodule, threatening milk 664 THE BREAST. abscess, has been removed by twenty or thirty leeches; the operation to be repeated if the case demand it. A poultice is manifestly a useful remedy. But poultices long applied to the delicate skin of the mamma are apt to bring out an eczema that adds to the discomfort. I think I have never had any such additional trouble when I used a poultice made with bread and milk thickened with the petals of chamomile. It is a habit or routinism of my practice, and I venture to recommend it to a trial under your direction. When the breast must suppurate, it ought to be favored by the use of demulcent poultices. Powdered slippery-elm makes a good one—so does flaxseed meal—but probably none is better than bread and milk with chamomile. When the suppuration has taken place, the matter ought to be dis- charged by means of a lancet, as soon as the abscess fairly points. When the cavity is become empty by the discharge of the pus, let the breast be compressed by means of strips of adhesive plaster, which con- stitute the most convenient suspensory and compress for the organ. I am confident the use of these adhesive strips has enabled me many times rapidly to cure a breast, which I should vainly have endeavored to cure in double the length of time by any other, kind of dressing. The breast having suppurated, and the pus being discharged, whether by a spontaneous opening or by means of the lancet, milk is sometimes seen to flow out together with the purulent matter. Such a waste of the milk prevents the aperture from healing; and the cavity of the abscess becomes a milk-fistula, which continues for an indefinite period to discharge milk. When I find such a one, I push to near the bottom of the canal a very small bougie, made extempore of cere-cloth. Filling the orifice of the fistula, and probably irritating the internal granula- tions to a more healthful activity, the bougie, generally, soon arrests the flow of milk from the orifice. The bougie becomes daily shorter at each successive repetition, and the fistula heals. If a woman have a suspicious nodule of long standing, in the breast, she ought not to nurse the child. The constant alternations of fulness and flaccidity, and the augmented vital activity required to carry on the secretion of the nutriment, expose her to the danger of an incon- venient increase of the tumor, and to inflammation radiating from its superficies. Let her wean the child, by giving it to a wet-nurse. If you decide to remove the tumor or nodule by the bistoury, let it not be done until the milk has completely disappeared. The breast is not fit for the surgeon while it is a secreting gland. And now, having nothing further to propose as to the breast, I shall bring this letter, the last of the series, to a close. THE BREAST. 665 I wish, my dear friends, these letters were more worthy of your perusal; and I might, doubtless, have rendered them so, had I allowed myself, which I could not, more leisure from the daily business of my vocation, for their composition. Many of them have been written while waiting on women in labor; and most of them at night, after the toils and anxiety of the day's prac- tice ; more than half of them, while suffering under an unspeakably dis- tressing hemicrania. But I had made the promise to write and publish a series of letters to you, on the subject of Woman and her Diseases— letters in which I would speak as nearly as possible in the same tone and manner I should employ in speaking on the subjects, with any one or two of you in my library here, where I am now writing. I have used that very manner in these communications ; and you, who remem- ber my manner of speaking to you in the lecture-room, will be able to judge whether or no I have done right in using a style as simple and natural as that you have been accustomed to in my public instruc- tions. Some critics have blamed me, and some endeavored to ridicule me for using so familiar a method, and as I am aware that no man has a right to print a bad book, nor even to apologize for faults in any book of his own making, I do not pretend to do so on the present occasion. I do, however, feel desirous that you should not forget the scene and the occurrences that so suddenly prompted me to engage in this task; nor overlook the fact that I did not begin these letters of 66Q pages until about the middle of last May. I have found the mechanical labor of it severe, " Sed tua me virtus tamen, et sperata voluptas Suavis amicitise, quemvis efferre laborem Suadet; et inducit noctes vigilare serenas Querentem dictis quibus, et quo carmine demum Clara tuss possim praepandere lumina menti Res quibus occultas penitus convisere possis." These beautiful lines of the poet Lucretius, I quote from the Treatise de Rerum Natura, and I do so in order that the dead Roman might speak, and say, in better language than any I could indite, how strong the motive that has induced me to this labor. Pray, then, receive this work of his head, his heart, and his hands, from your former Instructor, with kindness, and assist him to invoke for it the favorable consideration of all our brethren of the Medical Profession, who I hope will see in it the evidences of a sincere desire to promote the usefulness, and therein the dignity of our honorable vocation. 666 THE BREAST. I pray you ever to look upon the medical profession, not as a busi- ness, but as a great Morality—not as a trade, but as a Mission appointed by God, for the benefit of the children of men. Farewell, dear young gentlemen, and believe me, affectionately, your friend and respectful servant, CHARLES D. MEIGS. Philadelphia, 26th AX. 324 Walnut Street. INDEX. A B Bad training, 362, 382 Baer, Von, on corpus luteum of ovary, 413 Bandage after labor, 576 Barbette, Paul, on plague, 39 Barclay, Col., method of training, 171 Baudelocque on puerperal fever, 594 Bearing-down, 150 Bee-larva, non-sexual, 52 Bennett's observations on the womb, 153 --------ovarian dropsy, 334 ----—— prolapsus, 153 Betton, Dr., his case of inversion, 254 Bichat, vital triad, 363 Binder, the, 576 Bilboquet-pessary, 198 Bischoff on corpus luteum, 413 Bladder, inversion of, 141 Blanque, Helen, 161 Blood analyzed, 170,427 Bloodletting, in hysteria, 481 Blood-membrane, or endangium, 166, 358, 362 Blood of menstrua, analyzed, 428 Blumenbach on the clitoris, 134 Blundell, pessary, 198 Boivin on the menstrua, 427 --------flexion of the womb, 238 ---- - physometra, 318 --------ovaritis, 329 Boschisman women, 97 Bougie for contracted vagina, 105 ------for contracted womb, 454 Brainerd, his letter, 90 Breast, Letter on the female, 649 ------ weed in the, 651 Brierre de Boismont, Table of menstrua, 428 ------------------on change of life, 468 Brown's formula?, 323 Browne, Sir Thomas, Religio Medici, 46 Buffalo, migration of, 401 C Cancer uteri, Letter on, 307 Catheter, how used, 579 Caoutchouc pessary, 195 Carcinoma uteri, 307 Carminative, Dr. Brown's, 323 Carus, Professor, his curve, 145, 216 Cautery, actual, used by Jobert, 314 -------acid nitrate of mercury, 113, 312 -------nitrate of silver, 270 Case of abdominal neuralgia, 147 ------abortion, 545, 551, 552 ------absence of vagina, 101 ------after-pains, 566 ------amenorrhoea, 441, 447 ------anaemia, 362 Abdominal neuralgia, 146 Aberdeen epidemic, 598 Abortion, Letter on, 528 ——---- cases of, 545, 551, 552 ——— case of, signs mistaken, 291 —— ergot provokes, 532, 645 --------failed to excite, 532 --------tampon as a remedy for, 538 Abscess in labium, 95 - in mamma, 663 Absence of vagina, 101 Absorption of womb after labor, Lee's opinion of, 574 Abyssinian'custom of circumcision, 97 Acid nitrate of mercury as a cautery, 113, 312 Acini of ovary, 404 Acute ovaritis, 329 After-pains, 566 ----------case of, 569 Allison, Professor, on nerves of eyeball, 364 Alum in menorrhagia, 449 Amenorrhoea, 107 Amussat on retroversion, 211 Anaemia gravidarum, Letter on, 512 -------cases of, 362, 515 -------causes, neuralgia, 176 -------chalybeates in, 177 -------a puberic malady, 339 Analogy of labor with hysteria, 472 Analysis of blood, 170 ----------menstrual product, 428 Anne Ryder, her case, 279 Anteversion of the womb, 234 Antispasmodics, 483 Aphrodisiac force, 398 Argent, nitrat., 93, 270 Asdrubali on the binder, 576 -------- on protracted pregnancy, 530 Atresia vaginalis, 109 Aureole of the breast, 656 Aura-hysterica, 469 Auscultation in pregnancy, 501 __________________.------De Paul on, 501 __________________.------Kennedy on, 504 668 INDEX. Case of Anne Ryder, 279 ------change of life, 467 ------chlorosis, 362 ------chronic retroversio-uteri, 222 ------clitoris curiously diseased, 137 ------cohesion of vagina, 106 Dodonaeus's case of the Lady Abbess, 468 • double vagina, 127, 129 1 dysmenorrhoea, 455 • exact regularity in menstruation, 47 of enterocele in pelvis, 123 Fallopian tube fatally distended, 346 ■ fibrous tumor of womb, 275 fastidious patient, 36 false diagnostic of abortion, 197 fistulous opening of urethra cured, 119 Helen Blanque, 161 hysteria, 479, 483 • in a male, 473 Sydenham's 474 ■ immobility of the womb, 203 • imperforate hymen, 109 • inversio uteri, 246,250, 251, 254 • inverted bladder, by Crosse, 141 • menorrhagia, 444, 445, 447 ■ Mayor's, of retroversion, 227 ■ nascent polypus, 293 • nymphomania, 139 ■ ovarian pregnancy, 348 • ovaritis, 330 ■ puerperal anaemia, 515 fever, 626 • convulsions, 640 polypus uteri, 287, 290 prolapsed vagina, 119 womb, 201 pregnancy diagnosticated by Hunter, 490 -----------DePaul, 502 • with oedema, 508 ■ anaemia, 515 salivation, 493 vomiting, 495 relaxed symphyses, 74 retroversion, 215, 219 in pregnancy, 220 tubal pregnancy, 346 ulcerated vagina, 111 Catamenia, 392 Catheter, how used, 578 Causes of early fading, 373 Caustics, nitrate of silver, 94, 270 ------- acid nitrate of mercury, 113, 312 Caoutchouc pessary, 195 Cazeaux, 211 Celery, blanched, 175 Cell-life, 309 Cereoles, 105 Cerise, Dr., his Essay, 185 Cervix uteri, its structure, 255 ------leeches for the, 269 ------caustic for the, 94, 113, 270, 312, 449 ------inflamed, causes pruritus, and leucor- rhoea, 94 Cesarian operation, motives for the, 339, 340 Change of life, Letter on, 459 Chapman on menagoga, 433 Characteristics of women, 37, 53 Childbed fever, 583 Children, male and female, compared, 51 Chlorosis, 362 treatment of, 366 Chronic retroversion, 221 Cicatrices of vulva, 94 Circumcision in Abyssinia, 97 Civilization due to women, 61 Clitoris, 134 -------diseased, 138 -------amputated, 138 -------Blumenbach on the, 134 -------Burdach on the, 135 -------Parent du Chatelet, 136 -------Jacquemin and Collineau on the, 136 -------Louyer Villermay on, 137 -------Merriman on the, 138 Meigs's case of diseased, 139 Climate of United States, 373 Clot in the heart, 564 ; in the womb, 561; in the vagina, 559 Cohesion of labia, 130; vagina, 111 Collins, Dr., cases of childbed fever, 591 Colombat on inversion, 248 Conduct of the Physician, 37 Congenital absence of vagina, 101, 104; nar- rowness of the, 104 Conception not prevented by pessary, 204 Contagion of puerperal fever, 590, 588 Convulsions, puerperal letter on, 637 Corpus luteum, 409 -------------Meigs's paper on the, 417 Coste's views of the, 417 Coste, Professor, 417 Counter-sunk nipple, 656 Crosse's case of inverted bladder, 141 — remarks on inversion of womb, 253 Crural phlebitis, Letter on, 631 Cysts in the labia, 88 D Daillez, cases of inversion, 253 Deleurye on round ligaments, 210 Delicacy of women prevents diagnosis, 34 De Paul, obstetric auscultation, 501 Desormeaux and Dubois on ligamentarotunda, 211 Dessaussure's ascent, 365 Deviations of the womb, 142 Dewees's venesection in retroversion, 221 --------tinct. guaiac. 458 --------on cicatrix, 93 --------on inversion, 249 an opinion of his, 649 Development of gravid womb, 486 Diagnosis, hasty, 281 Dialogue, with Helen----, 161 ----------------retroversion, 215 puberty, 377 Dinner-pill, 386 Displacements of womb, 142 Digitalis, 520 Distinctive characteristics of women, Letter on, 53 Disorders of pregnancy, Letter on, 485 Distension of bladder, dangerous, 577 Doctor, the, 34 Dodonaeus, quoted, 468 Double vagina, cases of, 128, 129 Dropsy of the womb, 324 Duration of pregnancy, 529 Dysmenorrhoea, Letter on, 450 INDEX. 669 E Eclampsia, 637 Embryo, non-sexual, 51 Emansio-mensium, 106 Emmenagogues, letter on the, 433 Endangium, 167, 358 ----------Burdach, quoted on the, 360 ----------in diseases, 362 ----------Raciborski on the, 361, 607 Enterocele within the pelvis, 123 Epidemic puerperal fever, 595, 599 Ergot in polypus, 287 --------menorrhagia, 445 --------abortion, 532 Everted urethral membrane, 142 Exercise, 162, 176 Extra-uterine pregnancy, 346 External organs, 69 F Fabricius, case of atresia by, 96 Fainting without hemorrhage, 557 -------what it is, 558 -------with flooding, 559, 564 Falling of womb, 143 Fallopian tubes, the diseases of the, 343 --------fatal inflammation of, 345 --------pregnancy, 346 False membrane of dysmenorrhoea, 458 Fasciola of adhesive plaster, 658 Fastidious patient, 34 Female, distinctive characteristics, 53 Fever, childbed, 583 ------milk, 607 Fibrous tumors of womb, 304 Fistula of urethra cured, 119 Flexion of the womb, 238 Flourens, M. on unity of genera, 55 ------------on the brain, 646 Flooding from abortion, 538 --------after labor, 558 --------in labor, 564 G Galactophorous tubes, 658 Gendrin on menstruation, 406 Generative organs, 69 Generic forms of organs, 74 Genus, unity of a, 55 Germs, 47 ------non-sexual, 50 ------periodicity of, 398 Germiferous and fecundative attributes, 48 Germinal spot, 47 Georget, on hysteria, 478 Globe-pessary, 188 Gooch's canula, 285 Gordon on puerperal fever, 598, 600 Graafian vesicle, 48 Granulated urethral canal, 141 Granville's case ovarian pregnancy, 348 Graueix, Dr., 74 Gravid womb, how deployed, 487 Guaiac, Dewees's tinct. of, 458 Gynseciorum of Spach, 157 H Hsematosic tissue, 166, 358, 362 Hemorrhage, uterine, 539, 557 Hale, Horatio, quoted, 97 Hasty diagnosis, 281 Hatch, Dr., his case of inversio uteri, 252 Heart clot, the, 564 -----of the whale, power of, 443 Heberden, Dr., 156 Helen----'s case, 161 Hemans, Mrs., 59 Henle on corpus luteum, 412 Hermaphrodite, 136 Hervez de Chegoin, 195 Heterologue womb, 303 Hey on childbed fever, 592, 600 Hippocrates on prolapsus, 158 Holland, Dr., 646 Honey-bee, 52 Hooper, Dr., on tumors, 301 Hordeolum, a sign of conception, 493 Horseshoe pessary, 199 Huguier, Dr., on Duverney's gland, 88 Hunter, J., on Free-Martin, 137 Huschke on ovary, 404 Hydatids of womb, 553 Hydrometra, 324 Hymen, the, 202 Hypertrophied clitoris, 138 ------------nympha, 133 ------------womb, 305 Hysteria, letter on, 469 --------case in a male, 473 --------Laycock, Dr. Thos. on, 479 --------Sydenham's case, 474 ----—— sexual nature of, 475 I Ideal model, 267 Ignorance of medicine, general, 39 Immobility of the womb, 203 Imperforate hymen, 106 -----------------case of, 109 Influence of climate in the United States, 373 Ingleby's case, retroversion, 220 Insolation, effects of on health, 174 Infiltrated labia, 76 ---------and thickened vaginal membrane, 118 Inflammation of the non-gravid womb, letter on, 255 -----------------breast, 651 Intellectual powers of women, 56 Internal organs, 99 Inversion of bladder, 141 ----------womb, 241 ----------Hatch's case, 252 ---'■--------Levis's case, 251 ----------diagnosis of, 140 Iron by hydrogen, Quevenne's, 178, 183, 389 Itching of the privities, 93 J Jewish women, computation of term, 511 Jobert de Lamballe, the actual cautery, 314 Jacquemier on round ligaments, 211 670 INDEX. K Kennedy, Evory, 504 Kobelt, Dr., 80 Kraus's Lexicon, 352 L Labia, 75 ------minora, 95 ------infiltrated, 76 ------punctures of the, 77 ------rupture of the, 84 Labial abscess, 95 ------cysts, 88 ------cohesion with nympha, 130 ------thrombus, SO ------warts, 89 Lacerated perineum, 84 La Motte on prolapsus, 144 Lady Webster's pill, 386 Larva of the bee, non-sexual, 52 Laycock, Dr. Thos., on morbi simulati, 479 Lee, Dr. Robert, on contagion of puerperal fever, 594 -------------------dissection of puerperal fever cases, 599 -------------------dissection of crural phle- bitis, 633 -------------——^— ergot in abortion, 532 -------------------post-partum changes in the womb, 574 Lee, Thos. SafTord, on polypus, 277 --------------------tapping, 335 Leeches to the os uteri, 269, 439 Legouais, 615 Letter I. 33; II. 34; III. 46 ; IV. 53 ; V. 69 ; VI. 79; VII. 84; VIII. 95 ; IX. 99 ; X. 130; XI. 134; XII. 142; XIII. ISO; XIV. 187; XV. 200: XVI. 207; XVII. 234; XVIII. 241; XIX. 255 ; XX. 272 ; XXI. 289 ; XXII. 294 ; XXIII. 307 ; XXIV. 316; XXV. 324 ; XXVI. 327; XXVII. 343; XXVIII. 350; XXIX. 392; XXX. 402; XXXI. 409; XXXII. 419 ; XXXIII. 433 ; XXXIV. 441; XXXV. 450 ; XXXVI. 459 ; XXXVII. 469 ; XXXVIII. 485; XXXIX. 512; XL. 528; XLI. 556; XLII. 583 ; XLIII. 631; XLIV. 637; XLV. 649 Leucorrhoea, 182 Levatores ani, state of in prolapsus, 148 Levis, Dr., his case of inversion, 251 Ligamenta rotunda in retroversion, 210 Lisfranc on excision of cervix uteri, 311 Lochia, 571 Longet, M., quoted, 610 Louyer Villermay, on the clitoris, 137 M Mackintosh, cases of dysmenorrhoea, 454 Macula germinativa, 47 Mayor's case of retroversion, 227 Male and female compared, 48 Malgaigne on vaginal hernia, 121 Mammary abscess, 663 Mauriceau's excision of nympha, 133 Medical notes of Dr. Holland, 646 Medicine for the accouchee, 579 Membrana vasorum communis, 166, 358 Menorrhagia, 441 ------------cases of, 4 14, 447 ---■—------- Tampon for, 44S Menstrual blood analyzed, 428 ---------------Boivin's opinion of, 429 ---------------Roussel's opinion of, 431 Menstruation, Letter on, 392 ------------quantity of, 425 ------------tables of, 420 Mercury, acid nitrate of, 312 Merriman on retroversion, 212 ---------tables of duration of pregnancy, 529 ---------note on clitoris, 13S Metro-peritonitis, 607 Metroscopy, how effected, 268 Migration of animals, 400 Milk abscess, 664 ----fever, 607 ----leg, Letter on, 631 Mittelfleischbrucke, 126 Moreau on relaxed symphyses, 73 Motives to write, 33 Muller's opinion of cancer, 309 N Narrowness of vagina, 104 Nascent polypus, 293 Nausea and vomiting of pregnant women, 494 ----------prescription for, 497 Neuralgia, abdominal, from prolapsus, 146 Neurosity of Dr. Cerise, 185 Negrier on menstrua, 406 Ninth day, 582 Nipple, 655 Nipple, countersunk, 656 ------ inflamed, 661 ------ shield, 657 Nitrate of silver, 93, 270 Nondinae, 582 Nymphae, 95 --------hypertrophied, 133 Nymphomania, 139 0 Obstetrical auscultation, 557 CEdema gravidarum, 76 ----------threatens with eclampsia, 78 ----------case of, 508 ----------labiorum, 76 Oken,50,405 Ovarian cysts, 331 ----------pregnancy, 347 ----------stroma, 48, 403 Ovaries, 403 -------corpus luteum of, 410 Ovaritis, 329 Ovariotomy, 338 Ovisac, 415 Ovulation, 399 P Pain of abortion, 534 Pales couleurs, 362 Palpitation of the heart, 514, 518 ---------in chlorosis, 362 Pancoast's operation in spasm of vagina, 202 INDEX. 671 Pancoast's vaginal fistula, 120 Parent du Chatelet, de la Prostitution, 136 Pelvic articulations relaxed, 72 Perineum lacerated, 84 ---------protruded, 126 Periodicity of ovulation, 398 Peritonitis, 583 Pessary, 156 -------Evans's improved, 197 -------Warner's, 188 ■ how used, 203 Pet-vaginal, 318 Phlebitis, crural, Letter on, 631 Phlegmasia dolens, 631 Physical signs, 275 Physick, Dr., his method in abortion, 549 ------phlebitis, 636 ------his pessary, 189 Physometra, 316 Placenta, 530 --------forceps by Dr. Bond, 544 --------hook of Dewees, 544 Polypus uteri, 272 ------------Gooch's canula for, 285 Pouchet, Theorie positive, 407 --------on ovarium, 347 Pouting of navel, 499 Pregnancy, anaemia of, 512 ----------auscultation of, 559 ----------De Paul on signs of, 501 ----------Kennedy on signs of, 504 ----------salivation in, 493 ----------vomiting in, 494 Procidentia uteri, 197 Prolapsus uteri, 143, 150, 189, 200 Pruritus vulvae, 93 Puberty, letter on, 350 --------dialogue on, 377 Puerperal fever, letter on, 583 --------Armstrong on, 595 --------Baudelocque on, 594 --------Collins on, 593 -------- Gordon on, 595 --------Hey on, 592, 600 --------contagion of, 592 --------Lee on, 594, 617 ____---- Legouais on, 615 --------Rutter on, 592 --------Tonnelle on, 600 Purkinje's vesicle, 412 Q Quackery, why prevalent, 41 Qualities of the physician, 44 Quevenne's iron, by hydrogen, 178, 183, 389 Quenesville's iron, 183 Quickening, 491 Raciborski on endangium, 607 .------------puberty, 368 Rainald, Thomas, 394, 581 Randolph's operation, 102 Rectocele of vagina, 122 Relaxed symphysis, 72 Religio-medici of Browne, 46 Retroversio uteri, 210 ----------------Amussat on, 211 Retroversio uteri, cases of, 215, 219 ---------------dialogue on, 215 ---------------Mayor on, 227 ----------------Wier's case, 226 Rheumatism of womb, 436 Rhubarb, sweet tinct. of and gentian, 498 Riding out after lying-in, 582 Round ligaments, 210 Rupture of vagina in falls, 98 Rutter, Dr., his cases, 591 Sachets in leucorrhoea, 193 Sea-bathing, 385 Salivation in pregnant women, 493 Seneca, letter to Lucilius, 172 Serres, quotation from, 296 Seton for symphyseal inflammation, 74 Sex, 46, 50 ----in bees, 51 ----Burdach on, 50 ----in embryo, 50 ----proportion of, 51 Sieur la Motte, 144 Simon's analysis of blood, 170 — menses, 428 Simpson on ovariotomy, 341 Simulative prolapsus, 120 Sin of the organs, 275 Six miles a day for training, 177 Sitting up in the month, 582 Sore-nipple, 661 Spach's Gynaeciorum, 157 Speculum of Recamier, 269 Sphincterismus, 264 Spontaneous cure of inversion, 253 ovulation, 406 Spurred rye, 288, 445, 532 Stricture of vagina, 111 Stricture of cervix uteri, Mackintosh on, 454 Strangury after labor, 577 Stroma of ovaries, 48, 403, 415 Strophium of adhesive plaster, 675 Suckling, 658 Sydenham's case of hysteria, 474 Symphyses, relaxed, 73, 521, 522 Tablier des Hottentotes, 97 Tampon, 440 --------in abortion, 538 menorrhagia, 448 --------not in women in labor, 560 Tapping, danger of, 335 Tenesmus, 150 Theorie positive of Pouchet, 407 Thrombus labii, SO Tinct. hellebore, 457 ----- rhubarb and gentian, 498 Tonnelle's tables, 604 ----------on puerperal fever, 605 Trichiasis vulvae, 94 Touching, 268 Tom Crib, 171 Tumor of the womb, 103 Tympanitis, 319 ----------in puerperal fever, 609 Testing the circulation power, 164, 365 672 INDEX. Training, 171, 366, 384 Tympany, 318 Tapping, results of, 335 U Ulcer of vagina, 111, 113 Urethra, 141 ------- ulcerated, 142 Utero-abdominal supporter, 205 Uterus, inversion of, 241 ------ heterologue, 301 ------ retroverted, 210 ------ Wall's case, 214 ------ prolapsed, 143, 150, 189, 200 Vagina, 99 .-------absence of the, 101 -------congenital stricture of, 104 -------double, 127, 129 -------stricture of the, dangerous in labors, 115 Vaginal cystocele, 126 -------rectocele, 122 Vaginitis, 116 Varicose veins, inflamed, 511 Verrucae of the vulva, 89 Vesico-vaginal hernia, 121 -------------fistula, 119 Vesicle, germinal, 412 -------of Purkinje, 412 Virey, quoted, 43, 61 Vital triad of Bichat, 363 Vitellus, 47 Vitellary nature of corpus luteum, 417 Vomiting in pregnancy, 494 recipe for, 497 Vulva, the, 75 ------cicatrices of the, 94 ------■ phlegmon of the, 95 ------■ pruritus of the, 93 ------wounds of the, 98 W Wagner, Rudolph, the macula-germinativa, 47 Wall's, Dr. Walter, case of retroversion, 214 Walking six miles a day, 177 Walpole's letter, 40 Warner's, Mr. Joseph, pessaries, 188 Weir's case, retroversio, 226 Willis on fevers, quoted, 588 Woman, intellectual state of, 56 -------compared with man, 61 ------■- monotrematous from accident, 87 ,_______ religion and civilization promoted by, 61 Womb, anteversion of the, 234 ------ cancer of the, 307 ------ falling of the, 143 ------ inversion of the, 241 ------■ immobility of the, 202 ------ polypus of the, 272, 293 ------■ procidentia of the, 197 CATALOGUE OF BLANCHARD & LEA'S MEDICAL AND SURGICAL PUBLICATIONS. PHILADELPHIA, DECEMBER, 1853. TO THE MEDICAL PROFESSION. In submitting the following catalogue of our publications in medicine and the collateral sciences, we beg to remark, that no exertions are spared to render the issues of our press worthy a continuance of the confidence which they have thus far enjoyed, both as regards the high character of the works themselves, and in respect to every point of typographical accuracy and mechanical execution. Gentlemen desirous of adding to their libraries from our list, can in almost all cases procure the works they wish from the nearest bookseller, who can readily order any which he may not have on hand. From the great variation in the expenses of transportation through territories so extensive as those of the United States, prices cannot be the same in all sections of the country, and therefore we are unable to affix retail prices to our publications. Information on this point may be had of booksellers generally, or from ourselves, and all inquiries respecting any of our books will meet with prompt attention by addressing BLANCHARD & LEA, Philadelphia. December, 1853. TWO MEDICAL PERIODICALS, FREE OF POSTAGE, FOR FIVE DOLLARS PER ANNUM. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to postage, when not paid for in advance,.......$5 00 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - - 1 00 or, both periodicals furnished, free of postage, for Five Dollars remitted in advance. THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, Edited by ISAAC HAYS, M. D., i* published Quarterly, on the first of January, April, July, and October. Each number contains at least two hundred and eighty large octavo pages, appropriately illustrated, wherever necessary, by engravings on copper, stone, or wood. 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The rapid extension of mail facili- ties, will now place the numbers before subscribers with a certainty and dispatch not heretofore attainable; while by the system now proposed, every subscriber throughout the Union is placed upon an equal footing, at the very reasonable prio» of Five Dollars for two periodicals, without further expense. Those subscribers who do not pay in advance will bear in mind that their subscription of Five Dollars will entitle them to the Journal only, without the News, and that they will be at the expense of their own postage on the receipt of each number. The advantage of a remittance when order- ing the Journal will thus be apparent. As the Medical News and Library is in no case sent without advance payment, its subscribers will always receive it free of postage. It should also be borne in mind that the publishers will now take the risk of remittances by mail, only requiring, in cases of loss, a certificate from the subscriber's Postmaster, that the money was duly mailed and forwarded td§P Funds at par at the subscrfcer's place of residence received in payment of subscriptions. Address, BLANCHARD & LEA, Philadelphia. AND SCIENTIFIC PUBLICATIONS. 3 ASHWELL (SAMUEL), M.D. A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO WOMEN. Illustrated by Cases derived from Hospital and Private Practice. With Additions by Paul Beck Goddard, M. D. Second American edition. In one octavo volume, of 520 pages. One of the very best works ever issued from the press on the diseases of females.—Western Lancet. This is an invaluable work.—Missouri Medical and Surgical Journal. We strongly recommend Dr. Ashwell's Treatise to our readers as a valuable book of reference, on an extensive, complicated, and highly important class of diseases.—Edinburgh Monthly Journal of Med. Sciences. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, of 484 pages, with about two hundred illustrations. ABERCROMBIE (JOHN), M. D. PATHOLOGICAL AND PRACTICAL RESEARCHES ON DISEASES OF THE STOMACH, INTESTINAL CANAL, &c. Fourth edition, in one small octavo volume, of 260 pages. BENNETT (HENRY), M.D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Fourth American, from the third and revised London edition. In one neat octavo volume, of 430 pages, with wood-cuts. (Now Ready.) This edition will be found materially improved over its predecessors, the author having carefully revised it, and made considerable additions, amounting to between seventy-five and one hundred pages. We shall not call it a second edition, because, as Dr. Bennett truly observes, it is really a new work. It will be found to contain not only a faithful histo- ry of the various pathological changes produced by inflammation in the uterus and its annexed organs, in the different phases of female life, but also an ac- curate analysis of the influence exercised by inflam- mation in the production of the various morbid con- ditions of the uterine system, hitherto described and treated as functional.—British and Foreign Medico- Chirurgical Review. Few works issue from the medical press which are at once original and sound in doctrine ; but such, we feel assured, is the admirable treatise now before nsl. The important practical precepts which the author inculcates are all rigidly deduced from facts. . . . Every page of the book is good, and eminently practical. . . . So far as we know and believe, it is the best work on the subject of which it treats.— Monthly Journal of Medical Science. We refer our readers with satisfaction to this work for information on a hitherto most obscure and diffi- cult class of diseases.—London Medical Gazette. One of the best practical monographs amongst modern English medical books.—Transylvania Med. Journal. BEALE (LIONEL JOH N), M. R. C. S., &.C. THE LAWS OF HEALTH IN RELATION TO MIND AND BODY. A Series of Letters from an old Practitioner to a Patient. In one handsome volume, royal 12mo., extra cloth. BILLING (ARCHIBALD), M. D. THE PRINCIPLES OF MEDICINE. Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth, 250 pages. BLAKISTON (PEYTON), M. D., F PRACTICAL OBSERVATIONS ON CERTAIN CHEST, and on the Principles of Auscultation. R. S., &.C. DISEASES In one volume. 8vo., pp. 384. OF THE BENEDICT (N. D.), M. D. COMPENDIUM OF LECTURES ON THE THEORY AND PRACTICE OF MEDICINE, delivered by Professor Chapman in the University of Pennsylvania. In one octavo volume, of 258 pages. BURROWS (GEORGE), M. D. ON DISORDERS OF THE CEREBRAL CIRCULATION, and on the Con- nection between the Affections of the Brain and Diseases of the Heart. In one 8vo. vol., with colored plates, pp. 21(3. 4 BLANCHARD & LEA'S MEDICAL BUDD (GEORGE), M. D., F. R. S., Professor of Medicine, in King's College, London. ON DISEASES OF THE LIVER. Second American, from the second and enlarged London edition. In one very handsome octavo volume, with four beautifully colored plates, and numerous wood-cuts. pp. 46S. New edition. {Just Issued.) The reputation which this work has obtained as a full and practical treatise on an important class of diseases will not be diminished by this improved and enlarged edition. It has been carefully and thoroughly revised by the author; the number of plates has been increased, and the style of its me- chanical execution will be found materially improved. We feel bound to say thnt Dr. Budd"s treatise is greatly in advance of its predecessors. It is the first work in which the results of microscopical anatomy and the discoveries of modern chemistry have been brought fully to bear upon the pathology nnd treat- ment of diseases of the liver; and it is the only work in which a method of studying diseases of this organ, founded upon strictly inductive principles, is de- veloped.— Dublin Medical Press. The full digest we have given of the new matter introduced into the present volume, is evidence of the value we place on it. The fact that the profes- sion has required a second edition of a monograph such as that before us, bears honorable testimony to its usefulness. For many years, Dr. Budd's work must be the authority of the great mass of British practitioners on the hepatic diseases ; and it is satisfactory that the subject has been taken up by so able and experienced a physician.—British and Foreign Medico-Chirurgical Review. BUCKLER (T. H.), M. D., Formerly Physician to the Baltimore Almshouse Infirmary, &c. ON THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF FIBRO- BRONCHITIS AND RHEUMATIC PNEUMONIA. In one handsome octavo volume, extra cloth. (Now Ready.) BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH, G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp. 460. BRIGHAM (AMARIAH), M.D. ON MENTAL CULTIVATION AND EXCITEMENT. 18mo., extra cloth. In one neat volume, BROD1E (SIR BENJAMIN C), M. D., &c. CLINICAL LECTURES ON SURGERY. 1 vol. 8vo., cloth. 850 pp. BY THE SAME AUTHOR. PATHOLOGICAL AND SURGICAL OBSERVATIONS ON THE DIS- EASES OF THE JOINTS. 1 vol. Svo., cloth, pp. 216. BY THE SAME AUTHOR. LECTURES ON THE DISEASES OF THE URINARY ORGANS. 1 vol. 8vo., cloth, pp. 214. *%* These three works may be had neatly bound together, forming a large volume of" Brodie's Surgical Works." pp. 780. BIRD (GOLDING), A. M., M. D., &c. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. A new American, from the third and improved London edition. With over sixty illustrations. In one royal 12mo. volume, extra cloth, pp. 338. The new edition of Dr^ Bird's work, though not increased in size, has been greatly modified, and much of it rewritten. It now presents, in a com- pendious form, the gist of all that is known and re- liable in this department. From its terse style and convenient size, it is particularly applicable to the student, to whom we cordially commend it.—The Medical Exs-miner. . It can scarcely be necessary for us to say anything of the merits of this well-known Treatise, which so admirably brings into practical application the re- sults of those microscopical and chemical researches regarding the physiology and pathology of the uri- nary secretion, which have contributed so much to the increase of our diagnostic powers, and to the extension and satisfactory employment of our thera- peutic resources. In the preparation of this new edition of his work, it is obvious that Dr. Golding Bird has spared no pains to render it a faithful repre- sentation of the present state of scientific knowledge on the subject it embraces. Although, of course, there are many topics which are open to differences of opinion, we cannot point to any well-substantiated result of inquiry which the author has overlooked.— The British and Foreign Medico-Chirurgical Review. BY THE SAME AUTHOR. ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the third London edition. In one neat volume, royal 12mo. pp. 402. AND SCIENTIFIC PUBLICATIONS. 5 BARTLETT (ELISHA), M. D., Professor of Materia Medica and Medical Jurisprudence in the College of Physicians and Surgeons, New York. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. Third edition, revised and improved. In one octavo volume, of six hundred pages, beautifully printed, and strongly bound. In preparing a new edition of this standard work, the author has availed himself of such obser- vations and investigations as have appeared since the publication of his last revision, and he has endeavored in every way to render it worthy of a continuance of the very marked favor with which it has been hitherto received. The masterly and elegant treatise, by Dr. Bartlett is invaluable to the, American student and practi- tioner.—Dr. Holmes's Report to the Nat. Med. Asso- ciation. We regard it, from the examination we have made of it, the best work on fevers extant in our language, and as such cordially recommend it to the medical public.—St. Louis Medical and Surgical Journal. Take it altogether, it is the most complete history of our fevers which has yet been published, and every practitioner should avail himself of its con Of the value and importance of such a work, it is needless here to speak ; the profession of the United States owe much to the author for the very able volume which he has presented to them, and for the careful and judicious manner in which he has exe- cuted his task. No one volume with which we are acquainted contains so complete a history of our fevers as this. To Dr. Bartlett we owe our best thanks for the very able volume he has given us, as embodying certainly the most complete, methodical, and satisfactorv account of our fevers anywhere to be met with.— The Charleston Med. Journal and tents.—The Western Lancet. > Review. BY THE SAME AUTHOR. AN INQUIRY INTO THE DEGREE OF CERTAINTY IN MEDICINE, and into the Nature and Extent of its Power over Disease. In one volume, royal 12mo. pp. 84. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. In one neat volume, royal 12mo., with numerous illustrations, pp. 288. BY THE SAME AUTHOR. «. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LYSIS. With numerous illustrations. In one neat volume, royal 12mo. pp.350. BARLOW (GEORGE H.), M. D. A MANUAL OF THE PRINCIPLES AND PRACTICE OF MEDICINE. Iu one octavo volume. (Preparing.) COLOMBAT DE L'ISERE. A TREATISE ON THE DISEASES OF FEMALES, and on the Special Hv-iene of their Sex. Translated, with many Notes and Additions, by C. D. Meigs, M. D. Second edition, revised and improved. In one large volume, octavo, with numerous wood-cuts. pp. 720. The treatise of M. Colombat is a learned and la- | M. Colombat De L'Isere has not consecrated ten borious commentary on these diseases, indicating years of studious toil and research to the frailer sex erable research, great accuracy of judg- in vain; and a though we regret to hear it is at the expense of health, he has imposed a debt of gratitude as well upon the profession, as upon the mothers and daughters of beautiful France, which that gallant nation knows best how to acknowledge.—New Or- very considerabl ment, and no inconsiderable personal experience With the copious notes and additions of its experi- enced and very erudite translator and .editor, Dr. Meisrs, it presents, probably, one of the most com- plete and comprehensive works on the subject we j leans Medical Journal possess.—American Med. Journal. COPLAND (JAMES), M. D., F. R. S., &c. OF THE CAUSES, NATURE, AND TREATMENT OF PALSY AND APOPLEXY, and of the Forms, Seats, Complications, and Morbid Relations of Paralytic and Apoplectic Diseases. In one volume, royal 12mo., extra cloth, pp. 326. CHAPMAN (PROFESSOR N.), M. D., &c. LECTURES ON FEVERS, DROPSY, GOUT, RHEUMATISM, &c. &c. In one neat 8vo. volume, pp. 450. CLYMER (MEREDITH), M. D., &c. FEVERS- THEIR DIAGNOSIS, PATHOLOGY, AND TREATMENT. Prepared and Edited, with large Additions, from the Essays on Fever in Tweedie s Library o< Practical Medicine. In one octavo volume, of 600 pages. CARSON (JOSEPH), M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. In one very neat octavo volume, of 208 pages. 8 BLANCHARD & LEA'S MEDICAL CARPENTER (WILLIAM B.), M. D., F. R. S., &c, Examiner in Physiology and Comparative Anatomy in the University Of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hviriene, and Forensic Medicine. Fifth American, from the fourth and enlarged London edition. With three hundred and fourteen illustrations. Edited, with additions, by Francis Gurney Smith, M. D.. Professor of the Institutes of Medicine in the Pennsylvania Medical College, &c. In one very large and beautiful octavo volume, of about 1100 large pages, handsomely printed and strongly bound in leather, with raised bands. New edition. (Just Issued.) From the Author's Preface to tlie -present Edition. "When the author, on the completion of his 'Principles of General and Comparative Physiology,' applied himself to the preparation of his 'Principles of Human Physiology,' for the press, lie found that nothing short of an entire remodelling of the preceding edition would in any degree satisfy his notions of what such a treatise ought to be. For although no fundamental change had taken place during the interval in the fabric of Physiological Science, yet a large number of less important modifications had been effected, which had combined to produce a very considerable alteration in its aspect. Moreover, the progres>ive maturation of his own views, and his increased experience as a teacher, had not only rendered him more keenly alive to the imperfections which were inherent in its original plan, but had caused him to look upon many topics in a light very different from that under which he had previously regarded them; and, in particular, he felt a strong desire to give to his work as practical a character as possible, without foregoing the position which (he trusts he may say without presumption) he had succeeded in gaining for it, as a philosophical exposition of one important department of Physiological Science. He was led, therefore, to the determination of, in reality, producing a new treatise, in which only those parts of the old should be retained, which might express the existing state of knowledge, and of his own opinions on the points to which they relate." The American edition has been printed from sheets prepared for the purpose by the author, who has introduced nearly one hundred illustrations not in the London edition ; while it has also enjoyed the advantage of a careful superintendence on the part of the editor, who has added notices of Mich more recent investigations as had escaped the author's attention. Neither care nor expense has been spared in the mechanical execution of the work to render it superior to former editions, and it is confidently presented as in every way one of the handsomest volumes as yet placed before the medical profession in this country. The most complete work on the science in our language.—Am. Med. Journal. The most complete exposition of physiology which any language can at present give.—Brit, and For. Med.-Chirurg. Review. We have thus adverted to some of the leading "additions and alterations," which have been in- troduced by the author into this edition of his phy- siology. These will be found, however, very far to exceed the ordinary limits of a new edition, "the old materials having been incorporated with the new, rather than the new with the old." It now certainly presents the most complete treatise on the subject within the reach of the American reader; and while, for availability as a text-book, we may perhaps regret its growth in bulk, we are sure that the student of physiology will feel the impossibility of presenting a thorough digest of the facts of the science within a more limited compass.—Medical Examiner. The greatest, the most reliable, and the best book on the subject which we know of in the English language.—Stethoscope. The most complete work now extant in our lan- guage.—N. O. Med. Register. t The changes are too numerous to admit of an ex- tended notice in this place. At every point where the recent diligent labors of organic chemists and micrographers have furnished interesting and valu- able facts, they have been appropriated, and no pains have been spared, in so incorporating and arranging them that the work may constitute one armonious system.—Southern Med. and Surg. Journal. The best text-book in the language on this ex- tensive subject.—London Med. Times. A complete cyclopaedia of this branch of science. —N. Y. Med. Times. The standard of authority on physiological sub- jects. * * * In the present edition, to particularize the alterations and additionswhich have been made, would require a review of the whole work, since scarcely a subject has not been revised and altered, added to, or entirely remodelled to adapt it to the present state of the science.—Charleston Med. Journ. Any reader who desires a treatise on physiology may feel himself entirely safe in ordering this.— Western Med. and Surg. Journal. From this hasty and imperfect allusion it will be seen by our readers that the alterations and addi- tions to this edition render it almost a new work— and we can assure our readers that it is one of the best summaries of the existing fucts of physiological science within the reach of the English student and physician.—N. Y. Journal of Medicine. The profession of this country, and perhaps also of Europe, have nnxiously and for some time awaited the announcement of this new edition of Carpenter's Human Physiology. His former editions have for many years been almost the only text-hook on Phy- siology in all our medical schools, and its circula- tion among the profession has been unsurpassed by any work in any department of medical science. It is quite unnecessary for us to speak of this work as its merits would justify. The mere an- nouncement of its appearance will afford the highest pleasure to every student of Physiology, while its perusal will be of infinite service in advancing physiological science.—Ohio Med. and Surg. Journ. BY THE SAME AUTHOR. PRINCIPLES OF GENERAL AND COMPARATIVE PHYSIOLOGY. Intended as an Introduction to the Study of Human Physiology; and as a Guide to the Philo- sophical pursuit of Natural History. New and improved edition, (preparing.) by the same author. (Preparing.) THE MICROSCOPE AND ITS REVELATIONS. In one handsome volume, beautifully illustrated with plates and wood-cuts. AND SCIENTIFIC PUBLICATIONS. 7 CARPENTER (WILLIAM B-), M. D., F. R. S., Examiner in Physiology and Comparative Anatomy in the University of London. ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- LOGICAL ANATOMY. Second American, from a new and revised London edition. With one hundred and ninety illustrations. In one very handsome octavo volume. (Lately Issued.) In publishing the first edition of this work, its title was altered from that of the London volume, by the substitution of the word " Elements" for that of " Manual," and with the author's sanction the title of "Elements" is still retained as being more expressive of the scope of the treatise. A comparison of the present edition with the former one will show a material improvement, the author having revised it thoroughly, with a view of rendering it completely on a level with the most advanced state of the science. By condensing the less important portions, these numerous additions have been introduced without materially increasing the bulk of the volume, and while numerous illustrations have been added, and the general execution of the work improved, it has been kept at its former very moderate price. The best and most complete expose' of modern Physiology, in one volume, extant in the English language.—St. Louis Medical Journal. With such an aid in his hand, there is no excuse for the ignorance often displayed respecting the sub- jects of which it treats. From its unpretending di- mensions, it may not be so esteemed by those anxious to make a parade of their erudition; but whoever masters its contents will have reason to be proud of his physiological acquirements. The illustrations are well selected and finely executed.—Dublin Med. Press. To say that it is the best manual of Physiology now before the public, would not do sufficient justice to the author.—Buffalo Medical Journal. In his former works it would seem that he had exhausted the subject of Physiology. In the present, he gives the essence, as it were, of the whole.—N. Y. Journal of Medicine. Those who have occasion for an elementary trea- tise on Physiology, cannot do better than to possess themselves of the manual of Dr. Carpenter.—Medical Examiner. BY THE SAME AUTHOR. » A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of scientific words. In one neat 12mo. volume. (Now Ready.) This new edition has been prepared with a view to an extended circulation of this important little work, which is universally recognized as the best exponent of the laws of physiology and pathology applied to the subject of intoxicating liquors, in a form suited both for the profession and the public. To secure a wider dissemination of its doctrines the publishers have done up copies in flexible cloth, suitable for mailing, which will be forwarded through the post-office, free, on receipt of fifty cents. Societies and others supplied in quantities for distribution at a liberal deduction. CHELIUS (J. M.), M. D., Professor of Surgery in the University of Heidelberg, &c. A SYSTEM OF SURGERY. Translated from the German, and accompanied with additional Notes and References, by John F. South. Complete in three very large octavo volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles. We do not hesitate to pronounce it the best and most comprehensive system of modern surgery with which we are acquainted.—Medico-Chirurgical Re- view. The fullest and ablest digest extant of all that re- lates to the present advanced state of surgical pa- thology.—American Medical Journal. As complete as any system of Surgery can well be.—Southern Medical and Surgical Journal. The most learned and complete systematic treatise now extant.—Edinburgh Medical Journal. A complete encyclopaedia of surgical science—a very complete surgical library—by far the most complete and scientific system of surgery in the English language.—N. Y. Journal of Medicine. The most extensive and comprehensive account of the art and science of Surgery in our language.— Lancet. CHRISTISON (ROBERT), M. D., V. P. R. S. E., &.C. A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- tion-; Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- proved, with a Supplement containing the most important New Remedies. With copious Addi- tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. In one very large and handsome octavo volume, of over 1000 pages. There is not in any language a more complete and perfect Treatise.—N. Y. Annalist. In conclusion, we need scarcely say that we strongly recommend this work to all classes of our readers. As a Dispensatory and commentary on the Pharmacopoeias, it is unrivalled in the English or any other language.—The Dublin Quarterly Journal. It is not needful that we should compare it with the other pharmacopoeias extant, which enjoy and merit the confidence of the profession : it is enough to say that it appears to us as perfect as a Dispensa- tory, in the present state of pharmaceutical science, could be made. If it omits any details pertaining to this branch of knowledge which the student has a right to expect in such a work, we confess the omis- sion has escaped our scrutiny. We cordially recom- mend this work to such of our readers as are in need of a Dispensatory. They cannot make choice of a better.__Western Journ. of Medicine and Surgery. We earnestly recommend Dr. Christison's Dis- pensatory to all our readers, as an indispensable companion, not in the Study only, but in the Surgery also.—British and Foreign Medical Review. 8 BLANCHARD ,V LEA'S MEDICAL CONDIE (D. F.), M. D., &.C. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Fourth edition, revised and augmented. In one large volume, 8vo., of nearly 750 pages. (Now Ready.) From the Author's Preface. The demand for another edition has afforded the author an opportunity of again subjecting the entire treatise to a careful revision, and of incorporating in it every important observation recorded since the appearance of the last edition, in reference to the pathology and therapeutics of the several diseases of which it treats. In the preparation of the present edition, as in those which have preceded, while the author has appropriated to his use every important fact that he has found recorded in the works of others, having a direct bearing upon either of the subjects of which he treats, and the numerous valuable observations—pathological as well as practical—dispersed throughout the pages of the medical journals of Europe and America, he has, nevertheless, relied chiefly upon his own observations and experience, acquired during a long and somewhat extensive practice, and under circumstances pe- culiarly well adapted for the clinical study of the diseases of early life. Every species of hypothetical reasoning has, as much as possible, been avoided. The author has endeavored throughout the work to confine himself to a simple statement of well-ascertained patho- logical facts, and plain therapeutical directions—his chief desire being to render it what its title imports it to be, a practical treatise on the diseases of children. We feel assured from actual experience that no physician's library can be complete without a copy of this work.—JY.'Y. Journal of Medicine. Dr. Condie's scholarship, acumen, industry, and practical sense are manifested in this, as in all his numerous contributions to science.—Dr. Holmes's Report to the American Medical Association. Taken as a whole, in our judgment, Dr. Condie's Treatise is the one from the perusal of which the practitioner in this country will rise with the great- est satisfaction —Western Journal of Medicine and Surgery. , One of the best works upon the Diseases of Chil- dren in the English language.—Western Lancet. Perhaps the most full and complete ■work now be- fore the profession of the United States; indeed, we may say in the English language. It is vastly supe- rior to most of its predecessors.—Transylvania Med. Journal. A veritable paediatric encyclopaedia, and an honor to American medical literature.—Ohio Medical and Surgical Journal. We feel persuaded that the American medical pro- fession will soon regard it not only as a very good, but as the very best "Practical Treatise on the Diseases of Children."—American Medical Journal. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has been published, we still regard it in that light.—Medical Examiner. COOPER (BRANSBY B.), F. R. S., Senior Surgeon to Guy's Hospital, &c. LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. In one very large octavo volume, of 750 pages. (Lately Issued). For twenty-five years Mr. Bransby Cooper has I Cooper's Lectures as a most valuable addition to been surgeon to Guy's Hospital; and the volume | our surgical literature, and one which cannot fail before us may be said to consist of an account of I to be of service both to students and to those who the results of his surgical experience during that are actively engaged in the practice of their profes- long period. We cordially recommend Mr. Bransby I sion.—The Lancet. COOPER (SIR ASTLEY P.), F. R. S., &c. A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. Edited by Bransby B. Cooper, F. R. S., &c. With additional Observations by Prof. J. C. Warren. A new American edition. In one handsome octavo volume, with numerous illustra- tions on wood. BY THE SAME AUTHOR. ON THE ANATOMY AND TREATMENT OF ABDOMINAL HERNIA. One large volume, imperial 8vo., with over 130 lithographic figures. BY THE SAME AUTHOR. ON THE STRUCTURE AND DISEASES OF THE TESTIS, AND ON THE THYMUS GLAND. One vol. imperial 8vo., with 177 figures, on 29 plates. BY THE SAME AUTHOR. ON THE ANATOMY AND DISEASES OF THE BREAST, with twenty- five Miscellaneous and Surgical Papers. One large volume, imperial 8vo., with 252 figures, on 36 plates. These last three volumes complete the surgical writings of Sir Astley Cooper. They are very handsomely printed, with a large number oi lithographic plates, executed in the beet style, and are presented at exceedingly low prices. AND SCIENTIFIC PUBLICATIONS. 9 CHURCHILL (FLEETWOOD), M. D., M. R. I. A. ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American, from the last and improved English edition. Edited, with Notes and Additions, by D. Francis Condie, M. D.. author of a "Practical Treatise on the Diseases of Children," &c. With 139 illustrations. In one Very handsome octavo volume, pp. 510. (Lately Issued.) To bestow praise on a book that has received such marked approbation would be superfluous. We need only say, therefore, that if the first edition was thought -worthy of a favorable reception by the medical public, we can confidently affirm that this will be found much more so. The lecturer, the practitioner, and the student, may all have recourse to its pages, and derive from their perusal much in- terest and instruction in everything relating to theo- retical and practical midwifery.—Dublin Quarterly Journal of Medical Science. A work of very great merit, and such as we can confidently recommend to the study of every obste- tric practitioner.—London Medical Chazette. This is certainly the most perfect system extant. It is the best adapted for the purposes of a text- book, and that which he whose necessities confine him to one book, should select in preference to all others.—Southern Medical and Surgical Journal. The most popular work on midwifery ever issued from the American press.—Charleston Med. Journal. Were we reduced to the necessity of having but one work on midwifery, and permitted to choose, we would unhesitatingly take Churchill.—Western Med. and Surg. Journal. It is impossible to conceive a more useful and elegant manual than Dr. Churchill's Practice of Midwifery.—Provincial Medical Journal. Certainly, in our opinion, the very best work on the subject which exists.—N. Y. Annalist. We regard this volume as possessing more claims to completeness than any other of the kind with which we are acquainted. Most cordially and earn- estly, therefore, do we commend it to our profession- al brethren, and we feel assured that the stamp of their approbation will in due time be impressed upon it. After an attentive perusal of its contents, we hesitate not to say, that it is one of the most com- prehensive ever written upon the diseases of chil- dren, and that, for copiousness of reference, extent of research, and perspicuity of detail, it is scarcely to be equalled, and not to be excelled, in any lan- guage.—Dublin Quarterly Journal. After this meagre, and we know, very imperfect notice of Dr. Churchill's work, we shall conclude by saying, that it is one that cannot fail from its co- piousness, extensive research, and general accuracy, to exalt still higher the reputation of the author in this country. The American reader will be particu- larly pleased to find that Dr. Churchill has done full justice throughout his work to the various American authors on this subject. The names of Dewees, Eberle, Condie, and Stewart, occur on nearly every page, and these authors are constantly referred to by the author in terms of the highest praise, and with the most liberal courtesy.— The Medical Examiner. To these papers Dr. Churchill has appended notes, embodying whatever information has been laid be- fore the profession since their authors' time. He has also prefixed to the Essays on Puerperal Fever, which occupy the larger portion of the volume, an interesting historical sketch of the principal epi- No work holds a higher position, or is more de- serving of being placed in the hands of the tyro, the advanced student, or the practitioner.—Medical Examiner. Previous editions, under the editorial supervision of Prof R. M. Huston, have been received with marked favor, and they deserved it; but this, re- printed from a very late Dublin edition, carefully revised and brought up by the author to the present time, does present an unusually accurate and able exposition of every important particular embraced in the department of midwifery. * * The clearness, directness, and precision of its teachings, together with the great amount of statistical research which its text exhibits, have served to place it already in the foremost rank of works in this department of re- medial science.—N. O. Med. and Surg. Journal. In our opinion, it forms one of the best if not the very best text-book and epitome of obstetric science which we at present possess in the English lan- guage.— Monthly Journal of Medical Science. The clearness and precisi6n Of style in which it is written, and the great amount of statistical research which it contains, have served to place it in the first rank of works in this department of medical science. — N. Y. Journal of Medicine. Few treatises will be found better adapted as a text-book for the student, or as a manual for the frequent consultation of the young practitioner.— American Medical Journal. The present volume will sustain the reputation acquired by the author from his previous works. The reader will find in it full and judicious direc- tions for the management of infants at birth, and a compendious, but clear account of the diseases to which children are liable, and the most successful mode of treating them. We must not close this no- tice without calling attention to the author's style, which is perspicuous and polished to a degree, we regret to say, not generally characteristic of medical works. We recommend the work of Dr. Churchill most cordially, both to students and practitioners, as a valuable and reliable guide in the treatment of the diseases of children.—Am. Journ. of the Med. Sciences. We know of no work on this department of Prac- tical Medicine which presents so candid and unpre- judiced a statement or posting up of our actual knowledge as this.—JV. Y. Journal of Medicine. Its claims to merit both as a scientific and practi- cal work, are of the highest order. Whilst we would not elevate it above every other treatise on the same subject, we certainly believe that very few are equal to it, and none superior.—Southern Med. and Surgical Journal. demies of that disease. The whole forms a very valuable collection of papers, by professional writers of eminence, on some of the most importantaccidents to which the puerperal female is liable.—American Journal of Medical Sciences. BY THE SAME AUTHOR. ON THE DISEASES OF INFANTS AND CHILDREN. In one large and handsome volume of over 600 pages. BY THE SAME AUTHOR. ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of the Eighteenth Century. In one neat octavo volume, of about four hundred and fifty pages. 10 BLANCHARD cV LEA'S MEDICAL CHURCHILL (FLEETWOOD), M. D., M. R. I. A., &.c. ON THE DISEASES OF WOMEN; including those of Pregnancy and Child- bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- cis Condie, M. D., author of " A Practical Treatise on the Diseases of Children." In one large and handsome octavo volume, with wood-cuts, pp. 684. (Just Issued.) From the Author's Preface. In reviewing this edition, at the request of my American publishers, I have inserted several new sections and chapters, and I have added, I believe, all the information we have derived from recent researches; in addition to which the publishers have been fortunate enough to secure the services of an able and highly esteemed editor in Dr. Condie. This fifth edition, before us. is well calcu- Wenow regretfully take leave of Dr. Churchill's book. Had our typographical limits permitted, we should gladly have borrowed more from its richly stored pages. In conclusion, we heartily recom- mend it to the profession, and would at the same time express our firm conviction that it will not only add to the reputation of its author, but will prove a work of great and extensive utility to obstetric practitioners.—Dublin Medical Press. Former editions of this work have been noticed in previous numbers of the Journal. The sentiments of high commendation expressed in those notices, have only to be repeated in this; not from the fact that the profession at large are not aware of the high merits which this work really possesses, but from a desire to see the principles and doctrines therein contained more generally recognized, and more uni- versally carried out in practice.—N. Y. Journal of Medicine. We know of no author who deserves that appro- bation, on " the diseases of females," to the same extent that Dr. Churchill does. His, indeed, is the only thorough treatise we know of on the subject; and it may be commended to practitioners and stu- dents as a masterpiece in its particular department. The former editions of this work have been com- mended strongly in this journal, and they have won their way to an extended, and a well-deserved popu- larity. lated" to maintain Dr. Churchill's high reputation. It was revised and enlarged by the author, for his American publishers, and it seems to us that there is scarcely any species of desirable information on its subjects that may not be found in this work.—The Western Journal of Medicine and Surgery. We are gratified to announce a new and revised edition of Dr. Churchill's valuable work on the dis- eases of females We have ever regarded it as one of the very best works on the subjects embraced within its scope, in the English language; and the present edition, enlarged and revised by the author, renders it still more entitled to the confidence of the profession. The valuable notes of Prof Huston have been retained, and contribute, in no small de- gree, to enhance the value of the work. It is a source of congratulation that the publishers have permitted the author to be, in this instance, his own editor, thus securing all the revision which an author alone is capable of making.—The Western Lancet. Asa comprehensive manual for students, or a work of reference for practitioners, we only speak with common justice when we say that it surpasses any other that has ever issued on the same sub- ject from the British press.—The Dublin Quarterly Journal. DEWEES (W. P.), M.D., &c. A COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occa- sional Cases and many Engravings. Twelfth edition, wilh the Author's last Improvements and Corrections. In one octavo volume, of 600 pages. (Just Issued.) BY THE SAME AUTHOR. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. Tenth edition. In one volume, octavo, 548 pages. (Just Issued.) BY THE SAME AUTHOR. A TREATISE ON THE DISEASES OF FEMALES. one volume, octavo, 532 pages, with plates. (Just Issued.) Tenth edition. In DICKSON (PROFESSOR S. H.), M.D. ESSAYS ON LIFE, SLEEP, PAIN, INTELLECTION, HYGIENE, AND DEATH. In one very handsome volume, royal 12mo. DANA (JAMES D). ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with wood-cuts. ALSO, AN ATLAS TO THE ABOVE, one volume, imperial folio, with sixty-one mag- nificent plates, colored after nature. Bound in half morocco. ALSO, ON THE STRUCTURE AND CLASSIFICATION OF ZOOPHYTES. Sold separate, one vol., cloth. DE LA BECHE (SIR HENRY T.), F. R. S., &c. THE GEOLOGICAL OBSERVER. In one very large and handsome octavo volume, of 700 pages. With over three hundred wood-cuts. (Just Issued.) A5JI3 SCIENTIFIC PUBLICATIONS. 11 DRUITT (ROBERT), M.R. C.S., &c. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the last and improved London edition. Edited by F. W. Sargent, M. D., author of "Minor Surgery," &c. Illustrated with one hundred and ninety-three wood-engrav- ings. In one very handsomely printed octavo volume, of 576 large pages. No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery—that it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- cal affections—is a sufficient reason for the liberal patronage it has obtained. The work before us is a new edition, greatly enlarged and extended by the author—its practical part having undergone a tho- rough revision, with fifty pages of additional matter. The editor, Dr. F. W. Sargent, of Philadelphia, has contributed much to enhance the value of the work, by such American improvements as are calculated more perfectly to adapt it to our own views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consi- deration. Every medical man frequently needs just such a work as this, for immediate reference in mo- ments of sudden emergency, when he has not time to consult more elaborate treatises. Its mechanical execution is of the very best quality, and as a whole, it deserves and will receive from the profession, a liberal patronage.—The Ohio Medical and Surgical Journal. The author has evidently ransacked every stand- ard treatise of ancient and modern times, and all that is really practically useful at the bedside will be found in a form at once clear, distinct, and interest- ing.—Edinburgh Monthly Medical Journal. Druitt's work, condensed, systematic, lucid, and practical as it is, beyond most works on Surgery accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher favor. The il- lustrations of the volume are good, and, in a word, the publishers have acquitted themselves fully of their duty.—The Western Journal of Medicine and Surgery, The most accurate and ample resume of the pre- sent state of Surgery that we are acquainted with.— Dublin Medical Journal. A better book on the principles and practice of Surgery as now understood in England and America, has not been given to the profession.—Boston Medi- cal and Surgical Journal. An unsurpassable compendium, not only of Sur- gical, but of Medical Practice.—London Medical Gazette. This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery.—Medical Gazette. It may be said with truth that the work of Mr. Druitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearance of a manual, which includes so many topics of interest to the surgeon ; and the terse man- ner in which each has been treated evinces a most enviable quality of mind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &rc. &c. In four large super royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound. *#* This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians. The most complete work on Practical Medicine extant; or, at least, in our language.— Buffalo Medical and Surgical Journal. For reference, it is above all price to every prac- titioner.—Western Lancet. One of the most valuable medical publications of the day—as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. We rejoice that this work is to be placed within the reach of the profession in this country, it being unquestionably one of very great value to the prac- titioner. This estimate of it has not been formed from a hasty examination, but after an intimate ac- quaintance derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.—American Medical Journ. DUNGLISON (ROBLEY), M.D., Professor of the Institutes of Medicine, in the Jefferson Medical College, Philadelphia. HUMAN HEALTH; or, the Influence of Atmosphere and Locality, Change of Air and Climate, Seasons, Food, Clothing, Bathing, Exercise, Sleep, fee. &c, on Healthy Man; constituting Elements of Hygiene. Second edition, with many modifications and additions. In one octavo volume, of 464 pages. 12 BLANCHARD & LEA'S MIL DIVXTr DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, &c. With the French and other Synonymes; Notices of Climate and of celebrated Mineral Waters; Formulae for various Officinal, Empirical, and Dietetic Preparations, etc. Tenth edition, revised. In one very thick octavo volume, of over nine hundred large double-columned pages, strongly bound in leather, with raised bands. (Just Issued.) Every successive edition of this work bears the marks of the industry of the author, and of his determination to keep it fully on a level with the most advanced state of medical science. Thus the last two editions contained about nine, thousand subjects and terms not comprised in the one immediately preceding, and the present has not less than four thousand not in any former edilion. As a complete Medical Dictionary, therefore, embracing over FIFTY THOUSAND DEFINI- TIONS, in all the branches of the science, it is presented as meriting a continuance of the great favor and popularity which have carried it, within no very long space of time, to a ninth edition. Every precaution has been laken in the preparation of the present volume, to render its mecha- nical execution and typographical accuracy worthy of its extended reputation and universal use. The very extensive additions have been accommodated, without materially increasing the bulk of the volume by the employment of a small but exceedingly clear type, cast for this purpose. The press has been watched with great care, and every effort used to insure the verbal accuracy so ne- cessary to a work of this nature. The whole is printed on fine white paper; and, while thus exhi- biting in every respect so great an improvement over former issues, it is presented at the original exceedingly low price. A miracle of labor and industry in one who has written able and voluminous works on nearly every branch of medical science. There could be no more useful hook to the student or practitioner, in the present advancing age, than one in which would be found, in addition to the ordinary meaning and deri- vation of medical terms—so many of which are of modern introduction—concise descriptions of their explanation and employment; and all this and much more is contained in the volume before us. It is therefore almost as indispensable to the other learned professions as to our own. In fact, to all who may haveoecasion to ascertain the meaning of any word belonging to the many branches of medicine. From a careful examination of the present edition, we can vouch for its accuracy, and for its being brought quite up to thedate of publication ; the author states in his preface that he has added to it about four thou- sand terms, which are not to be found in the prece- ding one. — Dublin Quarterly Journal of Medical Sciences. On the appearance of the last edition of this valuable work, we directed the attention of our readers to its peculiar merits; and we need do little more than state, in reference to the present reissue, that, notwithstanding the large additions previously made to it, no fewer than four thou- sand terms, not to be found in the preceding edi- tion, are contained in the volume before us.— Whilst it is a wonderful monument of its author's erudition and industry, it is also a work of great practical utility, as we can testify from our own experience; for we keep it constantly within our reach, and make very frequent reference to it, nearly always finding in it the information we seek. —British and Foreign Med.-Chirurg. Review. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references. The terms generally include short physiological and pathological descriptions, so that, as the author justly observes, the reader does not possess in this work a mere dictionary, but a book, which, while it instructs him in medical etymo- logy, furnishes him with a large amount of useful information. The author's labors have been pro- perly appreciated by his own countrymen ; and we can only confirm their judgment, by recommending this most useful volume to the notice of our cisat- lantic readers. No medical library will be complete without it.—London Med. Gazette. It is certainly more complete and comprehensive than any with which we are acquainted in the English language. Few, in fact, could be found better qualified than Dr. Dunglison for the produc- tion of such a work. Learned, industrious, per- severing, and accurate, he brings to the task all the peculiar talents necessary for its successful performance; while, at the same time, his fami- liarity with the writings of the ancient and modem '• masters of our art," renders him skilful to note the exact usage of the several terms of science, and the various modifications which medical term- inology has undergone 'with the change of theo- ries or the progress of improvement. — American Journal of the Medical Sciences. One of the most complete and copious known to the cultivators of medical science.—Boston Med. Journal. A most complete Medical Lexicon—certainly one of the best works of the kind in the language.— Charleston Medical Journal. The most complete Medical Dictionary in the English language.— Western Lancet. It has not its superior, if indeed its equal, in the English language.—St. Louis Medical and Surgical Journal. Familiar with nearly all the medical dictiona- ries now in print, we consider the one before us the most complete, and an indispensable adjunct to every medical library.—British American Medical Journal. We repeat our declaration, that this is the best Medical Dictionary in the language.—West. Lancet. The very best Medical Dictionary now extant.— Southern Medical and Surgical Journal. The most comprehensive and best English Dic- tionary of medical terms extant.—Buffalo Medical Journal. BY THE SAME AUTHOR. THE PRACTICE OP MEDICINE. A Treatise on Special Pathology and The- rapeuties. Third Edition. In'lwo large octavo volumes, of fifteen hundred pages. Upon every topic embraced in the work the latest information will be found carefully posted up.— Medical Examiner. The student of medicine will find, in these two elegant volumes, a mine of facts, a gathering of precepts and advice from the world of experience, that will nerve him with courage, and faithfully direct him in his efforts to relieve the physical suf- ferings of the race.- Journal. -Boston Medical and Surgical It is certainly the most complete treatise of which we haveany knowledge..— Western Journal of Medi- cine and Surgery. One of the most elaborate treatises of the kind we have.—Southern Med. and Surg. Journal. mr"3TTTENTIFIC PUBLICATIONS. 13 DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Seventh edition. Thoroughly revised and exten- sively modified and enlarged, with nearly five hundred illustrations. In two large and hand- somely printed octavo volumes, containing nearly 1450 pages. On no previous revision of this work has the author bestowed more care than on the present, it having been subjected to an entire scrutiny, not only as regards the important matters of which it treats, but also the language in which they are conveyed; and on no former occasion has he felt as satisfied with his endeavors to have the work on a level with the existing state of the science. Physiology in the English language, and is highly creditable to the author and publishers.—From the Canadian Medical Journal. It has long since taken Tank as one of the medi- cal classics of our language. To say that it is by far the best text-book of physiology ever published in this country, is but echoing the general testi- mony of the profession .—JV. Y. Journal of Medicine. There is no single book we would recommend to the student or physician, with greater confidence than the present, because in it, will be found a mir- ror of almost every standard physiological -work of the day. We most cordially recommend the work to every member of the profession, and no student should be without it. It is the completest work on The most complete and satisfactory system of Physiology in the English language__Amer. Med. Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The most full and complete system of Physiology in our language.—Western Lancet. BY THE SAME AUTHOR. GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. Fifth edition, much improved. With one hundred and eighty-seven illus- trations. In two large and handsomely printed octavo vols., of about 1100 pages. (Now Ready.) The new editions of the United States Pharmacopoeia and those of London and Dublin, have ren- dered necessary a thorough revision of this work. In accomplishing this the author has spared no pains in rendering it a complete exponent of all that is new and reliable, both in the departments of Therapeutics and Materia Medica. The book has thus been somewhat enlarged, and a like im provement will be found in every department of its mechanical execution. In this work of Dr. Dunglison,we recognize the1 As a text-book for students, for whom it is par- same untiring industry in the collection and em- ticularly designed, we know of none superior to bodying of facts on the several subjects of which he it.—St. Louis Medical and Surgical Journal. treats, that has heretofore distinguished him, and we cheerfully point to these volumes, as two of the most interesting that we know of. In noticing the additions to this, the fourth edition, there is very little in the periodical or annual literature of the profession, published in the interval which has elapsed since the issue of the first, that has escaped the carriful search of the author. As a book for reference, it is invaluable.—Charleston Med. Jour- nal and Review. It may be said to be the work now upon the sub- ; We consider this work unequalled.—Boston Med. jects upon which it treats.— Western Lancet. < and Surg. Journal. It purports to be a new edition, but it is rather a new book, so greatly has it been improved, both in the amount and quality of the matter which it contains.—JV. O. Medical and Surgical Journal. We bespeak for this edition, from the profession, an increase of patronage over any of its former ones, on account of its increased merit. — N. Y. Journal of Medicine. BY THE SAME AUTHOR. NEW REMEDIES, WITH FORMULA FOR THEIR ADMINISTRATION. Sixth edition, with extensive Additions. In one very large octavo volume, of over 750 pages. One of trie most useful of the author's works.— diseases and for remedies, will be found greatly to Southern Medical and Surgical Journal. enhance its value.—New York Med. Gazette. This well-known and standard book has now reached its sixth edition, and has been enlarged and improved by the introduction of all the recent gifts to therapeutics which ihe last few years have so richly produced, including the anajsthetic agents, Ice. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physii'ians, it is unsurpassed by any other work in existence, and the double index for The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable, has enabled him to throw together ah extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire to examine the original papers.—The American Journal of Pharmacy. DUFTON (WILLIAM), M.R.C.S., &c. THE NATURE AND TREATMENT OF DEAFNESS AND DISEASES OF THE EAR; and the Treatment of the Deaf and Dumb. One small 12mo. vol. pp. 120. DURLACHER (LEWIS). A TREATISE ON CORNS, BUNIONS, THE DISEASES OF NAILS, AND THE GENERAL MANAGEMENT OF THE FEET. In one 12mo. volume, cloth. pp. 134. 14 BLANCHARD & LEA'S MEDICAL DE JONGH (L. J.), M. D., &c. THE THREE KINDS OF COD-LIVER OIL, comparatively considered, with their Chemical and Therapeutic Properties. Translated, with an Appendix and Cases, by Edward Carey, M. D. To which is added an article on the subject from "Dunglison on New Remedies." In one small 12mo. volume, extra cloth. DAY (GEORGE E.), M. D. A PRACTICAL TREATISE ON THE DOMESTIC MANAGEMENT AND MORE IMPORTANT DISEASES OF ADVANCED LIFE. With au Appendix on a new and successful mode of treating Lumbago and other forms of Chronic Rheumatism. octavo, 226 pages. One volume, ELLIS (BENJAMIN), M. D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Elher and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, revised and much exlended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, of two hundred and ninety-six pages. (Now Ready.) This work has received a very complete revision at the hands of the editor, who has made what- ever alterations and additions the progress of medical and pharmaceutical science has rendered ad- visable, introducing fully the new remedial agents, and revising the whole by the latest improvements of the Pharmacopoeia. To accommodate these additions, the size of the page has been increased, and Ihe volume itself considerably enlarged, while every effort has been made to secure the typo- graphical accuracy which has so long merited the confidence of the profession. ERICHSEN (JOHN). Professor of Surgery in University College, London, &c. THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical Injuries, Diseases, and Operations. In one very large and handsome octavo volume, with 2G0 illustrations. (Nearly Ready.) FERGUSSON (WILLIAM), F. R. S., Professor of Surgery in King's College, London, See. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully printed octavo volume, of about seven hundred pages, with three hundred and ninety-three handsome illustrations. (Now Ready.) The most important subjects in connection with practical surg&ry which have been more recently brought under the notice of, and discussed by, the surgeons of Great Britain, are fully and dispassion- ately considered by Mr. Fergusson, and that which was before wanting has now been supplied, so that we can now look upon it as a work on practical sur- gery instead of one on operative surgery alone, which many have hitherto considered it to be. And we think the author has shown a wise discretion in making the additions on surgical disease which are to be found in the present volume, and has very much enhanced its value; for, besides two elaborate chapters on the diseases of bones and joints, which were wanting before he has headed each chief sec- tion of the work by h general description of the sur- gical disease and injury of that region of the body which is treated of in each, prior to entering into the consideration of the more special morbid conditions and their treatment. There is also, as in former editions, a sketch of the anatomy of particular re- gions. We have now pointed out sume of the prin- cipal additions in this work. There was some ground formerly for the complaint before alluded to, that it dwelt too exclusively on operative surgery ; but this defect is now removed, and the book is more than ever adapted for the purposes of the practitioner, whether he confines himself more strictly to the operative department, or follows surgery on a more comprehensive scale.—Medical Times and Gazette. No work was ever written which more nearly comprehended the necessities of the student and practitioner, and was more carefully arranged to that singleporpose than this.—N. Y. Med. and Surg. Journal. The addition of many new pages makes this work more than ever indispensable to the student and prac- titioner.—Rariking's Abstract, January, 1863. For the general practitioner, who does not make a specialty of surgery, it is certainly invaluable. The style is concise, pointed, and clear. The de- scriptions of the various operationsare concentrated and accurate, so that in cases of emergency, the principles of the most difficult operations may be obtained by a reference of a few moments to its pages.—Western Lancet. Among the numerous works upon surgery pub- lished of late years, we know of none we value more highly than the one before us. It is perhaps the very best we have for a text-book and for ordi- nary reference, being concise and eminently practi- cal.—Southern Med. and Surg. Journal. FRICK (CHARLES), M. D. RENAL AFFECTIONS; their Diagnosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth. GUTHRIE (G. J.), F. R. S., &c. THE ANATOMY OF THE BLADDER AND URETHRA, and the Treat- mem of the Obsiructions to which those Passages are liable. In one volume, octavo, 150 pages. AND SCIENTIFIC PUBLICATIONS. 15 FOWNES (GEORGE), PH. D., &c. ELEMENTARY CHEMISTRY; Theoretical and Practical. With numerous illustrations. A new American, from the last and revised London edition. Edited, with Addi- tions, by Robert Bridges, M. D. In one large royal 12mo. volume, of over 550 pages, with 181 wood-cuts, sheep, or extra cloth. (Just Ready.) The lamented death of the author has caused the revision of this edition to pass into the hands of those distinguished chemists,, H. Bence Jones and A. W. Hoffman, who have fully sustained its reputation by the additions which they have made, more especially in the portion devoted to Organic Chemistry, considerably increasing the size of the volume. This labor has been so thoroughly performed, that the American Editor has found but little to add, his notes consisting chiefly of such matters as the rapid advance of the science has rendered necessary, or of investigations which had apparently been overlooked by the author's friends. The volume is therefore again presented as an exponent of the most advanced state of chemical science, and as not unworthy a continuation of the marked favor which it has received as an ele- mentary text-book. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adopted to the wants of the student. It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the work. and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular, viz.: of omitting details of indispensable importance, of avoiding technical difficulties, in- stead of explaining them, and of treating subjects of high scientific interest in an unscientific way.— Edinburgh Monthly Journal of Me ileal Science. The rapid sale of this Manual evinces its adapta- tion to the wants of the student of chemistry, whilst the well-known merits of its lamented author have constituted a guarantee for its value, as a faithful exposition of the general principles and most im- portant facts of the science to which it professes to be an introduction.—British and Foreign Medico- Chirurgical Review. GRAHAM (THOMAS), F/R. S., Professor of Chemistry in University College, London, &c. THE ELEMENTS OF CHEMISTRY. Including the application of the Science to the Arts. With numerous illustrations. Willi Notes and Additions, by Robert Bridges, M. D., &c. &c. Second American, from the second and enlarged London edition PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations. PART II. (Preparing) to match. The great changes which the science of chemistry has undergone within the last few years, ren- der a new edition of a treatise like the present, almost a new work. The author has devoted several years to the revision of his treatise, and has endeavored to embody in it every fact and inference of importance which has been observed and recorded by the great body of chemical investigators who are so rapidly changing the face of the science. In this manner the work has been greatly increased in size, and the number of illustrations doubled ; while the labors of the editor have been directed towards the introduction of such matters as have escaped the attention of the author, or as have arisen since the publication of the first portion of this edition in London, in 1850. Printed in handsome style, and at a very low price, it is therefore confidently presented to the pro- fession and the student as a very complete and thorough text-book of this important subject. GROSS (SAMUEL D.), M. D., Professor of Surgery in the Louisville Medical Institute, &c. A PRACTICAL TREATISE ON THE DISEASES AND INJURIES OF THE URINARY ORGANS. In one large and beautifully printed octavo volume, of over seven hundred pases. With numerous illustrations. A volume replete with truths and principles of the utmost value in the investigation of these diseases.— American Medical Journal. Dr. Gross has brought all his learning, experi- ence, tact, and judgment to the task, and has pro- duced a work worthy of his high reputation. We feel perfectly safe in recommending it to our read- ers as a monograph unequalled in interest and practical value by any other on the subject in our language; and we cannot help saying, that we es- teem it a matter of just pride, that another work so creditable to our country has been contributed to our medical literature by a Western physician. —The Western Journal of Medicine and Surgery. We regret that our limits preclude such a notice as this valuable contribution to our American Medical Literature merits, We have only room to say ihat the author deserves the thanks of the profession for this elaborate production; which cannot fail to augment the exalted reputation ac- quired by his former works, for which he has been honored at home and abroad.—N.Y. Med Gazette. Whoever will peruse the vast amount of valuable practical information it contains, and which we have been unable even to notice, will, we think, agree with us, that there is no work in the English language which can make any just pretensions to be its equal. Secure in the esteem and confidence of the profession in this country, at least, its distin- guished author will doubtless receive their warmest congratulations that he has-sueceeded in producing a treatise so creditable to himself, and, as we hum- bly believe, to American surgical literature.—N. Y. Journal of Medicine. It has remained for an American writer to wipe away this reproach ; and so completely has the task been fulfilled, that we venture to predict for Dr. Gross's treatise a permanent place in the literature of surgery, worthy to rank with the best works of the present age. Not merely is the matter good, but the getting up of the volume is most creditable to transatlantic enterprise; the paper nnd print would do credit to a first-rate London establishment; and the numerous wood-cuts which illustrate it, de- monstrate that America is makin; rapid advances in this department of art. We have, indeed, unfeigned pleasure in congratulating all concerned in this pub- lication, on the result of their labours; and expe- rience a feeling something like whatanimates a long- expectant husbandman, who, oftentimes disappointed by the produce of a favorite field, is at last agree- ably surprised by a stately crop which may bear comparison with any of its former rivals. The grounds Of our high appreciation of the work will be obvious as we proceed; and we doubt not that the present facilities for obtaining American boo"ks will induce many of our readers to verify our re- commendation by their own perusal of it.—British and Foreign Medico-Chirurgical Review. 16 BLANCHARD Did not the perusal of the work justify the high opinion we have of it, the names of Dr. Walshe, the originator, and of Dr. Ballard, as the editor of the volume, would almost of itself have satisfied us that it abounds in minute clinical accuracy. We need not say that the execution of the whole reflects the highest credit not only upon the gentlemen men- tioned, but upon all those engaged upon its produc- tion. In conclusion, we are convinced that the possession of the work will be almost necessary to every member of the profession—that it will be found indispensable to the practical physician, the pathologist, the medical jurist, and above all to the medical student.—London Medical Times. We hail the appearance of this book as the grand desideratum.—Charleston Medical Journal. This little work, if carefully read by even old practitioners, cannot fail to be productive of much good; as a guide to the younger members of the pro- fession in directing their attention specially to the best mode of investigating cases so as to arrive at Confessedly one of the veTy best works on the principles and practice of physic in the English or any other language.—Med. Examiner. Asa text-book it has no equal; as a compendium of pathology and practice no superior.—New York Annalist. We know of no work better calculated for being placed in the hands of the student, and for a text- book; on every important point the author seems to have posted up his knowledge to the day.— Amer. Med. Journal. One of the most practically useful books that ever was presented to the student. — N. Y. Med. Journal. tains, we should be glad to copy the whole table of contents and make some extracts from its pages, but our limits forbid. We have no hesitation in recom- mending the work as one of the most complete on this subject in the English language; and yet it is not so voluminous as to be objectionable on this ac- count, to any practitioner, however pressing his engagements.—Ohio Medical and Surgical Journal. , DEATH, IN MEDICAL CASES. Society for Medical Observation. In one very rzist Issued.) correct diagnosis, it will prove exceedingly valua- ble. The great difficulty with beginners, who have not been under the immediate training of an expe- rienced physician, is continually found to be in the appreciation of the true condition of the organs and tissue*. Let such provide themselves with this work and study it thoroughly, and they will find much of the difficulty removed.—Southern Medical and Surgical Journal. This is truly a very capital book. The whole medical world will reap advantages from its publi- cation. The medical journals will soon show its influence on the character of the il Reports of Cases" which they publish. Drs. Ballard and Walshe have given to the world, through a small but useful medical organization, a cheap but invaluable book. We do advise every reader of this notice to buy it and use it. Unless he is so vain as to imagine him- self superior to the ordinary human capacity, he will in six months sec its inestimable advantages.— Stethoscope. WALSHE (W. H.), M. p., Professor of the Principles and Practice of Medicine in University College, London. DISEASES OF THE HEART, LUNGS, AND APPENDAGES; their Symptoms and Treatment. In one handsome volume, large royal 12mo., 512 pages. WHAT TO OBSERVE AND SCIENTIFIC PUBLICATIONS. 29 WILSON (ERASMUS), M.D., F. R. S., Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- can, from the last English edition. Edited by Paul B. Goddard, A. M., M D. With two hun- dred and fifty illustrations. Beautifully printed, in one large octavo volume, of nearly six hun- dred pages. In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself, is sufficiently expressive of its value. A work very desirable to the student; one, the possession of which will greatly facilitate his progress in the study of Practical Anatomy.—New York Journal of Medicine. Its author ranks with the highest on Anatomy.— Southern Medical and Surgical Journal. It offers to the student all the assistance that can be expected from such a work.—Medical Examiner. The most complete and convenient manual for the Btudent we possess.—American Journal of Medical Science. In every respect, this work as an anatomical guide for the student and practitioner, merits our warmest and most decided praise.—London Medical Gazette. BY THE SAME AUTHOR. THE DISSECTOR; or, Practical and Surgical Anatomy. Modified and Re- arranged, by Paul Beck Goddard, M. D. A new edition, with Revisions and Additions. In one large and handsome volume, royal 12mo., with one hundred and fifteen illustrations. In passing this work again through the press, the editor has made such additions and improve- ments as the advance of anatomical knowledge has rendered necessary to maintain the work in the high reputation which it has acquired in the schools of the United States, as a complete and faithful guide to the student of practical anatomy. A number of new illustrations have been added, espe- cially in the portion relating to the complicated anatomy of Hernia. In mechanical execution the work will be found superior to former editions. BY THE SAME AUTHOR. ON DISEASES OF THE SKIN. Third American, from the third London edition. In one neat octavo volume, of about five hundred pages, extra cloth. (Just Issued.) Also, to be had done up with fifteen beautiful steel plates, of which eight are exquisitely colored ; representing the Normal and Pathological Anatomy of the Skin, together with accurately colored delineations of more than sixty varieties of disease, most of them the size of nature. The Plates are also for sale separate, done up in boards. The increased size of this edition is sufficient evidence that the author has not been content with a mere republication, but has endeavored to maintain the high character of his work as the standard text-book on this interesting and difficult class of diseases. He has thus introduced such new matter as the experience of the last three or four years has suggested, and has made such alterations as the progress of scientific investigation has rendered expedient. The illustrations have also been materially augmented, the number of plates being increased from eight to sixteen. The "Diseases of the Skin," by Mr. Erasmus Wilson, may now be regarded as the standard work in that department of medical literature. The plates by which this edition is accompanied leave nothing 10 be desired, so far as excellence of delinea- tion and perfect accuracy of illustration are con- cerned.—Medico-Chirurgical Review. As a practical guide to the classification, diag- nosis, and treatment of the diseases of the skin, the book is complete. We know nothing, considered in this aspect, better in our language; it is a safe authority on all the' ordinary matters which, in this range of diseases, engage the practitioner's attention, and possesses the high quality—unknown, we believe, to every older manual—of being on a level with science's high-water mark; a sound book of practice.—London Med. Times. Of these plates it is impossible to speak too highly. The representations of the various forms of cuta- neous disease are singularly accurate, and the color- ing exceeds almost anything we have met wilh in point of delicacy and finish.—British and Foreign Medical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, beautifully printed, with four exqui- site colored plates, presenting more than thirty varieties of syphilitic eruptions. Syphilis and has cleared up many obscure points in connection with its transmissibi'ity, pathology and sequelae. His facts and references will, we are satis- This, in many respects, is a remarkable work, pre- senting views of theory and principles of practice which, if true, must change completely the existing state of professional opinion.—New York Journal of Medicine. Dr. Wilson's views on the general subject of Syphilis appear to us in the main sound and judi- cious, and we commend the book as an excellent monograph on the subject. Dr. Wilson has pre- sented us a very faithful and lucid description of fied, be received as decisive, in regard to many questiones vexatse. They appear to us entitled to notice at some length. We have perhaps been some- what prodigal of space in our abstract of this book. But it is certainly a very good resume of received opinions on Syphilis, and presents, to many, original and striking views on the subject —Med. Examiner. WHITEHEAD (JAMES), F.R.C.S., &c. THE CAUSES AND TREATMENT OF ABORTION AND STERILITY; being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions of the Uterus. In one volume, octavo, 368 pages. 30 BLANCHARD & LEA'S MEDICAL WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, with illustrations. (Now Ready.) So little is generally known in this country concerning the causes, symptoms, and treatment of aural affections, that a praclical and scientific work on that subject, from a praclitioner of Mr. Wilde's great experience, cannot fail to be productive of much benefit, by attracting attention to this obscure class of diseases, which too frequently escape attention until past relief. The im- mense number of cases which have come under Mr. Wilde's observation for many years, have afforded him opportunities rarelv enjoyed for investigating this branch of medical science, and his work may therefore be regarded as of the highest authority. WEST (CHARLES), M. D., Senior Physician to the Royal Infirmary for Children, tee. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. In one volume, octavo, of four hundred and fifty pages. The Lectures of Dr. West, originally published in the London Medical Gazette, form a most valuable addition to this branch of practical medicine. For many years physician to the Children's Infirmary, his opportunities for observing their diseases have been most extensive, no less than 14,000 children having been brought under his notice during the past nine years. These have evidently been studied with great care, and the result has been the production of the very best work in our language, so far as it goes, on the diseases of this class of our patients. The symptomatology and pathology of their diseases are especially exhibited roost clearly; and we are con- vinced that no one can read with care these lectures without deriving from them instruction of the most important kind.—Charleston Med. Journal. I Every portion of these lectures is marked by a ge- neral accuracy of description, and by the soundness of the views set forth in relation to the pathology and therapeutics of the several maladies treated of. The lectures on the diseases of the respiratory ap- paratus, about one-third of the whole number, are particularly excellent, forming one of the fullest and most able accounts of these affections, as they present themselves during infancy and childhood, in the English language. The history of the seve- ral forms of phthisis during these periods of exist- ence, with their management, will be read by all with deep interest.—The American Journal of the Medical Sciences. WILLIAMS (C. J. B.i, M. D., F. R. S., Professor of Clinical Medicine in University College, London, &n. PRINCIPLES OF MEDICINE; comprising General Pathology and Therapeu- tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hygienics. Edited, wilh Additions, by Meredith Clymer, M. D. Fourth American, from the last and enlarged London edition. In one octavo volume, of nearly five hundred pages. Now Ready. This new edition has been materially enlarged and brought up by the editor. It possesses the strongest claims to the attention of the medical student and practitioner, from the admirable manner in which the various inquiries in the different branches of pathology are investigated, combined, and generalized by an experienced practical physician, and directly applied to the investigation and treatment of disease.—Editor's Preface. The best exposition in our language, or, we be- lieve, in any language, of rational medicine, in its present improved und rapidly improving state.__ British and Foreign Medico-Chirurg. Review. Few books have proved more useful, or met with a more ready sale than this, and no practitioner should regard his library as complete without it. —Ohio Med. and Surg. Journal. BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE RESPIRATORY ORGANS; including Diseases of the Larynx, Trachea, Lungs, and Pleurae. With numerous Additions and Aotes, by M. Clymer, M. D. With wood-cuts. In one octavo volume, pp. 508. THE HORSE BY THE SAME AUTHOR. THE DOG. Edited by E. J. Lewis, M. D. With numerous and beautiful illustrations. In one very handsome volume, crown 8vo., crimson cloth °-ilt. ILLUSTRATED MEDICAL CATALOGUE. BLANCHARD & LEA have now ready a Catalogue of their Medical and Surgical Publi- cations, containing descriptions of the works, with Notices of the Press, and specimens of the Illustrations, making a pamphlet of forty-eight large octavo pages. It has been prepared with great care and without regard to expense, forming one of the most beautiful specimens • of typographical execution as yet issued in this country. Copies will be sent by mail anc' i the postage paid, on application to the Publishers, by inclosing a three cent postage stem/ I AND SCIENTIFIC PUBLICATIONS. 31 B. & L. subjoin a condensed list of their publications in general and educational literature, of which more detailed catalogues will be furnished on application. HISTORY AND BIOGRAPHY. 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