• -<vas to remove the cannula, and with a pair of scissors to divide the cyst midway between the sutures; a piece of lint dipped in oil was then inserted, and secured by strapping; lastly, the external wound was partially closed at its extremities by sutures." After the artificial opening is formed in the manner described, it is kept from closing up, either by the daily introduction of tents, or as Le Dran first proposed, by the insertion of a very large but short cannula. 827. The character of the discharge will be very much changed by the contact of air Avith the cyst-wall, and, when the operation succeeds, it will gradually decrease in quantity until the cyst is occluded, when the artificial opening may be allowed to close. If the discharge from the cyst becomes very offensive, an injection of dilute Liquor Sodae Chlorinata has been used with advantage. 828. In the cases reported, Avhere this operation was per- formed, some were entirely successful, in others it was but pallia- tive, a fistula being left, the ovarian sac not having closed, and in others it terminated fatally. I have no means of knowing OVARIAN DROPSY. 391 definitely the percentage of cures resulting from it, as it has not been as extensively performed as other operations for the same disease, still from the cases reported. I think it worthy of a trial. 829. The artificial opening has likewise been made from the cyst through the vagina, and also through the rectum, and, when the cyst is low down in the recto-vaginal space, the vaginal open ing would probably be preferable. 830. Excision of a portion of the cyst,—This operation consists in making a small incision through the abdominal Avail, evacuating the contents of the cyst, and then draAving it out through the opening, excising a larger or smaller portion of it, returning it to the abdomen and closing the external wound. The object to be attained by the operation is, first, the evacuation of the fluid, and, second, an artificial communication between the cyst and the peritoneal cavity, the fluid that is effused by the cyst being reabsorbed by the peritoneum. The operation is predicated upon the fact that in cases Avhere cysts were accidently ruptured, their contents being discharged into the peritoneal cavity, the fluid was absorbed by the peritoneum, and the patient thus cured. It has been recommended by some authors to make an incision not more than an inch in length, either in the linea alba, or linea semi- lunaris, through which the cyst may be drawn out and excised. Others, hoAvever, among whom is Mr. Baker Brown, consider that the patient runs no more risk from an incision two or three inches in length, than from one an inch, and that this large incision enables the surgeon to determine the vascularity of the cyst, and the character of its adhesions, to avoid severing any blood-vessels in the excision, or to tie any that might be divided by the knife. 831. In regard to the success of this operation Mr. Baker Brown says:—" The excision of a portion of the cyst is an opera- tion more free from danger than complete extirpation, and less tedious in its results than the formation of an artificial oviduct. But it has a limited application. The conditions likely to favor its success are : The cyst unilocular, its walls thin, and possessed of little vascularity, very few or no adhesions, the fluid only slightly albuminous, and of a light specific gravity. When these favorable circumstances coexist with unimpaired general health, 392 DISEASES OF WOMEN. or very little ailment, then only should this operation be per- formed. If pressure had been tried without success, or was interdicted by the existence of prolapsus uteri, or by any other objection, an additional reason to try this operation would exist. Now, by preferring the longer incision, and, being prepared to extirpate the whole cyst if necessary, the surgeon will be able to explore the parts to ascertain what operation is most eligible. For instance, if the Avails of the cyst are found thicker and more vascular than Avas expected, it will be safer to proceed to extir- pate the entire cyst, after tying its predicle, than to run the risk of profuse hemorrhage by cutting out a portion. Or, if the cyst is found to be thin, unilocular, unattached, and unvascular, and the fluid thin, then the plan of excising a portion may be adopted with reasonable prospect of success." 832. Extirpation.—Extirpation, or the entire removal of the diseased mass, is the last resort of the surgeon Avhen other measures fail, or in cases in which they are not applicable. There is no need of disguising the fact, that it is a most serious and dangerous operation, and that it has often been the means of shortening the lives of patients, who might othenvise have lived for months, and perhaps years. Yet in other cases it has been the means of restoring numbers to health, who otherwise Avould have shortly succumbed to the disease. The question here arises, is ovariotomy justifiable? This question can be best answered by each practitioner after examining the evidence on both sides. This evidence I propose briefly to give. 883. First—Ovarian dropsy in many cases is essentially a chronic disease; many women living for years Avho are subjects of the disease, and even enjoy a comparative degree of health. Thus, " Sabatier examined the bodies of several women Avho had carried these encysted tumors during half a century, Avithout alarming derangement of health. Dr. AshAvell states that cases have fallen under his observation, in which women have become pregnant, and have been many times safely delivered, notwith- standing a dropsy of the OArary; and others, Avhen the tumor, although of considerable size, had existed for many years Avithout tapping, or any other than mere palliative treatment. Again, we OVARIAN DROPSY. 393 have numerous cases reported where the patients were frequently tapped, and yet lived for many years. 834. Notwithstanding that some women have lived for many years with ovarian dropsy, in a very large majority of cases the disease has ultimately proved fatal;' and in at least a majority of cases, the disease has proved fatal in from one to five years. Again, in those cases in Avhich ovariotomy has been proposed as a remedy, it is almost certain not only that the disease will prove fatal, but that in a comparatively short time. 835. In regard to the success of the operation, it is as great as in other operations which are sanctioned by the entire profession. Thus, in 68 cases, collected and tabulated by Dr. Churchill, 41 recovered and 25 died, or one in about two and a-half; these cases embraced those of every variety, with and without adhesions, in which the operation could not be completed, and 8 cases in which there was an error in the diagnosis ; the table must, therefore, at least, be considered as a fair statement of the success attending the operation. Dr. Atlee, of Philadelphia, has tabulated 172 legitimate cases of ovariotomy; of these 123 recovered, and 49 died, dr one in 3 25-49, or 28 21-43 deaths in 100 cases. Mr. S. Lee has collected 114 cases of ovariotomy, of which 74 cases recovered, and 40 died, or nearly one in three. Now, according to Dr. Simpson, the results of amputations in the Paris hospitals from 1836 to 1841, were— Out of 201 amputations of the thigh, 126 died, or 6 in every 10 " 192 " " leg, 106 died, or 5J " " 10 " 91 " " arm 41 died, or 4J " " 10 Thus, it will be seen that ovariotomy has been as successful as operations that are considered fully justifiable, and that are per- formed every day. 836. Does ovariotomy, however, effect a perfect cure of the disease, so as to secure the patient against its return ? This question may be ansAvered in the affirmative. Dr. Simpson con- siders that the pathological nature of multilocular disease of the ovary is such that it has no tendency to recur after its complete removal. . From the character of its morbid structure, and its 394 DISEASES OF WOMEN. clinical history, it is certain that it presents no liability to spring up again, like malignant or tubercular disease in the same locality, or in distant and in different organs of the body. The other ovary might be partially affected, and if so, might require removal along Avith the first, a step Avhich, at the time, Avould probably not add much to the absolute danger of the operation, seeing the abdomen Avas once opened." Contrast this Avith other opera- tions. " The surgeon amputates a limb, or excises a tumor for some form of carcinomatous disease, hazarding more or less the life of his patient, for the temporary removal of a diseased action which is almost perfectly certain to recur. He ties the subclavian for aneurism; but is it not a disease which is very liable to coexist in different vessels at the same time, or to form consecutively in different parts; and if the patient escapes the great and imminent dangers of the operation, has he any surety against its reappear- ance elsewhere? You amputate the thigh to get rid of a scrofulous or tubercular knee-joint. But in hoAV many cases is local tubercular disease the mere result of a general diathesis, that ere long will betray itself in some other part or organ." 837. From the dangerous character of the operation, and the importance of having direct and explicit rules to guide the surgeon, it would be supposed that we would have many minute descriptions of it in the various treatises on the subject. Yet so far as my reading has extended, and it has been tolerably extensive, I have seen but one description that I Avould be willing to put into the hands of the student or practitioner as a guide. It is a well-known fact, that in such operations as this, success does not depend upon the skill Avith which the operator uses the knife, but upon his attention to the small matters preparatory for the operation, during it, and in the after treatment. The only author that gives this necessary description is Mr. Baker BroAvn, and I can not do better for my readers than to give his description. 838. Conditions rendering the operation of ovariotomy justifi- able.—1. " The surgeon should be satisfied, by most careful and repeated examination, that the tumor is ovarian; and those with whom he may consult should take equal pains to form an unbiased opinion. OVARIAN DROPSY. 395 2. " That the tumor is increasing, and that the disease will be most likely to progress to a fatal issue if alloAved to take its course. 3. "That such of the different modes of treatment already described as appear to be suitable to the case, excepting the excision of a portion of the cyst, have been fairly tried without lasting benefit. 4. " That the tumor is not cancerous. 5. " That the patient is not so reduced, in her general health and vigor, as to render her an unfit subject for a formidable operation. 6. " That there is no evidence of the existence of adhesions. 7. " That the fluid is not highly albuminous. 839. Preparations for the operation.—" As all important operations are liable to fail from the neglect of little things, both in preparatory proceedings and in the operation itself, the following suggestions, all of which are really of moment, may be useful to those who are about to operate for the first time. 1. " If the weather be cold, the patient should have, ready to wear, a flannel waistcoat, and a pair of flannel drawers; the waistcoat should be put on before the operation. 2. " She should have a warm bath the night before the opera- tion, to cleanse the skin, and thereby insure free perspiration after the operation. 3. " The bowels should be opened by a dose of ox-gall or castor oil and an enema, on the morning of the operation day. 4. " A hot-water bottle should be prepared for her feet. 5. " There should be a thermometer in the room, and the temperature should be kept systematically at not lower than 66 degrees, nor higher than 70 degrees. A kettle should also be boiling on the fire, so as to make it possible to insure a degree of moisture in the air by the steam. This is especially requisite when the wind is in the east, or the weather hot and dry. 6. "If the operation take place on the bed Avhich the patient is afterward to occupy, the lower part of it should be prepared and guarded by a mackintosh-sheet and an old blanket, which can be afterward removed. There should be a hassock or stool for the feet to rest upon; the feet and legs should be clothed in warm 396 DISEASES OF WOMEN. stockings, and the hands and arms enveloped in a warm flannel gown. 7. " As the patient will have chloroform administered, she should not take.any food for some hours previous to the operation, and, to avoid sickness -.afterward, a supply of ice should be pre- pared for her to suck for two or three hours before the operation; this is of much consequence. 8. " There should be plenty, of hot water in the room, in which, in cold weather, both the operator and his assistants should immerse their hands before touching the patient; and there should be from three to six basins of Warm water ready for immersing sponges, or warming flannels, etc. 9. "The duties of each assistant should be clearly assigned and understood before entering the room, so as to avoid confusion, and also to save time, an important point when the peritoneum is exposed. 10. " Four or six large needles should be got ready, armed with the best twine, Avell-waxed, for the interrupted suture, and one large needle to carry the double ligature (also of twine, not of silk) for the pedicle. Several smaller ligatures, for blood- vessels, should also be ready, and a flannel bandage to go round the abdomen after the operation is completed; also a supply of lint and a few adhesive straps. 11. Instruments.—" One or two scalpels, a pair of scissors, a pair of vulsellum-forceps, a pair of good common forceps, tenacu- lum, trocar, and cannula of large size, together with the needles and ligatures, should be ready on a tray. lastly—" As much will depend upon the after-treatment, it will be well to arrange beforehand that the operator, or some other competent surgeon, should remain Avith the patient all night; indeed, she should not be left for more than tAvo hours at a time, for the first three or four days. 840. Mode of operating.—"The patient being placed conve- niently on her back, and brought under the influence of chloro- form, an exploratory incision, from two to three inches in length, should first be made in the linea alba. Having divided the peri- toneum, and reached the cyst, two or more fingers should be OVARIAN DROPSY. 397 passed over its surface to ascertain if adhesions exist; if these are slight and recent, they should, if possible, be broken down by the fingers, or, if they are few and small in diameter, so as to bear division, they may first be tied, to guard against hemorrhage, and aftcnvard divided, but if they are spread out to a considerable breadth, it is better to desist from any further procedure with a view to extirpation. If, on the contrary, there are no adhesions, or only such as can be easily, broken, the incision should be enlarged to four inches, or more if necessary. The next step is to tap the cyst or cysts with a proper trocar and cannula, and in the evacuation of the fluid to take care that none of it escapes into the cavity of the abdomen; then, if there be only one cyst, and that not thick nor vascular, a portion of it only may be excised in the manner heretofore described. If the cyst, however, should be found to be thick, or Arascular, or multilocular, it will be the safest procedure to have recourse immediately to complete extirpation in the following manner : The pedicle of the tumor is to be taken in the left hand, and gently draAvn outAvard from the pelvic cavity, an assistant carefully keeping bacl<, by Avarm flan- nels, the bowels and omentum. The course of the blood-vessels in the pedicle should noAV be carefully observed, so that the latter can be safely punctured by a scalpel or bistoury, and through the opening thus made an aneurismal-needle, carrying a double ligature of the strongest twine, be passed and firmly tied on each side of the pedicle. Mr. Wilson advises that, instead of passing a ligature round the pedicle, each vessel should be tied separately ; this some regard as an important improvement. This ligature should be passed as near to the tumor as possible, so that, by the entire length of the pedicle being preserved, the ligatured end may be kept external to the abdominal cavity, together with the ligature, as recommended by Messrs. Duffin and Erichsen; this done, the tumor should be removed by dividing the pedicle half an inch from the ligature, which should be given to an assistant, and held at the inferior end of the opening. The operator then closes the wound—and this, I need hardly say, should be done, as in all operations exposing the peritoneum, as soon as possible— by introducing deep sutures, about an inch from the incised edges, 398 . DISEASES OF WOMEN. through the parieties of the abdomen, taking care to avoid the peritoneum ; these sutures should be about half an inch apart. The edges of the Avound should then be more carefully brought together by superficial interrupted sutures occupying the inter- mediate space betAveen the deep ones. It now only remains to prevent the end of the pedicle and the ligatures from returning into the abdomen ; for this purpose, a common director, with its convex surface turned toAvard the abdomen, should be passed through the ligatures, so as to be firmly held by them at right angles to the wound. The ends of the ligatures should now be secured to the abdomen by adhesive plaster, and the Avound dressed with common Avater-dressing; this done, the abdomen must be supported by a many-tailed flannel bandage, comfortably tight, the patient be placed in bed, and Avarmth applied to the extremities. Two grains of opium are to be at once given, and one grain repeated every three or four hours until pain is allayed. Ice, milk, barley-water, or Aveak broths should constitute the diet for the first twenty-four hours ; aftenvards, stronger animal broth may be allowed, and Avine, if the condition of the patient admit of it. It is better, if possible, that the boAvels should be confined for four or five days after the operation; the bladder should also be emptied every six hours by the catheter. The temperature of the room should be carefully maintained for the first week after the operation. 841. " I have not enjoined the use of any particular length of incision ; for this matter must, I am of opinion, be regulated by the special circumstances of each case, the rule on the surgeon's part being to extract the cyst Avith the least danger to the patient, and through the smallest practicable incision, Avithout incurring the risk of a failure in the operation. A small incision of an exploratory nature should be the first; if the operation be pro- ceeded with, it must be enlarged sufficiently to admit the extrac- tion of the apparent cyst, and further increase will be very easy, if, by its peculiarly compound nature, its position or relations, or other circumstances, demand it. 842. " It is desirable, Avhen the diseased ovarian mass of one side is removed, and before the abdominal incision is closed, to OVARIAN DROPSY. 399 look at the condition of the other ovary, which not uncommonly is also diseased, and, when such is the case, it may be at once removed. • 843. " The dangers to be apprehended after ovariotomy are: 1. The shock of the operation; 2. Hemorrhage; 3. Acute in- flammation—peritonitis; 4. Inflammation of a low or typhoid character. 1. " Now that Ave have the benefit of chloroform, the dangers from the shock of the operation are greatly lessened ; but in some of high nervous susceptibility and debililated frame the shock may be fatal or severely felt, even though chloroform has been employed during the surgical proceedings, and the patient has not regained consciousness until they are over, and the wound dressed. Like similar cases from other operations these demand the use of stimulants and other means of support. 2. " Hemorrhage is unfortunately not so uncommon, the source of it being mostly from the cut pedicle or supporting base of the tumor. It will be seen, hoAvever, that in one of my cases the fatal bleeding had its source in the divided vessels of an adhesion ; and it is this event Avhich has induced me to recommend the tying of any divided bands of adhesion Avhere they have any thickness, and do not readily break doAvn before the finger. The tying of the stalk as I advise, Avill, I think, generally provide against hemorr- hage from it, care being taken to leave the pedicle out of the wound. Hemorrhage may kill either by the exhaustion imme- diately induced, or by the peritonitis it kindles. 3. "Acute peritonitis, in a more or less severe form, is a most frequent occurrence after extirpation; its origin we may trace to the natural effort of the system to close the Avounds made in the tissues in the operation by effusion of plastic lymph. Every precaution is to be taken against the advance of this inflammation, and its treatment must be based on the ordinary principles. 4. "Peritonitis of a Ioav or typhoid type appears later than the preceding conditions, and is seen Avhen any of the cut tissues put on an unhealthy appearance, and when probably some morbid excretions get into the blood. Here, again, no special directions 400 DISEASES OF WOMEN. are necessary, since the ordinary principles of treatment are those to be pursued. 844. " It will sometimes happen that unlooked-for conditions present themselves after the abdomen is laid open, and complicate or even render impossible the operation; among such is an unusual vascularity of the cyst, and consequent danger of fatal hemorrhage. Examples of this condition have occurred suffi- ciently aggravated to deter from completing the operation; in such cases the surgeon must rely on his oavii judgment. No precise rules can be laid doAvn, but I imagine the vascularity of the sac need rarely arrest the operation. Unexpected attach- ments of the cyst posteriorly to the intestines, or to other viscera, of such a nature that it Avould be dangerous to destroy them, will operate more frequently in discountenancing extirpation. Cancer, indeed, may not. be discovered until after the operation is com- menced, and be so situated as at once to stop it. 845. "Noav, in all these cases, excepting cancer, where the steps previous to the draAving forth of the cyst have been proceeded with, and we are compelled to cease from attempt at extirpation, the excision of a portion of the cyst is a mode of treatment still available." 846. I have thus endeavored to present to my readers a brief, yet complete history of ovarian dropsy, and the various means which have been employed for its relief, and in all that has been stated on the subject, I have been careful to embody nothing but what has been fully proven by careful observation. Especial care has been taken in the description of the treatment so far as space would permit, and as I hope, so minutely, that the reader Avill have no difficulty in applying the different measures recommended in practice: and I might conclude this chapter in the words of Dr. Blundell: "In the present ill success of our practice, all these operations are Avell worth your consideration; and if you can bring one of them to such perfection as to cure some of the unhappy individuals who noAV fall victims to the disease, you will, indeed, be conferring an invaluable good on the fairest and least offending part of our species." TUMORS OF THE OVARY. 401 Tumors of the Ovary. 847. Of those morbid growths which have their origin from the ovary, we have two varieties, the non-malignant or fibrous, and the malignant or cancerous. The consideration of neither of these varieties is of practical importance, as the treatment of them is merely palliative, and conducted on general principles, the only point of interest being their diagnosis from other diseases. 848. Fibroid tumors of the ovary.—Fibroid tumors of the ovary are very similar to the same growths in the uterus; in fact, in many cases it is very hard to determine whether the growth had its origin from the uterus beneath the peritoneum and had become detached, or Avhether it had its origin from the ovary. They may have their origin within the substance of the ovary, distending that organ nearly equally in every direction, or they may be situated immediately beneath the peritoneal covering, and project from one side of it. These tumors are generally very small, not larger than a pea or patridge's egg. Cruvelheir says, however, that they vary from a feAV drachms to thirty or forty pounds; these large tumors are thought by most authors to be always malignant. The growth of fibroid tumors of the ovary is always very slow, and they rarely give rise to symptoms of much im- portance. 849. Cancer of the ovary.—This disease is of much more fre- quent occurrence than the growths last described, indeed, the ovary stands second in the list of organs attacked by cancer. It is more frequent than cancer of the breast, and nearly as frequent as the same disease of the uterus. Cancer of the ovary is the most formidable affection to Avhich the ovary is liable, as it proves certainly fatal, and is not amenable to the treatment adopted for cancer in other parts of the body. 850. Three varieties of ovarian cancer may be distinguished, the areolar, scirrhous, and encephaloid cancer. The first of these has already been described under the head of ovarian dropsy; it consists of numerous fibrous sacs, generally containing a glutinous viscid matter. The second variety or scirrhus, presents the same characteristics that it does in other organs; it is of variable size, uneven and tuberose, and when cut into it creaks under the 26 402 DISEASES OF WOMEN. scalpel, and shows a whitish firm structure, intersected by strong membranous divisions. The third variety or encephaloid cancer, is rarely met with; it varies considerably in structure; generally it consists of a fibrous sheath, intersected with fibrous septa, within this fibrous structure we find effused the cerebriform matter. The density of the growth varies much, sometimes it is almost aa compact as scirrhus, Avhile at others it gives a distinct fluctuation. 851. Symptoms.—In the early stages of the disease, the symp- toms are very obscure, and it is generally only AA'hen it has so increased in size as to produce mechanical inconvenience, that complaint is made; and at this time it is very difficult, if not impossible, to distinguish it from other lesions of these organs. 852. Scirrhous cancer is very sIoav in its growth as a general rule, and it may exist for years without producing any dangerous symptoms. Encephaloid, on the other hand, has generally a rapid growth, and it may become of enormous size in a few months; the symptoms presented by this variety are always much better marked. According to M. Colombat: "When the disease ap- proaches a fatal termination, the tumor, which becomes irregular, and more and more enlarged, softens in certain points; the shooting pain, which has been compared to the pricking of needles, becomes more and more severe, and extends to the neighboring parts, to the uterus, vulva, loins, and thigh corresponding to the diseased side; hemorrhages and discharges of an ichorous char- acter and a disgusting odor, escapes from the vagina, which, by extension of the degeneration, often exhibits fungous vegetations, of a granulated and livid reddish appearance. The pains extend by sympathy to the knees, legs, breast and shoulders; the stomach, particularly, is affected, so that digestion is imperfectly performed, and the patient, who acquires an extreme disgust for food, is also troubled with nausea and vomiting, together Avith obstinate con- stipation of the bowels; lastly, a state of insomnia, amounting to almost sleeplessness, a permanent condition of hystericism, rapid emaciation, and continued fever, are harbingers of her approaching end, the inevitable termination of this scene of pain." 853. Where but one ovary is affected by the disease, menstrua- tion may not be disturbed; cases are even reported in which TUMORS OF THE OVARY. 403 conception occurred, and in which gestation went on the usual time, the female being delivered of a healthy child, though the malignant growth was of considerable size. Cancer of the ovaries frequently occurs with ovarian dropsy, and in many cases it has existed with it without being detected until ovariotomy was being performed. 854. Diagnosis.—In the early periods of the disease, it can not be distinguished from non-malignant growths of the ovary; but after it becomes fully developed, the severity of the symptoms will generally be sufficient to make the distinction. The diagnosis of the situation of the disease may be effected in the manner already pointed out, when describing fibroid tumors of the uterus, etc. 855. Treatment.—Active medication in this disease would be exceedingly injurious; no measures can be resorted to with the faintest prospect of effecting a cure. The treatment pursued should be directed to sustaining the general health of the patient, and to palliate as far as possible her sufferings. Dr. Churchill recommends, both in cancer and fibroid tumors of the ovary, when they have enlarged so as to produce compression in the pelvis, to push them above the brim, and in this manner relieve the mechan- ical symptoms. 404 DISEASES OF WOMEN. CHAPTER XIII. Puerperal Fever. 856. Puerperal or child-bed fever is one of the most dangerous diseases to which the parturient female is liable, and, though it is not of unfrequent occurrence, both sporadically and as an epidemic, yet we find that scarcely any two Avriters on the subject agree in regard to the pathology of the disease. This discrepancy in the opinions of writers upon the subject has doubtless arisen from the fact, that in the different epidemics of the disease, it varied greatly, not only in the phenomena which it presented during life, but also in the lesions which were found upon post-mortem exami- nations. Still, from reading the different treatises on the disease, notwithstanding the difference in the opinions of the Avriters, the mind will be forcibly impressed Avith the fact, that the disease itself was the same, though, from local causes or other circum- stances, its manifestations were different. The opposite plans of treatment followed by different writers, do not appear to have been founded on any actual difference in the disease, but upon a pre-concehred theory of its character. 857. It is not worth Avhile, in the short space that I have to devote to the description of the disease, to enter into a considera- tion of the many theories advanced in regard to its nature, as I think that each of my readers will be able to obtain a correct knowledge of it from the chapter on its pathological anatomy. 858. Causes.—The predisposing causes of puerperal fever are such as depress the vital powers of the system, and lead to unhealthy action in general. Among these might be named, low and ill-ventilated abodes, deficient food, intemperate habits, anxiety and a desponding state of the mind, etc. These causes have reference, however, principally to sporadic cases; for, Avhen the disease prevails as an epidemic, nearly every puerperal female within the affected district suffers from an attack. In these PUERPERAL FEVER. 405 epidemic visitations, the disease attacks alike the rich, in their well-provided lying-in apartments, with all the attention that could be desired, with every comfort and convenience, and the poor, in the hovel or the cellar, without any convenience or attention. 859. The exciting causes of the disease, when it does not prevail epidemically, are, an exposure to cold or to dampness, imprudence in rising from the bed at too early a period, in taking improper food, stimulants, etc. Retention of a portion of the placenta is also given as a cause of the disease, the suppression of some accustomed excretion, etc. Of the exciting causes of epidemic puerperal fever we know but little. It has been ascribed by some authors to the state of the atmosphere; by others to a contagion carried from one parturient female to another by the physician; and by still another it is considered to be an erysipe- latous inflammation which may be communicated either by the peculiar constitution of the atmosphere, or by contact with the morbid product of the disease, carried either upon the hands or clothes of the practitioner. 860. This brings us to the consideration of the contagious or non-contagious character of the disease, about which so much has been said and Avritten, and upon which some of our most eminent medical practitioners are at variance. Among those who affirm the contagious character of the disease, might be mentioned Drs. Ramsbotham, Denman, Burns, Hamilton, Blundell, Gooch, Lee, and others; and an equally eminent list of obstetricians might be named who oppose it. Without entering into the discussion of this matter, however, I will give the views of Dr. Meigs on this subject, in Avhich I place the most implicit con- fidence, from the known accuracy of his observations, and from his extensive experience. He says, " I have practiced midwifery for many long years. I have attended some thousands of women in labor, and passed through repeated epidemics of child-bed fever, both in town and hospital. After all this experience, however, I do not, upon careful reflection and self-examination, find the least reason to suppose that I have ever conveyed the disease from place to place in any single instance. Yet for many 406 DISEASES OF WOMEN. years I carefully considered whether such a transfer by a third person might be possible, and carefully read the statements of various authors to that effect. In the course of my professional life, I have made many microscopic researches of child-bed fever, but never did suspend my ministry as accoucheur on that account. Still I certainly never was the medium of its transmission. I have, in numerous instances, gone from the bedside of women dying of child-bed fever, whether sporadic or the most malignant degree of epidemic, without making my patients sick. I have also endeavored to assist my brethren when they had such cases and I had none. In a series of labors, 468 in number, and beginning with No. 1, I find that Nos. 18 and 19 were affected, and that No. 18 died with child-bed fever; No. 31 was sick, but recovered; Nos. 195 and 259 were sick, but recovered; but 291 died, as did also 293. Nos. 332, 339, 435, 444, were attacked, and recovered. The above 13 cases were in 468 labors, of which 3 died and 10 recovered. Now, if I was the medium of contagion for any one of that series of 468 confinements, why did I poison them in the ratio and order above set forth; and why did I not communicate the disease in more than 13 out of 468 cases? What became of my nebula from 31 to 195; to 259, and between 291 and 435, and so to the end, or 468 ? Such a table is far more easily explained by regarding the falling-out of the cases as coincidences and acci- dents, than as material causations, through a private pestilence." 861. The believers in the non-contagious character of the dis- ease, do not, however, ignore the fact that suitable attention and care on the part of the practitioner should be paid to cleanliness, etc., as there can be no doubt of the virulent character of the morbid matter produced by the disease, and that if brought in contact with tissues that will absorb it, it will reproduce the disease. Thus, when attending cases of puerperal fever, the following rules should be strictly observed. 1. That after examining any case of this disease, the hands should be carefully washed with soap and water, the nails cleaned, and kept pared short. And after making an autopsy on any dead body, his hands should be washed with a solution of chloride of lime until the cadaveric odor had entirely disappeared from them, and it would be better to com- PUERPERAL FEVER. pletely change his dress. 2. That when it is possible, the practitioner should visit first his other patients, and afterward the cases of puerperal fever, and that if this can not be done, he should first have his clothes well aired, or change before visiting other parturient cases. 862. From the facts before us, we have good reason to believe that puerperal fever arises either from the absorption of a morbid material generated by a local inflammation, the primary disease being local; or that, in epidemics of the disease, the circulating fluids are first affected, the primary disease being general, while the local inflammation is secondary, or the effect of a morbid condition of the blood. In the first instance, the disease usually commences as a metritis, though sometimes as an inflammation of the peritoneum, or the uterine appendages, the first symptoms presented being those of acute local inflammation; but as the disease advances, the constitutional affection may become so marked that it will present all the characteristics of the malignant typhoid fever, so often met with in epidemics ; this is the sporadic form of the disease. In epidemics of the disease, in the most of instances, the affection of the blood, as before stated, is the prim- ary affection, which has a tendency to localize itself in the uterus and its appendages, owing to their great susceptibility to disease after parturition ; even in this case the secondary local inflamma- tion has always a tendency to aggravate the general disease. 863. I do not consider that it is necessary for practical purposes to try to point out the distinctions between the several seats of the local inflammation, further than to give the pathological changes in the different structures; all that we Avish to determine in practice is, whether puerperal fever exists, and its form, whether merely inflammatory, the constitutional effect or fever being caused by the local inflammation, or Avhether it is typhoid, the blood crasis being affected; in other Avords, whether the fever is the result of the natural reaction of the system, or whether it is the result of a septic condition of the blood. 864. Pathological Anatomy.—In considering the post-mortem appearances presented by puerperal fever, Ave have to look: 1. To the lesions of the uterus. 2. Of the veins and lymphatics of 408 diseases of women. the uterus. 3. Of the peritoneum. 4. Of the uterine append- ages, the ovaries and fallopian tubes. 5. Of other organs inci- dentally involved by the puerperal process. In reference to the comparative frequency of these lesions in different organs, the following tables will be found interesting : Inflammatory Lesions in 371 Fatal Cases of Puerperal Fever. (From Duges.) Peritonitis was observed in.........................................266 cases. Metritis, or pus in veins, etc.......................................200 " Ovaritis...................................................................... 48 " Gastritis and Enteritis............................................... 4 " Pleuritis .................................................................... 40 " Pericarditis................................................................ 6 " Arachnitis ................................................................. 1 " Pus in Muscles or Joints............................................ 8 " Inflammatory Lesions in 222 Fatal Cases of Puerperal Fever. (From Tonnelle.) Peritonitis was observed in......................................193 cases. Metritis and Ovaritis...................................................197 " Pus in the Uterine Veins, or Lymphatics......................112 " Gastritis and Enteritis.............................................. 6 " Pleuritis.................................................................... 43 " Pneumonia................................................................ 21 " Pericarditis and Hydro-Pericarditis............................. 1 " Pus in Liver, Pancreas, Muscles, etc........................... 19 " Pus'in Joints.............................................................. 12 " 865. These tables show that in a large majority of cases the disease locates itself in the uterus or peritoneum, or in other words that the local disease is a metritis or peritonitis; that the ovaries are not near so liable to be affected, and the general nature of the disease, as seen in the frequent affection of other portions of the system. In the separate consideration of each of these morbid processes, I will depend principally on the description of Prof. Rokitansky, who has probably examined more cases of this disease than any other writer. PUERPERAL FEVER. 409 866. Puerperal Endometritis.—Prof. Rokitansky considers this affection to be invariably an exudative process, varying, how- ever, greatly, as it regards the plasticity of the inflammatory exudation; in some cases of pure inflammation, the exudation being organizable like that in croup, while in others, it is a putrid inorganizable matter. He says: 867. " In certain cases, we find the internal surface of the uterus lined by a yellowish or greenish dense exudation, of greater or less thickness and extent; either in small patches, or investing the entire uterus, and either firm or loosely agglutinated, and occasionally partially or entirely detached from the subjacent tissues, so as to appear corrugated or plicated. The uterine mucous membrane under this coating is found reddened, tumefied, and slightly softened; the free parts are discolored, and invested with a dirty reddish or brownish secretion, and with remnants of the deciduous membrane. The exudation generally interpene- trates largely the exposed raw tissue of the placental portion of the uterus, and causes it to assume a peculiar ulcerated appear- ance. This is the form of inflammation usually seen in sporadic cases of the disease, in those marked by high inflammatory symp- toms; the next described, is the condition met with in epidemics of the disease, or where it assumes a typhoid character. 868. " In other cases, the exuded matter is a gelatinous, puru- lent dirty yellow, loose and easily detached layer, beneath which, the internal stratum of uterine tissue appears spongy, infiltrated, soft, and may be easily detached in the shape of a dirty yellowish red, or partly greenish and brownish pulp. The internal surface of the uterus presents, in addition to the exudation, a glutinous secretion of a similar tinge. 869. " Again, the internal surface of the uterus may not pre- sent a trace of coagulable lymph, but be invested by a purulent sanious and very discolored exudation, beneath which, we find the uterine mucous membrane infiltrated, in more or less extensive or circumscribed patches, Avith a similar product; and it may either be easily removed in the shape of a thin and much discolored pulp, or it has already become detached, and is mixed up with the contents of the uterus, in the shape of a friable discolored floe- 410 DISEASES OF WOMEN. culi. In the place of the destroyed tissue, we occasionally dis- cover the products of a reactive process, in the shape of a more or less consistent sero-purulent secondary exudation." 870. " Again, the internal layer of uterine tissue may be coATered with a thin opaque or more dense, pale-green or broAvn- ish, or dark-chocolate or coffee-colored product, beneath which, it is converted to a greater or less depth, into a loose, infiltrated, fetid pulp, of a similar tint. This condition, which differs from ordinary sphacelus, has been termed putrescence of the uterus." 871. These various morbid appearances correctly mark the violence of the general disease, the plasticity of the exudation depending entirely upon the condition of the blood; thus, Avhen the disease presents a simple inflammatory character, the exudate will be coagulable lymph, but as it assumes the typhus character, the exudation gradually loses this character, until it presents the unorganized dark fetid product. 872. According as the disease attacks the uterus sooner or later after parturition, the uterus will be found more or less enlarged, its involution being stopped when attacked by inflamma- tion ; and it will be more or less relaxed, softened, and infiltrated. Thus, if the inflammation commences tAvo or three days after delivery, it will be as large as an infant's head; but if several days have elapsed, it may not be more than two, three, or four times its natural size. 873. Inflammation of the Veins and Lymphatics of the Uterus.—u Uterine phlebitis is generally a primary affection, originating in the open mouths of the veins at the insertion of the placenta, and caused as well by their laceration, as by contact with the external atmosphere, with the traumatic secretion of the part, and with the product of exudation on the internal surface of the uterus. It is either confined to a small portion of the veins, or it spreads over the greater part of the veins of the uterus belonging to the spermatic or uterine system of vessels. In the latter case, a secondary inflammation of the trunk of the sper- matic vein, brought on by coagulation of the blood, may,*on the one hand, extend through the vena cava to the right auricle, or on the other, along the iliac and crural veins, to the cutaneous veins PUERPERAL FEVER. 411 of the lower extremity; in this case, the symptoms of phlegmasia dolens are induced." 874. " If incisions be made in various directions from the point of insertion of the placenta, to the lateral parieties of the uterus and broad ligaments, a large number of veins become apparent, which are dilated and varicose, and filled with yellow or greenish- yellow viscid pus, or even with chocolate-colored sanies. Their orifices at the placental portion of the uterus, are either closed up by loose pale coagula, or they are covered over with an exudation which attaches itself to the spongy tissue of the raw surface, or, lastly, they are exposed so that their contents exude on the application of a slight pressure. The coats of the veins are relaxed and pale, the lining membrane is opaque, and discolored by the contents of the vessels, and after a protracted duration of the disease, it appears tumefied, thickened, partially gangrenous and ichorous. The tissue surrounding the veins, and especially the cellular tissue at the lateral portions of the uterus, is infil- trated with a yellow gelatinous or purulent matter, which is much discolored if the contents of the veins are ichorous; the tissue is relaxed, soft, friable, and lacerable. At different points there are abscesses of greater or less dimensions, which not unfre- quently burst internally, and discharge their contents into the uterus." 875. Inflammation of the uterine lymphatics is of much less frequent occurrence than the same disease of the veins, and is generally complicated with the latter. When it occurs, the lymphatics on each side of the uterus, in the broad ligaments, and passing up with the spermatic veins, may be observed dilated and varicose, the coats of the vessels thickened and firm, and of a pale color, and they contain a yellow, yellowish-green, purulent fluid. Sometimes they are so much distended as to present the appear- ance of small abscesses; by the distension of the lymphatics, their course may be traced from the uterus to the neighboring lymphatic glands, which are sometimes similarly affected. 876. Though inflammation of the veins and lymphatics may occur as the sole and primary disease, yet in a very large majority of cases it is found in connection with metritis. 412 DISEASES OF WOMEN. 877. Inflammation of the Peritoneum.—We have already seen that peritonitis occurs in about six out of every seven cases of puerperal fever, and yet it rarely exists as a separate primary affection. It is most frequently found occurring with metritis, with metrophlebitis, ovaritis, and inflammation of the uterine lymphatics. 878. "Puerperal peritonitis is not unfrequently limited to the peritoneal covering of the uterus and its appendages, when it presents more or less redness, with more or less distinct conges- tion and a thin partial exudation, or a more dense and extensive layer of a viscid and consistent or loose and fluid secretion." 879. " We not only find the peritoneal covering of the internal sexual organs attacked in this way, but also the peritoneum of the entire hypogastric abdominal region. The disease may even spread over the whole parietal and intestinal peritoneal lamina; the symptoms, however, predominating on the peritoneum of the internal sexual and adjoining organs. The entire peritoneum is often uniformly involved in the disease, not only without any predominance of the symptoms in the sexual organs, but some- times even with an apparent subordination of these symptoms." 880. The products of these processes vary very much; they may be firm, yellowish-gray concretions, loose, yelloAvish, mem- branous, grumous, gelatinous, or fibrinous coagula, which glue the intestines to one another, or to the parieties of the abdomen, or they may be yellow and greenish-yellow, thin, sero-purulent or thick purulent, dirty green and brownish, red, hemorrhagic, thin, opaque, sanious effusions, the result of septic peritonitis. The product is sometimes very limited in amount, and may merely present a thin covering of the internal sexual organs, or a few membranous or fibrinous flocculi of coagulable lymph, scattered through the abdominal cavity; but in the case of universal perito- nitis, it is generally extremely copious, whatever the particular variety of the product." 880. Puerperal peritonitis, no doubt, in a majority of cases, arises from an extension of the inflammation of the uterus or its appendages by a contiguity of tissue, though it may occur as the primary disease. Prof. Rokitansky thinks that the disease is PUERPERAL FEVER. 413 often, and even generally, the result of a primary condition of the blood of the female, which predisposes to exudative processes, and is totally distinct from the physiological tendencies of the blood during pregnancy. 881. Puerperal Ovaritis. —Inflammation of the ovaries is not of near so frequent occurrence in puerperal fever as the lesions heretofore described; it is generally observed as a complication of inflammation of the other parts heretofore described, though it may exist as the primary disease. 882. We have seen, when describing simple inflammation of the ovary, that the disease was most frequently confined to the Graafian follicles, but in the puerperal inflammation it involves the entire structure of the ovary. The puerperal process in the ovary resembles that described as occurring in the uterus, the plasticity of the inflammatory product bearing a direct relation to the condition of the circulating fluids. 883. The ovary is always more or less enlarged, of the size of a hen's or goose's egg, and presenting the various changes which have been heretofore mentioned. Thus, " the deposit may be serous, or fibrinous and fusible, filling the tissues, and causing the follicles to present an opaque appearance; or it may be a yellowish, or reddish, gelatinous, Auscid product, which is deposited in the stroma in large quantities; the latter being at the same time friable or semi-fluid, the follicles tumid, their coats swollen, and their con- tents opaque and flocculent; or, it may present various discolor- ations, and be at the same time collapsed and pulpy, its tissue distended by a dirty yellowish-brown, brownish-green, chocolate- colored fluid, or converted into a fetid pulp." 884. Puerperal inflammation of the ovary sometimes terminates in suppuration and the formation of an abscess. It may com- mence at separate points, Avhich gradually coalesce, or it may be set up in a single spot and gradually involve the entire structure; these abscesses sometimes attain a considerable size. " It is sometimes borne for a long time Avithout marked symptoms, and nature does her utmost to prevent a free discharge of it into the peritoneal cavity; for adhesions are formed between the ovary and the adjoining viscera, either in consequence of peritonitis 414 DISEASES OF WOMEN. having been combined with the inflammation of the ovary, or from circumscribed inflammations of the peritoneum having been set up in the course of the ovarian disease. When at last, the sup- purative process has eaten away the fibro-serous investment of the ovary, and caused its rupture, the discharge follows, from a yielding of the adhesions into a circumscribed cavity; now partial inflammatory attacks of the peritoneum ensue, or the pus meets with an organ which presents firm attachments. In the former case, the circumscribed processes not unfrequently pass into universal peritonitis, or this is induced by an extravasation of the pus through the relaxed adhesions. Again, in either of these cases, the suppuration may extend to the adjoining viscera, and the contents of the abscesses be discharged outward, indirectly through a circumscribed peritoneal sac, or directly in the hypo- gastric or umbilical regions, or into a portion of the intestine, into the bladder or vagina. 885. Summary of the Anomalies in other Organs, accompa- nying the above-described processes.—I have already quoted freely from the writings of Prof. Rokitansky, but under this head I shall give his remarks entire, as it is probably the best description of the disease extant. 886. " Beside the changes which occur in the original seats of the puerperal processes hitherto examined, there are so many important and various anomalies in other organs and tissues, that it is not sufficient merely to give a supplementary account of the anatomical results, but that as copious an explanation of them as possible becomes necessary. We shall, in the first instance," describe and account for the general appearance of the body, and then arrange the separate morbid processes, as much as possible, in groups, according to their mutual resemblance. 887. " The dead subject presents a remarkable disfiguration of the countenance, tumefaction and discoloration of the external genitals, excoriation, ulcerative destruction of various characters, with or without laceration of the perineum, various vaginal discharges, tympanitic distension of the abdomen, a livid erythema of the common integument at different parts of the body, white and often large coalescing miliary vesicles on the thorax and PUERPERAL FEVER. 415 abdomen. Yellow, greenish, bilious, feculent, chocolate-colored fluids escape from the mouth. 888. "The abdomen presents, in most cases, even if the peritoneal inflammation has been slight or entirely absent, a tympanitic distension of the intestines; this symptom is most developed in universal peritonitis; the entire intestine is then so much distended by gases, that it causes impressions upon the uterus, and forces the epigastric contents of the abdomen into the cavity of the diaphragm, and with the latter into the thorax as far as the fourth and third ribs. The firmer the exuded (plastic) matter, the more firmly the intestinal coils and the other abdom- inal organs are agglutinated to one another and to neighboring organs. The coagulable lymph is chiefly contained in the lower segment of the abdominal and pelvic cavities, but also in the lateral parts of the abdomen, betAveen the mesenteries and in the A'icinity of the large epigastric viscera, within spaces that have become more or less circumscribed by the adhesions. It not unfrequently causes, especially on the surface of the liver, shallow depressions, and gives to the superficial layer of this organ, if of a purulent or sanious character, a greenish, and to the spleen a blackish tinge. The reddening and vascularity of the peritoneum are generally inconsiderable; but most evident at those parts which are free from pressure, and take the form of narrow or broader striae. The membranes of the intestinal canal are all tumefied, the intersticial cellular tissue infiltrated, the layers easily distinguishable and lacerable. The intestine generally contains, in addition to a large quantity of gas, a yellow, serous, feculent fluid, Avhich mounts up to the duodenum and stomach. This fluid is in part the product of an exudative process that occurs in the greater part of the intestinal mucous membrane, and which we shall have occasion subsequently to examine more closely. The duodenum and stomach may also be found to contain a copious amount of yellowish-green or intensely bitter green biliary fluid. 889. "We have here to advert briefly to two symptoms that occur during the course of puerperal peritonitis, and which not unfrequently coexist—they are, vomiting of the biliary matters contained in the duodenum and the stomach, and of sero-feculent 416 DISEASES OF WOMEN. matters from the intestine. The former is to be explained by the paralysis of the muscular coat of the intestine, caused by the peritoneal exudative process, and the fixation of the intestine by plastic exudations; it commences at the duodenum and the stomach, the peritoneal covering of which generally remains un- attacked. The latter is caused by the exudative process, and the consequent irritation of the intestinal muscular coat Avhich forms a counterpoise to, and even counteracts, the paralysis at some points; it is the more frequent and the more considerable, the less marked the paralyzing influence of the peritoneal affection is. 890. " Almost all organs appear in a state of relaxation, Avhich is proportioned to the primary or secondary dyscrasia of the blood, and to the extent in which the blood has become deprived of its fibrine by the fibrinous exudations caused by inflammations of the peritoneum, the pleura, etc. It is owing to a moistening or imbibition of the tissues with the attenuated serum of the blood, Avhich easily exudes through the vascular coats, and is for the same reason coupled with pallor or discoloration, owing to the coloring matter Avhich adheres to the serum. In the abdomen Ave find that the kidneys and the liver are chiefly distinguished by the softening, pallor, or pale-red discoloration, oedema and imbibition, relaxation and friability of their tissues. In the thoracic cavity, the lungs are chiefly affected by these and similar deviations; the muscular portion of the heart, too, is, like the other muscles, and especially those that are involved in the peritoneal inflammatory process, soft, pale, moist, and lacerable. All the serous mem- branes and the lining membrane of the vessel are infiltrated Avith serosity, and are more or less reddened, and the serous cavities contain various quantities of a transuded, pale, or dark-red scrum. The brain alone, as in numerous other allied processes, e. g. in typhus, forms an exception, inasmuch as it appears denser and harder, drier and paler than usual. 891. "The spleen is very frequently, though not always tumefied; it is so particularly in secondary disease of the blood, whether or not accompanied by the secondary processes (deposits), that Ave shall subsequently have to notice. The lungs are reduced in size, and denser, in consequence of the upAvard pressure exerted PUERPERAL FEVER. 417 by the contents of the abdomen; their inferior lobes are of a dark- purple color, and in a condition of hypersemia. 892. "We noAv proceed to enumerate the separate morbid processes in the different organs, and point out their relations to the original puerperal disease. 893. " Our first attention is due to the exudative processes on the various mucous and serous membranes. That affecting the intestinal mucous membrane is of particular importance. The entire tract is generally involved; it is but slightly reddened, and commonly exhibits a thin, watery, serous, or Auscid-gelatinous, or gelatino-purulent or genuine purulent product; the tissue fuses, and the sub-mucous cellular tissue is more or less infiltrated. In this manner the diarrheas of the puerperal state are established. The exudation is rarely of a firm, fibrinous, or croupy nature, but most commonly its serous character predominates, and this is more the case the larger or more fibrinous the product, resulting from the coexistent attack of peritonitis. In certain cases, the process that takes place on the mucous membrane of the colon assumes a dysenteric type, and, as in the above-named forms, corresponds to the exudation upon the internal surface of the uterus or to the product of metrophlebitis. Similar processes, though generally accompanied with a coagulable product, are occasionally discovered on the mucous membrane of the stomach, the oesophagus, and the bladder, and in the lungs, in the shape of (partial) apthous pneumonia; this is chiefly the case when the blood has not been exhausted of its fibrine. 894. "Among the exudative processes that take place on serous membranes, the most frequent, after that occurring on the peritoneum, is pleuritis, Avhich is often coexistent with peritonitis; pericarditis is of less frequent occurrence. We also meet Avith exudations in the synovial bursae, and especially in that of the knee-joint, the sterno-clavicular and humeral articulations, and, lastly, in the capsule of the aqueous humor. The exudations are very copious, fibrinous, and purulent. A thin, soft exudation is often found upon the dura mater, accompanied by a slight reddening of the latter. 895. "All these processes may be variously combined, and 27 418 DISEASES OF WOMEN. they are dependent upon the primary or secondary disorganization of the blood, and especially upon that caused by the absorption of pus in metrophlebitis. 896. "Next in order come the processes dependent upon secondary phlebitis of the larger veins, and of the capillary venous systems of various organs and tissues. 897. " The former are generally developed in the vicinity of the original morbid affection, as in the plexus pampiniformis, the trunk of the internal spermatic vein, the internal iliac and crural veins; though they frequently, too, are generated at a distance, as in the cerebral sinuses and the pulmonary artery. These give rise to the so-called metastases or lobular abscesses, which we shall now proceed to examine. 898. "We often find larger or smaller circumscribed spots in the most Ararious organs and tissues; the dark-red points of conges- tion, or small accumulations of pus or sanies, which we have repeatedly adverted to. They are remarkably frequent and numerous in the organs of sanquification, especially in the lungs and the spleen; they are next seen in the kidneys, and more rarely in the ovary; they are occasionally met with in the brain; in the thyroid and parotid glands; in all muscles, particularly in the heart; in fibrous tissues, as in the dura mater and the perios- teum. Again, they are very common in the mucous tissue, espe- cially of the bladder and the intestines; they occur throughout the cellular tissue, but they seem to predominate in the cellular tissue of the extremities, of the mediastina, of the neck, the iliac muscles, and the intestines and stomach." 899. " We have already demonstrated that these processes are genuine exudative processes, or that they consist in a coagulation of the blood within the capillaries (capillary phlebitis). In the latter case, the coagulum fuses in a manner corresponding to the disease of the blood, and to the deleterious matter absorbed into the blood, and forms a purulent sanious fluid or gangrenous pulp." 900. " They may probably be invariably considered as the result of a secondary infection of the blood, of a poisoning of the blood by the introduction of some product from the original nidus PUERPERAL FEVER. 419 of disease, and particularly of venous pus and sanies in metro- phlebitis. They consequently always give rise to purulent and sanious products, and terminate fatally as capillary phlebitis. They enter into various combinations Avith one another, and with the exudative processes occurring upon serous and mucous mem- branes. Owing to their position at the surface of the organs, we always find that pleurisy supervenes upon their occurrence in the lungs, and peritonitis upon their deposition in the spleen." 901. " A black softening of the mucous membrane of the fundus ventriculi, or of the esophagus, or of both at the same time, which is indicated during life, by the vomiting of black coffee- ground like matter, is of frequent occurrence. It not rarely reaches that degree of intensity, that the fundus of the stomach, and sometimes the diaphragm also, and the esophagus, with the adjoining cellular tissue and mediastinum are ruptured, and the fluid that would have been evacuated by the mouth is effused into the abdominal and thoracic cavities." 902. " After difficult labor, the cartilages of the pelvic synch- ondroses are liable to inflammation, in consequence of the traction exerted upon them, and if the blood has assumed a septic condi- tion, the inflammation may terminate in gangrenous fusion of the cartilage, the latter being converted into a dirty brown and very much discolored fluid, contained within the investing ligamentous tissue." 903. " The blood contained in the cavities and large vessels pre- sents various and more or less evident changes. Its fibrine may be converted into consistent, viscid, greenish-white, or yellowish coagula; or after previous extensive discharges of fibrine, it may be attenuated, watery, exuding through the coats of the vessels and the adjoining tissues, and presenting but few and trifling, gelatinous, soft coagula. Again, after previous purulent or sanious absorption, it is of a dirty brown-red or chocolate color, viscid, glutinous, depositing dirty-AAThite, opaque, fibrinous concre- tions, which in the heart form numerous ramifications, or present- ing dark-red coagula, which are paler at the surface, and fusible. Lastly, if the disease has run a rapid course, the blood is much reduced in quantity, and even without defibrination having taken 420 DISEASES OF WOMEN. place, it is attenuated and discolored, and transudes all the tissues. The fibrine is sometimes found deposited on the valves of the heart in the shape of vegetations, Avithout the demonstrable occur- rence of previous pericarditis. The severe jaundice affecting women during the puerperal state, is always dependent upon pyaemia, and never upon an appreciable derangement of the liver." 904. Secondary Terminations.—" Puerperal peritonitis gener- ally terminates in the same manner as ordinary peritonitis; we notice, as particularly important, the unfavorable terminations in suppurations — phthisis — of the peritoneum and the adjoining tissues (ulcerative perforations of the diaphragm, the abdominal parieties, the intestines, the bladder, the vagina, etc.,) and in peritoneal tuberculosis. The exudations upon the internal sexual organs may become converted into cellular tissue, and by fixing the tubes in an unfavorable position, even without occlusion of the fimbriated extremity, cause sterility." 905. " The exudative processes occurring on the internal sur- face of the uterus, as well as the exudation in the uterine paren- chyma accompanying the former and metro-phlebitis, not unfre- quently degenerate into suppuration of the uterus, and the consequent purulent and sanious abscesses, extending chiefly from the point of insertion of the placenta in various directions, may discharge themselves into the peritoneal cavity. The affec- tion generally runs its course as acute uterine phthisis." 906. " A very remarkable and important result of the exuda- tive processes on the internal surface of the uterus is tabes of the uterus, which is manifested by extreme brittleness and friability of the uterine fiber. The uterus very rarely attains such a degree of involution as to resume the size of the unimpregnated organ; it generally remains considerably enlarged, of the size ot a duck's egg, or a man's fist; its tissue at the same time is porous, of a pale red, and at some parts of a slate color; the insertion of the placenta continues visible, by the relaxation of the tissue and the irregularity of the inner surface, or the mucous membrane is at this place invested by a yellowish-white ashy sub- stance, the remains of the exudation, and generally presents a retiform appearance." PUERPERAL FEVER. 421 907. Symptoms.—The symptoms of puerperal fever vary very much in different cases and in different epidemics of the disease; this variation in different cases, depends not only upon the extent of the local inflammation, on the organ or organs attacked, but also on the constitution and habits of the patient, and the degree of constitutional affection. However much the symptoms may vary in different cases and at different times, yet they are so marked as a general rule, and indicate so distinctly the character of the pathological lesions, that there is very little danger of the disease being mistaken. Instead of considering separately the symptoms presented by each of the different local inflammations described as metritis, peritonitis, etc., all that is necessary for practical purposes, will be to consider the disease as it presents the inflammatory or typhoid form, or as the inflammatory or typhoid symptoms predominate. 908. Puerperal Fever presenting more or less inflammatory symptoms.—In a large majority of cases, in the commencement of the disease, whether it is sporadic, or occurs epidemically, if the local inflammation be the primary disease, it will present the inflammatory form. In from two or three days to a week after delivery, the patient will complain of a sense of lassitude or weariness, with sometimes a sensation of soreness and weight in the hypogastric region, and a feeling, as she will express it, " as if she was not getting along well." This is shortly succeeded by rigors of greater or less severity, either partial or general, to which inflammation succeeds; these rigors or chills may be so slight, that the patient would not notice them without her atten- tion was especially called to them, and in this case, the fever would appear to have been the first symptom. As soon as the fever becomes developed, the face is flushed, the skin hot and dry, there is considerable thirst, sometimes nausea and vomiting, and a more or less violent pain across the forepart of the head. The pulse during the chill is full and strong, and somewhat accelerated, and as the fever becomes developed, it is hard and quick, varying from 110 to 140 in a minute, and the respiration is hurried in pro- portion. The secretions are arrested or diminished in quantity; 422 DISEASES OF WOMEN. the tongue is coated with a white fur, and the mouth clammy, the urine is high colored and acid, and the bowels confined. 909. With the development of the fever the local pain becomes more or less marked, according to the seat of the inflammation; if the peritoneum is affected, it is generally very severe, and commences first in the iliac or hypogastric regions, where it may continue, or it may involve a large portion or the entire abdomen. The tenderness on pressure is exquisite, and as the inflammation extends, it may become so acute that the patient can not bear the slightest pressure, not even the weight of the bed-clothes. In those cases in which the peritoneum is not involved in the disease, the inflammation being confined to the uterus or ovaries, the ten- derness is not near so great, the pressure having to be made deep, so that the fingers make pressure on the inflamed organs before the pain is much increased. The pulse likewise varies somewhat according to the seat of the inflammation, for when the perito- neum is involved, it is small and incompressible—wiry, while if the inflammation affects the uterus and ovaries alone, it is gener- ally hard and full. It must be recollected, however, that peri- tonitis exists in six out of every seven cases of puerperal fever, either as a complication of metritis, or as the primary disease. 910. These inflammatory symptoms may terminate in a longer or shorter time, in the typhoid form. Sometimes they appear only for the first few hours, or they continue for two, three, or four days, or they may continue to the termination of the disease either in recovery or death. For the first day or two of the disease, the lochia may continue but grow gradually less and less in quantity, or in some rare cases it may be suppressed from the commencement, or it may continue throughout the course of the disease. The secretion of milk is in the great majority of cases suspended in the early part of the disease, and the mammae become flaccid; though in a few cases reported this secretion has continued the entire course of the disease. 911. As the disease advances, all the symptoms mentioned become aggravated, the local pain and tenderness increases, the PUERPERAL FEVER. 423 patient lies upon her back, with the thighs drawn up to take off the tension of the abdominal muscles; the least motion increases the pain, the breathing becomes shorter and laborious, delirium sometimes sets in, there is subsultus tendinum, and hiccough, and death soon terminates her sufferings. 912. It is very rarely that puerperal fever retains its inflam- matory character to the last, yet it sometimes occurs, and these cases are marked by the same symptoms that characterize the synochal grade of fever. 913. Typhoid puerperal fever.—By the term "typhoid" we understand a prostrated condition of the system, the vital power being so overpowered by the disease that a high inflammatory reaction is impossible. In this form of the disease there is a greater or less affection of the blood mass (septic condition of the blood) caused either by the epidemic influence in this case being the primary disease, or from the absorption of some morbid mate- rial from the seat of the local inflammation (the endometritis, metrophlebitis, or peritonitis). We can readily understand why puerperal fever in the majority of cases should sooner or later present these symptoms of great depression of the vital power. More or less exhaustion always succeeds to parturition, from the intense degree of muscular poAver required to expel the foetus, the circulation is likeAvise more or less disordered from the rup- ture of the relations existing betAveen the mother and the foetus in utero, and not only this, but at this time without the excre- tions are free, there is more or less matter approaching a state of disorganization circulating in the blood, which needs but the stimulation of the epidemic constitution of the atmosphere here- tofore spoken of, to produce that septic condition of the blood which is the essential condition of typhus. And not only this, but the uterine organs themselves present the very conditions necessary for the absorption of morbid materials generated by the inflammatory process; there is often ruptures or lacerations of the uterus or the vagina, through which any putrid discharges may be readily absorbed, and the uterus presents at the insertion of the placenta a large traumatic surface, with the open mouths of the utero-placental veins constantly in contact with the contents and 424 DISEASES OF WOMEN. secretions of the uterine cavity. Any morbid material entering the circulation in this manner is liable to propagate the same morbid changes in the blood, i. e., to cause a disorganization of any material in the blood not sufficiently vitalized to resist the morbid influence. It is proved by experience that this morbid process in the blood is propagated in the same manner that diastase or yeast affects any albuminous matter with which it is placed in contact. We have a good illustration of the effects of the absorption of putrescent materials, even in very small quan- tity, in Avounds made during dissection or in making post- mortem examinations, the absorbed material exciting such chemi- cal changes in the constitution of the blood, that its Avhole char- acter is speedily changed, and its vital properties are altogether destroyed. In a large majority of cases as already stated, the disease assumes the character above described, the constitutional affection being the principal disease; sometimes tAvo, three, four, or more days elapse before the disease assumes, this character; at others it immediately succeeds the first inflammatory reaction, and at others it is manifest in the commencement of the disease. 914. In the two first instances, the first symptoms are those heretofore described, but in a longer or shorter time they are succeeded by symptoms of prostration; the pulse becomes small, weak, and contracted, though still rapid, the face pale, the tongue more or less coated with a dark yelloAv, or brown fur, or it may be clear, red, and dry, there is nausea and slight efforts at vomiting, diarrhea, etc. There is a morbid heat or dryness of the skin, or in some rare cases there is a constant clammy perspiration; the countenance presents a marked change, it is sometimes suffused, more frequently sallow, dejected, ghastly, and indicative of extreme distress; the eyes are sunken and inexpressive, and a dusky livid ring may be observed around the under lid. 915. The degree of local pain varies very much, even when there is peritonitis ; sometimes it is very severe, at other times it appears to depend wholly upon the tympanitic distension of the abdomen. The frequency and duration of pain in puerperal fever PUERPERAL FEVER. 425 where the peritoneum was involved, was carefully observed by Dr. Ferguson; in 173 of his patients he found that The number of his patients that had no pain was 19 a a who had pain fori day ' 51 Li a u a 2 days l 48 u u a a 3 a i 22 a a a a 4 U ' 18 u a a a 5 a i 6 a a it a 7 U ( 5 a a a u 8 a i 4 916L Shortly after the disease is established, the abdomen becomes tympanitic, and in some instances becomes very much distended and tense, and in a more advanced stage the presence of effusion may be detected. 917. When the disease assumes a low or malignant type from the commencement, the first indication of the impending mischief, says Dr. Copeland, " is the great rapidity, softness, and weakness of the pulse, often attended by pain and tenderness at the epigas- trium, by sickness and vomiting, followed by general distension and pains darting through the abdomen. But in the majority of cases there are neither chills nor rigors; in a feAv, a feeling of coldness only; and in still fewer, slight rigors. In this state of the disease the patient soon becomes despondent, predicts her dissolution, is afterward apathetic, and makes little or no inquiry for her infant. The milk and lochia are either little or not at all diminished, or are more than usually abundant. The abdominal pain and distension are sudden and quick in their action; but the pain soon ceases, the distension remaining, and afterward changing its character, if the disease continues above two or three days. The tongue, from the commencement is flabby, broad, and slimy, or covered by a mucous or creamy coating; the pulse is usually from 120 to 140, or even upward, fluent, soft, or broad; and the general surface presents a lurid, dusky, or dirty hue, and is covered by a clammy or offensive perspiration. The countenance is pale and inexpressive, unless where the pain is acute, when it becomes anxious and covered with perspiration. The mind is but 426 DISEASES OF WOMEN. little disturbed, beyond a state of complete apathy. As the disease proceeds, respiration is short, suspirous, or difficult; the pulse small, soft, or irregular; the bowels frequently relaxed, and the stools offensive, or passed without control. Distressing feel- ings of sinking, leipothymia, or restlessness supervene, and are soon followed by symptoms of impending dissolution." 918. At any period of the disease, the above-named symptoms may become complicated Avith those arising from pleuritis, gastritis or enteritis, pneumonia, etc. The occurrence of any of these complications alter the general symptoms of the disease, and they therefore vary greatly from this cause; they also vary much in different cases where no complications exist. 919. When the disease progresses toward a fatal termination, there is effusion into the peritoneal cavity, and with this effusion there is a remission of the local pain, but with this absence of the local pain the other symptoms are all aggravated. The pulse becomes small and weak, fluttering, and so rapid that it can scarcely be counted, the patient appears to suffer more, and there is a constant watchfulness; the tongue becomes dry and brown, and there is sometimes vomiting of a dark coffee-ground looking fluid : the patient retains her position on the back, and there is a constant tendency to slide down toward the foot of the bed; she picks at the bed-clothes, and appears to be unconscious of any thing that is going on about her, etc. Sometimes there is deli- rium, and when it occurs it may be looked upon almost as a fatal symptom. 920. But if the pulse be found less frequent and stronger, the skin cool and soft, the tongue cleaner, no nausea present, the thirst less, and the patient gets refreshing sleep, and can change her position and lie upon her side, we may hope for a recovery. 921. Diagnosis.—From the symptoms above named, and the time at which the disease occurs, (shortly after parturition) there are but two diseases, or morbid states, with Avhich there is any danger of its being confounded; these are, hyteralgia, and a disease described by Dr. Ramsbotham under the name acute tympanitis, or false peritonitis. 922. It may be distinguished from neuralgia of the uterus by PUERPERAL FEVER. 427 the periodical exacerbations and remissions of this latter, and from the less degree of constitutional suffering. From severe and long-continued after-pains by the fact that in this the uterus can be felt to contract and harden with each pain, and that there is little or no constitutional suffering. 923. The diagnosis between what Dr. Ramsbotham terms acute tympanitis and puerperal fever must be very obscure, from the symptoms which he gives of the disease. He says, " The attack mostly commences two or three days after delivery, and is usually introduced by a rigor; this is often very severe, more so, indeed, than when it proceeds from peritoneal inflammation. It is a great mistake to believe that shivering is always indicative of the com- mencement of an inflammatory attack; for here, although not the slightest appearance of inflammation can be observed after death, the rigor is strongly marked. To this succeed great heat and dryness of skin, which also is often more intense than in peri- tonitis. I have already said, that in peritonitis the surface is sometimes soft and moist from the commencement; but this I never remarked in the affection now under consideration. The pulse rises rapidly in frequency, often beating one hundred and thirty or one hundred and forty strokes in a minute; sometimes it is fluttering and tremulous; at others, fuller and firmer than in peritonitis. The mouth is generally dry ; the tongue occasionally furred, or it is harsh and red. The countenance becomes early changed, though not so anxious as in peritonitis. Most severe pain in the head is experienced, with intolerance of light and noise, uninterrupted wakefulness, and in many cases even delirium. Very early in the disease the abdomen swells inordinately and rapidly, becomes very tense and painful, and the transverse colon, particularly, can in many instances be distinctly traced; pressure aggravates the sufferings. The milk ceases to be secreted; the lochia are generally suppressed; there is great languor; an unwillingness to speak or take nourishment: the patient lies upon her back, with her legs drawn up, unsolicitous about herself, her infant, or her friends; the bowels are obstinately constipated. As the disease gains ground, the belly increases in size, pain, and tightness; the tongue becomes dry and brown; there is hiccough, 428 DISEASES OF WOMEN. or vomiting of offensive matter, muttering delirium, subsultus tendinum, and most of the symptoms that denote the last stage of fever; but if recovery is to be expected, the swelling and tenseness of the abdomen subside; the pain gradually goes off; the pulse becomes slower; the tongue moister; the skin cooler and softer; there is no vomiting; the intellect remains unimpaired; and a desire is expressed for food; and the bowels act, together with the expulsion of a large quantity of flatus." 924. We have here a disease which, according to Dr. Rams- botham, presents all the characteristics of puerperal fever, without there being any signs of local inflammation after death. This would go to prove the fact that puerperal fever is principally a disease of the blood, (a general or constitutional affection,) and not, as many writers would have us believe, a local affection. 925. As to the diagnosis between this and puerperal fever, we need not trouble ourselves, as they are certainly both the same, with the exception of the local inflammation, and require similar treatment. 926. Prognosis.—The prognosis in puerperal fever will vary according to whether it is sporadic, or Avhether it prevails as an epidemic, and according to the character of the epidemics, some that have occurred being very malignant, Avhile others have been comparatively mild. In those cases that present the symptoms of acute inflammation first named, the prognosis will be much more favorable than in those presenting a typhoid character. And lastly, it will vary according to the period of the disease at which the treatment is commenced, and the energy Avith which it is followed up. In the language of Prof. Meigs, " If the nurse allow the precious moments of the forming stage to elapse before the alarm is taken, or if the physician, through inattention or failure in making the diagnosis, pursues, in the beginning, a feeble or erroneous practice, no human skill, sagacity, or devotion can be relied upon to rescue the victim, Avho has already begun to die before the first hand is extended for her rescue." 927. Treatment.—The indications to be fulfilled in the treatment of puerperal fever are, to subdue the local inflammation as soon as possible, and thus prevent the severe constitutional affection; to PUERPERAL FEVER. 429 stimulate and keep free the secretions and excretions, and thus relieve the system of all disorganized material as soon as formed; and to keep up the strength of the patient by appropriate tonics and stimulants. We will consider separately the treatment in the two forms of the disease noticed—the inflammatory and the typhoid. 928. A careful practitioner attending a puerperal patient will be able to distinguish the disease at its commencement, or shortly aftenvard; for, as a general rule, it is ushered in during his daily attendance. But, if an epidemic of the disease exists, careful directions should be left with the nurse or friends to apprise him of the first morbid symptoms. As soon as the disease is recognized, an active cathartic should be administered, to remove any irritating or morbid matters from the bowels, and also as a powerful means of diverting the circulation from the inflamed organs, and. of relieving the congested state of the vessels. In this instance, many practitioners prefer the Compound Powder of Jalap and Senna (3j), with the Bi-Tartrate of Potassa (gr. x. to xv). Others prefer a combination of Podophyllin, Leptandrin, and some active stimulant, as Capsicum, as in the following formula : R Podophyllin, gr. x. Leptandrin, gr. xx. Capsicum, gr. xv. M. Ft. Pulvis, No. x. These powders are administered one every three hours, until the bowels are freely evacuated; many who use this formula add to each dose of it the Bi-Tartrate or Nitrate of Potassa, gr. v. to x. Whichever agent is used, it should be continued at intervals through the first three or four days, sufficient to keep the bowels open; though it should not be administered so as to weaken the patient, and to prevent this, it would be well to combine with each succeeding dose that has to be given, an increased quantity of some active stimulant. The operation of the first cathartic may be assisted, should it prove tardy, by the use of enemas of warm water. 929. Without waiting for the action of the cathartic, our next endeavor should be to get the extremities warm, and cause a 430 DISEASES OF WOMEN. determination to them and to the surface. We can not here use the hot foot-bath as we could in other diseases, but we find an excellent substitute for it in three or four thicknesses of flannel wrung out of hot water, to which mustard enough has been added to make it stimulating; these should be wrapt around the feet and legs, and may be kept warm for any length of time by the application of bottles of hot water, or sacks of hot salt or bran. Internally we may administer the Tincture' of Gelseminum in drachm doses every three hours, until its specific effect is produced, with one of the following powders: R Asclepin, Diascorein, Comp. Powd. of Ipecac, and Opium, aa. 3ss. Nitrate of Potassa, 3j. M. Ft. Pulvis, No. x. This should be continued until the cathartic has operated. If "during this time, or after the opera- tion of the cathartic, there should be nausea or vomiting, or if the disease were ushered in with it, " an emetic is indispensable," and its administration, according to the best authorities in all branches of the profession, "good practice." It must be recollected, however, that emetics are only indicated in the first stages of the disease, and when nausea or vomiting is present. It might be supposed that the operation of the emetic would increase the violence of the peritonitis, when this exists, by the powerful contraction of the abdominal muscles, and the consequent com- pression of the abdominal viscera, attendant on the act of vomiting. But experience has proven that this is not the case; the local as well as the general symptoms being mitigated by emetics. The advantages to be derived from the judicious use of emetics are two-fold: they remove any irritating or morbid mate- rials from the stomach, and fit it to receive kindly those remedies upon which the life of the patient depends ; they likewise exert a powerful revulsive effect upon the local disease, increasing the secretions from the skin, kidneys, and intestinal canal. It might be asked here, if emetics prove thus valuable when nausea and vomiting exist at the commencement of the disease, why not PUERPERAL FEVER. 431 administer them when these symptoms are not present ? All that I can say in regard to this is, that I have the best authority for recommending them in such cases, though in others, I have not. For an emetic we can use nothing better than the Compound Powder of Lobelia in infusion, giving it in divided doses, but so as to produce speedy and thorough emesis. If, however, there is nausea, and it is not thought best to administer an emetic, the irritation of the stomach should be subdued by small doses of an infusion of our neutralizing powder, with the application of a sinapism over the epigastrium. 930. To relieve the local pain, fomentations of Stramonium or of Hops may be used in many cases with great advantage; they should be applied as hot as they can be borne, and frequently changed, so as to keep up a continuous heat; careful directions should always be given to the nurse in regard to their application; for, if left on until they become cold, they will aggravate the disease instead of proving a benefit;*or if they should be applied too wet, the patient's clothes as well as the bed will become damp and make her uncomfortable. From the difficulty of having fomentations properly applied, several authors, among whom may be mentioned Gooch, Ferguson, and Locock, prefer a well-made Linseed poultice, as a constant application to the abdomen. The best local application with which I am acquainted, is the Tincture of Stramonium, diluted with four parts of water, kept hot on the stove, and three or four thicknesses of flannel wrung out of it and applied to the abdomen; in changing it, the layer next to the abdomen may remain, and the applications made upon it; in this manner the abdomen is not exposed, and the applications can be made very warm. Though warm applications are indicated in the majority of cases, yet some will be met with where it will increase the pain and suffering, and in these cases it is recommended to change them for cold applications. Thus, in the epidemic of Aylesbury, says Dr. Ramsbotham, Cely found that cold evapo- rating lotions used to the loins, abdomen, and vulva, alleviated pain, repressed tympany, and proved more grateful to the patient than fomentations. 931. The measures above named, should be used together, with 432 DISEASES OF WOMEN. promptness and perseverance; there is no time to be lost in a disease that runs its course so rapidly as this; in other diseases, we might have time to wait to see the advantage to be derived from single measures, but here they have to be used together. As soon as the cathartic has operated, and the irritation of the stomach has been subdued, Ave resort to what I have great reason to believe will be found to be a specific in this as well as other acute inflam- mations ; this agent is the Yeratrum Ariride, or White Hellebore. The tincture will probably be found the best means of administer- ing the agent, though I have used the concentrated agent Veratrin with much success. At this time, or even at the commencement of the disease, providing there is no gastric irritation, the Tincture of Veratrum Yiride should be substituted for the Tincture of Gelseminum, giving it in five-drop doses every three hours, with the powders, and continuing it, and increasing the dose a drop at a time until the pulse is reduced to 60 or 70 beats, per minute. It is necessary in administering this agent, that the physician should visit his patient frequently, so as to observe the effects of the medicine, or that the nurse should be capable of noting its effects upon the pulse; for as soon as the pulse is reduced, as above stated, the dose of the remedy must be decreased so as to maintain the advantage gained; but not so as to produce any greater depression of* the circulation. It is evident that if we can control the circulation, and keep it at the point named, the local inflammation will be subdued per force. The only difficulty that arises in the use of the Veratrum Viride is, its tendency to produce nausea and vomiting; but this may be guarded against by first removing any gastric irritation, and watching its action and reducing the dose, providing it produces nausea. In the place of the Veratrum Viride some practitioners make use of the Tincture of Aconite (root), giving it in doses of from three to five drops in combination with the Tincture of Gelseminum. 932. I have not yet mentioned the Alkaline Bath, which is a very important adjuvant to the treatment; it may be used with much advantage whenever the skin is hot and dry; but it must be used carefully, so as not to expose the surface to the atmosphere, which might cause a chill; and it should always be accompanied PUERPERAL FEVER. 433 with sufficient friction to produce an agreeable glow upon the skin. 933. If tympanitis should arise during this treatment, the fomentations may be wet Avith Oil of Turpentine, and enemas of Tincture of Xanthoxylum (3iij), Liquor Sodae Chlorinati (3ss), and Warm Water, (Oct.j), may be used at intervals until it is removed. 934. As a common drink, the patient may use an infusion1 of the Eupatorium Purpureum, of Marsh Mallow, or of Peach-leaves : ice or ice-Avater will prove very grateful to the patient, and will also be highly beneficial. 935. Vaginal injections of Avarm water have been highly recommended as affording great relief in this disease; they not only assist in relieving the local pain and tenderness, but they also remove any morbid secretion from the parts, and thereby lessen the dangers of absorption. If the lochia or the discharge attendant on metritis be fetid, a weak solution of chlorinated soda may be used. 936. If the above measure should fail in arresting the disease in the first two or three days, it is probable that it will assume a typhoid character, when the treatment will have to be altered to meet the severe symptoms of prostration that ensue. 937. In the treatment of the typhoid form of puerperal fever, it is even more necessary to keep the secretory and excretory organs in an active condition, than in the other form ; the very fact that this condition owes its origin to a depraved condition of the blood, points directly to the importance of effecting its removal through the excretions. But while endeavoring to effect this, the most strenuous efforts should be made to keep up the strength of the patient, and to subdue the local inflammation. 938. As long as the inflammatory symptoms continue, the measures first recommended should be continued, but as soon as symptoms of depression appear, they will have to be combated by active tonics and stimulants, as: R Quinia Sulphas, gr. xxxx. Hydrastine, gr. xx. M. Ft. Pulvis, No. viij. Let one of these powders be given 28 434 DISEASES OF WOMEN. every three or four hours, as circumstances may require, with from half a drachm to one drachm of Tincture of Xanthoxylum to each dose. With this, if the prostration is great, we may give stimulants, as, brandy, wine, porter, etc. The bowels should still be kept open, but the agents used for this purpose must be stimulating, and such as will have no tendency to produce gastro- intestinal irritation; probably no agent will answer the purpose better than the Compound Powder of Jalap and Senna heretofore referred to, combined Avith a small quantity of Capsicum, or Xanthoxylin. Or instead of this, and especially if there be much tympanitis, we might use equal parts of Leptandrin, Dias- corein, and Juglandin. 939. To stimulate the kidneys to action, it is recommended to use the stimulating diuretics, as Oil of Turpentine, Copaiba, etc.; these agents not only prove diuretic, but they are likewise of advantage in relieving the tympanitis. The surface should be frequently bathed Avith the alkaline-bath and spirits, and much care should be used to keep the extremities warm. 940. The diarrhea which so frequently occurs in the typhoid form of this disease, is sometimes hard to control; for this it has been recommended to use the Muriated Tincture of Iron, in doses of thirty or forty drops, repeated every tAVO hours with or without some preparation of Opium. Where the diarrhea is slight this might be sufficient, and it then would probably be better than any other; but in many cases this will not check the diarrhea, and we will haATe to resort to other measures. The Aromatic Tincture of Guiacum. with as much Tannic Acid as it will dissolve, and given in half-drachm or drachm doses every two or three hours, will generally prove effectual in checking it; or instead of this, Ave might use equal parts of Geraniin and Myricin in five or six- grain doses, and repeated as often as necessary. If the discharges from the bowels are offensive, the Pyroligneous Acid, or an infusion of the Baptisia Tinctoria, or a solution of the Chlorinated Soda, may be administered with the astringents. 941. In the typhoid, as well as the inflammatory form of the disease, the circulation may be controlled by the use of the Veratrum Viride, and by this means the rapid disorganization PHLEGMASIA DOLENS. 435 attendant on the disease may be checked until other agents will have time to act. 942. If the patient should desire acid drinks, they may be taken with much advantage in any stage of the disease, as they are not only refreshing, but strongly antiseptic, counteracting the septic condition of the blood. 943. The above are the general principles of treatment, and, if pursued energetically, they Avill be found successful; other measures might be mentioned which have been used with much advantage, and the treatment recommended might have been more minute, yet it is impossible to lay doAvn specific rules for the treatment of every symptom or complication that may arise in this disease, in the space that I have to allot to this affection. In conclusion, I would say that the management of convalescence in this disease should be the same as in typhoid fever, having especial reference, however, to the puerperal state. Phlegmasia Dolens. i 944. This affection has received and is known under various names, as, phlegmasia dolens, plegmasia alba dolens, oedema lactium, sparganosis, milk leg, white leg, swelled leg, etc., etc., and as many theories have been advanced in regard to its character as it has names. It is a disease of the puerperal state, occurring generally betAveen the fourth day and third week after delivery. It may arise after first pregnancies, though in a large majority of cases it occurs in females who have borne several children; it is also said to arise more frequently in Avomen of a delicate consti- tution, and those' who suffer from uterine irritation after delivery. 945. The disease consists in a colorless swelling of one or both legs, the left leg being said to be more frequently affected than the right; with swelling, there is pain, tenderness on pressure, and more or less fever. As to the pathological lesions causing these symptoms, there are various and conflicting opinions; some regard it as an inflammation of the veins of the thigh and leg, and hence one of its names, "crural phlebitis ;" others, again, consider it a species of cellulitis, involving the cellular tissue of the leg, while others consider that the disease is confined to the lymphatics, 436 DISEASES OF WOMEN. and others have combined these different lesions in varying pro- portions to suit their individual fancy. In support of the opinion that the disease Avas, as one of its names indicates, crural phlebitis, Dr. Robert Lee gives the folloAving conclusions derived from post- mortem observations: " That the inflammation of the iliac and femoral veins gave rise to all the symptoms of phlegmasia dolens, and that the inflammation commenced in the uterine branches of the hypogastric veins, and thence extended to the femoral trunks of the affected side." Prof. Rokitansky's observations go to support, partially, this view of the subject, yet he appears to consider the cellulitis the prominent affection; he says: " Two lesions seem to be essentially connected Avith this affection. It either depends upon an inflammation of the veins of the inferior extremity, and especially of the crural vein, or upon an inflamma- tion of the cellular tissue, which gives rise to the most various products. The latter form is particularly likely to cause the characteristic symptoms which a so-called sero-lymphatic or sero- purulent product, i. e., fibrinous or purulent exudation, diluted by a large amount of serum, induces." Among those who considered that the lymphatic system of vessels were first affected, and that the disease Avas inflammatory, might be mentioned Drs. Denman, Ferrier, Caspar, and DeAvees. The reasons for this opinion are well-given in a very able paper by Dr. J. D. Collins, of Kentucky; he says: " From a careful investigation of the history and symptoms of this disease, I have been brought to the following conclusions: That it is caused by the pressure of the foetus on the numerous lymphatics that are located about the loAver part of the superior and upper part of the inferior straits of the pelvis. " This pressure causes obstruction in the lymphatic circulation— this obstruction induces irritation, and the irritation ultimates in inflammation, Avhich soon involves the glands of the whole of the lower extremity, unless arrested by some agent. What are the evidences upon which I come to these conclusions ? They are of two kinds, viz.: positive and negative. The positive are— 1. " That the lymphatics of the pelvic straits stand out more prominently than any other circulating vessels. PHLEGMASIA DOLENS. 437 2. " They are less able to resist pressure than any other vessels. Why ? Because the visatergo of the lymphatic circu- lation is more feeble than any other circulation in these parts. 3. " There is an effusion of lymph long before the veins become involved. How do I know this ? 1st, because of the peculiar character and appearance of the SAvelling; 2d, because the serum drawn off by scarifying the parts is found to contain large quantities of lymph. 4. " Because we find the lymphatics much swollen, etc., before the veins become involved. " My negative reasons are— 1. " It can not be the veins, because the phenomena of inflam- mation of the veins is not evidenced in this disease, until it has existed for some days, and sometimes weeks. 2. " Because inflammation of the veins elsewhere does not present the same appearance and phenomena that exist here, viz.: effusion of lymph in cellular tissue, etc. 3. " Because the treatment which is successful in combating inflammation of the veins elsewhere does not answer the same purpose in this case. 4. " Because a dissection of a portion of vein from the diseased parts, in its primary stage, does not show any trace of inflam- mation. 5. " If it were inflammation of the veins, resulting from pressure of the foetus upon them, they would take on the inflam- mation sooner than they do here. " There is no doubt in my mind that the veins do become involved ultimately, unless the disease is arrested in its primary stage. All of the post-mortems show the veins, as well as the lymphatics, to be involved, but the post-mortems are not reliable, so far as determining the primary cause of hardly any disease— they only sIioav the extent of diseased action." 946. Symptoms.—The disease is usually ushered in with rigors of greater or less severity, and which continue for a longer or shorter time; these chills are succeeded by more or less fever, the pulse often rising to 120 or 140 beats in a minute; the bowels are mostly constipated, the tongue furred and moist, the skin dry, 438 DISEASES OF WOMEN. and the urine scanty and high colored. There are also the other symptoms of pyrexia sometimes present, as headache, want of sleep, nausea, or vomiting, etc. Shortly after the rigors, the patient complains of deep-seated pain in the hypogastrium and loins, which is soon referred to one or other groin. In a short time, the affected limb commences SAvelling, and this is accom- panied with more or less pain and tenderness. In a majority of cases, the swelling will be found to commence in the calf of the leg; if examined, it will feel hard and tense, and as if it Avas closely attached to the bone; pressure at this part Avill produce considerable pain. This is a valuable diagnostic symptom, as it appears before the swelling of the thigh; it soon, however, involves the entire upper portion of the limb. Dr. Denman observes, " that before the appearance of any swelling or sense of pain in the limb about to be affected, Avomen become very irritable, with a sense of great weakness, and grievously oppressed in their spirits, without any apparently sufficient reason; com- plaining only of transient pains in the region of the uterus, and from these the approach of the disease has frequently been foretold. After a short time, they are seized with an extremely acute pain in the calf of the leg, extending to the inside of the heel, and then, observing the course of the lymphatics, stretching up to the ham, along the internal part of the thigh, to the groin, occasioning a slight soreness on the lower part of the abdomen." 947. The fever accompanying the disease generally assumes an intermittent or remittent form, the paroxysms occurring in the after part of the day. If the disease has commenced during the period of the lochial discharge, this Avill be very apt to be sup- pressed, or become changed and fetid in character. 948. The enlarged limb is Avhite, pale, and shining ; it may be, and is generally, warmer than natural, though sometimes its tem- perature is not changed, and at others it feels colder than the other limb. At the commencement and toward the termination of the swelling, the leg will be found to pit upon pressure, but when it is at its hight, it is tense, and no impression can be made upon it. The entire limb is more or less tender on pressure, though this is particularly marked along the course of the vessels. PHLEGMASIA DOLENS. 439 It is stated that the femoral vein may be traced from the groin doAvn the thigh, feeling hard, or rolling under the finger like a cord; the inguinal glands are likeAvise sometimes enlarged, and they have been known to suppurate. 949. Terminations.—Under appropriate treatment, the disease usually terminates in resolution; the febrile symptoms subsiding in a short time, and the SAvelling being gradually reduced, the patient regains the use of her limbs. It is a tedious affection, and it may be months after the acute symptoms have subsided before the sensations in the affected parts will become natural. Suppuration may take place in any portion of the affected part, involving more or less of the cellular tissue of the thigh, leg, or groin; the suppuration has been known in some cases to be so extensive as to cause death from the consequent exhaustion. The disease may terminate fatally, though this is not common. Dr. Burns says, "This is not generally a fatal disease; but it is tedious and often accompanied with hectic symptoms. Death, hoAvever, may be caused by suppuration or gangrene, or by exhaustion proceeding from the violence of the constitutional disease ; or by exertion made by the patient, which has sometimes suddenly proved fatal; or, after the leg appears to be getting better, daily shivering, with vomiting, pain in other parts, and rapid pulse, with delirium precede death." 950. Diagnosis.—This disease may be distinguished by its occurring shortly after parturition, by the tense, white swelling of the limb affected, by the pain and tenderness along the course of the vessels, and by the hard, cord-like, and painful condition of the femoral vein. 951. Treatment.—If the case be acute, and the condition of the patient such as to justify it, the bowels should be freely moved with the Compound Powder of Jalap and Senna and Bi-Tartrate of Potassa; this will remove any morbid accumula- tions from the boAvels, relieve the congested state of the vessels, and produce a beneficial degree of revulsion; it should be repeated at sufficient intervals through the disease to produce one, but not more than tAVO evacuations daily. The feet should be bathed in warm Avater, and some diaphoretic agent administered internally, 440 DISEASES OF WOMEN. until free perspiration is induced; with the diaphoretic we may advantageously combine the Sulphate of Quinia, as in the follow- ing formula: 5* Comp. Powd. of Ipecac, and Opium, 3j- Asclepin, Quinia Sulphas, aa. gr. xxxx. M. Ft. Pulvis No. xij. Let one of the powders be given every three hours until diaphoresis is produced, and the febrile symp- toms are subdued. To remove the local inflammation, nothing will be found better than the Tincture of Veratrum Viride, given as was recommended for puerperal fever. Or in the place of this, the Tincture of Cimicifuga or Black Cohosh, and Gelseminum, may be given in drachm doses, and repeated every two or three hours, until the specific effect of the remedies is produced. The alkaline bath should in no case be omitted. 952. To the affected limb in the acute stage, we may apply flannel cloths wet with a strong infusion of Stramonium, or the tincture of the same diluted Avith four or five times its quantity of water. It is recommended to apply these applications cold, so long as the part is above the normal temperature, but if the cold applications should produce chilliness, to use them warm. In the only two cases that I have treated, I employed in one the bruised Leaves of Stramonium, wet with equal parts of vinegar and Avater, and applied as hot as they could be borne; in the other, I used the Tincture of Stramonium, diluted with five parts of Avater, applied Avith flannel also hot; in both cases, it had the happiest effect. As soon as the acute symptoms are removed, the limb may be bandaged from the toes up, and the bandage tightened from day to day, as the enlargement diminishes; this bandage it will be better to make of flannel, as a more steady compression can be made with this; it is not so liable to shrink, and it keeps the leg warm. 953. A very important measure in the treatment is the use of diuretics to promote a free secretion from the kidneys; many agents may be employed for this purpose, but I prefer the following: FUNCTIONAL DISEASES. 441 fy Oleo Res. Eupurpurin, 3ss. Ferri-ferocyanuretum, gr. xx. M. Ft. Pillula, No. x. Let one of these pills be given every three, four, or six hours, as may be necessary. 954. In the chronic form of the disease, or after it has lasted for two or three months, in addition to the use of the bandage, diuretic remedies and proper attention to the general health, the Compound Syrup of Stillingia and Iodide of Potassium may be used with much advantage. If the disease terminates in suppura- tion, it will have to be treated in the same manner as abscess in any other portion of the body, recollecting, however, that the abscess will be of the cold, or diffusive character, and that a stimulating course of treatment will be necessary. CHAPTER XIV. Functional Diseases. 955. Functional diseases are said to be those " which are dependent on deviation from the natural or healthy action of any part of the organization, indicated by symptoms during life, which on examination after death, are found to be unconnected Avith any discernible change of structure. Under this head, we class Leucorrhea, Amenorrhea, Dysmenorrhea, Menorrhagia, Chlorosis and Hysteria. We have already noticed the numerous structural changes of the uterus and its appendages, which are capable of producing, and do produce, each of these morbid con- ditions, they being but symptoms arising from the structural diseases, so that the definition given of a functional disease will not apply in a majority of instances to these conditions. Still, as each of these diseases may arise without there being any percept- 442 DISEASES OF WOMEN. ible structural lesion, it is necessary to give them a. separate consideration. Leucorrhea. 956. Leucorrhea is defined by Dr. AshAvell to be : " An exces- sive and altered secretion of the mucus, furnished by the mem- branes lining the vagina and uterus, by the follicles of the interior. of the cervix uteri, and by the lacume of the vestibulum; gener- ally Avhite, or nearly colorless and transparent; usually Avithout much odor; glutinous, muco-purulent, or purulent; sometimes yelloAV, green, or slightly sanguinous, and of varying degrees of consistency. The amount of constitutional derangement depend- ing on the severity of the affection and the susceptibility of the patient." This definition correctly describes the symptom, the vaginal discharge, but it does not give the slightest idea of the cause producing the discharge called leucorrhea. Dr. Tyler Smith, in his recent Avork on leucorrhea, considers that hyper-secretion of mucus is the disease, or, in other words, that the discharge is the disease, not admitting that a previous change in the struc- ture of the parts, or an inflammatory action was essential to the production, of the discharge. He also attributes structural dis- eases, such as erosions, ulcerations, etc., to this morbid discharge. He says: " In maintaining the important part played by the cervical secretions in inducing morbid conditions of the os uteri, I do not wish to be understood as saying that they are the only causes of these conditions. What I contend for is, that in the majority of cases in which leucorrhea is present, in combination with non-malignant disease of the os and cervix, the morbidly active condition of the cervical glands is the primary and essential disorder. Among the other causes of morbid change in the os and cervix uteri, the varying vascular and.mechanical conditions of these parts in menstruation, coitus, pregnancy and parturition, must of course be enumerated. Eruptive conditions of the cutaneous covering of the os uteri, in the shape of aptha, herpes, or eczema, form another class of causes of cervical discharge, etc." 957. The first and most important question that arises in the consideration of this morbid condition is, what causes are capable of giving rise to a hyper-secretion of mucus? In considering this LEUCORRHEA. 443 question, we must bear in mind, that the same causes that produce a hyper-secretion of mucus from other mucous membranes, will give rise to it in the mucous membrane lining the genital organs, and that the same pathological laws govern diseases of the mucous membrane wherever situated. Suppose, for instance, we take the hyper-secretion of mucus from the posterior nares and upper portion of the pharynx as the type* of similar processes in other portions of the system, as it is equally frequent, and can be better observed. We find that this hyper-secretion depends upon an inflammatory action, which may have been at first acute, but soon subsides into the chronic form. This chronic inflammation gives rise to permanent dilatation of the vessels, to thickening of the mucous membrane, and to hypertrophy of the mucous follicles; we may observe, that the mucous membrane is tumid, receiving an inordinate supply of blood, and that this tumefaction extends to the follicles, which are enlarged and prominent, and with this tumefaction we have an increased secretion of mucus. This pro- cess here and in other portions of the system is called chronic inflammation, and is amenable to the treatment used for chronic inflammatory conditions elsewhere. Why the lining membrane of the vagina, the cavity of the cervix, or of the cavity of the uterus should form an exception to this, I am at a loss to discover. 958. It has been urged against this view of the subject, that the debility of the system which so frequently exists, is proof positive that the local disease is also one of debility. This, how- ever, is but a poor argument, for it is well known that debility of the entire system may exist, and that there may yet be a hyper- gemic, congested, or inflamed condition of any single organ or part. 959. That chronic inflammation is the cause of a very large majority of cases of leucorrhea, I have strongest reason to believe. I have never been consulted in a case of this disease but what I could readily satisfy myself of this fact. There is no doubt, how- ever, but that there is frequently transient leucorrhea without the presence of inflammation, but these cases being slight do not often come under the notice of the practitioner. Dr. Bennet thinks "that this term leucorrhea, if retained at all, ought in sound 444 DISEASES OF WOMEN. pathology, to be reserved for those forms of passive mucous hyper-secretion of the vaginal, cervical, and intra-cervical mucous membrane which often temporarily exist independently of inflam- matory lesions, and independently of uterine ailment. These passive and fleeting conditions of hyper-secretion, really and truly are the reflex of general conditions of health, and seldom come under the eye of the profession as distinct morbid states." 960. We have already described the three principal sources of this discharge, from the vagina, the canal of the cervix, and the cavity of the cervix, under the heads of vaginitis, inflammation of the cervix uteri, and internal metritis, giving the character of the discharge, the pathological conditions producing it, the means of diagnosis, and the treatment, and I have only referred to it in this place to direct the reader's attention to Avhat I consider to be the true pathological condition of the parts, when the discharge ("leucorrhea") exists. Amenorrhea. 960. By amenorrhea we understand the suppression of the menstrual discharge after it has once appeared, or its non-appear- ance at the age of puberty, or the age at Avhich it would normally appear. The first of these, in which the menses having once appeared are suppressed, has received the name of " suppressio mensium," while in the second, AA'here it has never appeared, it is called "emansio mensium." We will first consider emansio men- sium, or the non-appearance of the menses. 961. Emansio mensium, or absent menstruation.—According to Dr. Carpenter, "in the Human female, the period of Puberty, or of commencing aptitude for procreation, is usually betAveen the thirteenth and sixteenth years; it is generally thought to be some- what earlier in warm climates than in cold, and in densely popu- lated manufacturing tOAvns than in thinly peopled agricultural districts. The mental and bodily habits have also considerable influence upon the time of its occurrence; girls brought up in the midst of luxury or sensual indulgence undergoing this change earlier than those reared in hardihood and self-denial. The changes in which puberty consists are, for the most part, AMENORRHEA. 445 connected with the re-productive system. The external and in- ternal organs of generation undergo a considerable increase of size; the mammary glands enlarge; and a deposition of fat takes place in the mammae and on the pubes, as well as over the Avhole surface of the body, giving to the person that round- ness and fullness, which are so attractive to the opposite sex at the period of commencing womanhood. The first appearance of the catamenia usually occurs while these changes are in pro- gress, and is a decided indication of the arrival of the period of puberty; but it is not unfrequently delayed much longer; and its absence is by no means to be regarded as a proof of the want of aptitude for procreation, since many women have borne large families, Avithout having ever menstruated." 962. Without, therefore, the non-appearance of the menses has produced a derangement of the general health, Ave can not justly consider it a pathological state, and any an€ all medication should be positively avoided. Amenorrhea here may be dependent upon congenital deficiency, malformation, or upon structural disease of the genital organs; or it may depend upon a slow and partial development of the uterine organs ; or upon debility; or upon the opposite condition, plethora. 963. In the first case, the ovaries may be wanting, and if this is the case, menstruation as Avell as conception can not occur; the general health may be good, the body Avell developed, and the female strong and vigorous. But there will be no development of the generative organs, the breasts will resemble those of the male, the voice will be deeper, and in all respects there will be a mixture of masculine Avith feminine peculiarities. In this case, the absence of menstruation will be normal. Again, the uterus may be wanting, though the ovaries are present; the female will be well developed, the breasts prominent, and all the characteristics of puberty present, with the exception of the menstrual secretion. In this case, also, the absence of menstruation can not be con- sidered a pathological condition. 964. We have already noticed in a previous part of the work, that amenorrhea may be caused by congenital or acquired occlu- sion of the os or cervix uteri, of the vagina or vulva, or from the 446 DISEASES OF WOMEN. presence of an imperforate hymen. In each of these cases, all the symptoms of menstruation may be present, and the menstrual fluid secreted, but its escape will be» prevented by the mechanical impediment. The symptoms, means of diagnosis, and treatment have all been given under the separate heads, and the reader is referred to the previous description of each of these lesions for the necessary information. 965. The absence of menstruation may depend upon a slow and partial development of the uterine regions, either with or Avithout general debility. In this case, there is nothing to be done, or that can be done, without this partial development depend upon debility, when the same measures recommended in chlorosis should be adopted; amenorrhea, dependent upon debility of the system, will also be considered under the same head. 966. We have then only to consider amenorrhea when it exists in connection with a full development of the body and of the sexual organs, and when this retention has caused more or less disturbance of the general health, the symptoms being those due to a vascular turgescence. 967. Symptoms.—According to Dr. Ashwell, the symptoms of this condition are "headache, tension and weight about the brain, with a sensation of fullness and throbbing in the center of the cranium, or about the cerebellum; a florid countenance, torpor, lassitude; pain in the back and loins; a full and generally a slow pulse, though occasionally, in irritable females, it is rapid; irregu- lar circulation, evidenced by the feet and hands being the one hot and the other cold, or at short intervals both remarkably hot and remarkably cold; the skin sometimes harsh and dry, and at others clammy. It is not to be supposed, if the amenorrhea continue, that these symptoms will pass away after the attempt at menstruation is over. They may do so for the first few periods, but subsequently they continue during the catamenial intervals, recurring with aggravation as the menstrual epoch again approaches. If the malady has been long neglected, or inefficiently treated, a cure will not soon be accomplished. The constitution sympathizes so entirely, that months and perhaps years may elapse before it resumes its healthy and natural actions. AMENORRHEA. 447 968. Causes.—It is said that this variety of amenorrhea is most frequently met with in females who have led sedentary and indolent lives, and who have indulged in luxurious and gross diet; it is attributed by some authors to excessive uterine congestion, to torpor of the uterine vessels, or to spasm of their extremities. 969. Treatment.—The treatment will have to be varied accord- ing to whether it be undertaken during an interval, or at the menstrual period. If at the menstrual period, the feet should be bathed in warm water, and the Avarm hip-bath used, or instead of this last the patient may be directed to sit over the vapor of a decoction of bitter herbs, as tansy, hops, etc.; this should be repeated two or three times a day, as long as the menstrual molimen continues. The application of mustard plasters to the breasts and inside of the thighs is also said to have proved very beneficial; they should be applied for four or five days at the time of the menstrual period, and used so as to produce irritation and redness, but not continued so long that there will be any danger of vesication. 970. If the boAvels are constipated, they should be kept open with the Compound Powder of Jalap and Senna; drastic cathartics are inadmissable. During the menstrual period Ave may admin- ister the Tincture of Gelseminum, in half-drachm doses, every three or four hours, just sufficient to produce the characteristic heaviness of the eye-lids, and Avith this the Caulophyllin, in doses of from one to three grains. This treatment will produce the necessary degree of relaxation, relieve the determination of blood to the head, and slightly stimulate the uterine organs. 971. During the menstrual interval the patient should make daily use of the hand-bath, accompanying it Avith brisk friction; the bowels should be kept regular; the diet should be nutritious, yet plain and unstimulating; and, lastly, the patient should be instructed to take plenty of exercise in the open air. 972. It will be seen, by the above treatment, that I am opposed to the use of those agents termed emmenagogues, and I am so from the fact that nature is, in every case, sufficient to bring on this discharge, if Ave but remove the impediments thrown in the way, and that direct stimulation of the uterine organs is pernicious in a 448 DISEASES OF WOMEN. majority of cases, as there is already too great a degree of excite- ment. 973. Suppressio Mensium, Suppressed Menstruation.—Under this head we have to consider those cases in which the menses being once established have become suddenly suppressed. This may occur at any period of menstruation, or at any age; it most frequently arises from cold taken during the menstrual period, from getting the feet Avet, sitting on the damp ground, or cold applied to the vulva. Though this is the most frequent cause, yet it may arise from severe mental emotions just preceding or during the menstrual Aoav ; from coitus during menstruation, from fever or other acute disease commencing at this period, etc. I have also noticed in several cases that suppression of the menses of a very intractable character has occurred from a long sea voyage; in the cases that I have noticed, menstruation Avas checked either at the first period after going on board ship, or else that after this period had passed, there Avere no more symptoms of their appearance during the voyage, the constitutional suffering commencing in one, two, or three months after landing. 974. Symptoms.—The amount of disturbance consequent upon suppression of the menses varies very much in different cases; in some cases, there is a slight headache, a feeling of weight in the pelvis, pain in the back, and in the limbs, etc, but so slight as to give the patient but little uneasiness; but more frequently there is a slight chill, followed by more or less fever, Avith head- ache, hot skin, quick pulse, thirst, nausea, etc. Sometimes the suppression is folloAved by inflammation of the uterus, either general, or of the cervix only; in these cases, the symptoms present will be more severe. Dr. Churchill states that the most puzzling sequlae of suppression is, " a species of hysteria, simu- lating inflammation, but Avithout the usual accordance of symptoms, (some one or other of the important being absent,) and changing from one organ to another as soon as our remedies are brought to bear upon it. I have seen the head, lungs, and stomach successively thus affected, and suddenly and apparently spontane- ously relieved. The patient is very liable to attacks of fainting and hysteric paroxysms." Capuron mentions that attacks of apo- AMENORRHEA. 449 plexy and paralysis sometimes result from sudden suppression^ the menses. Other authors state that aphonia, derangements of vision, amaurosis, and cutaneous disorders follow from the same cause. 975. These symptoms are very much mitigated in some cases by the occurrence of vicarious menstruation, or the establishment of a supplementary hemorrhage from some other portion of the body. The mucous membrane of the nose, of the lungs, stomach, and bowels, are the most common seat of this discharge, though it has been known to occur from the axilla, from the ears, the mammae, the mouth and gums, fingers and toes, from ulcers, in fact from nearly every portion of the body. This hemorrhage generally consists of blood only, and'unless very great in quantity, lasts for several days, and it may reappear at each menstrual period until the menses are reestablished. Though this hemorr- hage might at times seem alarming, as Avhen from the lungs to indicate tuberculosis, yet Avhen the suppression of menstruation is taken into consideration, it has not that importance which it Avould othenvise have. This vicarious hemorrhage is probably an effort of nature to establish a supplementary issue for the men- strual secretion, which has been suppressed. 976. Again, there are other cases AAdiere the suppression of the menses does not assume the acute form spoken of, the discharge, instead of being at once checked, continuing for several menstrual periods, though each time it becomes less in quantity and lighter in color, being preceded and succeeded by a leucorrheal discharge, until at length it does not present the slightest trace of color. This supplementary leucorrheal discharge occurring at each men- strual period might be classed Avith vicarious menstruation. 977. Diagnosis.—There is no difficulty in determining that the discharge has ceased, but the important point that Ave have to decide is, whether the cessation is, or is not, due to pregnancy. In married Avomen the suppression will nearly always be attributed to pregnancy, but in some cases, both in the married and unmar- ried the female will consult the physician for suppression of the menses, hoping that the remedies used will produce abortion. In such cases, therefore, we should be very cautious in giving emen- agogues, unless we can satisfy ourselves that pregnancy does not 29 450 DISEASES OF WOMEN. exist, or if we can not do this, to use palliative measures until such time as it may be ascertained. 978. Treatment.—The first point to be attended to in this form of amenorrhea, is to remove any inflammatory condition of the uterus, if this should exist, in the manner heretofore described. If the patient is seen soon after the discharge is suppressed, we should employ such measures as will tend to recall the discharge. For this purpose her feet should be bathed in warm AATater, the warm hip-bath should be used, or she might sit over the \rapor of a decoction of bitter herbs, and some Avarm diaphoretic infusion should be given, as an infusion of eupatorium perfoliatum, as- clepias, tuberosa, etc. Or, we might use with advantage the com- bination heretofore mentioned: fy Asclepias Tuberosa, Eupatorium Perfoliatum, aa. Sj. Sanguinaria Canadensis, 3j. Nitrate of Potassa, 5ij- M. Ft. Pulvis. This powder may be given in doses of from twenty to forty grains every two or three hours, until free diaph- oresis is produced. In connection with the warm hip-bath and foot-bath I have used the following prescription with much ad- vantage. 1$ Asclepin, 3ss. Veratrin, gr. ij. Caulophyllin, 5ss. M. Ft. Pulvis, No. x. Let one of the powders be given every three hours. Under this treatment, I have seen the discharge reproduced in six or eight hours. 979. If we are unable to reestablish the discharge, we will have to wait until the next period for this purpose, but during the intermediate time such symptoms as may arise should be palliated as much as possible, the bowels kept regular, and the secretions from the skin and kidneys free. 980. At the recurrence of the next menstrual period, or a day or tAVO before, a brisk purgative may be given, and the same AMENORRHEA. 451 measures recommended above pursued again. The application of the mustard plasters to the breasts and inside of the thighs as before recommended, may be used with advantage; we may also use electricity, galvanism, or electro-magnetism, with advantage. 981. In chronic suppression, or where the disease has existed for some time, and where it is accompanied with a debilitated state of the system, other measures will have to be employed. The general health should be restored by the administration of tonics and the preparations of iron, by the use of the bath, and appropriate exercise. Any inflammation of the uterus, especially of its cervix, must be removed by appropriate treatment; the frequency of inflammatory disease of the cervix uteri in chronic suppression of the menses should always cause a rigid examina- tion of the symptoms present, and if these should justify it, of the uterine organs, both by the touch and sight. 982. The most successful means of removing this variety of amenorrhea according to all authors, is the administration of the various preparations of iron; of these, the carbonate, the citrate, lactate, sulphate and hydroclorate of iron, have each been recommended as preferable to the others. Of these I use the first named, and I believe it will be found as beneficial as any of the others. The reason, probably, that the different preparations of iron have been used with such advantage, is, that in a large number of cases either the disease originated in a deficiency in the quantity or quality of the blood, or the retention of the men- strual secretion, the blood not only suffering in quality from the interruption of a process of excretion, but also from the con- gested state of uterine organs Avhich furnishes a reservoir of impure blood, which tends gradually to derange and contaminate the whole mass. This derangement of the blood, consisting prin- cipally in a destruction of the red globules, the iron supplies the necessary material for its renewal, and from its effects in this case iron has assumed a prominent place in the list of emena- gogues. 983. If, after any inflammation of the uterine organs that may exist is removed, and the general health restored, the menstrual secretion does not appear, we may resort to those remedies which 452 DISEASES OF WOMEN. are supposed to exert a specific influence on the uterine organs, or emmenagogues. Of these agents, I might enumerate the savin, black hellebore, aloes, gamboge, etc., which prove emmena- gogue by their drastic cathartic effect upon the boAvels, acting especially upon the large intestine, causing an irritation and determination of blood to the pelvis, and thus indirectly proving emmenagogue ; again, the black cohosh, blue cohosh, and their active principles, macrotin, and caulophyllin, guiacum, madder rue, borax, etc., have been termed emmenagogues, though the modus operandi of their action is not knoAvn. Electricity, mag- netism and galvanism act as direct stimulants to the uterine organs and the nerves that supply them, and they have therefore proved efficient emmenagogues. Of the emmenagogue combina- tions that I have seen used with good effect, I may mention first, a favorite prescription of my own : £ Caulophyllin, 3j. Ext. Aconiti, gr. viij. Aloes, Ferri-Sulphas, aa. gr. xxxx. M. Ft. Pillula, No. xxxx. The dose of these pills are two morning, noon and night. They have thus far proved very efficient in my practice, under the circumstances named. If the female be troubled with piles, hoAvever, the aloes should be omitted, and one-eighth of the quantity of podophyllin substi- tuted for it. The alkaline tincture of guiacum, formula of Dr. Dewees, will also be found to be a valuable remedy, principally in those cases where the suppression is accompanied with pain in the lower extremities and back, and a sensation of weight and fullness in the pelvis; it is composed of " £ Pulv. g. Guiaci. opt. 3 iv. Carb. sod. vel. Potass., 3 iss. Pulv. Pimento, 3 j. Alcohol dil., lb j. Digest for a few days." The dose of this tincture is one DYSMENORRHEA. 453 drachm three or four times a day. Another combination which is used extensively, is: 5* Aloes, Myrrh, Sulphate of Iron, aa. 3 j. Oil of Savin, f. 3 j. Make thirty pills; one of them may be given three, four, five, or six times a day. This list might be increased almost indefi- nitely, but these emmenagogue formulas must be empirical, as the disease occurs under so many different circumstances and presents such varying characters. The only rational mode of practice is, to correct any dyscrasia to which the patient is subject, especially any disease of the uterine organs, restore the general health, and nature, in a large majority of cases, will re-produce the physiolo- gical menstrual secretion. Dysmenorrhea. 984. By dysmenorrhea, we understand a painful and difficult flow of the menses, they being generally, though not invariably, scanty in quantity, in severe cases containing clots, fibrous shreds, or even an entire false membrane. In many Avomen, the menstrual flow is always accompanied and preceded by pains in the back, limbs, and in the hypogastric region; these pains, however, are but slight and of short duration, and do not produce much uneasi- ness, and are not to be considered as dysmenorrhea; but when these symptoms are aggravated, so as to produce extreme suffer- ing, this disease is said to exist. We have to notice three varie- ties of this affection: Neuralgic Dysmenorrhea, Inflammatory Dysmenorrhea and Mechanical Dysmenorrhea. 985. Neuralgic Dysmenorrhea.—This form of dysmenorrhea may attack females of any age, though it is said to occur more frequently after the age of thirty than earlier in life, and in unmarried females than in the married, or in married women who have had no children. It is also more frequently observed in those of a delicate and nervous habit of body, but it may arise in those of an opposite condition. 454 DISEASES OF WOMEN. 986. Symjifoms.—Sometimes the menstrual period is preceded for a few days by a disordered condition of the general health; the boAvels are constipated, the appetite impaired, there is great languor, irritability, etc. iNIost generally, however, the first symptoms appear but a few hours before, or at the commencement of the menstrual flow. The patient then complains of a sharp, darting, lancinating pain in the region of the uterus, and which radiates from this point to the ovarian regions, to the back, down the thighs, etc.; sometimes the pain in the lumbo-sacral region, in the groins and thighs is excessive, far worse than the uterine pain. Again, there may be severe pain in the mammae, which may precede the appearance of the menses for two, three, or four days; or it may occur at the commencement of the discharge. Sometimes during the Aoav of the discharge, there may be severe expulsatory pains resembling those of labor, and Avhich greatly aggravate the suffering. There is rarely any febrile excitement present, though the pulse is sometimes quickened, and in a majority of cases, the skin will be found harsh and dry. The character and quantity of the discharge varies much in differ- ent cases; sometimes for the first few hours, or for a day or two, it is passed in drops, but it then becomes free, and with the free discharge there is an entire or partial cessation of pain; at others, it may occur in slight gushes, each discharge being accompanied with severe pains, or small clots or fibrinous shreds may be discharged at this time; in others, again it may appear for a day or two, and then cease to again reappear, or it may con- tinue throughout the menstrual period in usual quantity. As soon as the menstrual period is past, the pain ceases, and the patient regains her usual health. This species of dysmenorrhea may exist for only one menstrual period, or it may be habitual, or it may occur or be greatly aggravated at one period, and then for the next, or for two or three periods, it may be absent or very mild, but will again recur upon the least over-excitement or exposure. 987. Causes.—Cold is considered to be the most frequent cause, especially when taken during menstruation, soon after delivery, or after abortion. It is also said to arise from violent DYSMENORRHEA. 455 mental emotions, sudden shocks, etc., when occurring at the menstrual period. 988. Treatment.—If called during an attack of dysmenorrhea, our efforts should be directed to relax the system, alleviate the pain, and promote the menstrual discharge. Thus, the patient should be directed to use the warm pediluvia, the warm hip-bath, or to sit over a decoction of bitter herbs, and the following taken internally: fy Tincture of Gelseminum, Compound Tinct. of Virginia Snake-root, aa. Of this, a teaspoonful may be taken every one, two, or three hours, until free perspiration is induced, and the specific effect of the Gelseminum is produced. In severe cases, it will also be beneficial to use enemas of warm water, to each of which may be added from one to two drachms of the Compound Tincture of Lobelia, and if the pain be very severe, twenty or thirty drops of Laudanum. In some cases, the administration of equal parts of Quinia, Prunine and Prussiate of Iron, in doses of six or eight grains, will be followed by marked relief. In cases in which the discharge is profuse, the Extract of Cannabis Indica may be advan- tageously used in doses of from half a grain to one grain, and repeated every two or three hours, until its narcotic effect is produced. In one case of severe dysmenorrhea, I employed electro-magnetism, passing the current from the uterus to the spinal column, by introducing the positive pole to the cervix uteri, and placing the negative pole upon the back, the pain was quickly relieved, and the discharge augmented, though the benefit only lasted during that menstrual period, the next being as severe as ever; as mitigating present symptoms, I think it worthy of a trial. 989. During the menstrual interval our efforts should be directed to restore the general health, the bowels should be kept regular, the secretions from the skin and kidneys free; the daily bath should be used, and plenty of exercise in the open air taken. If there should be any tenderness over the lumbar or sacral regions of the spinal cord, an irritating plaster should be applied, 456 DISEASES OF WOMEN. and Avorn until it was removed; much advantage may likeAvise be derived from a daily use of vaginal injections of cold or tepid water. 990. The use of carbonic acid as a local anaesthetic to the vagina and uterus, has been strongly recommended by Dr. Simp- son and others, in this affection, it is said not only to give tem- porary relief, but that a permanent cure may be effected by it. Dr. Simpson uses a common Avine-bottle for the formation of the carbonic acid gas, and forms it by mixing in the bottle six drachms of crystalized tartaric acid, with a solution of eight drachms of bi-carbonate of soda, in six or seven ounces of Avater. A long flexible caoutchouc tube conducts the gas from the bottle into the vagina. The cork fixing this tube into the mouth of the bottle, should be adapted so as to prevent the escape of gas by its sides. With this view, the cork should be perforated by a metallic tube, and covered externally with a layer of caoutchouc. Dr. DeAvecs used the same kind of an apparatus, but formed the gas by mixing dilute sulphuric acid and carbonate of lime; he recommended it strongly as a palliative in carcinoma uteri. 991. In regard to the benefit to be derived from its use, Dr. Simpson says : " I have used carbonic acid as a local anaesthetic, principally in neuralgia of the vagina and uterus, in dysmenorrhea, and in morbid states of the pelvic organs, accompanied with pain, as in carcinoma, etc. I have found it also sometimes of use in irritable states of the neighboring organs. Two years ago, I had under my care, from Canada, the wife of a medical gentleman, who was suffering from that most distressing disease—dysuria and irritability of the bladder. Many modes of treatment had been tried in vain. The injection of carbonic acid gas into the vaginal canal several times a day at once produced relief, and ultimately effected a perfect cure. She has remained Avell since her return to America, and lately became a mother. Occasionally relief follows immediately. In two or three instances I have seen the use of the gas continued daily for months. I have the notes of one case where the patient was invalided and almost entirely kept the supine posture for years, from feeling of pain and bearing down in the uterus and neighboring parts, particularly on attempt- DYSMENORRHEA. 457 ing to sit or walk. Many modes of treatment were tried by myself and others, with little or no benefit. She has, however, at last regained in a great measure the power of progression, and freedom from suffering in the erect posture, a result which she herself ascribes to the local application of carbonic acid gas, which I recommended to her some months ago; and in the use of it she has regularly persevered. Dr. Major states that in dys- menorrhea he has employed the injection of carbonic acid gas into the vagina in a great number of* instances, and generally with decided advantage, the pain being almost always relieved by this treatment. He directs the remedy to be used two or three times a day, and for five or six minutes each time." 992. Inflammatory Dysmenorrhea.—This form of dysmenorrhea presents nearly the same symptoms as the neuralgic form during the menstrual period; but instead of the patient being free from pain during the menstrual interval, she has all the symptoms of the inflammatory affection continuing. This form of the disease likewise affects the general health more than the preceding. Dr. Bennet thinks that we may connect with inflammatory dysme- norrhea that form which has been described under the head of pseudo-membranous, and which is characterized by the expulsion of shreds and casts of plastic lymph from the cavity of the uterus. " I believe that the formation of these membranes coincides almost invariably with the present or past existence of uterine inflamma- tion. In other Avords, I have found, in the great majority of cases of this description that have come under my observation, that there has been at'first inflammatory disease, although the removal of this disease has not ahvays freed the patient from the liability to the formation of the pseudo-membranous casts. It would appear as if habit alone sufficed in some instances to perpetuate their formation, or at least their occasional occurrence, even after the removal of inflammation, if they have once occurred under its influence." The production of these dysmenorrheal mem- branes ahvays aggravates the uterine suffering, their expulsion being accompanied by severe tormina like the pains of labor. 993. Diagnosis.—This form of dysmenorrhea may generally be distinguished from the other two, by development of pain as a 458 DISEASES OF WOMEN. permanent menstrual condition in a person othenvise menstruat- ing without pain. In this form likewise the symptoms of inflam- mation Avill generally be present through the menstrual interval. If these symptoms be present, or if the disease resists the usual remedies for the affection, an examination should be made to determine the condition of the uterine organs, when the inflamma- tion will be detected. 994. Treatment.—The treatment during the menstrual Aoav will be the same as for neuralgic dysmenorrhea, our object being to mitigate the pain and promote the menstrual discharge. But during the menstrual interval our efforts should be directed to the removal of the inflammation; this being the cause of the pain- ful menstruation, its removal will be folloAved by a cure of the dysmenorrhea, Avhich is but a symptom. 995. Mechanical Dysmenorrhea.—The term mechanical dysme- norrhea is applied to that form Avhich is supposed to arise from stricture of the canal of the cervix. The attention of the profes- sion was first called to this cause by Dr. Mackintosh of Edinburgh. He states that he has found it a very frequent cause of the affec- tion, though this is denied by other authors. There can be no doubt that stricture of the cervix, either congenital or acquired, does sometimes exist, but from the contradictory statement of authors it is impossible to determine its frequency; when it does exist, however, it may be a cause of dysmenorrhea. The symp- toms of this form of dysmenorrhea do not differ materially from those of the other forms. The peculiar character of the dysme- norrhea, when caused by congenital contraction, according to Dr. Bennet, is the absence of any uterine symptom during the interval of menstruation, and intense agonizing pain for a feAV hours before the flow of blood appears, either then disappearing, or lasting throughout the period; these pains commencing with men- struation in early youth. The obstruction may merely be at the OS internum, spasmodically contracted ; in which case, as soon as it has been overcome, the blood escapes freely, and pain disap- pears. But, if the os internum is permanently contracted, or the contraction exists in the cervical canal, the pain may continue throughout the catamenial period. MENORRHAGIA. 459 996. Treatment.—Where it is ascertained that the dysmenorr- hea is dependent upon contraction of the cervical canal, it may be relieved by its cautious dilatation. This dilatation may be effected by the use of graduated elastic or metallic bougies, com- mencing with one of a small size, and gradually increasing it until the canal is sufficiently dilated. In using these bougies the patient should be placed in the usual position for making an examination, the index-finger of one hand being introduced to the cervix uteri, the bougie may be guided by it to the os, and by a slight rotatory motion it should be carefully introduced through the cervix to the fundus. The frequency with which the bougie is introduced, must depend altogether upon the degree of irrita- tion it produces; if any should arise, every two or three days will be sufficient. After using the bougie the patient should be care- fully watched, and if any symptoms of uterine inflammation should arise, they must be met with appropriate treatment. In addition to the mechanical dilatation of the cervix, the same course of treatment for the restoration of the general health should be pursued as recommended in the other forms. 997. Each of the three varieties of dysmenorrhea generally causes sterility; this is almost invariably the case in the severe forms, but in the slighter impregnation may occur. If conception does occur, it may be folloAved by an entire disappearance of the dysmenorrhea afterward. Menorrhagia. 998. Menorrhagia, or profuse menstruation, may occur at any age, and either in the plethoric and robust, or in those of a delicate and exhausted habit of body. The term menorrhagia signifies merely an increase in the catamenia, the standard with which it is compared being the normal quantity discharged by the female, and not any definite amount supposed to be the average quantity of blood discharged during menstruation. Thus, in some females the discharge is always very profuse, and yet still compatible with health, while this same amount of discharge would be considered as menorrhagia in others. Excessive menstruation may occur in two ways; either as it regards the frequency of its v 460 DISEASES OF WOMEN. return, or the quantity lost at each period: in the first, the excessive menstrual discharge, either as to frequency or quantity, is the normal uterine secretion, shoAving no tendency to coagulate either within the uterus or Avhen discharged; in the second, the discharge is actually a hemorrhage, resulting, probably, from an exhalation from the uterine vessels, the discharge coagulating both within the uterus, forming clots, and after it has passed from the genital organs. These tAvo varieties Ave will consider separately. 999. Menorrhagia, with the discharge of the normal menstrual fluid.—As I have already stated, we have no standard by which we can determine the existence of this species of menorrhagia; the fluid being normal in quality, its variation in the frequency of its recurrence, or in the quantity discharged, will have to be determined by the previous history of the patient. Thus, if the periods of recurrence were tAventy-eight days, the appearance of the menses at intervals of tAvo or three weeks Avould be called menorrhagia; or, if the normal quantity discharged was six Or eight ounces, the loss of fifteen or tAventy ounces would be profuse menstruation, and still each of these circumstances, occurring in other females, Avould be normal. 1000. Symptoms.—The symptoms attending profuse menstrua- tion are such as we should anticipate from any exhausting discharge; thus, there is debility, languor, inactivity, the face is pale, the hands and feet cold, etc. There is generally a sensation of weakness or slight pain in the back, and, as the disease continues, a constant aching, more or less severe, in the lumbar regions, in the hips and thighs, and in the hypogastrium. "If," says Dr. Churchill, "the disease be not relieved, and especially if uterine leucorrhea be present, all these symptoms become aggra- vated. The exhaustion and languor increases, the face becomes sallow, an aching pain is felt across the loins, extending around trie lower part of the abdomen; pain in the left side, repeated and severe headaches, derangement of the stomach and boAvels; in short, all the secondary symptoms, and the derangement of the health which follow in the train of anemia, no matter in what way this may have been produced. In some extreme, but rare cases, MENORRHAGIA. 461 we have diarrhea and anasarca, with nervous symptoms, melan- choly, and e\Ten epilepsy resulting from this disorder." 1001. Causes.—As already stated, menorrhagia of this, as well as the other variety, may occur both in the debilitated and the plethoric, though much more rarely in the latter. It may be caused by cold, by too great physical exertion, or mental excitement, and, it is said, from immoderate sexual indulgence. A very frequent cause of menorrhagia is undue lactation; it also arises from hemorrhage after parturition or abortion. 1002. Treatment.—The treatment of profuse menstruation will vary according to whether the patient is plethoric or debilitated, but in either case the first indication is to remove the exciting cause. 1003. In the plethoric, if the discharge is not too profuse, and it can not Avell be if the discharge still retains the menstrual character and the patient is not debilitated, but little treatment is necessary during the menstrual period. If the discharge is excessive, the patient should keep the recumbent posture, the room kept cool, and the diet plain and unstimulating, and all kinds of excitement avoided. If the bowels are constipated, they may be evacuated Avith equal parts of the Compound Powder of Jalap and Senna and the Bi-Tartrate of Potassa, or by the use of laxative enemas. If we should Avish to check the discharge, cold water or vinegar may be applied to the abdomen and vulva, with the internal administration of the Tinctures of the Oils of Erigeron and Cinnamon. 1004. During the menstrual interval, the diet should be plain and unstimulating; daily exercise in the open air should be taken ; the bowels kept regular, and the cutaneous secretions free by the daily use of the bath. 1005. In the debilitated it is important that this exhausting discharge should be checked as soon as possible; the patient must be kept in the horizontal position on a hard bed or sofa, and the extremities kept warm by the use of hot bricks or bottles of hot water. Internally we may administer such astringent remedies as exert a beneficial influence in checking hemorrhage from other parts of the system; of these the Oils of Erigeron and Cinnamon 462 DISEASES OF WOMEN. Avill be found very efficient. I employ them in tincture, as in the folloAving formula: Ipl Olea Cinnamoni, . Olea Erigeroni, aa. 3j. Alcohol, Sij. Mix. This may given in doses of half a drachm to one drachm, and repeated as often as it may be necessary. I have also used with much advantage a strong infusion of Trillium Pendulum and Lycopus Virginicus, given in wine glassful doses every two, three, or four hours. 1006. During the menstrual interval, such measures will have to be employed as will restore the general health; and by this means prevent the excessive discharge at the next menstrual period. In addition to the means employed for this purpose, the patient should make daily use of vaginal injections of cold water, and, in addition to the daily sponge-bath, the entire pelvis, loins, and hypogastrium may be bathed daily with salt Avater, and accompanied with brisk frictions Avith the hand; this will be found to be an important means of restoring tone and vigor to the pelvic organs. For the week preceding the next menstrual period the patient may use Avith advantage the infusion of Trillium and Lycopus mentioned above. 1007. Menorrhagia, with the discharge of blood directly from the uterine vessels, the discharge being coagulable.—This variety of menorrhagia is of very rare occurrence, Avithout there exists some structural disease of the uterus, which may be detected by an examination. This form of meuorrhagia may occur either in the robust or plethoric, the hemorrhage being acute, or in those of a debilitated or feeble constitution, the hemorrhage being passive. 1008. Symptoms.—In active menorrhagia, says Dr. AshAvell, " there generally exists immediately before the expected period, and occasionally for a few days prior to the flow, considerable tension and fullness within the pelvis, accompanied by a feeling of weight and throbbing in the uterus. The mammas often sym- pathize, becoming tumid, hot, and tender on pressure, and the external genitals are sometimes slightly swoolen and painful. The MENORRHAGIA. 463 pulse is quickened, there is oppression of the head, and often decided headache, with sympathetic fever. In this way the acute or active form of menorrhagia is ushered in, and is throughout characterized by a predominance of inflammatory or spasmodic symptoms, or by a combination of both. When inflammation is present, there will be fixed pain in the uterine regions; a hot, dry skin, and a frequent, hard and full pulse. Where spasm prevails, the pain will not be constant; but, having continued a longer or shorter time, and often most severely, it will subside, and after an interval again occur with throes resembling the pains of labor. The discharge, too, is equally variable, ceasing for short periods, during the pain, and returning when it subsides. The pulse, during the spasm, is contracted, irritable, and quick; afterward it becomes softer and slower, giving proof by this rapid change of a state of the system, neither of inflammation nor debility, but of irritation. The progress, duration, and severity of these attacks are extremely variable. Sometimes the discharge comes on and continues by gushes, and numerous coagula are expelled. The patient, in many instances, is thus relieved, the headache, tension, and pain in the uterine region are quickly diminished; the pulse is softer and less quick; the skin cooler and moist; and the remainder of the period is passed over with tolerable comfort. In the more protracted and aggravated cases, the discharge often continues from three to six days, not without diminution, but still with such proneness to return, that the patient is compelled to avoid exertion, and to maintain almost constantly the recumbent position. On the subsidence of the Aoav, she is weak and exhausted, and several days elapse before she regains her usual freshness of countenance and strength of pulse. It is easy to mark the transition from this to the passive form of menorrhagia; for, although at first, the recurrence of the events just now described, may not seriously impair the health, yet, after a time, the loss produces a marked impression on the system; the flow lasting lono-er, and the number of days between the catamenial periods being so diminished that scarcely one attack is over before another approaches. Thus, the active and acute variety is merged in the passive form of the disease." 464 DISEASES OF WOMEN. 1009. The passive form of menorrhagia is by far the most frequent; it varies in degree from a slight excess over the normal discharge to a profuse and rapidly debilitating hemorrhage. Men- struation may occur at the regular intervals, or these may be shortened, the menses appearing at intervals of tAvo or three weeks; the length of the menstrual Aoav may also be greatly increased. The symptoms are those of exhaustion and debility; the pulse is feeble, and occasionally quickened, the extremities cold, the face colorless, want of appetite, pain and weakness of the back, indisposition to exercise, etc. This variety is said to be almost always accompanied with leucorrhea. 1010. Another species of menorrhagia that we might notice here^ occurs at the commencement and close of menstruation, and generally results merely from uterine congestion. In the young female the first periods of menstruation may be accompanied by more or less menorrhagia, but after this the menstrual function will be physiologically performed, still the loss of blood at these times is Arery rarely such as to call for medical interference. It is not so, however, at the close of menstruation, the occurrence of menorrhagia at this time being both frequent and profuse. It may arise merely from uterine congestion, and in many cases this is probably the cause ; thus the menses may disappear for two or three periods, and, when it does appear again, there is such a determination to the uterine organs that menorrhagia is the result. It may likewise occur at this period from the presence of malignant groAvths, and tumors, but apart from these, I believe, it is most frequently caused by inflammation either of the entire uterus, or more frequently of the cervix. On this point Dr. Bennet says : — "In nearly all the instances of very obstinate hemorrhage at the change of life which I meet Avith, I find on examination that the congestion and hemorrhage are kept up by inflammation and ulcerative disease. Indeed, some of the very worst instances of protracted and severe hemorrhage that I have ever seen, have been cases of this description; and, what satisfac- torily proves that the inflammatory affection is the cause of the continued hemorrhage, is, that when it is cured the hemorrhage generally ceases. This is not, however, invariably the case. I MENORRHAGIA. 465 have occasionally met with females at the critical period of life, in whom the hemorrhage obstinately persisted after the removal of the inflammatory and ulcerative disease of the cervix, which had probably in the first instance given rise to it. In several of these cases, however, time or dilatation of the cervix has subsequently proved that the hemorrhage did not proceed from a sound uterus. but was connected with the presence of a polypus, or of a fibrous tumor, so small and obscurely situated as not to have been recognized at first." 1011. Causes.—The causes of these varieties of menorrhagia are the same as those named in profuse menstruation. 1012. Diagnosis. — The fact that uterine hemorrhage exists can always be ascertained from the patient, but, whether it does or does not arise from structural disease of the uterus, can only be known by a strict vaginal examination. This should ahvays be made if the hemorrhage does not yield to the use of the ordinary remedies, the various morbid conditions, capable of giving rise to uterine hemorrhage, have been already described, and the reader is referred to them for their distinctive marks. 1013. Treatment—In the acute form of the disease our object should be to equalize the circulation and cause a determination to the surface and extremities, and thus relieve the congested state of the uterine organs. For this purpose the feet may be bathed in warm water, and the following powders administered internally. R Compound Powder of Ipecac, and Opium, 3j. Caulophyllin, 3ss. M. Ft. Pulvis, No. x. Let one of these powders be given every three or four hours, until free diaphoresis is produced. At the same time a large mustard plaster should be applied to the lumbar and sacral region of the spine, and continued intermittingly so as not to produce vesication, until the pelvic pain is subdued. Another combination, which may be used with advantage, is strongly recommended by Dr. I. G. Jones, he says, that he has rarely seen it fail to manifest a very sensible and almost imme- diate effect in restraining and gradually checking the excessive discharges from the uterus; the following is the formula: — 30 466 DISEASES OF WOMEN. I£ Macrotys Rac. Trillium Pend. Fol Rubus Strigosus, aa. 5ss. Sanguinaria Can., 5ij. Pulverize, mix. Make a decoction in a quart of water, and sweeten; the dose is a table spoonful every half hour." The administration of the Tinctures of Lobelia, and Syrup of San- guinaria, equal parts, in doses sufficient to keep up a degree of nausea, have likewise been recommended. Should the hemorrhage be alarming, cold may be applied to the abdomen and vulva, and the vagina plugged with sponge or linen cloths. During the menstrual interval the same course of treatment should be pursued as recommended for profuse menstruation in the plethoric; and should there be any inflammation of the uterus or its cervix, which may be the cause of this form, it should be ascertained and removed. 1014. In the passive form, or the menorrhagia of debility, we resort immediately to the use of astringents, here the Tincture of Cinnamon and Erigeron will be found beneficial, it may be given in drachm-doses, and repeated every half hour or hour, until the hemorrhage is checked. The Trillium Pendulum, Rubus Strigosus, Gallic Acid, etc., have also been used with advantage. The patient should be kept in the horizontal position, on a hard bed or mattress, the extremities kept Avarm by the use of hot bricks or bottles of hot water, but otherwise she should be kept cool. If the above measures are not sufficient to arrest the discharge, Ergot may be administered in doses of five grains and repeated every one or two hours, or the tampon may be used, or the extremities may be ligated : this last measure will nearly always prove effectual in checking the discharge until other means have had sufficient time to act. 1015. During the menstrual interval the means already men- tioned should be resorted to, to improve the general health, all causes tending to produce the disease should be avoided, especially such as tend to produce excitement of the genital organs. The directions of Dr. Ashwell in this disease, are to the point. He CHLOROSIS. 4.67 says : " Sexual intercourse and stimulants, mental excitement and physical effort, must be avoided for ten or twelve days before the periodical returns. When there are increasing pallor, oedema, threatened dropsies, softening of the cervix, and aggravated debility—sea air, or mild but nutritious diet, consisting of animal food and milk, or malt liquor, must be enjoined. Where there is universal coldness of surface, especially of the extremities, fric- tions, by stimulating embrocations, the flesh-brush, and horse-hair gloves, the wearing of flannel and worsted stockings, are indi- cated. The salt hip-bath, the local salt shower-bath, applied night and morning, by a common garden watering-pot, over the hypogastric and lumbar regions, are often advantageous. Nor is the injection of cold water, once or twice a day, into the rectum, to be neglected. Astringent vaginal injections are deservedly relied on, especially if carefully administered as already urged, during the intervals. Still, there are cases where cold injections can not be borne. Local fullness, excitement, and pain follow their use; and sometimes I have attributed to their employment, an earlier and larger return of the hemorrhage. They are most beneficial where there is copious leucorrhea, and from the cure of this morbid secretion, good may generally be anticipated. It must be remembered, that the unmarried are liable to congestive menorrhagia, and I have often thought that their cure was more difficult and protracted, and their hemorrhages larger, than Avhere many children had been borne; but on this point, I am not pre- pared to give a positive opinion." Chlorosis. 1016. Chlorosis, or green-sickness, is defined by Dr. Ashwell, to be: "A peculiar affection of the general health; in which debility, languor, and deranged stomachic functions are prominent symptoms; most frequently occurring when puberty is or ought to be established, although it may exist at any subsequent period, always characterized by anaemia of the system, and a yellowish, dirty-green pallor of the surface. When a disease of early youth, almost invariably connected, either with entire absence of menstruation, or with a scanty, painful, and irregular performance 468 DISEASES OF WOMEN. of the function; and if a disease of later life, in addition to these causes, it may have been preceded and produced by menorrhagia or leucorrhea." This disease is strictly a disease of the blood, and may arise in either male or female; it very rarely occurs in males, however, and when developed in the female, it is nearly always associated with some derangement of the menstrual func- tion, hence it is considered by most authors to be a disease either dependent on derangement of the menstrual functions, or else that the blood-disease is primary, and the menstrual derangement the effect of it. In a large majority of cases, it occurs at or near the period of puberty, and it has thus been considered a disease peculiar to this period. 1017. Pathology.—As it is an admitted fact, that chlorosis is a disease of the blood-mass, we have to ascertain in what this con- sists—what change the blood undergoes to produce this condition of the system, and then Avhat influence the uterine organs have in producing this change. According to Becquerel and Rodier the blood of a healthy female consists of water 791.1 parts in 1000, solid constituents 208.9 parts in 1000. This 208.9 parts of solid constituents consists of: fibrine 2.2, corpuscles 127.2, albumen 70.5, fat 1.6, extractive and salts of serum 7.4. In chlorosis, all the constituents of the blood retain their normal proportion, with the exception of the red globules, which are diminished from their normal amount 127.2 to 70.50, or even as low as 27. With this diminution in the red globules, we may have a diminution in the entire quantity of the blood—there is not only poor blood (spanemia), but also deficiency of the blood (anosmia). Andral states: " That the quantity of blood in circulation may be so diminished, as no longer to penetrate the minute vessels of the cutaneous surface, in which its place is supplied by a thin serous fluid; and after death, a deficiency or even total absence of blood is observed, not only in the large arteries, veins and right side of the heart, but likewise in the capillary system, which is remark- ably pale and colorless. In these cases, the membranous and parenchymatous tissues, such as the brain, lungs, liver, kidneys, alimentary canal, and the parenchyma of the heart and muscles, are also remarkably pale and exsanguinous." The red globules CHLOROSIS. t 469 of the blood appear to be that part on which its vivifying and calorific properties chiefly depend. This is proved by the fact, that when they exist in their normal proportion, the different functions of nutrition, secretion and excretion, are all normally performed; the body is well developed, the skin reddened, the color of the blood bright, etc.; while in persons in whom they are much below the normal standard, the functions of nutrition, secretion and excretion are inactive, the surface pale or sallow, the muscles flabby, etc. 1018. We have now to examine how this diminution of the red globules is produced, and what relation the uterine system has to this condition. In many cases of chlorosis it has been observed, that if at the age of puberty the catamenia did not become established, or, if established, that it had become suddenly checked, that the health began to deteriorate, and this condition of the blood was produced. " It might seem difficult," says Dr. Williams, " to understand how irregularity of the uterine function operates in producing this condition. That in many cases it is a cause, and not an effect of anaemia, is plain from the well-known fact that no signs of anaemia have occurred until cold, over- exertion, or mental excitement, or some circumstance has suddenly checked the flow of the catamenia; it has not returned; and then the patient begins to lose color, and gradually to exhibit the ansemic state. In many cases, I have known this to occur in young females, who have previously suffered from acute rheuma- tism, implicating the heart. It would seem that, in these cases, some injury is done to the blood-particles, and to the powers by which they are repaired; this is manifest, not only from the pallidity, but from the yellowish and almost greenish hue which the complexion sometimes presents, and which obviously depends on a discoloration of the textures by the altered blood, as in the neighborhood of a bruised part. In some of these cases of chlorosis, the appetite is depraved; there is such a complete disrelish for animal food and other nourishing articles, and such a craving for sour things, and even for matters destitute of nourish- ment. Is chalk, cinders, etc., that it might be supposed that this perverted appetite is the cause of the anaemia, by deterring the 470 DISEASES OF WOMEN. patient from taking that food which is capable of making red blood ; and undoubtedly such an appetite, when indulged, must contribute to this result; but it is not so constantly present as to be considered the chief cause." 1019. Again, the disease may partly depend upon a lesion of innervation, the uterus and ovaries being supplied Avith nerves from the sympathetic system, which also supply the organs of digestion and sanguification; a disease of the uterus and ovaries will affect the formation of the blood through the medium of the nerAres. That this is the case in structural and functional disease of these organs can not be doubted, for in almost every variety of uterine disease we find that the digestive organs sympathize greatly with the diseased uterus or ovaries. In proof that this is one cause of the malady, Andral states that "it frequently happens, that by stimulating the nervous system of these chlorotic patients by the physical and moral emotions of matrimony, we produce a more natural complexion and color of the Avhole cutaneous surface, thus indicating a correspondent improvement in the process of sanguification ; and in proportion as the anaemia disappears under the influence of this new modification of the nervous system, the whole train of diseased action, the difficult respiration, constant sensation of uneasiness and listlessness, impaired digestion, gastralgia, vomiting, tympanitis, and limpid urine, together with all the strange nervous symptoms, which seemed dependant on some organic alterations of the solids, gradually subside and eventually vanish, as a fresh supply of blood is generated in the system. 1020. Causes.—The causes of chlorosis are all such as depress the vital powers of the system; the special influence of derange- ment of the menstrual function has already been noticed. The primary cause of the menstrual derangement, and thus of chlorosis, may have been a delicate, feeble state of the constitution from childhood, the vital powers not being sufficient to perfect the development of the uterine system and its physiological function, menstruation; this may again react in the manner spoken of, upon the general health, and chlorosis is the result. It may also be produced by any exhausting discharge, as menorrhagia, profuse CHLOROSIS. 471 menstruation, leucorrhea, etc. Or by insufficient and innutritious food, crowded and ill-ventilated apartments, residence in a damp, cold, or marshy locality, etc. 1021. Symptoms.—The symptoms of chlorosis are at first those of debility; the patient is weak and languid, dislikes to take exercise, and is easily fatigued; she is not cheerful, but dull and listless; there is a habitual melancholy; she loves solitude, and weeps without cause. The appetite is impaired and perverted, food is loathed, and innutritious substances desired, as chalk, dirt, etc. The bowels are nearly ahvays constipated, the tongue is coated Avith a dirty white fur; there is flatulence, and all the symptoms of indigestion, sometimes tympanitis; the breath is offensive; there is usually more or less frequent headache, palpitation of the heart; the pulse is quick, weak and com- pressible. 1022. In the aggravated form of chlorosis, says Dr. Ashwell, " Debility, languor, and listlessness, are more marked; depression is more complete ; the appetite is more morbid, Avith a desire for slate-pencil, chalk, acids, pickles, and other things equally per- nicious. The complexion becomes still more characteristic: it is a yellowish, dirty green, and the lips, gums, conjunctiva, and the lining membrane of the mouth are bloodless; the tongue, too, is of a still paler white, and being soft and flabby, it is easily indented by the teeth; the breath is offensive; there is nausea; sometimes vomiting, and frequent heartburn; the bowels, though generally constipated, are occasionally in a state of irritable and painful diarrhea. There is acute and anomalous headache, attended by every variety of distressing sensation, such as heavy weight in the front or at the back of the head, vertigo, fixed and intense pain in one particular spot, paralytic feeling and neuralgia. There is a dark line underneath the eyes, about the alae of the nostrils and at the angles of the mouth; the eyelids are dark and ©edematous in the morning; the ankles and legs are frequently so at nio-ht; the cellular or soft tissues are flaccid, and the surface generally, especially of the upper and lower extremities, is cold. If menstruation has continued up to this time, its intervals become more distant, the discharge itself is scanty, 472 DISEASES OF WOMEN. continuing to flow only for a few hours, and in quality it is often serous and pale, and of offensive odor. There is sometimes a general dryness of surface; the skin is no longer resilient; there is a splitting and brittleness of the finger-nails; the hair loses its glossy brightness, falls off in large quantities, and alters in color. It is not uncommon in advanced chlorosis, for the abdomen to be full and painful; and Avithout decided phthisical complication, there may be slight, short cough, pain under the left mammae, and hysteria in a variety of forms. At this period, one or several symptoms being confirmed, so far mislead as to induce the belief that the lung, the brain, the liver, or the heart may be organically diseased. Such is the malady Avhen fully developed." 1023. Treatment.—In the treatment of chlorosis we have three prominent indications to fulfil: First, to remove any disease Avhich may exist independently of the chlorotic condition, and which may, by its continuance, tend to keep it up. Second, to restore the blood to its normal condition, by the use of tonics and iron, nutritious diet, appropriate exercise, the use of the bath, etc., and Third, to stimulate the uterine organs to a performance of their natural functions. 1024. Diseases of the system existing in connection with chlorosis will have to be treated in the usual manner, having especial reference, however, to the debilitated condition of the system. Tavo of these, however, deserve special notice: disorders of the stomach and constipation of the bowels, or Avhat is of rare occurrence—diarrhea. We have already seen that the stomach is the first organ specially affected in this disorder, that the appetite was vitiated, that it Avas frequently accompanied Avith nausea and vomiting, that the tongue was coated, and the breath offensive. As a healthy condition of the stomach is of the first importance in the treatment of any disease, and especially of this, where the entire success of the means we adopt depend upon a normal absorption and assimilation of the remedies given, and a healthy performance of the digestive functions, so that we may restore the deficient elements of the blood; it becomes necessary that we have some definite knowledge of the condition of this viscus in chlorosis. According to Dr. Budd, " the continued disturbance CHLOROSIS. 473 of the secreting function of the stomach seems to lead to an inflammatory, or a catarrhal state of the mucous membrane. The digestive power is greatly weakened, and, under the influence of unhealthy or decomposing mucus, the starchy principles of the food undergo fermentation in the stomach, by which large quanti- ties of lactic acid are formed. The undue acidity of the stomach, or the great disturbance of its secreting function, lessens the secretion of the liver, and the continuance of the disorder causes a sallow appearance of the countenance." In many cases of chlorosis this condition of the stomach exists, and it is so promi- nently marked that it can hardly be mistaken. What is the remedy for this condition of the stomach ? Can it be overcome by the use of tonics, iron, cathartics, and the various remedies recommended for chlorosis ? It may; but, in my opinion, the easiest and surest way of restoring the tone of the stomach, is to first remove the morbid secretions from it by an emetic, which will not only accomplish this, but will also stimulate the stomach to a normal performance of its functions, and- modify, by the shock which it gives to the system, the abnormal nervous irritability. I may be wrong in estimating the proportion of cases in which this condition of the stomach exists, but in all of the cases that I have seen, with but one exception, it was present. My use of emetics, in such cases, commenced as a dernier resort; in the first case I had employed the means recommended by authors for the disease, but the patient gradually declined under the use of them, the condition of the stomach was evident, and I determined, not- withstanding her weakness, to employ an emetic; the Compound PoAvder of Lobelia was administered in infusion in the usual man- ner, accompanied with copious draughts of warm Avater, free emesis occurred, and the quantity of decomposing nauseous mucus thrown off of the stomach was astonishing. The immediate benefit derived from the emetic Avas surprising, at least it surprised me, as I was fearful of the result; in a few hours afterward, the patient expressed a desire for her supper, which she had not done for three months before, and from this date, under the influence of mild tonics, the soluble preparations of iron, nutritious diet, and exercise, she rapidly regained her health. I have used emetics 474 DISEASES OF WOMEN. in several other cases of debility at this period with equal advantage : but in none but this in which chlorosis Avas so well marked. The only account of the use of emetics in this disease that I have seen is by M. Colombat. He says: "Emetics, first proposed by Mercatus, (1554,) may be appropriate for cases in which the disease is complicated Avith some gastric disorder. Buillon relates that all the remedies employed for the cure of the daughter of a goldsmith, aged eighteen years, and affected Avith chlorosis, proved unsuccessful; but he adds that the young patient was thrown from a carriage, Avhich gave her a great fright, and brought on abundant vomiting of bile; from that moment her appetite returned, her face resumed its natural color, and her health was perfectly restored in a short time." 1025. Constipation of the bowels is a very frequent condition in this disease, and it is of much importance that it should be overcome; the cause of the constipation is probably torpor of the bowels, caused by deficient innervation. To remove this difficulty, the majority of authors recommend aloetic purgatives—aloes and some of the preparations of iron. But a much better remedy will be found in the Compound Tincture of Tamarac, or Bones' Bitters; this may be given in doses of a table spoonful three times a day, half an hour before eating, and if it should be necessary, its action may be assisted by the use of laxative enemas. 1026. To restore the deficient elements of the blood, the vege- table tonics, and the different preparations of iron should be used. At first, the mildest preparations should be used, as an infusion of Staphylea Trifoliata, Wild Cherry Bark, Hydrastis Canaden- sis, etc., with the Citrate, Lactate, or Carbonate of Iron. These agents may be replaced by others of the same class, especially the concentrated preparations, Hydrastine, Prunine, Cornin, etc., as the stomach and digestive organs regain their tone; infusions are always better borne by the stomach in debilitated conditions of the system, than the active principles, and they should there- « fore be used first. No special rule can be laid down as to the agents used, the practitioner having to select for each case those remedies which are best received by the stomach. It must be CHLOROSIS. 475 recollected too, that an agent used for some time will lose its effect, or will have to be replaced by another of the same class. 1027. If amenorrhea exists with the chlorosis, nothing can be done or should be done toAvard restoring the menstrual secretion until some improvement is made in the general health, and even then, those agents termed emmenagogues should not be employed. The application of the mustard plasters to the thighs and breasts as heretofore spoken of, the daily use of the salt hip-bath, the ammoniacal injection, composed of one drachm of the pure Liquor Ammonia to a pint of milk, daily thrown into the vagina, will often prove sufficient. The iron recommended for the chlorosis is the best emmenagogue known in such caces, and from my experience, I think that in nearly every case, if the health is restored, and no structural disease exists, nature is sufficient to restore the men- strual discharge. 1028. In regard to the hygienic treatment, I can not do better than to quote from M. Colombat. He says: " Whatever may have been the cause that has brought on chlorosis, Ave should remove the patient from all exposure to cold and humidity; she should breathe a dry, pure and moderately Avarm air, and it is because these conditions exist during the spring and autumn, that those seasons are most favorable to the cure of the disease. A dry, breezy situation, in a sunny exposure, ought to be recom- mended. Clothes, which by the nature of their tissue, slightly irritate the skin, are to be preferred to any others. Flannel worn next to the skin, and especially alcoholic and aromatic frictions to the Avhole surface of the body, should likeAvise be proposed, with the view of exciting the action of the capillary vessels, of invit- ing the blood into them, and promoting perspiration. The food must consist of roast meats, fresh eggs, farinaceous vegetables, ripe fruits, and bitter and aromatic plants; for example, succory and celery. As a drink during meals, we may employ with advantage, a mixture of chalybeate Avater with wine. Between the repasts, the patient may allay her thirst with some refreshing, slightly acidulated drink. Nevertheless, though a careful regimen ought to be strictly observed, it is not Avell to be too exclusive; if we meet with great reluctance in giving up the injurious 476 DISEASES OF WOMEN. articles which the patients desire, it would be necessary at first, to respect their longings, however strange they might seem, and even to satisfy them, unless they were directed to substances evidently hurtful. We should always commence by regulating the meals, and by forbidding fruit, salad and all crude articles; we ought, moreover, to consult the digestive functions,-and wholly proscribe articles well known to be indigestible. 1029. " Whatever be the aversion to exercise felt by chlorotic persons, we ought invariably to insist upon its employment, regu- lating it, however, by the strength of the patient. Should the muscular debility be so great as to prevent her from walking, we must resort to mixed and passhe exercises. Riding in a carriage, or still better, on horseback, especially if a man's saddle is used, in open and elevated places, where the air is pure, are proper modes of exercise, particularly if pleasant conversation can be added to the charms afforded by .diversity of A'iews and landscapes. Boating excursions, which exert a favorable effect upon all the organs, and which unite to all the advantages of exercise, that of being agreeable to young persons, and of producing a useful stimulation by the presence of individuals of the opposite sex; music, which occasions a salutary excitation in lymphatic persons, and finally, sea-bathing, and swimming in running water, are different hygienic means, which it is well to recommend to ner- vous, sad and melancholy women, and to those of great moral sensibility. Traveling can not be too strongly recommended to persons in whom the disease is kept up by acute sorroAv, or by any moral affection whatever; the use of mineral Avaters taken at the springs, offers in this respect, incalculable advantages, not only from the medicinal action of the waters themselves, but also, because the patients enjoy at such places the various charms of a numerous and brilliant society, and attractions which are con- stantly changing. 1030. " The use of very tight corsets ought to be forbidden; sleep should not be protracted beyond eight or nine hours, and care must be taken that the patient's bed is neither too Avarm nor too soft, because such beds often increase the feebleness and con- stipation of very sensitive women, especially those in whom the HYSTERIA. 477 chlorotic state has been developed and maintained under the influence of disappointed love. We should forbid exciting drinks, wine, highly nutricious food, vivid emotions, the frequenting of balls and shoAvs, the reading of highly-wrought romances, the examination of lascivious pictures, and lastly, Ave should, as far as possible, suppress all circumstances capable of disturbing the sensibility, or of exciting the passions too strongly." Hysteria. 1031. By the term hysteria, Ave understand a peculiar nervous affection not entirely confined to females, but in a large majority of cases seen in them, and generally the result of some structural or functional disease of the uterine organs. Dr. Condie states that he "has repeatedly seen all the phenomena characteristic of hysteria in the male subject. The fact of their recurrence in males is also stated by Sydenham, Louyr, Villermay, Georget, Ferriar, Frotten, Conolly, and others." We have to consider it, however, only as it occurs in females. 1032. Pathology.—Various opinions have been advanced in regard to the pathology of hysteria, and yet none of them appear so reasonable as the most ancient one, that it arises from some disease of the uterine system. If Ave examine the anatomy of the uterus and its appendages, Ave find that it is abundantly supplied with nerves from the hypogastric plexus of the sympa- thetic, and from the spermatic or ovarian plexus of the same system. It will also be noticed that the hypogastric plexus is not formed solely by branches from the sympathetic system, but that it likewise receives numerous small branches from the spinal nerves, and thus a connection is formed between the uterus and spinal cord. As the uterine organs receive nerves from the sympathetic system, which also supplies the organs of digestion, sanguification, and secretion, it is evident that disease affecting the uterus will also affect more or less the entire portion of the system supplied with those nerves, by sympathy. This fact is well proved in almost all diseases of the uterine organs, the disease affecting in a marked degree the functions of digestion, assimilation, secretion, and excretion. The intimate connection 478 DISEASES OF WOMEN. existing between the uterus and ovaries, through the medium of the nerves connecting the sympathetic system and the cerebro- spinal, and through the branches of the spinal nerves which pass through the hypogastric plexus to these organs, will account anatomically in part for the nervous irritability that is manifested. Dr. Carpenter says: "The clinical history of hysteria would lead us to suppose that the convulsive action depends rather upon some state of the blood which alters its relation to the nervous tissue, as its exciting fluid, than upon any change in the nutritive supply which it affords as would induce a more permanent disorder in the system. Taking all the phenomena into account, there seems much reason to think that a general excitability of the nervous system, such as is only an exaggeration of that which is charac- teristic of the female sex, is induced by some defect of nutrition, comparatively permanent in its nature." This defect of nutrition may occur in two ways; first, through nervous sympathy, as already mentioned, and second, through the circulation. It is supposed, and with much plausibility, that the constitution of the blood is affected by the condition of every tissue Avith which it comes in contact, so that if any diseased condition of the uterus exists, the circulation of blood through that organ, will change the condition of the entire circulating fluid. 1033. Symptoms.—I can not do better than to give the symp- toms of this singular and ever-varying malady as they are described by Newton and Powell. " Most of the disquieting feelings, strange and wayward fancies of nervous females arise from hysteria. A paroxysm is usually preceded by general uneasiness, anxiety and oppression; a sensa- tion of choking, or as if a ball were rising up from the abdomen into the throat, to which sensation the appellation of globus hysteri- cus has been given; stiffness about the larynx, headache and cramps. M. George says: ' Hysteric patients in the hospital of the Salpetriere, are so well accustomed to take warning by these precursory symptoms, as never to be seized unexpectedly; they go to bed, and are tied down until the fit is over.' Sometimes the paroxysm ends here; but more generally the anxiety and sufferings increase, extreme depression of spirits, often weeping, HYSTERIA. 479 ensues; there is a painful sense of stiffness and coldness of the limbs ; noise in the ears; vertigo; confusion, and to these rapidly succeed temporary loss of sense and consciousness, and of com- mand over the voluntary muscles, during which, the most vehement struggles are alternated with moments of repose. Occasionally, there is a tetanic rigidity of the muscles of the trunk or back, and the body is throAvn up in the form of an arch, but the limbs are more generally contorted ; the patient often beats her breast, tears her hair, grinds the teeth, bites the tongue or lips, or other- wise injures herself. The assistants are often struck, bitten or scratched, and have vociferous epithets heaped on them; terrific screaming, sobbing, laughing and vacant staring may rapidly suc- ceed each other. During the struggling, the heart beats tumultu- ously, the countenance becomes flushed and swollen, and the breathing laborious. After a variable continuance of from a few minutes to some hours or even days, of repeated intervals of struggling and repose, as here described, the patient either falls asleep or gradually returns to a state of consciousness and her ordinary "condition, save feelings of fatigue and soreness, which disappear in a few days. Such are the prominent features of the hysteric paroxysm; but it varies greatly in intensity and duration. The convulsions may be severe, with lucid intervals, and of fre- quent occurrence for days, or a deep, quiet sleep or coma may fill up the intervals, from which nothing can arouse the patient. In some women, the paroxysms return monthly, or at the men- strual flow; in others, at variable intervals dependent on disturb- ances of the physical or mental equability. It is remarkable that plumpness of person, roseate hue of countenance, and general appearance of good health are not incompatible, but often attend the worst of sufferers from this affection through life, so faithfully is the nutritive function preserved amid the many and frequent storms of nervous functional derangement. 1034. " So variable are the protean shapes which hysteria may assume, that there is scarcely an organ or its function that may not be invaded and the gravest maladies counterfeited, calculated to lead to errors in diagnosis and prognosis, compromising, if not 480 DISEASES OF WOMEN. the life and Avelfare of the patient, at least the reputation for close discernment of the practitioner. 1035. " Sudden, extreme, and anomalous symptoms should not be hastily pronounced upon at the bedside of the patient. Hysteric distention of the intestines by flatus has been mistaken for pregnancy; hysteric hiccup, for that of approaching death; hysteric colic, for acute peritonitis; hysteric.stridulous breathing, for croup; hysteric cough, for hooping-cough; hysteric limpid urine, for diabetes; intense urinary irritation, for nephritis; interior irritation, for inflammation; hysteric headache, for ence- phalitis ; hysteric tenderness and swelling of the knee-joint, for white swelling; hysteric coma, for apoplexy; hysteric wayAvard- ness, for mania, etc. 1036. " Diagnosis.—The suddenness of an attack of epilepsy, the cry, the fall, the distortion of the features, frothing at the mouth, livid turgescence of the face, small quantity of air admitted in inspiration, and the profound coma are sufficient to distinguish it from the hysteric paroxysm A\Thich certainly similates epilepsy more than any other affection. The Avant of correspon- dence between the violence of functional disturbance and the symptoms of organic disease Avill generally guide in distinguishing hysteric imitations or counterfeits. The history of the individual will aid; examination of the spine also. 1037. " Causes.—Whatever impairs the constitution and in- creases the excitability of the nervous system, may become an exciting cause of hysteria. The anemic state favors its incursion; an irritable habit produced by errors in early physical training; early vicious practices; emotional and imaginative reading; spinal, uterine, or gastric irritation; strong and impassioned feelings ; startling sights, sounds, or intelligence ; grief, jealousy, or unrequited love. The ancient doctrine Avas that the uterus was the seat of the disease, but modern physicians regard it as seated in the nervous system or centers." 1038. Treatment.—The treatment of hysteria will be of two kinds: palliative treatment while the paroxysm is on, and treat- ment for the radical cure of the affection by removing any uterine HYSTERIA. 481 disease that exists; strengthening the digestive organs, and restoring the general health. 1039. If called to see a patient suffering under an attack of hysteria, it is recommended to administer anti-spasmodics, as Assafoetida, Valerian, Musk, Castor, Scutallaria, etc. These agents may prove very efficient at times, but I have never had any success with them. I have used the Tincture of Gelseminum, given in drachm-doses every half-hour or hour until the paroxysm was broken, in some cases with great success, yet again I have seen it fail. The Tincture of Lobelia and Capsicum, however, I consider almost an infallible agent. I administer it in half- teaspoonful or teaspoonful doses every ten or fifteen minutes, until it nauseates the patient, or produces vomiting, and I have found in every instance that nausea or vomiting and hysteria were incompatibles. There can be no doubt that impressions produced upon the mind have great influence in checking these paroxysms or in keeping them off, and the Lobelia and Capsicum will be found to produce such a disagreeable impression on the patient, that rather than experience the effects of the medicine, if she is certain that it will be given, she will resist, and that successfully, the approach of the paroxysm; at least this has been my experience. Sometimes it will be impossible to administer anything, on account of the spasmodic closure of the jaws, but the medicine can generally be introduced into the corner of the mouth; if it can not be given this way, it may be injected into the rectum, using double the quantity of the medicine that would be given by the mouth. Sir Charles Clark recommended strongly the cold water douche; bringing the patient's head to the edge of the bed, he would pour on pitchersfull of cold water, until the paroxysms had ceased. In one case related by Dr. Watson, of a young lady, who for many days had been affected by trismus, so that she was unable to open her jaws, and could therefore neither speak nor eat, this treatment was adopted. Sir C. Clark being called in, recognized the nature of the affection. He had her placed with her head hanging over a tub by the side of the bed, and proceeded to pour pitchers of cold water on her face. Before he had emptied the second, the patient could scream and com- 31 482 DISEASES OF WOMEN. plain, giving very audible indications that she could open her mouth. Dr. Watson says, "Although these patients get great relief by the treatment, they do not like it; and if they are con- vinced that it will be put in force, they will generally manage not to require it." 1040. The treatment after the paroxysms are over, must be conducted on general principles, any disease of the uterine organs existing must be removed, and the general health restored in the •manner heretofore pointed out. In reference to the preventive treatment, Dr. Ashwell makes the following judicious remarks: " Where a tendency to the disease is evident, or where one or several decided hysteric seizures have occurred, it is evident that every prophylactic measure should be early and fully adopted. The remarks on the physical education of female youth already made, have a distinct reference to this important subject, and it can not be too strongly urged, that nature and common sense are the best arbiters in every matter relative to female health. Of all the influences capable of molding the female constitution, there are none so powerful as light, air, food, and exercise; and certainly, in reference to the two latter, nothing can be more at variance with propriety than our modern customs. It were easy to censure the way in which female education is conducted, but it would be to little purpose, till such plans are adopted as shall insure a higher appreciation of physical health and vigor. Happily of late some degree of reformation is observable; and the young ladies in our fashionable boarding-schools are beginning to realize its blessings. Animal food, and not farinacious puddings and slops; wholesome malt liquor, instead of water, tea, or bad wine; run- ning, jumping, and vigorous play, are more occasionally heard of without being condemned as fit only for the vulgar. By and by, it is to be hoped, that a sounder education will be built on these natural principles ; and instead of days and weeks deA^oted, as they now are, to music, absurd accomplishments, and romantic nonsense, some hours, at least, daily, or weekly, will be given up to history, general literature, and the economy of every-day life." DISEASES OF THE BREAST. 483 CHAPTER XV. DISEASES OF THE FEMALE BREASTS. BY PROF. R. S. NEWTON. 1041. The space allowed to me precludes the idea that I should enter into a minute description of the minor affections of the female mammas. It is to those more terrible forms of disease of the breasts that I would call attention. There have been written many very excellent and learned dissertations on the subject in hand, and at a first thought it would seem that nothing had been left unsaid which could throw light on the subject; yet all these fine essays, all the deep research, all the experiments and statistics of the books, in a practical point of view, amount to but little. Physicians, with all their skill, and with a perfect knowledge of the experience and opinions of others, who have written on this class of diseases, still have to endure the mortifying spectacle of the unchecked ravages of such affections, and their own inability to arrest their progress. It matters little whether we are able to give the rationale of the cure or not, if any one really can affect a cure of a reasonable proportion of the more malignant forms of disease, to which the female breast is liable, he will have done more for humanity than all the learned essayists who have written on the subject. 1042. Having made this class of diseases a special study during the past sixteen years, and having had extensive opportunities to investigate the subject, I deem it my duty to offer to the pro- fession my opinions, which, in many respects, will not differ from views advanced by others, but in other particulars the divergence will be very material. One of the simplest divisions of diseases of the breast is that of Mr. Syme, viz.: 1. Those in which there is merely derangement of its nutritive or sensitive action, causing simple enlargement, induration, and pain; 484 DISEASES OF WOMEN. 2. Those in which there is a collection of purulent fluid; 3. Those in which there is a morbid growth, limited to the part in which it originates ; and 4. Those in which the growth is of a malignant kind,—that is, tends to spread, ulcerate, or fungate, and affect the patient's constitution. 1043. But to comprehend the nature of the diseases to which the mammae are subject, we must understand their structure and functions. So far as its anatomy is concerned, we may learn something of its complicity from the statement of Sir Astley Cooper, that he had heard a good anatomist say, " The breast is so complicated that I can make nothing of it." 1044. The breasts are situated on the anterior portion of the chest, upon the lower part of the platysma myoides muscle, upon the anterior portion of the pectoralis major, upon the serratus major anticus and oblique externus abdominis, and usually cover the space from the third to the seventh rib. The breasts are essentially glands, and, when well developed, constitute the most beautiful apparatus in the body. In location and number they differ in different classes of animals, there being generally two for each young one to be nourished by their milk. It has been often supposed, that the provision of a. pair of breasts, as in the human female, was a provision of nature to supply nourishment for twins, when accidentally produced. This seems not to be the case, but to correspond with that common duplication of our organs, the natural provision for disease. If one eye is diseased, the other may serve the purposes of sight, and so, if one breast shall be the seat of disease—a very common occurrence—then the sound one Avill answer all the purposes for which the apparatus is intended. 1045. These glands are not situated on the chest so as to pro- ject the nipples directly forward, but rather laterally, so as to make the projecting nipple more convenient to the mouth of the child. Sir Astley Cooper has written very elegantly of the adaptedness of the breast to the convenience of the child, and I would suggest to the student a careful examination of the subject, as he will be more likely to detect even a slight variation from the normal position, and which will enable him to escape errors in DISEASES OF THE BREAST. 485 diagnosis. It is quite true that in those who have borne and nursed many children, the gland becomes pendulous, and the nipple may project forward without any disease being present. And in some tribes, as the woman of South Africa, etc., this elongation and relation of tissue is so great that the breast may be, and is often, thrown over the shoulder, that the child may nurse as it is carried on the back of its mother. 1046. When viewed as a mass, the mammary gland is a coni- form body, somewhat globular, with its base rather cupped to fit the bend of the ribs. The number in the human female is usually two, but cases have been recorded in which there were four, as was the case of a very respectable mother seen by Dr. Robert Lee and Sir Astley Cooper. [Cooper on the Breast, pp. 25 and 26.] But such casesvare to be regarded as accidental developments. The mammary gland, in its structure, is not unlike that of the salivary and parotid glands, though on a more magnificent scale. It is made up of from fifteen to thirty lobes, varying in size from one-fourth to one inch in diameter, the size being greater as we approach the base of the gland. The lobes are again divided into smaller compartments, called lobules, and these again are sub- divided into coecal vesicles. The ducts of excretion are thoroughly lined with a beautiful tessellated epithelium; they all converge toward the nipple, upon which they open by a number of small apertures, ranging in number from ten to twenty. In their course thoy dilate into small ampulae, which vary in capacity. 1047. The breast is divided anatomically into two parts, the internal and the external, both of which require careful study. Per- haps the true way to get a knowledge of the gland is to begin at its development, and end by giving its physiology. The mammary gland originates from the mucous layer of the epidermis, as a mere papillary projection, as early as the fourth or fifth month of foetal life. It soon develops into a complicated glandular struc- ture, very irregular at first, but which acquires symmetry as birth approaches. All its parts converge to form the mammilla, or nip- ple, which is not, as is supposed by many, in the center of the glandular body, but nearest the abdominal margin, and also nearer the posterior than the anterior margin. Or, as Sir Astley Cooper 486 DISEASES OF WOMEN. says: " from one-half to three-quarters of an inch above the lower edge of the pectoralis major." The lactiferous canals, which are thrown nearly together in the virgin, separate and enlarge in the lactating woman, and hence the nipple is increased in size, in such as have nursed. It is also longer, and can never after be made to acquire the solidity of the virgin state. Imme- diately on the apex of the nipple, there is a small indentation, caused by the orifices of the lactiferous tubes. Before puberty the nipple is quite smooth, but it is afterward masked by small papillae, which increase in size up to forty years of age. It acquires a wrinkled aspect after the age of fifty, and in old women has a warty appearance. The shape of the nipple is sometimes, but not always, changed by nursing; in the virgin, it is a rounded cone, with the base or broad part resting on the breast, but in women who have nursed many children, their order is reversed, or else occupies some medium place between the vir- gin state and the last-named condition. Its color is very various, passing through all the shades of red, and is often even of a very dark muddy color; generally, however, it loses much of its color as old age advances, and during utero-gestation, is possessed of a higher color than at other times. I desire to be minute in the description of the various parts of this gland, for no one is com- petent to judge of its pathological states, until he is well ac- quainted with its entire structure. 1048. In respect to the cuticle covering the gland, I need only notice that it is much more thin and delicate in women with fair skins and red hair, and is hence more apt to be abraded by the mouth of the child. The nipple is generally darker than the rest of the breast, which is owing to the rete mucosum, the character of which will be more fully explained presently. 1049. The areola or colored circle of skin which surrounds the nipple, has received a large share of attention, and as I deem an acquaintance with its characteristics of considerable importance, I shall feel warranted in also referring to it, at least briefly. The areola is but a spreading of the nipple, or a continuation of it, and, like the nipple, depends for its color upon the rete mucosum. In girls, before puberty, it is simply a colored circle around the DISEASES OF THE BREAST. . 487 nipple, but after puberty, during gestation, and in lactating women, it becomes more or less uneven, in consequence of the development of small, tubercles, which open on the surface, con- tain a mucous excretion, but have no connection with the lactiferous tubes ; in fact, they are not very different from the common seba- ceous glands of the skin. The color of the nipple and areola depend very much upon the condition of the uterine apparatus, and this is so true that its physical aspect has long been held as quite expressive of the condition of the uterus. Owing to the presence of erectile tissue, and the abundant supply of blood- vessels, the nipple may be erected as in the case of the male penis, and this erection may depend either upon a state of the genitals, or upon the passions. It is a known fact that there is a most intimate relation of sympathy between the nipple and the uterus or the genitals, and that when the latter are in a state of excitement, the nipple is more or less erected, and that there is an increased engorgement of blood in the nipple at such times, and hence, too, the color of the areola is then deeper. On the other hand, to illustrate the completeness of this sympathy, it may not be amiss to state that many females are so sensitive on the nipples, as to be at once excited by passion when, the nipple is touched or handled. Instinctively men recognize this law of inter-relation. It will be understood that the rete mucosum is but the coloring pigment which tinges the entire skin, and that it is the same in every respect as that deposited in the eye to confer color. The more abundantly blood be supplied, the more plenti- ful will be the pigment, and the darker the part so colored. 1050. The mammary gland is well supplied wjth blood-vessels, the chief arteries being the branches of the thoracica longa, exter- nal mammary, which, like the former, is a branch of the axillary artery, branches of the internal mammary artery, and another branch from the same. Outside of these principal branches, there are a number of less important branches ramifying through them, most of them reaching the nipple. The veins begin at the nipple in minute capillaries, and as they recede from it, unite in large trunks, entering the internal mammary and intercostal veins. 1051. The absorbents are very numerous and well distributed. 488 DISEASES OF WOMEN. These have for their office the separation of the milk from the blood. The nerves of the mammary gland are the axillary and the sternal, or the posterior and anterior branches of the above nerves, so called from their distribution. The posterior consists of the third, fourth and fifth branches of the dorsal nerves, all of which reach the nipple. The anterior consists of the reflected branches of the fourth dorsal nerve. To these nerves the nipple is indebted for its extreme sensibility. There are many openings and a few stray fine hairs in the areola, but the orifices do not connect, as before stated, with the lactiferous tubes. 1052. The gland is in reality inclosed betAveen two fascia, or a single fascia which has separated to accommodate the gland, and which may be traced to the ligamentous substance covering the sternum. From this fascia numerous fibrous processes are given off, which Sir A. Cooper calls ligamenta suspensoria, since by them the breast is suspended in its situation. They are firmly attached to the skin, and though admitting the gland to change position enough to resist violence, they still hold it firmly within certain bounds. These ligamenta suspensoria distribute them- selves upon the posterior surface of the skin, adding greatly to its whiteness and solidity. They also pass out from the gland, enve- lope the lactiferous tubes, and by connecting with the interior cutis of the nipple, prevent its displacement from the gland. Between these ligaments, if such they may be called, we find folds of fat, which, acting as cushions, prevent the gland from sustaining injuries from blows, etc. Indeed, these ligamenta sus- pensoria form a net-work, keeping all the parts together, and at the same time, increasing the secreting surface of the gland. The deeper-seated fascia sends its fibers in both directions—into the aponeurosis of the pectoralis major, and into the body of the gland, thus securing it to the body. 1053. The tubes of the mammary gland are both numerous and varied; e. g., the straight tubes of the nipple, the areolar tubes or reservoirs, the mammary ducts, differing only in their disposition or size; as a general remark, they enlarge as they pass from the nipple to the reservoirs. Along side of these tubes, we find the arteries, equally distributed, and conferring on the tubes great DISEASES OF THE BREAST. 489 vascularity. The veins do not run parallel always, and are less branched, the functions of the parts requiring a greater influx than "reflux current. The tubes are lined with a folded mucous membrane, which is highly vascular. It must be borne in mind, that most of these ducts are entirely separate and distinct from all others, a fact which is easily determined by injection. 1054. The gland itself is a conglomerate structure of small glands, the interspaces, when not occupied with tubes, arteries, veins, or nerves, being filled with fat. The glandules vary in size from the head of a pin to that of a buck-shot, and when injected, are nearly round. 1055. Of the milk-cells, little need be said, since their charac- ter can not materially further the investigations of the pathologist. Into these milk-cells the milk is secreted from the blood, and of course, if not in a physiological condition, soon present us with a pathological state. The milk passes from these cells to the mam- mary tubes, and after reaching the areola, is deposited in the reservoirs ready for use. 1056. The axillary and internal mammary arteries furnish the gland, and though greatly distributed, it is only necessary to regard the above larger trunks, as the sources of supply. The veins of the breast empty into the axillary, the cephalic, the inter- costal, the internal mammary, the external jugular and subclavian. The veins of these glands are often engorged in certain diseased states, and some of the best surgeons have been in the habit of opening them, to allow the accumulated blood to escape. There is no doubt but it affords, as I have often witnessed, immediate relief, and I greatly prefer the operation to the more tedious one of using leeches to accomplish the same end. The same thing can, however, be accomplished with great certainty, by other treatment, as I shall have occasion hereafter to show. 1057. I shall be sufficiently understood, if I say, that the breasts are literally permeated by absorbent vessels, or ducts, which, Avhen many unite, may sometimes make a tube as large as a small quill. Such a one is found on the inner side of the axil- lary vein, and between the first rib and clavicle. These tubes are intimately connected with the blood-vessels, and with the 490 DISEASES OF WOMEN. glandules, etc. These absorbents are frequently diseased, and indeed, many of the more malignant forms of mammary disease may he traced to that source. 1058. The nerves of the breast are derived from the dorsal branch of the spinal column, and are so minute in their ramifica- tions that the anatomist can hardly promise himself success in tracing them. I need not attempt to trace the reflex nerves, for the labor would not be satisfactory, even though I had space at command. 1059. It is an interesting study to trace the effects of gestation and lactation on the breasts, and though the profession have a sort of general and indefinite knoAvledge on the subject, it must be admitted that too feAV entertain correct vieAvs on this point. To arrive at expertness in reading the phases through which the breasts pass, requires a close and careful study of the organ in the living subject, which modest Avomen, before marriage, will not per- mit, and on others the circumstances are usually adverse. But before we attempt to explain the nature of the changes which are wrought on the breast by gestation and lactation, it may be well to inquire how any such sympathy can exist between the uterus and its appendages, and the breasts? It is presumed that no intelligent physician will deny that such sympathy exists, and hence I shall not here refer to the evidences upon which the asser- tion is based. Any treatise which is perfect should examine the uterine and mammary systems as constituting the same apparatus, but as this has not been done, I can only briefly show Avhy this should be so. 1060. The sympathy between the uterine appendages and the mammary glands, has been explained by supposing that the epi- gastric artery sent more blood to the internal mammary artery, and hence to the breast itself, during gestation than at any other times; and while I admit that this is altogether probable, the manifestation between the genitals and the breasts, or the mam- mary glands and the uterine appendages, is so instantaneous, as it were, that I think we must look to more rapid transmission of influences than such as can be conveyed by the circulation. This sympathy is entirely nervous, in the first place, and whatever DISEASES OF THE BREAST. 491 influence of a permanent nature is transmitted by the blood, is of a secondary character. The great sympathetic nerve, whose branches are incorporated with the dorsal nerves of the breast, is also largely distributed to the uterine appendages. It is to be understood that other parts of the system are also reached by the great sympathetic, and other parts, also, partake of the sympathy, but in a less marked degree; I have already stated that the nipple is furnished with erectile tissue, and hence we might expect it to be more prominently effected than other organs in which no such tissue exists. Very many facts, illustrative of this sympathy, might be cited, but one, it seems to me is quite sufficient, i. e., advantage is taken of this sympathy, by the reckless and fear- less, to produce abortion by simple irritation of the nipple at certain periods of gestation. And whether we are enabled to give a satisfactory explanation of the phenomena or not, the mere fact stands undisputed, and we must base our conclusions on it. 1061. During gestation more blood is sent to the breasts, their color is darkened, and they become more solid, or even swell, and become quite painful. They are tender to the touch, and if it be in a first pregnancy, they at once undergo that evolution by which they are matured. The nipple enlarges, the areola becomes much darker, and the papillae become protuberent; in fact, the entire organ looks as though it were, as it is, engorged. The increase of the diameter of the areola is from one to two inches. The increased darkness of the areola depends upon the more abundant supply of the rete mucosum, and by its being rendered more visible in consequence of the stretching of the skin, which is the necessary result of the enlargement of the gland. The areola will also be found thickened, in consequence of the development of the papillae. The glands and blood-vessels around the nipple, and on the body of the gland, will also be more prominent than before. 1062. After lactation has been established, all these indica- tions, except deepening of the color of the nipple and areola, are increased. In old age, the tubes of which I have been speaking, become more or less ossified. I need not here enter into a descrip-, 492 DISEASES OF WOMEN. tion of those influences brought to bear on the female breast about the time of the cessation of the catamenia, as I shall have occa- sion hereafter to treat this subject more in detail. I have given such facts as I conceive to be necessary in the proper study of the diseases of the breast, and to which too little attention has been paid by surgeons. Perhaps no surgeon in America, of my age, has had more experience in treating the diseases of the female breast than myself, and certainly none have been more successful; which success I imagine to depend both upon my knowledge of the glands and the plans which I have adopted for the treatment of their diseases. From these considerations, I feel warranted in laying my experience before the profession, fully believing that when others are guided by the same principles that I have adopted, they will be equally successful. 1063. Numerous morbid specimens ought to be carefully examined, for I assure you that an intimate acquaintance with their appearance, structure, and physical characteristics, will be highly advantageous to you, both in determining the kind of diseased growth, and its mode of development. Were this not so, experience could never add to the success of a surgeon; your knowledge of the general pathology of such growths would be all that would be requisite to enable you to treat them with entire success—a supposition which is not to be entertained. By com- paring together a great number of such morbid structures, we learn to recognize the peculiarities of each, and to detect those peculiarities in practice. If there is any science in surgery and medicine, of course it will be applied only when we understand the pathological states that are to be reduced to physiological conditions. There are certain forms of morbid structure, for the removal of which there are specific agents, and nothing but care- ful examinations of those structures can enable you to diagnose them. 1064. If you shall have first examined these structures, and made yourselves perfectly familiar with their pathology, the strong presumption is that you will not commit those grave blunders which have so disgraced many honorable members of the profession. The -necessity for thoroughly studying the char- DISEASES OF THE BREAST. 493 acter of these growths, in all possible ways, will be sufficiently ob\rious by remembering that diseases of the breast may be properly divided into two great classes, the curable and the incurable. The physician, who is entitled to be called scientific, never guesses at what he is to do ; if he does, he is a quack who strikes in the dark, and who is as apt to kill as to cure. I have so frequently seen operations on the breast, which I now know were unnecessary, that I feel it my duty to guard you against rashness in this respect. 1065. The diseases of the female breasts are exceedingly numerous, and are greatly modified in different constitutions. What would be a dangerous tumor in one case, and which Avould require a prompt operation, would be simple in another, and require no operation. I need hardly call your attention to age and the general health, to impress this truth, and yet some surgeons, judging from the language of the books, and from what I have seen, act upon the principle that a tumor is a tumor, and must, in all cases, be removed. I venture to affirm, that one-half of the tumors of the breast which are called cancer, are not truly such, and in this opinion I do not stand alone. 1066. The causes which give rise to these tumors are also so exceedingly varied, that the fair presumption is a variety of effects; opposite causes usually producing opposite effects. Sir Astley Cooper has drawn a delightful picture in his excellent work on the breasts, after having endeavored to impress upon the profession the great necessity of carefully manipulating the living tumor, and of scrutinously examining the morbid specimens on exhibition. He says: 1067. " The result of such knoAvledge is frequently the source of great security and happiness to a person afflicted with a disease in the breast, as well as of great satisfaction to the sur- geon. I have scarcely witnessed a stronger expression of delight than that which has illumined the features of a female — perhaps the mother of a large family dependent upon her for protection, education, and support — who, upon consulting the surgeon for some tumor in her bosom, and expecting to hear from him a con- firmation of the sentence she had pronounced upon herself, 494 DISEASES OF WOMEN. receives, on the contrary, an assurance that her apprehensions are unfounded. Pale and trembling she enters the surgeon's apart- ment, and, baring her bosom, faintly articulates — Sir, I am come to consult you for a cancer in my breast; — and when, after a careful examination, the surgeon states, he has the pleasure of assuring her that the disease is not cancerous—that it has not the character of malignancy—that it is not dangerous, and will not require an operation ; the sudden transition from apprehension to joy brightens her countenance with the smile of gratitude ; and the happiness of the moment can hardly be exceeded, when she returns, Avith delighted affection, to the family from which she had previously considered herself destined soon to be separated by death, with the alternative only of being saved by a dubious and painful operation." 1068. For the purpose I have in view, I shall adopt the very natural classification of affections of the breasts, which is made by Birkett, viz.: 1. Diseases occurring before puberty; 2. Diseases occurring during the establishment of puberty; and 3. Diseases occurring after the establishment of puberty. 1069. It will be apparent that the diseases occurring in either of these periods will admit of a very wide and diversified subdi- vision, each of Avhich will be examined in detail, as I progress with the general subject. It is difficult to determine at Avhat precise age the earliest development of mammary disease occurs, but within a few days of birth. The mammary gland, or the rudi- mentary gland, begins to develop after the sixth month of foetal life, and, like any other gland, may at once become the subject of disease. Diseases occurring in the mammary glands before puberty, and especially when the patient is still an infant or child, are mostly of an inflammatory character, and they vary only in the extent and termination of that inflammation. 1070. Within two or three days after birth, the mammas, or their rudiments, acquire a state of tumefaction, and soon there is observed, issuing from the papillae, a milk-like secretion, which of itself, and independent of all other circumstances, is a demonstra- tive proof of the preexistence of the secreting gland. Many DISEASES OF THE BREAST. 495 mothers, exceedingly ignorant of the processes of nature, and Over-careful, become very anxious to have this secretion removed, or to have the excretion stopped. To accomplish its stoppage^ they resort to frictions, etc., and inflammation results as the consequence of such harsh treatment of the tender gland. The attention of the parent is first called to the part by the hardness, tumefaction, and tenderness which the child evinces when it is touched. Now all this is natural enough, and, if let alone for a few days, will cease of itself, and leave the parts in a healthy condition. It is true that in rare cases, the tumefaction may last for some days ; the natural inflammation may assume a somewhat intense degree; but still, if it be let alone, it will resume its natural state in a short time. 1071. Nothing can be more irrational than to rub, squeeze, pinch or irritate so tender an apparatus as the developing mam- mary gland. Where this injudicious course is adopted, there may be extensive and acute inflammation, ending in abscess, in which event the assistance of the physician will be needed. The treatment must, in every case, be on general principles, modified by the tender age and constitution of the patient. The inflam- mation often extends beyond the glandular structure, as was the case with a child less than one month old, seen by Mr. Wagstaffe, in which the inflammation extended from the upper part of the breast down the right side to the umbilicus. Where the attack is so severe as in this case, the inflammation spreads very rapidly over a large space. To bathe the inflamed surface with cooling lotions, and to poultice the abscess which may form, is about all the treatment that is required. 1072. Again, the tumefaction and pain may follow the cessation of hemorrhage from the vulva, as was observed by Barrier in a female infant only five days old. In this case there was but little attending inflammation, yet the case was interesting as another evidence of the very close sympathy existing between the mammae and the genitals. 1073. Birkett reports a case in which there was an abscess formed in the breast of a child three months old, and whose mother stated to Mr. Birkett that, unlike her other children, the 496 DISEASES OF WOMEN. breasts of this one had not had the usual milky discharge from the mammary gland; and in another case, Avhere the child was sixteen months old, an abscess was present, and the breast SAvelled very much, in which there was also a discharge from the vulva, shoAving that the genitals were in an irritated condition—another evidence of the sympathy of the parts. But however often we may be called to treat such tumefactions and swelling of the infantile breasts, we shall find the symptoms rapidly subsiding after the slightest attention; and that in no case do they end in serious lesions. 1074. When we approach nearer to puberty, the breasts become more subject to disease, and not unfrequently we shall find, that they then readily assume a form of malignancy which demands our utmost attention. And what adds to the difficulties attendant on their treatment, is the modesty of those thus afflicted, and their indisposition to permit examinations to be made, while the disease is yet in its incipient stages. 1075. With the complete development of the ovaries, and the establishment of the catamenia, the mammary glands rapidly enlarge, and assume their perfect shape; the 'areola deepens, and the nipple evolves into its natural prominence, of course not acquiring the size and shape Avhich it is afterward to attain. Changes thus occurring are perfectly natural, and do not com- monly give rise to disturbances which require surgical attention; yet they sometimes do, and it is therefore incumbent on me to make some suggestions respecting those diseased conditions. 1076. We are to bear in mind that this natural period of female development varies with climate, habits and constitution. It may be stated to range from nine to sixteen years of age, and M. Bourgat Saint Hilaire relates the case of a little girl, born in Louisiana, on the 13th of December, 1837, having from birth well- formed breasts, and having the pubes covered with hair, as in a girl of fifteen. The catamenia appeared when the child Avas three years of age, and continued to appear monthly, as in women generally, after puberty has been fully established. The quantity of the catamenial discharge was as great as in women fully developed; the time of the discharge being usually four days. DISEASES OF THE BREAST. 497 This is certainly an anomalous case, but none the less interesting as a fact. A similar case is reported in vol. 2, of the Medico- Chirurgical Transactions, by Sir Astley Cooper. This child was the daughter of a waterman at Lincoln. The catamenia appeared before she was three years old; at first occurring at long intervals, but becoming more regular as she acquired age. "The catame- nia," says Sir Astley, " exactly resembled that of most women, except that it Avas rather of a darker color." The breasts were very full, being as large as those of most women at twenty years of age. Her pelvis Avas well developed, and the pubes covered with a light-colored hair. She did not seem to possess the sexual desire, and was not more modest than most children at her age. When six years of age she menstruated regularly every 21st day, the discharge lasting four days. She had frequent leucorrhea, and when in her seventh year, exhibited much more modesty than before. This girl had other sisters who did not manifest any forwardness. Other cases have been recorded, but these are quite sufficient to show that the breasts, in connection with the ovaries, may be developed at a very early age ; while on the other hand, numerous cases are recorded where neither the ovaries nor the breasts Avere ever developed. 1077. Even at the early age of twelve, or at the period when puberty is being established, the breasts may become the seat of cancer, and other malignant diseases, though such instances are not common, by any means. Mr.Bransby Cooper relates the case of a girl aged 13, on whom he found carcinoma medulbe of the breasts, which was removed, and who died, notwithstanding the operation. Lyford reports a similar case in the London Lancet, and also refers to a specimen in the museum of St. Bartholomew's Hospital, which was taken from a girl aged sixteen years, i a 1078. The diseases most apt to attack the mammary gland, at the period of puberty, are inflammation and its sequelae, and often ending in chronic abscess, which, if suffered to run on, may finally develop itself into malignant tumor. Girls, at the establishment of puberty, have most to fear from tubercular diseases of the lungs, mournful instances of which we see almost daily. 32 498 DISEASES OF WOMEN. 1079. The surgeon who expects to master the treatment of diseases incident to the breasts, must not neglect to glean from every source all such information as will lead into an understand- ing of the basis of those pathological states Avhich form their development. He ought to examine with a microscope the com- posit cells of every morbid growth, the pus, the fibres, the blood- vessels, the tissues, and the chemical nature of the attendant secretions. 1080. As it will be to the diseases which affect the mammary glands after puberty, that I shall direct your attention more par- ticularly, I close this lecture by reminding you of some of the effects of common inflammation in the breasts. This has been divided, by Sir Astley Cooper, into three stages, which he very appropriately terms adhesive, suppurative, and ulcerative. Ad- hesive inflammation produces a firm and very sensitive enlarge- ment, which, in consequence of the tardiness of the dense fascial membrane in yielding to the enlargement, often occasions excru- tiating pain and suffering to the patient. The solidity of the SAvelled gland depends upon the engorgement of the interstices with the serous and fibrous portions of the blood. The blush of inflammation is well marked, and the throbbing quite sensible. Shiverings reveal the fact that the general system is influenced by the local inflammation. This shivering is succeeded by heat and copious perspiration. As the disease progresses the cuticle separates, ulceration is established in the cutis, and a discharge follows. This process is completed in from one to three weeks— the disease running its course much more rapidly in some than in others. This kind of inflammation mostly attacks young mothers, and for obvious reasons. When we endeaAror to arrest the first stage, we shall not often be compelled to treat the suppurative stage. Fomentations, and washings Avith cool lotions, will be found of great benefit, and a poultice, in which there has been incorporated a large quantity of Veratrin, will be serviceable. Or, if the suppurative stage has been reached, then we must rely upon hop and poppy fomentations, and hyoscyamus poultices. The abscesses of the ulcerative stage are to be opened with the lancet, as soon as there is much evidence of accumulated matter, and DISEASES OF THE BREAST. 499 then the part is to be treated with poultices and fomentations— then minutia of Avhich will be noticed hereafter. 1081. The limited space at my command, compels me to abbre- viate what I have to say in relation to the diseases of the breasts, to say nothing of those minor affections which frequently require medical or surgical interference. The acute inflammations which are to be observed occasionally attacking the breasts, does not differ very materially from the same forms of inflammation when observed elsewhere, and if there be a difference, it is easily under- stood to result from the peculiar anatomical structure of the mammary gland. It is to be remarked, however, that the intimate relations which exist between the breasts and the uterus, and betAveen the uterus and the great nervous centers, may occasion by reflex or secondary actions, peculiar hysterial or nervous phe- nomena, which do not attend the acute inflammation of other localities. The acute sufferings attendant on inflammation of this gland arise from its peculiar sensitiveness; its perfect nervous connections, and in the treatment of common acute inflammation of the gland, we shall be compelled to induce an obtuseness of the nervous centers, as far as possible, to blunt the sensory ganglia. 1082. From peculiarity of structure, there is a great tendency to the confinement of the inflammation to a particular spot, where we soon observe that the inflammation has passed through its adhesive stage, and has become hard, shining, and marked by a throbbing sensation, which may be regarded as more or less characteristic of the suppurative process. The general system has already partaken of the disturbance, and we witness the occurrence of tremors, shiverings, heat, and dryness of the cuticular surface, and, finally, profuse perspiration. Soon after, the cuticle sepa- rates, or splits into rugous cracks, and ulceration is at once established, the matter being discharged through the apertures or cracks in the cuticle. 1083. In any particular case, unless by remedies Ave may arrest the progress of the disease, all these stages will have been accom- plished in from two to three weeks. Individual peculiarities, arising from general irritability, the depth to which the abscess has 500 DISEASES OF WOMEN. formed, etc., will lengthen or shorten each case, but usually all the stages are completed in the course of three weeks, and after this, the whole tendency of the disease is to malignancy. Inflam- mation of this kind results from various causes, some of the most palpable of which I shall notice. When the child is first put to the breasts, its suction-efforts tend to draw an extraordinary flow of blood in the direction of the nipple. This is the case only while the child draws before the milk begins to flow. All parts of the tissue thus become periodically injected by an, unusual quantity of blood, which, not returning with equal facility, is left in the engorged tissues, where it becomes a source of irritation, and finally, consequently, of inflammation. Then, again, there is constant and violent exposure of the breasts to a cold air, after they had been snugly and warmly accommodated in the dress. At one moment, they are full, Avarm, and dry, and a few moments afterward, they are flaccid, cold and Avet, favoring great irregu- larities in the circulation, and thus maintaining a ready impressi- bility to every source of irritation. The disastrous practice of nurses and midwives encouraging the use of stimulating drinks, and refusing the child the use of the breasts, before several days have elapsed, and when the callostrum corpuscles have become agglutinated, has given rise to many a mammary abscess, and no doubt the same practice has been to some extent encouraged by physicians. 1084. In treating the adhesive stage of this kind of inflamma- tion, we should endeavor to equalize the general circulation, to move the bowels, stimulate the functions of the skin, by the free use of diaphoretics, and to brace the system by the free and judicious use of tonics, not forgetting the great value of warm fomentations to the breasts. The use of cathartics will often prove of great advantage by their revulsive efforts. If these means do not arrest the disease, and the second, or suppurative stage shall have been reached, then poultices of Poppy and Gelseminum should be applied, the breast being bathed in a decoction of Veratrum Viride, all of which should be tepid. The internal administration of the following pill, at the same time, will be found to be of great value: DISEASES OF THE BREAST. 501 |fc Gelsemin, gr. iii. Podophyllin, gr. ii. Sanguinarin, gr. i. Scutellarin, gr. iv. Make into six pills, and give one at morning, one at noon, and one at bed-time. If the bowels are already open, then omit the Podophyllin, and substitute in its place Quinine, iv. gr. 1085. In regard to the abscess which may have formed, let me here remark, that they ought to be opened in every instance, no matter whether they shall be deep or shallow. No possible harm can result to impede the cure, but, on the other hand, the use of an abscess-lancet will greatly relieve the immediate sufferings of the patient, and enable us to inject a very weak solution of Sesqui-Carbonate of Potash, or of Muriated Tincture of Iron into the abscess, which will very greatly facilitate adhesion, granula- tion, and restoration of the organ. Of course every opening should be made where the fluctuation is most distinct. The neglect of these abscesses and endeavors to discuss them when once formed, is a prolific source of malignant mammary tumors. Sir Astley Cooper, in his excellent treatise on this subject, relates a case where an ordinary milk-abscess, which had been somewhat neglected, degenerated into a true fungoid excrescence of the whole gland, which finally destroyed the woman's life. After the abscess has been healed, if a peculiar hardness remain, as is often the case, then it should be an object to discuss such induration by the use of Iodine, etc. 1086. The child should not be allowed to suck the diseased breast, but the milk should be regularly drawn by a glass tube prepared for the purpose; or else by the use of the breast-pump. The breast ought not to be squeezed or roughly used, as every physician of much experience has seen a greater or less number of mammary ulcers which have arisen from such improper manipulation of the breasts. Abscesses of the mammary glands often arise from cracks and fissures on the nipple, rendering it unpleasant to have the child put to the breasts, and hence they are allowed to become engorged with milk, which soon produces 502 DISEASES OF WOMEN. irritation and inflammation. This is particularly apt to be the case when one breast is sore, and both the mother and physician should be guarded against allowing the milk to accumulate in the breast over and above the ordinary quantity, since the incidental distention would greatly favor, or give rise to inflammation— which, in every instance, is to be regarded as a symptom of a pathological state, requiring close and circumspect attention. 1087. Incidental to chronic inflammation, there is another ab- scess which requires the most careful inspection, and as it is long in forming, it has been denominated the chronic abscess. It is distinguished from acute abscess, by the length of time in Avhich it is forming, by the little pain accompanying it, absence of heat and redness on the breast, and the want of rigors and those other constitutional disturbances which have been mentioned as being characteristic in acute abscess. For these reasons we are not led to suspect the formation of matter, and thus a malignant tumor is suffered to arise and progress with its ravages, Avhich, had the nature of the disease been clear from the first, Avould have been averted. Upon pressure over such abscesses, the patient is very sensitive, and if we examine closely, the presence of matter will be detected by fluctuation. Let it be borne in mind that there is always more or less induration around the matter so formed, and hence we are liable to suppose that there is a tumor requiring excision. Sir Astley Cooper reports several cases which had been sent to him of this nature, and which had deceived those who sent them. In lancing such abscesses, or any others, the lancet should be put in so as not to cut the lactiferous tubes across—in other words, the blade should be put in parallel to the nipple, as the tubes run from the base towards the apex of the gland. It has been customary to give mercurials in this abscess, to alter the secretions; but it seems to me that no practice could be more injudicious. That Stillingia, combined with some of the more positive tonics are indicated, I do not deny; but generally, a due attention to the functions of the kidneys, skin, liver, stomach, and the diet are all-sufficient, along with opening the abscess, to effect a cure. If, after the abscess has been opened, sinuses form that refuse to heal, then stimulating injections are DISEASES OF THE BREAST. 503 indicated, in order to produce that inflammation which the tissues were unable to set up. 1088. There is another abscess of the breasts which seems to me to warrant some attention. I refer to what Sir Astley Cooper calls the Lactiferous SAvelling, which is nothing more nor less than a lactiferous aneurism—the excessive enlargement of a single milk- tube. To enable the practitioner to recognize it at once, I beg to briefly describe it. The swelling is like a ridge running from the nipple toAvard the base of the gland. The woman complains of a feeling of great distention, which is almost insupportable, when the child attempts to suck, OAving to the increased flow of milk in the adjoining tubes. The breast is uncolored, but the cutaneous veins are greatly distended, while the fluctuation in the tumor is most distinct. 1089. When opened, little or nothing than milk is discharged, and if the opening is suffered to be closed, the tube is again soon similarly distended. If not opened by the surgeon, ulceration occurs, and an opening folloAVS near the nipple, which can hardly be healed until the child has ceased to suck, and until milk is no longer secreted. The requisite treatment is apparent—puncture the tumor, and keep the child from the breast until milk is no longer secreted. Or if the child be yet very young, and it be desirable to retain the activity of both glands, open the abscess, making a free incision, and then inject a stimulating solution, so as to induce inflammation, during the progress of Avhich, the breast may be artificially relieved of its milk, until adhesion has been completed. With all justice, this disease might be called Mammary Ranula, Avhich it resembles in every respect, except that the one is produced by an accumulation of saliva, and the other of milk. 1090. There are four kinds of watery tumors of the mammary glands. The first of these are mere sacs filled with serous fluid, and named by Sir Astley Cooper Cellulose Hydatids. This variety is distinguished by freedom from pain, enlargement of the breast, no fluctuation at first, but which finally appears ; the breasts then grow more rapidly, and fluctuation can soon be detected in a number of places at one time; the cutaneous veins are varicose, 504 DISEASES OF WOMEN. and the breasts though many pounds heavier than usual—perhaps three or four times as large as common—are still free from pain; but a few patients complain of heat, and sometimes pain in the shoulder. The tumor moves easily on the pectoral surface, and is at the same time very pendulous. It may involve a part or the whole of the mammary gland. 1091. In its progress at one of the points of fluctuation, the breast inflames, ulcerates and opens, Avhen a glairy mucilaginous fluid, mixed with serum, is discharged. Other sacs, if there be more than one, go through the same process, forming sinuses, which do not readily heal. The general health may be, and mostly is, good; nor do the adjacent structures seem to partake of the disease. The disease may progress, until so much fibrous structure has been formed, that the breast becomes one great tumor, which fills the patient and her friends with the apprehen- sion of cancer. These larger sacs contain smaller ones, and these again, yet smaller ones, giving the idea of cellular dropsy. They vary in size, of from one-twentieth to half an inch in dia- meter, and rarely to one inch. The sacs are larger. The cysts are exceedingly vascular, the veins are engorged, and in opera- tions bleed profusely, which disposition is manifested even after the tumor has been extirpated. There is no danger of confound- ing it Avith either of the abscesses already described, and when the sac is opened, the surgeon is at once led to a knowledge of the complaint. Sometimes a true scirrhous tubercle will have hydatids associated, but then Ave shall find that there are also present those darting pains, excessive hardness, etc., characteristic of scirrhus. For the treatment of this complaint, there is required only a simple dissection of. the sacs and the immediately surrounding indurations, which usually effects a radical cure, with little or no further treatment, than a genial diet. Though. the disease is not generally painful, there are some cases in which much uneasiness is felt from the first, as has been noticed by Cooper and others. These cases, however, seem to be excep- tions, and may generally be accounted for by idiosyncrasy, etc. 1092. The second form of hydatid disease is marked by the following peculiarities: the breast is enlarged; hardened by fibri- DISEASES OF THE BREAST. 505 nous effusion; there are distributed through it various sacs con- taining serum, which fluctuate; from the inner wall of the sacs hang a number of polypous bodies which seem to float in the fluid contained in the sacs; many of these bodies are detached and floating loosely in the serum of the sacs; they vary in size, the largest not larger than small beans; generally, they are ovoid, and when opened, are found to be composed of many lamina, as in the layers of an onion, and which readily separate. This form is also characterized by the absence of pain. The best descrip- tion and plates of this form of disease is found in Cooper's work on the Breasts. When the disease has advanced, so as to require treatment, that will have to be surgical, the breast must be removed, inasmuch as the great mass of the gland is diseased. 1093. The third species of hydatid disease of the breast, is that which has been called animal or globular. This form con- sists essentially of sacs filled with similar, but smaller sacs, filled with fluid, having no vascular connection with the surrounding parts. These hydatids are not confined to the breasts, but are often found in the liver, in the lower part of the abdomen, in ovarian tumors, lungs, the brain, around the heart, etc. The hydatid is contained in a cyst, which is surrounded by a fibrinous effusion, the result of inflammation. This fibrinous matter is highly vascular, but the hydatids are not immediately connected therewith. Cooper describes these cysts as a " semi-diaphanous bag, filled by a clear Avater, and it is uniformly smooth on the inner surface." Having no opening or inlet, it is nourished by absorption through the walls of the cysts. They are self-propa- gating, for if we collect the fluid of a sac, we shall find it filled with miniature hydatids. They are animalcules, having a separate and independent existence, and propagate on their interior sur- face their own species. They are sometimes found on the abdom- inal viscera with a mouth and tail added, and then receive their food through the mouth like other animals. Sir Astley Cooper regards them as the true link between the vegetable and animal kingdom. It is supposed to have been deposited wherever found, from the blood, and acting as a foreign body, is soon inclosed by the adhesive process. 506 DISEASES OF WOMEN. 1094. The proper treatment is to make an incision into the hydatid tumor, discharge the contents of the cysts, and then it readily heals, and, if the fluid should accumulate, a seaton may be passed through it, so as to set up sloughing. Perhaps it Avould be safer and more economical to inject the cyst, as soon as evacuated, with a solution of Sesqui-Carbonate of Potash, and thus insure a radical cure. The fourth form of Mammary Hydatids will be described further on. 1095. There is a tumor resulting from uterine sympathy, mostly found in females from seventeen to forty years of age, which is denominated Chronic Mammary Tumor. It is mostly found in single or barren Avomen. It usually springs from the surface of the breast, and is therefore superficial and very movable; it is of sIoav groAvth, painless, generally, though sometimes gives rise to a sensation of rheumatic pain in the shoulder ; it is commonly more tender just prior to the recurrence of the monthly flow of the menses. 1096. These tumors seldom acquire a weight of more than four or five ounces, though they have been found weighing as much as one pound. They will exist for many years, then disappear altogether, and, therefore, are in no sense malignant. The tumor is of a conglomerate or lobular form, and the name of lobulated Mammary Tumor has been suggested by Cooper. LTpon dissection one is led to think that the tumor is only an added number of lobules, without the lactiferous tubes. It differs from malignant tumors of the breasts by the youth of the patient, generally, by the absence of pain, by the good health of the patient, the slow progress, its superficial situation, its extreme mobility, and lastly, its lobular character, which is at once revealed to the sense of touch. 1097. The pressure of stays, blows, etc., encourage the devel- opment of the tumor, but the real cause is in the uterus. We shall, therefore, be at once led to the principles Avhich are to govern us in the treatment of the disease. Every function must be encouraged to normal action. The digestion, secretion and excretions must be inquired into; but, above all, the state of the uterus must claim special consideration. To the breast, over the DISEASES OF THE BREAST. 507 seat of the tumor, an iodine ointment plaster should be worn, unless there be considerable inflammation, in which case it will be best to employ cooling lotions and poultices of hops and bitter herbs. We must, hoAvever, not expect to induce their absorption while the uterus is the seat of irritation, inflammation, or ulcera- tion. The disease rarely requires an operation, and it will be our duty to make its character known to the patient, Avho is always alarmed as to the possibility of its terminating in cancer. Mar- riao-e is almost sure to cure it when it occurs in single women, and a due attention to the uterus in those who are married is all that is required. But if the patient is determined to have it removed, no operation is more simple and certain to effect a radical cure, no possible danger attends the operation in any way, either imme- diately or remotely. 1098. In certain specific inflammations of the breasts, Gelatine is effused, which becomes vascular from the surrounding parts. It resembles cartilage, and in it ossific matter, especially phos- phate of lime is deposited. These tumors have been described as Cartilaginous and Ossific tumors. The pain attending these tumors is very severe, the skin is warmer than natural, the tumor is very hard, and more painful before -than after menstruation. The treatment is extirpation, as affording the only relief. 1099. Adipose tumors are frequently formed in and on the mammary gland. These tumors may grow on the surface covered only by the skin, or they may be merely an enlargement of those fatty masses which occupy the interspaces between the lobules. They can not be discussed, and the better plan is to remove the tumor at once, Avhich may be readily done. Scrofulous swellings of the breasts are sometimes presented to the surgeon, but they are rare, and require no special treatment. 1100. Sir Astley Cooper describes an irritable tumor of the breasts, cases of which I have seen myself in several instances, and it seldom or never occurs before puberty. When the complaint attacks the glandular structure, there is little or no swelling of the breasts, but one or more of the lobes become very tender to the touch, and when handled gives rise to pain, which does not subside for many hours. This pain affects the entire arm and shoulder, 508 DISEASES OF WOMEN. and generally prevents the patient from lying on that side when in bed. It may also affect that side of the body more or less. There are alternate sensations of heat and cold in the breasts; the pain is neuralgic, darting here and there along the nervous tracts—the stomach sympathizes, vomiting ensues, the pain is more acute before menstruation, there is no sign of inflammation, and the skin retains its natural color. Both breasts may be affected, or only one, or even a part of either one. This pain may continue for months or years, and the plan of treatment must be constitutional. The breasts may be bathed in an infusion of Gelseminum, Poppy and Lobelia, while the Gelsemin or Vera- trin are given internally. 1101. But occasionally these symptoms are associated with a tumor, clearly defined, which is exquisitively sensitive to the touch, and at intervals exceedingly painful, especially before men- struation. They vary in size, but do not usually become large. They may exist in this painful state for a great Avhile, when the pain may cease, and the tumor finally disappear. The treatment must be constitutional—and so ordered as to lessen the nervous irritability of the patient. An operation is by no means admissi- ble, for the extraction of a tumor does not effect a cure; and more than one case has occurred where this has been clearly proven. I once, in my earlier practice, committed this mistake, and have known of similar errors in others. The mistake is a sad one, and we can not exercise too much care in diagnosing this as well as other similar affections of the breast. The space at my command prevents a further consideration of those minor affec- tions of the breasts, and I shall, therefore, close this article by presenting briefly some views of cancer of the breasts, in which the profession and the public are more immediately interested, as the disease in all its forms is a source of great dread, and gene- rally too often fatal in its effects. 1102. Carcinomatous or cancerous degeneration of the mam- mary glands has thus far baffled the skill of the medical pro- fession. It is true that here and there we sometimes hear of a surgeon who has had much success in the treatment of Cancer, but until recently, as the disease, exist where it might, DISEASES OF THE BREAST. 509 was considered incurable, it was thought disreputable to adapt its treatment as a specialty, and hence, too many physicians have neglected its proper study. For sixteen years I have made this form of disease a special study, while I have not neglected my general surgical and medical practice, and I have constantly endeavored to teach the classes before whom I have lectured for the past ten years, all that I knew in relation thereto; I neither have, nor do I desire to make any secret of my knowledge in relation to the treatment of cancer, and I therefore repudiate the idea of being merely a " Cancer Doctor." I regard cancer as any other disease—one phase of the pathological states of man, and of which every physician should be informed. It would be just as unphilosophical to cease our endeavors to understand the nature of vomito, because Ave can not always cure it, as to neglect the study of cancer, because the profession has acknowledged its inability to cure it. Such an admission is a disgrace, since Ave know that in various parts of Europe and America, there are practitioners who do cure cancer in all its forms, and what one can do another ought to try. I have treated several hundred cases from all parts of the country, and while I have sometimes failed to effect cures, especially in the early years of my practice, I am proud to say that I have relieved, radically, hundreds who will sustain this declaration. There are few surgeons in America who have had so extensive a practice in the treatment of carci- nomatous disease as myself, and therefore, few, if any, in this country, have had more experience than myself. If I shall be instrumental in fixing the attention of the profession to the im- portance of this subject, I shall have been amply satisfied for the trouble of preparing this paper. While I have hundreds of cases that might be detailed, my space is so circumscribed, that I shall be compelled to confine my remarks mostly to general principles. 1103. Carcinomatous tumors differ from every tissue found in the body, which, after proper development, gives rise to an ulcer, which in its extension destroys the surrounding parts. There is no difficulty in identifying carcinoma, since all the varieties depend upon constitutional peculiarities, the tissues 510 DISEASES OF WOMEN. which surround it, the stage of the disorder, etc. The anatomical revelations of cancer are so peculiar and distinct from all other tissues, remove every doubt as to its character. 1104. There are five prominent forms of cancer of the breasts: Lobular carcinoma, intra-glandular carcinoma, encysted carcinoma, carcinoma of the nipple, and cutaneous carcinoma. 1105. When carcinoma first begins to develop, one form is characterized by a stony hardness, to Avhich the name carcinoma fibrosum is given; but when the tumor is soft, imparting an elastic sensation, it is called carcinoma medullare, and all other forms are, at most, only varieties of these tAvo. 1106. In every case, the tumor will have acquired some size before its presence is detected. When examined, the tumor feels hard, or it will be perfectly movable beneath the skin. At this time it gives no pain, was accidentally discovered; the health is good; but after a few Aveeks, the lump has grown, lancinating pains are felt, and if the adipose tissues are thin, the skin is seen to be elevated by the tumor. It is still hard to the touch, and gives a sensation of roughness to the touch. If the growth shall now be removred, it will have a greyish-yellow tint, having a sort of peduncle by which it was connected to the tissue of the gland. Fibrous lines, radiating from the tubercle, extend betAveen the subcutaneous adipose tissue toward the skin—the tubercle itself looking speckled in the center, OAving to the remains of the ducts of the engorged gland tissue. 1107. After a few more weeks or months, the gland, when again examined, Avill be found to have enlarged, it is more painful, and noAV adheres to the cutis, which, as Birkett says, may be " slightly puckered in." 1108. The adipose tissue covering it has noAV been mostly absorbed, and the attachment betAveen the tumor and skin is so perfect that one readily moves the other. On either side of the tumor the skin is much thicker than usual. Unless the tumor shall be removed, the skin becomes harder, and, finally, the Avhole gland has disappeared, to give place to the tumor. The surface of the breasts is hard and rough, while the skin looks as though it was ready to burst from its extreme tension. It is reddish, DISEASES OF THE BREAST. 511 shining, and looks as though it were very sensitive, which, strange to say, is not always so. 1109. Another stage of development is soon established; the integuments begin to slough away, and an ulcer is at once established. Before this ulcer has been completely formed, small cutaneous eminences appear, the center of which decays,, and is thrown off, leaving a little hole, Avhich continues to enlarge, until it unites with others, and a large sloughing ulcer is formed. Or the ulcer may form by scaly cracks from Avhich an oozing takes place, and these cracks uniting, result in a foul ulcer. Sometimes the development seems to be suddenly arrested, but such an occurrence is at all times an unfavorable circumstance, since the disease is at work on new tissues, and suddenly we find every symptom greatly aggravated. 1110. Soon after the attachment of the skin to the tumor, the axillary glands become affected; prickling of the skin in that region increases; oedema of the arm follows; and great pain is felt from any motion involving the action of the thoracic muscles, as in breathing, AA'hich is often very painful. A dull leaden hue characterizes the aspect of the patient; the countenance is uneasy and depressed; the strength fails; the scent nauseates her; she has pain in the bowels, and the patient sinks under her multiplied maladies. 1111. Carcinoma is rarely developed in the mammary gland before the age of tAventy-eight, though it is sometimes found as soon as the establishment of the function of menstruation, and some few cases are reported where it occurred in children. From 28 to 50 years it is very common. It is sometimes found in women who have attained the age of 90 years. It may attack married or single Avomen, those who are prolific or those Avho are sterile. Celibacy seems to favor the disease, notwithstanding the figures of Dr. Lever to the contrary. For while the percentage in married is to its percentage in single women, as 85 to 6, we must remember that the percentage of married to single women is even greater. 1112. There is, evidently, a cancerous cachexia, but it is very difficult to describe it. It may be known only by experience, in 512 DISEASES OF WOMEN. which it will be observed that such Avomen are those Avho are impressible to misfortune, and who have had much real or imagi- nary trouble. 1113. Those who have a strumous diathesis are most subject to cacoplastic deposits, but to point out any signs which would enable us to say that any woman was liable to or free from the horrors of carcinomatous disease, is out of the question, in our present state of knowledge. Cancer is a local manifestation of a consti- tutional dyscrasia, and we shall generally find, along with the earliest manifestations of the disease, defective nutrition. 1114. To be better enabled to comprehend the disease, its development has been divided into stages, which, however, answers the purposes of convenience only inasmuch as the whole process is a degeneration from the outset, and the constant tendency is to a fatal termination. At first the tumor is found small and rolling like a stone under the integuments, and is generally situated on the peripheral extremity of a lobe. This new groAvth may be attached to the surface of the gland, betAveen it and the integu- ments, and under or in the subcutaneous adipose tissue. In this event, it is called extra-glandular; or Avhen it rises, as it some- times does, from the very center of the gland, it is called intra- glandular. In that event, it is situated immediately behind the nipple and areola. When it becomes attached to the skin, it is said to have passed into the second stage. The adipose tissue has been displaced, the tumor extends right and left, and greedily contaminates the surrounding parts. When the cutis begins to thicken, groAV red and glossy, the third stage is said to have been reached. When the tumor becomes attached to the thoracic walls, it is said to have entered on the fourth stage. In the first of these stages the patient complains of no pain, and this is so true, that she admits considerable manipulation Avithout the mani- festation of any uncommon sensitiveness. When it happens to be in contact with the minute branches of the inter-costal nerves, it is more painful. The pain is of the lancinating kind, and is not confined to the gland. The pain, no doubt, arises from stretching the nervous filaments, and hence the pain is often referred to the sentient extremities of the nerve whose trunk had been thus DISEASES OF THE BREAST. 513 stretched. While the pain in some cases is not intolerable, in other instances it is excrutiatingly severe. The external charac- teristics do not become clear until the third stage has been reached, when an oozing takes place from the cuticular surface, which, drying, forms a scab; in others, a fissure in the skin appears, which at first may, or may not, be attended with redness. At last, however, a redness surrounds the scab or fissure, as the case may be, the discharge is more copious, and soon the surface begins to excoriate, which is evidently a result of carcinomatous contamination. 1115. The fourth stage is that of necrosis, more particularly. Development does not cease here; but the earlier developments die, and fall off. As now seen, the ulcer is a frightful, a gap- ping, and eroded sore, the edges of which are elevated, with deeply excavated, and irregular surfaces, from which there is poured out a most offensive ichor, which is the debris of the decomposed carcinomatous tissue, mixed with serum, serous fluid, and blood. The nipple is often depressed, a circumstance which may arise from the elevation of the surrounding skin, or from the tension made on the tubes attached to it by the growth behind it. 1116. It would be desirable to determine, if possible, the pro- bable duration of the disease, but such an attempt would be futile. Sometimes death will take place in four months; again, it may last many years; but, from my experience, I should be led to say that the disease will run its course in three years, on an average. There is a fact connected with the second stage of carcinomatous growths of the breasts to which I must make some allusion. I refer to the implication of the axillary lymphatic glands, which actually undergo an organic change, and while I do not profess an ability to give a rational explanation of the circum- stance, I must nevertheless remark, that I think the fact is an index to the constitutional management of the disease. The con- stitutional effects of these various stages must claim our attention briefly. Generally, when the tumor appears about the "change of life," we shall be apt to learn that some common malaise has been experienced. The patient does not begin to feel ill until the second and third stages have been established. Her sleep will 33 514 DISEASES OF WOMEN. then be disturbed, she is duller than in ordinary health; she has nausea in the morning, and usually constipation all the time. All these symptoms are intensely aggravated during the fourth stage. The arm of the affected side SAvells, becomes oedematous, and painful on slight motion; the breathing is difficult and the patient is often constantly sick at the stomach. Racking pains are felt in the bones, jaundice supervenes, and great constipation is often experienced. 1117. Of the treatment I shall be brief, for I have already occupied my allotted space. It is universally admitted that the mere removal of the tumor with a knife will not effect a radical cure. If a cure is to be effected in this way, it is when the tumor is in its first stage, and a large part of the sound tissues sur- rounding it have been removed therewith. It is evident that no operation of any kind should be attempted until the constitution is in the best possible state—not until every function is in a state of activity. The disease is both constitutional and local, and in its treatment our remedies must be both general and special. For this reason, when a patient comes to me for treatment it is my first care to put her on a properly nutritious diet; to regulate the functions of the skin, liver, kidneys, etc., to effect which objects, of course a variety of remedial agents are to be employed. Comp. Syrup of Stillingia, Iodide of Potassium, and Prussiate of Iron are usually given, along with such other agents as may seem to be indicated, as narcotics in extreme irritability, stimulants in great depression, etc.; particularly should we look to the digestive functions, and when Ave have removed the anemic habit of the patient, she is then ready for an operation. For the sake of econ- omy the patient is put under the influence of chloroform, and the entire diseased mass is at once removed with the knife, after which I usually cover the surface with some tonic escharotic, as Chloride of Zinc, which seems to act more rapidly and greedily on the car- cinomatous tissue. This is followed by poultices to slough the surface; and again, time after time, Avhile a visible shred of the diseased tissue remains, this plan is followed, during which time the system is toned up to the highest pitch, and the functions are all closely watched. In this way, by the union of constitutional DISEASES OF THE BREAST. 515 and local treatment, if the constitutional stamina is good, we shall often, nay, if we proceed judiciously, nearly always effect a cure. Nor is the cure temporary, as can be demonstrated by cases now in this city, whom I discharged ten or twelve years since. As every case will differ from the common type, we shall be com- pelled to vary our plan of treatment. What I have thus written I know by experience, and I ask that attention to the subject which its great importance demands. The practice here given has been pursued by many who have witnessed my operations and attended my clinic lectures, and I am proud to say with great success. 1118. There are many other forms of disease of the breasts, but as my space is filled, I close this article, by referring the reader to the eighth chapter of my edition Syme's Surgery, for further particulars concerning cancer, its treatment, and the results of my practice. » INDEX. PAGE f 79 Abdominal Manipulation, or hypogastric touch,.... 66 444 Abrasion of Cervix Uteri, 230 114 Abscess of Labia,........ 81 1085 of Breasts,........... 501 781 of the Ovary,......... 375 330 Pelvis,............... 169 960 Amenorrhea,.............444 961 absent Menstruation,.. 444 967 Symptoms,............446 968 Causes,............... 4.47 969 Treatment,........... 447 973 suppressed Menstrua- tion, ............... 448 974 Symptoms,............ 448 977 Diagnosis,............ 449 978 Treatment,........... 450 1 Anatomy of the Female Or- gans of Generation,.... 33 749 Anteflexion of the Uterus, 362 749 Anteversion of the Uterus, 362 751 Causes,............... 363 752 Symptoms,............ 364 754 Diagnosis,............ 364 755 Treatment,............365 105 Apthse of the Vulva,..... 79 49 Bladder, anatomy of,..... 56 188 removal of Calculus from 107 233 disease of, in Cystocele, 124 746 Bond's Instrument for Re- troverted Uterus,....... 360 1041 Breasts, Diseases of,......483 1044 Anatomy of,.......... 484 1080 Inflammation of,......498 PAGE If 1085 Breasts, Abscess of,....... 501 1087 Chronic Abscess of,--- 502 1088 Lactiferous Swelling of, 503 1090 Cellulose Hydatids of,.. 503 1095 Chronic Mammary Tu- mor, ............... 506 1100 Irritable Tumor of,--- 607 1102 Carcinoma, or Cancer of, 608 66 Broad Ligaments,........ 61 1102 Cancer of the Breast,.... 508 1103 Pathology,............ 509 1106 Symptoms,............ 510 1114 Diagnosis,........... 512 1115 Prognosis,............ 513 1117 Treatment, ........... 514 849 Cancer of the Ovary,..... 401 851 Symptoms, ...........402 844 Diagnosis,............ 403 855 Treatment, ...........403 480 Cancer of the Uterus,---249 481 Pathology,............ 250 487 Symptoms,............ 252 494 Diagnosis,............ 255 497 Prognosis,............ 257 498 Treatment,........... 257 256 Cancer of the Vagina,--- 134 258 Diagnosis,............ 135 259 Prognosis,............ 135 260 Treatment,............ 136 650 Cannula, double, for the li- gation of Polypi,........314 Carcinoma of Uterus, See Cancer. 472 Cauliflower Excrescence of Cervix Uteri,..........243 (517) 518 INDEX. PAQI ^ 473 Cauliflower Excrescence of Cervix Uteri—Pathology, 244 475 Symptoms............. 246 476 Diagnosis,............ 247 477 Prognosis,............ 247 478 Treatment,............ 248 479 Excision of the Cervix Uteri in............ 248 433 Caustic in Inflammation of the Cervix Uteri,---223 440 in Hypertrophy of the Cervix Uteri,.......217 462 in Ulceration of the Cervix Uteri,....... 238 478 in Cauliflower Excres- cence, .............. 248 469 in Corroding Ulcer,... 242 499 in Cancer Uteri,...... 257 261 in Cancer Vagina,.... 136 590 Cellular Polypus,......... 292 408 Cervix Uteri Congestion,.. 209 410 Symptoms, ........... 209 413 Causes,.............210 414 Treatment,........... 210 417 Inflammation of,......211 419 Causes, ............ 212 422 Symptoms,......... 214 426 Treatment,......... 218 434 results of Inflammation, 223 444 Erosion of,............230 446 Symptoms,.........232 447 Treatment, ......... 232 436 Hypertrophy of,.......225 437 Causes,............. 225 438 Symptoms,.........226 439 Treatment,.........226 454 Ulceration of,......... 234 458 Symptoms,.......... 236 459 Treatment, .........236 479 Excision of,........... 248 856 Child-bed Fever,......... 404 1016 Chlorosis,................ 467 1017 Pathology,............ 468 1020 Causes,............... 470 1021 Symptoms,---.......471 PAG« 1023 Chlorosis—Treatment,___472 9 Clitoris,................. 37 408 Congestion of Cervix Uteri, 209 410 Symptoms,............ 209 413 Causes,............... 210 414 Treatment,............ 210 634 Conception -with the pre- sence of Polypus,.....308 573 Conception, blighted,..... 286 74 Constitutional efFects of Uterine Disease,........ 64 464 Corroding Ulcer of the Uterus,................ 240 465 Pathology,............ 240 466 Symptoms,............241 468 Diagnosis,............ 242 469 Treatment,........... 242 945 Crural Phlebitis,......... 435 232 Cystocele Vaginal,....... 123 100 Discharges, examination of, 77 71 Diseases of Females, Path- ology of,............... 63 75 Diagnosis of,......... 64 104 of the External Organs of Generation,...... 79 164 of the Urethra,........ 96 192 of the Vagina,........ 109 296 of the Perineum,...... 156 327 of the Pelvic Cellular Tissue,............. 168 343 Venereal,............. 177 399 of the Uterus,........ 206 663 Nervous,........... 321 691 Displacements,...... 333 772 of the Fallopian Tubes and Ovaries,........ 372 955 Functional diseases of, 441 1039 of the Breasts,...... 483 955 Disorders of Menstruation, 441 691 Displacements of the Uterus, 333 794 Dropsy of the Fallopian Tubes,................. 373 789 Dropsy (encysted) of the Ovary,................ 377 * INDEX. 519 PAGE f 559 Dropsy of the Uterus,.... 282 984 Dysmenorrhea,........... 453 985 Neuralgic,............ 453 986 Symptoms, ......... 454 987 Causes,............. 454 988 Treatment,......... 455 992 Inflammatory,........ 457 993 Diagnosis,.......... 457 994 Treatment,......... 458 995 Mechanical,........... 458 996 Treatment,......... 459 653 Ecraseur of Chasaignac,.. 316 980 Electricity in Amenorrhea, 451 721 in Prolapsus Uteri,___348 961 Emansio Mensium,.... 444 1024 Emetics in Chlorosis, ___473 983 Emmenagogues in Ame- norrhea, ............... 452 849 Encephaloid Cancer of the Ovary,................ 401 122 Encysted Tumor of Labia,. 83 124 Diagnosis,.......... 84 126 Treatment,.......... 84 253 of the Vagina,........ 133 789 Dropsy of the Ovary,.. 377 725 Episcraphia,............. 350 444 Erosion of Cervix Uteri,.. 230 446 Symptoms,............ 232 447 Treatment,............ 232 479 Excision of Cervix Uteri,. 248 126 of Encysted Tumor of Labia,.............. 84 130 of Oozing Tumor,..... 86 658 of Uterine Polypi,--- 318 184 of Vascular Tumor of Meatus Urinarius,.. 104 151 of Warty Tumors of Vulva,............. 92 472 Excrescence, Cauliflower,. 243 1 External Organs of Genera- tion, Anatomy of,...... 33 104 Diseases of,........... 79 770 Extirpation of the Uterus, 372 832 in Ovarian Dropsy,... 392 PAGB 41 Fallopian Tubes, Anatomy of,.................... 54 774 Abscess of,........... 373 774 Dropsy of,............ 373 772 Inflammation of,...... 373 774 Obliteration of,....... 373 573 False Conception,........ 286 856 Fever, Puerperal,.........404 631 Fibrous Polypus,......... 305 848 Fibrous Tumors of the Ova- ries, ................. 401 586 of the Uterus,........291 587 Pathological Anatomy of,................. 291 599 Metamorphosis and Dis- eases of,..... ...... 296 612 Symptoms of non-pedi- culated, .......... 300 622 Diagnosis,.......... 302 625 Treatment,......... 303 631 Symptoms of Pedicu- lated, ............ 305 637 Diagnosis,.......... 310 646 Prognosis,.......... 312 647 Treatment,......... 312 •648 by Ligation,........ 312 653 by the Ecraseur,.... 315 657 by Torsion,......... 318 658 by Excision,........ 318 662 by the use of Caustic, 320 264 Fistula Vesico-Vaginal,.. 137 265 Causes,............... 137 266 Diagnosis,............ 138 269 Treatment,........... 139 271 Palliative method,..... 140 272 Desault's method,..... 140 273 Cauterization,......... 141 276 Suture,............... 143 283 Special Instruments for the Approximation of the edges,.......... 147 284 Anaplasty, ........... 147 286 Fistula Recto-Vaginal,--- 149 289 Treatment,........... 150 292 Case of Prof. Freeman,, 151 520 INDEX. PAGE 340 Fistula Vesico-Uterine,--- 173 341 Utero-intestinal,....... 175 342 Recto-vesical,......... 175 574 Fleshy Mole of Uterus,... 287 956 Fluor Albus,............. 442 955 Functional diseases of Ute- rus, ................... 441 4 Genital Organs, anatomy of,.................... 34 344 Gonorrhea,............... 177 345 different varieties of,.. 178 348 Symptoms,........... 178 355 Diagnosis, ............ 182 958 Treatment, .......... 183 650 Gooch's Cannula,......... 314 448 Granular Inflammation of Cervix Uteri,.......... 232 1016 Green Sickness,.......... 314 490 Hemorrhage in Cancer Uteri,.............. 254 475 in Cauliflower Excres- cence, .............. 247 467 in Corroding Ulcer,---242 760 in Inversion of the Uterus, ........... 368 635 Uterine from Polypus,. 308 143 Venous from Vulva,... 90 154 Hernia Vulvar,.......... 93 156 Vaginal, ............. 94 559 Hydrometra,............. 282 560 Varieties, ............ 282 562 Causes,.............. 283 563 Symptoms, ........... 283 565 Diagnosis,............ 284 567 Treatment, ........... 285 577 Hydatids Uterine,........ 288 12 Hymen,.................. 38 196 Persistent,............ 110 193 Imperforate, ..........109 199 Treatment, ......... HO 436 Hypertrophy of CervixUteri, 225 436 Causes,............... 225 438 Symptoms, ........... 226 PAQl 438 Hypertrophy of Cervix Uteri—Treatment,......226 1031 Hysteria,................ 477 1032 Pathology,............ 477 1033 Symptoms,............ 478 1036 Diagnosis,............ 480 1037 Causes,...............480 1038 Treatment ............ 480 508 Hysteritis, ...............262 509 Acute,................ 262 518 Chronic,.............. 266 527 Internal, ............. 270 866 Puerperal,............ 409 133 Imperforate Hymen,...... 109 436 Induration of Cervix Uteri, 225 104 Inflammation of the Vulva, superficial,.......... 79 110 Phlegmonous,....... 80 169 of the Urethra,....... 98 210 of the Vagina, acute.. 115 21* Chronic,............ H8 827 of cellular tissue of Pel- vis, ................ 168 344 Gonorrhea, ........... 177 417 of the Cervix Uteri,... 211 419 Causes,.............212 422 Symptoms,.......... 214 426 Treatment, ......... 218 434 results of,.......... 223 508 of the Uterus,........ 262 509 Acute, ............. 262 518 Chronic,......"...... 266 527 Internal,........... 270 866 Puerperal, ......... 409 772 of the Fallopian Tubes. 373 776 of the Ovaries,........ 374 877 of the Peritoneum..... 412 873 of the Veins and Lym- phatics, ............ 410 757 Inversion of the Uterus... 365 759 Causes, .............. 366 760 Symptoms, .....'..... 268 763 Diagnosis,............ 369 764 Treatment, ........... 369 INDEX. 521 PAGE If 665 Irritable Uterus,......... 322 666 Diagnosis,............ 323 670 Treatment,............ 324 157 Itching of the Vulva,..... 94 6 Labia Majora,............ 35 117 Labia, cohesion of,....... 82 122 Encysted Tumors of,.. 83 115 (Edema of,........... 82 127 Oozing Tumor of,..... 85 138 Thrombus, or Sangui- neous Tumor of,....." 88 134 Varices of,............ 86 296 Laceration of Perineum,.. 156 296 History,.............. 156 298 Causes,............... 157 299 Means of Prevention,.. 158 301 Consequences of,...... 159 302 Treatment, ........... 159 306 operation of Mr. Baker Brown,............. 161 307 Contra-indications to operating,.......... 161 308 Time of operating,--- 162 310 Instruments required,. 162 312 Mode of operating,___ 163 314 Division of the Sphinc- ter Ani,............ 164 315 Insertion of the Quill Sutures,___........ 164 316 Insertion of the Inter- rupted Sutures,......165 319 Operation in recent cases,.............. 166 320 After-treatment,...... 166 956 Leucorrhea,.............. 442 423 from Cervical Canal,.. 215 527 Uterine,.............. 270 218 Vaginal,.............. 118 648 Ligature in Polypus Uteri, 312 151 in Warty Tumors of Vulva, ............. 92 184 in Vascular Tumor of Meatus Urinarius,.. 104 772 in Inverted Uterus . . 372 PAGE 65 Ligaments of the Uterus,. 61 66 broad,................ 61 67 round,................ 62 1041 Mammary, diseases of,.... 483 1080 Inflammation of,...... 498 1085 Abscess of,........... 501 1087 Chronic Abscess of,---502 1088 Lactiferous swelling of, 503 1090 Cellulose Hydatids of,. 503 1095 Chronic Tumor of,.... 506 1100 Irritable Tumor of,---507 1102 Cancer of,............ 508 11 Meatus Urinarius,........ 38 180 Vascular Tumor of,... 104 995 Mechanical Dysmenorrhea, 458 999 Menorrhagia, with the dis- charge of the normal menstrual fluid,........ 460 1000 Symptoms,............ 460 1001 Causes,............... 461 1002 Treatment,............ 461 1007 with the discharge of blood difectly from i the uterine vessels,.. 462 1008 Symptoms,.......... 462 1011 Causes,............. 465 1012 Diagnosis,.......... 465 1013 Treatment,.......... 465 961 Menses, Abscesses of,..... 444 973 Suppressed,........... 448 961 Menstruation, absent, .... 444 973 Suppressed,........... 448 999 Excessive,...........460 984 Painful,.............. 453 975 Vicarious,............ 449 944 Milk-leg,................ 435 571 Moles,................... 286 574 Fleshy,............... 287 577 Vesicular,............ 288 580 Symptoms,............ 289 583 Diagnosis,............ 290 584 Treatment,............ 290 5 Mons Veneris,............ 34 522 INDEX. PAQX 985 Neuralgic Dysmenorrhea,. 453 986 Symptoms,............ 448 987 Causes,............... 449 988 Treatment,............ 450 663 Nervous affections of the Uterus,................ 321 8 Nymphae,................ 36 177 Occlusion of the Urethra,. 103 179 Treatment,............ 103 198 of the Vagina,........ 113 199 Treatment,.......... 114 115 (Edema of the Labia,..... 82 121 Inflammatory,......... 83 127 Oozing Tumor of Labium, . 85 130 Treatment,............ 85 457 Os Uteri, ulceration of,--- 235 423 Dilatation of, in Inflam- mation, ............. 214 43 Ovaries,................. 55 776 Inflammation of,...... 374 778 Causes,............ 374 779 Symptoms,.......... 374 781 Terminations,....... 375 783 Diagnosis,.......... 376 784 Treatment,.......... 376 881 Puerperal,.......... 413 847 Tumors of,............ 401 848 Fibroid Tumors of,---401 849 Cancer of,............ 401 851 Symptoms,.......... 402 854 Diagnosis,.......... 403 855 Treatment,.......... 403 789 Ovarian Dropsy,.......... 377 790 Pathology,............ 378 792 Simple Cysts,......... 378 794 Multilocular, or Prolifer- ous Cysts,.......... 379 796 Structure,........... 380 799 Contents,........... 382 800 Symptoms,.......... 382 803 Diagnosis,.......... 383 813 Treatment,..........385 815 by Compression and Pal- pation, ............. 385 PAO« 816 Ovarian Dropsy—by Tap- ping, ............... 386 819 Tapping with Pressure, 388 820 Tapping and Injection of Iodine,.......... 388 82() Artificial Oviduct,..... 389 830 Excision of a portion of the Cyst,............ 391 832 Extirpation,...........392 832 Ovariotomy,.............. 392 833 reasons for and against, 392 838 conditions rendering it justifiable,.......... 394 839 preparations for the ope- ration, ............. 395 840 mode of operating,.....396 843 dangers to be apprehend- ed after,............ 399 776 Ovaritis,................. 374 70 Pathology, Uterine,...... 63 62 Pelvic Fascia,............ 60 330 Pelvic Abscess,........... 169 327 Cellulitis,............. 168 327 History,.............. 168 329 Causes,............... 168 330 Terminations,........,. 169 331 Duration,............. 170 332 Symptoms,............ 170 333 Diagnosis,............ 171 334 Treatment,............ 171 338 Fistulous passages re- maining after,...... 173 340 Cases of,.............. 173 52 Perineum,................ 58 296 Perineum, Laceration of,.. 156 877 Peritonitis, Puerperal,---412 714 Pessaries,................ 343 944 Phlebitis, Crural, ........435 873 Uterine,..............410 944 Phlegmasia Dolens,....... 435 945 Pathology of,.......... 436 946 Symptoms,..........437 950 Diagnosis,.......... 439 951 Treatment,..........439 INDEX. 523 PAGE 110 Phlegmonous Inflammation of Labia,........... 80 111 Causes,............... 80 112 Diagnosis,............ 80 113 Treatment,............ 81 550 Physometra,............. 279 554 Symptoms,............281 556 Diagnosis,............ 281 667 Treatment,............ 282 631 Polypus Uteri—Symptoms,. 305 637 Diagnosis,............ 310 646 Prognosis,............ 312 647 Treatment,............ 312 648 by Ligation,........... 312 653 by the Ecraseur,...... 315 657 by Torsion,........... 318 658 by Excision,.......... 318 662 by the use of Caustic,.. 320 693 Procidentia Uteri,........ 334 693 Prolapse of the Uterus,... 334 697 Causes,....;.......... 334 703 Symptoms,............ 339 709 Diagnosis,............ 340 710 Treatment,............ 341 711 by rest in the horizontal position,............ 341 712 by Astringent Injections, 341 714 Pessaries,............. 343 718 Rational Method....... 346 721 Galvanism,........... 348 724 Perineal Supporter,--- 349 725 Episcraphia,.......... 350 231 Prolapse of Vagina,...... 122 232 Prolapsus Vesicae,........ 123 157 Pruritus of Vulva,........ 94 158 Symptoms,............ 94 i60 Treatment,............ 95 , 856 Puerperal Fever,......... 404 858 Causes,............... 404 864 Pnthologica) Anatomy,. 407 866 Puerperal Endometritis, 409 873 Inflammation of Veins & Lymphatics of Uterus, 410 877 Inflammation of the Peritoneum,......... 412 PAGB f 881 Puerperal Fever—Puerperal Ovaritis, ........... 413 885 Pathological changes in other portions of the system,............ 414 904 Secondary terminations, 420 907 Symptoms,............ 121 908 Symptoms of the Inflam- matory form,........421 913 Symptoms of the Ty- phoid form,....... 423 921 Diagnosis,..........426 926 Prognosis,.......... 428 927 Treatment,......... 428 286 Recto-Vaginal Fistula,--- 149 289 Treatment,............ 150 292 Case of Prof. Freeman, 151 240 Rectocele,................ 128 727 Retroflexion of Uterus,---350 727 Retroversion of Uterus,... 350 729 Causes,............... 352 730 Symptoms,........... 352 735 Diagnosis,............ 355 738 Treatment,............ 356 676 Rheumatism of Uterus,... 326 677 Causes,............... 327 678 Symptoms,............ 327 683 Influence on the progress of Pregnancy,.......329 684 Influence on Labor,.. . 330 686 - Diagnosis,.......... 331 687 Treatment,......... 331 85 Ricord's Speculum,....... 71 296 Rupture of Perineum,.... 156 293 of Vagina,............ 154 138 Sanguineous Tumor of the Labia,.............. 88 140 Diagnosis,............ 89 141 Treatment,............ 89 849 Scirrhus of the Ovary,---401 489 of the Uterus,-------- 249 100 Secretions, examination of, 77 88 Simpson's Uterine Sound,. 72 4 INDEX. PAGE 84 Speculum, use of,......... 70 85 Ricord's,.............. 71 85 Ferguson's,........... 71 175 Stricture of the Urethra,.. 102 176 Treatment,............ 102 202 Stricture of the Vagina,.. .113 205 Treatment,............ 114 364 Syphilis,................. 186 366 Stages of,............. 188 369 Inoculation,........... 189 370 Simple Chancre,....... 190 371 Indurated, or Hunterian Chancre,........... 190 372 Phagedenic Chancre,... 191 377 Secondary Symptoms,.. 192 382 Syphilitic Vegetations,. 197 383 Mucous Tubercles,..... 198 385 Diagnosis,............ 198 388 Treatment of Primary,. 200 392 Treatment of Secondary, 203 816 Tapping in Ovarian Dropsy, 386 819 with Pressure,......... 388 820 with Injection of Iodine, 388 138 Thrombus, or Sanguineous Tumor of the Labia,... 88 140 Diagnosis,............ 89 141 Treatment,............ 89 657 Torsion for removal of Polypi,............... 318 80 Touch, as a means of Diag- nosis, ................. 67 60 Transversus Perinsei,..... 60 55 Triangular Ligament,.... 59 122 Tumors, Encysted, of the Labia,.............. 83 127 Oozing of the Labia,... 85 138 Sanguineous of the La- bia, ................ 88 148 Warty, of the Vulva,.. 92 180 Vascular, of the Meatus Urinarius,.......... 104 253 of the Vagina,........ 133 586 Fibroid, of the Uterus,. 291 612 Non-pediculated,...... 300 PAQl 631 Tumors—Pediculated (Poly- pi,) ................ 305 847 of the Ovary,......... 401 550 Tympanitis, Uterine,...... 279 464 Ulcer, Corroding,......... 240 454 Ulceration of the Cervix Uteri,..............234 458 Symptoms,............ 236 459 Treatment,............ 236 49 Urethra,................. 56 188 Dilatation of, for remo- val of Calculi,...... 107 168 Inflammation of,....... 98 180 Tumors at orifice of,... 104 175 Stricture of,........... 102 185 Foreign bodies in,..... 106 168 Urethritis,............... 98 169 Symptoms,............ 98 170 Treatment,............ 99 527 Uterine Leucorrhea,....... 270 559 Dropsy,.............. 282 873 Phlebitis,............. 410 88 Sound,............... 72 550 Tympanitis,........... 279 23 Uterus, Anatomy of,...... 43 749 Anteflexion of,........ 362 749 Anteversion of,....... 362 480 Cancer of,............ 249 480 Carcinoma of,......... 249 472 Cauliflower Excrescence of,................. 243 464 Corroding Ulcer of,--- 240 399 Diseases of the,.......206 691 Displacements of the,.. 333 559 Dropsy of the,......... 282 771 Extirpation of the,--- 372 586 Fibroid Tumors of,--- 291 508 Inflammation of,......262 509 Acute,.............. 262 518 Chronic,............ 266 527 Internal,........... 270 757 Inversion of,.......... 365 665 Irritable,............. 322 571 Moles and Hydatids of, 286 INDEX. 525 PAGE f 631 Uterus, Polypus of,........305 693 Prolapse of,........... 334 727 Retroflexion of,........ 350 727 Retroversion of,...... 350 676 Rheumatism of,........ 326 192 Vagina, Diseases of,...... 109 256 Cancer of,............. 134 210 Inflammation of,...... 115 210 Acute,.............. 115 218 Chronic, ........... 118 192-198 Occlusion of the,...... 109 231 Prolapse of,........... 122 232 the Anterior Wall,.. 123 240 the Posterior Wall,.. 128 249 Entire Circumference, 131 293 Laceration of,___.___ 154 202 Stricture of,.......... 113 253 Tumors of,............ 133 232 Vaginal Cystocele,........ 123 233 Symptoms,............ 123 234 Diagnosis,............ 124 235 Treatment,............ 124 80-84 Vaginal Examination,.... 67 218 Leucorrhea,........... 118 240 Rectocele,............. 128 241 Causes,............. 129 242 Symptoms,.......... 129 244 Diagnosis,.......... 130 245 Treatment,..........130 210 Vaginitis, Acute,......... 115 212 Causes,............. 116 213 Diagnosis,...........116 214 Treatment,.......... 117 218 Chronic,.............. 118 ;221 Symptoms,.......... 118 223 Diagnosis,.......... 119 224 Treatment,.......... 120 134 Varices of the Labia,..... 86 135 Causes,............... 87 136 Treatment,............ 87 577 Vesicular Mole,..........288 264 Vesico-Vaginal Fistula,... 137 265 Causes,............... 137 PAGE 266 Vesico-Vaginal Fistula— Diagnosis,............ 138 269 Treatment,............ 139 271 Palliative Method,..... 140 272 Desault's Method,..... 140 273 Cauterization,......... 141 276 Suture,............... 143 283 Special Instruments for Approximation of the Edges,.............. 147 284 Anaplasty,............ 147 340 Vesico-Uterine Fistula,... 173 873 Veins of Uterus, Inflamma- tion of,............... 410 10 Vestibule,................ 38 975 Vicarious Menstruation,.. 440 104 Vulva Superficial, Inflam- mation of,.......... 79 105 Appearances,......... 79 106 Causes,......v........ 79 107 Treatment, ........... 79 110 Phlegmonous Inflamma- tion of,........... 80 111 Causes,............. 80 112 Diagnosis,.......... 80 113 Treatment,...........81 143 Venous Hemorrhage from 90 148 Warty Tumors of,..... 92 149 Symptoms, ......... 92 150 Causes, ............ 92 151 Treatment,.......... 92 157 Pruritus of,........... 94 158 Symptoms,......... 94 160 Treatment,......... 95 122 Tumors of the,........ 83 154 Vulvar Enterocele,........ 93 155 Treatment,............ 93 148 Warty Tumors of the Vulva, 92 149 Symptoms,.......... 92 150 Causes,............. 92 151 Treatment,.......... 92 253 of the Vagina,........ 133 956 Whites,.................. 442 *J:» &T5H *i~\ *lU *:* a- ■% ,'M km *■ ■.*: S" .-'-a 1$ - - —.O *> » r/l &■"► *5: . .. 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