3Nnm3w do Aavaan tvnouvn 3NOia3w do Aavaan tvnouvn 1 / If-' x v NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE S Wl ±w? N t7 ' ^ § "^ N s7 SNiDiasw do Aavaan tvnouvn 3Nioia3w do Aavaan tvnouvn snidiosw do Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE SNmasw do Aavaan tvnouvn snidiqsw do Aavaan tvnouvn snidiqsw do Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE aNiDiasw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn 3noio3w do Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE SNiDiasw do Aavaan tvnouvn 3nidiq3w do Aavaan tvnouvn 3nidic]3w do Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NLM005808901 snidiosw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn c ill T3 NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE 3NOIQ3W jo Aavaan tvnouvn aNiDiaaw jo Aavaan tvnouvn 3nidichw do Aavaan tvnouvn o NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE snidiosw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE snidiosw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn ' snidiosw do Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE snidiosw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE te^r Guernseys Obstetrics. v THE APPLICATION PRINCIPLES AND PRACTICE OF HOMCEOPATHY OBSTETEICS DISORDERS PECULIAR TO WOMEN AND YOUNG CHILDREN. BY HENRY N. GUERNSEY, M.D., FORMERLY PROBaSSOB «P«©«MB!BB4C&..41N_P DISEASES OF WOMEN AND CHILDREN IN THE H0MC30PATHIC MEDICAL COLLEGE OF PENNSf LVANf A ? TBQBMSSO&, OF MATERIA MEDICA IN THE HAHNEMANN MEDICAL COLLEGE OF PHILA- DELPHIA ; MEMBER OF THE AMERICAN INSTITUTE OF HOMCEOPA- THY ; HONORARY MEMBER OF THE HAHNEMANNIAN SOCIETY OF MADRIS DE TTXLIO, ETC. WITH JYUMfiHOZTS IZZZTSTftATIOJYS. SECOND EDITION. REVISED, ENLARGED AND GREATLY IMPROVED. BOERICKE & TAFEL, NEW YOKE: 145 Grand St. PHILADELPHIA: 635 Arch St., and 125 South Eleventh Street. ENGLAND: HENRY TURNER & CO., LONDON AND MANCHESTER. 1873. WQ I8Y3 Entered according to Act of Congress, in the year 1873, by H. N. GUERNSEY, M.D., In the Office of the Librarian of Congress, at Washington. Sherman & Co., Printers, Philada. Westcott & Thomson, Slereotyp«r$ and Electrotypers, Philada. PREFACE TO THE FIRST EDITION. In preparing this work for the press, I need not remark upon the great interruption a large practice and the great labor of lecturnig one hour or more every day in the week for six months out of the twelve upon some medical subject, and many other duties at the College besides, have occasioned. Very many physicians can testify to the all-engrossing of almost every moment of time in conducting a large practice. Add to this the labor as above indicated, and most physicians can understand that it is an easy matter for many imperfec- tions to creep into a work of this size, prepared under such pressing circumstances. No one can be more conscious of these imperfections than myself. This being the pioneer of all works of this kind ever published, it will be an easy mat- ter to offer criticisms and to improve on the issue of future editions. The same reasons have compelled the long delay in the publication of the work, due entirely to the impossibility of more rapidly supplying the copy. Nor indeed could the work have made its appearance so promptly, but for the assistance rendered by my friend and colleague, J. H. P. Fkost, M. D., in preparing the physiological parts, description of diseases, etc., and in carrying the whole through the press. Both the author and publisher desire to acknowledge the liberality of Messrs. Lindsay & Blakiston in furnishing a considerable part of the illustrations employed in this work. The plan of treatment may seem to some rather novel, and perhaps, on its first view, as objectionable, inasmuch as it may seem like prescribing for single symptoms; whereas such is 7 8 PREFACE TO THE FIRST EDITION. not the fact. It is only meant to state some strong charac- teristic symptom, which will often be found the governing symptom, and on referring to the Symptomen Codex all the others will surely be there if this one is. There must be a head to everything; so in symptomatology—if the most in- terior or peculiar, or key-note, is discernible, it will be found that all the other symptoms of the case will be also found under that remedy that gives existence to this peculiar one, if that remedy is well proven. It will be necessary, in order to prescribe efficiently, to discover in every case that which characterizes one remedy above another in every combination of symptoms that exists. There is certainly that, in every case of illness, which pre-eminently characterizes that case, or causes it to differ from every other. So in the remedy to be selected, there is or must be a combination of symptoms—a peculiar combination, characteristic, or more strikingly key- note. Strike that and all the others are easily touched, attuned or sounded. There is only one key-note to any piece of music, however complicated, and that note governs all the others in the various parts, no matter how many variations, trills, accompaniments, etc. Such a work as the present was needed, indeed urgently called for, and I have spared no pains to render it useful to students and to the junior members of the profession, for whom it was especially designed, and to whom it is respectfully dedicated by THE AUTHOB. PREFACE TO THE SECOND EDITION. In placing before the profession a second edition of his work the author desires to call attention to the fact that he has endeavored to make it more acceptable and valuable by a thorough revision of the entire text of the first edition; by rewriting parts, and even whole chapters, wherever it was deemed necessary to do so ; by a free consultation of the most recent authorities, thus bringing it up to the advanced opin- ions of the day; and especially by the addition of much new material, chiefly gathered from the writings of experienced homoeopathic practitioners, from the valued verbal communi- cations of numerous esteemed professional friends, and from personal experience. While, however, new measures of practice have been introduced, nothing has been recommended that has not fully borne the test of practical experimentation. Thus, for instance, in the use of the forceps in breech pres- entations, mentioned on page 260, while it may seem to many a novel and problematical procedure, yet it has re- ceived the endorsement of Dr. James Kitchen, of Philadel- phia, one of the most experienced and skillful of accoucheurs, of the author, and of other practitioners. It is proper that the author should here place on record an expression of his increased confidence in the methods of practice strictly medical which were laid down in the first edition of the work, and which were regarded by certain critics as chimerical. Increased experience has only served 9 10 PREFACE TO THE SECOND EDITION. to add to the author's faith in the efficiency of homoeopathic medication in the greatest exigencies of life, and this faith has been additionally strengthened by the related experience of many of the most eminent and skillful practitioners of the homoeopathic school. The Clinical Index, it is hoped, will prove a great help to the busy practitioner. By it the therapeutical parts of the work may be read " cross-wise," as Dr. Hering expresses it, which will facilitate the selection of the remedy at the bed- side. A copious General Index has been supplied to this edition, a glance at which will indicate the additions and improvements that have been made. The author desires to express his thanks to the many friends who have kindly made suggestions for the improve- ment of this edition, and to acknowledge his special obliga- tions to Dr. B. J. McClatchey, of Philadelphia, editor of the Hahnemannian Monthly, for valuable assistance in pre- paring the material for, and carrying the work through, the press. 1423 Chestnut Street, Philadelphia, August 1, 1873. A Treatise on Obstetrics. CHAPTEB I. THE BONES OF THE PELVIS. OBSTETRICS, as a science and as an art, has relation to the phe- nomena of pregnancy and parturition considered as physiological processes. Its study naturally includes a consideration of the develop- ment necessary to the occurrence of pregnancy, the period of preg- nancy itself, and the conditions which, succeeding parturition, may be regarded as its consequences. At the same time, however, all inequalities in form and function, and all difficulties and disorders attendant upon, connected with, or following after these processes, with their proper treatment, must be thoroughly understood, in order that the student may become an accomplished and successful ac- coucheur and physician. The anatomy and physiology of the pelvis, therefore, and of the parts of which it is composed, of the organs which it contains, and of those which are functionally associated with them, demand the first attention. And it is to be remembered that no mere description of these several organs and regions can alone be sufficient to impart a knowledge of them adequate to the purposes of the obstetrician, for the bones of the pelvis and their relations to each other, the pelvis as a whole and its relations to the mechanism of pregnancy and parturition, and the soft parts in situ, must be care- fully and scrutinizingly studied, on the skeleton and on the cadaver. In describing the anatomy of these parts and organs, a well-formed adult—having passed through the successive stages of progressive development, from the embryonic formation to that of maturity—is taken as a standard. The Pelvis is composed of four bones—viz., the sacrum, the coccyx, and the ossa innominata. The sacrum and coccyx form the posterior part of the pelvis, and are placed on the median line, while 11 12 bones of the pelvis. the ossa innominata form the sides and front. These bones unitedly form a cavity or basin (xs/ms, a basin), which gives general support to the contents of the abdomen, and the surfaces of which afford places of attachment to numerous muscles. In the adult it occupies the centre of the body, and is interposed between the lower end of the vertebral column, to which it gives support, and the inferior extremi- ties, upon which it rests; articulating superiorly with the last lumbar vertebra, and inferiorly with the femoral bones. In the erect position it is placed obliquely with regard to the trunk of the body; the inner surface of its anterior wall—the symphysis pubis—looking upward and backward, while the inner surface of its posterior wall—the sacrum—looks downward and forward. A brief description of the several bones which compose the pelvis will prepare the way for a more particular account of it. The Sacrum is the largest bone of the series of vertebra?, and is situated at the lower part of the spinal column and at the superior and posterior part of the pelvis, presenting the appearance of a wedge forced between the ossa innominata. It is concave in front and con- vex behind, and is curved upon itself from above downward and for- ward. Superiorly it articulates with the last lumbar vertebra. This articulation, owing to the projection forward of the anterior part of the articulating surface of the sacrum, and to the projection backward from this point of the body of the bone, forms a considerable promi- nence called the sacro-vertebral angle, or promontory of the sacrum, the angle being obtuse relatively with the lumbar portion of the vertebral column. Inferiorly the sacrum articulates with the coccyx. It is from four to four and a half inches in length and of nearly equal breadth, but in consequence of its spongy texture and the numerous foramina by which it is perforated, it is the lightest bone, for its size in the skeleton. It is triply wedge-shaped, as will be shown by the following description: In the first place, it is wider at its base, supe- riorly, than at its apex, having a breadth above of four and a half inches, from which it rapidly tapers toward its coccygeal extremity • secondly, it is broader on its anterior than on its posterior surface • and, thirdly, while the antero-posterior thickness of the bone at its base is two and a half inches, that of the apex is usually not more than two lines. It presents for examination an anterior and a pos- terior surface, two lateral surfaces, a base, an apex, and a central canal. The anterior surface is comparatively smooth and concave. This concavity is an important feature in the construction of the pelvis • THE sacrum. 13 varying in degree in different subjects, being usually estimated at from one-half to three-fourths of an inch. In the middle of this depres- sion there are four transverse ridges, which show the lines of union of the five segments of bone of which the sacrum is originally com- posed. At the ends of each of these ridges are the anterior sacral foramina—eight in number—through which pass the anterior branches of the sacral nerves. These foramina are rounded in form, the supe- rior being the largest and the inferior the smallest. Opposite to the extremities of the ridges above described, the margins of the foramina are beveled to form a groove, which runs toward the lateral mar- gins of the bone, so that on their outer side the nerves transmitted are in a great measure protected from pressure by the descending head, during parturition, by being thus sunk below the surface of the bone. On the inner side, the transverse ridges themselves answer a similar purpose of preventing undue pressure upon the nerves, which pass as it were beneath them. External to these foramina, on either side, are the lateral masses of the bone, which complete its anterior surface. The posterior surface is very rough, irregular, convex and much narrower than the anterior surface. Along the median line it is studded with eminences—rudimentary spinous processes—which af- ford greater surface and security to the muscles that originate from, and that are inserted into, the sacrum. These processes and tubercles form an irregular bony ridge, whose projections afford greater firm- ness of attachment to the numerous ligaments which unite this bone to the os innominatum of either side; while the general contour of the ridge itself renders the convexity of this posterior surface even greater than the corresponding concavity of the anterior surface. This convexity presents in both directions, longitudinally and laterally; so that the slope from the posterior surface inclines toward each lateral border, as well as toward the base above and the apex below. At the base of the spinous ridge, and immediately external to it, are the lamince, broad and well marked superiorly, but narrower and less pronounced as the apex is approached; while external to the laminae are a series of indistinct tubercles which correspond to the articulating processes of the lumbar vertebrae. The first or upper pair are large and well developed, the second and third more indistinct, and the fourth and fifth, which are usually blended together, are called the sacral cornua, and articulate with corresponding processes of the coccyx. External to these processes on either side are four posterior sacral foramina, through which are transmitted the posterior branches of the sacral 14 BONES OF THE PELVIS. nerves. On the outer side of these foramina, a second series of indis- tinct tubercles will be found, which constitute the rudimentary pos- terior transverse processes of the sacral vertebrae. The sacral canal extends centrally throughout the greater part of the bone. In its lower portion it is often incomplete in consequence of the non-development of the spinous processes and laminae. It is triangular above, follows the curvature of the sacrum, and is both narrowed and flattened from before backward in its descent toward the apex. It gives lodgment to the sacral nerves, which pass out through the anterior and posterior sacral foramina by which the canal is perforated. Each lateral border is divided into two distinct parts, a superior or iliac and an inferior part. The superior, auricular or ear-shaped part is covered by cartilage for articulation with the ilium. Posteri- orly it is marked by irregular impressions, to which the posterior sacrao-iliac ligaments are attached. The inferior part of the lateral border is thin and curved, and gives attachment to the greater and lesser sacro-ischiatic ligaments and to some portions of the gluteus maximus muscle. The anterior branch of the fifth sacral nerve passes through a small indentation at the lower edge of this border and at its angle of junction with the coccyx. The base is directed upward and a little forward, and is largest in its transverse diameter. In the middle and anteriorly it is sur- mounted by a transverse oval surface, placed obliquely, to correspond with the body of the last lumbar vertebra, with which it is articulated by the medium of intervertebral cartilage. Upon each side of this articulating facet a smooth surface is observed, concave transversely, convex from before backward, inclined forward, covered in the recent subject by the anterior sacro-iliac ligaments, and continuous with the iliac fossa. The anterior margin of these surfaces is formed of a rounded lip or border, which separates them from the anterior sur- face, and forms the posterior part of the superior strait, as will be hereafter shown. Behind the -articulating surface is observed the orifice of the sacral canal, and the two articular processes of the upper segment of the bone. The apex is directed downward and a little forward, and presents a transverse oval surface by which it is articulated with the coccyx. In the female the sacrum is broader than in the male; less curved especially in its upper part; and directed more obliquely backward : thus at the same time increasing the projection of the promontory of the sacrum, and the capacity of the cavity of the pelvis. THE ILIUM. 15 The pyriformis and coccygeus muscles are attached to the sacrum on either side; the gluteus maximus and erector spinse behind. The Coccyx corresponds to the sacrum in general appearance, shape, and mode of formation. From the gradual diminution in size, from above downward, of the four or five pieces of which it is composed, it presents the form of an inverted triangular pyramid. Its anterior surface is concave, and marked by three transverse grooves. It gives attachment to the levator ani muscle, the anterior sacro-coccy- geal ligament, and affords support to the lower portion of the rectum. The posterior surface is convex, marked by similar grooves, and pre- sents on each side a row of tubercles. The superior and largest pair of these—the cornua of the coccyx—project upward to articulate with the cornua of the sacrum; by which articulation the fifth sacral foramina is formed, for transmitting the posterior branch of the fifth sacral nerve. The posterior surface of the coccyx is covered in by and gives attachment to the posterior sacro-coccygeal ligament, and has attached to it some fibres of the gluteus maximus muscle. The borders of the bone are thin, and give attachment to the coccygeus muscle and the sacro-sciatic ligaments. To the rounded apex is at- tached the tendon of the external sphincter ani muscle. The only articulation of the coccyx is with the sacrum above, by means of an oval articulating surface. The Os Innominatum is so called from the impossibility of giving it a truly descriptive name. The bone is developed from three primary centres of ossification, and in early life consists of three separate pieces, which are then regarded as distinct bones, and named the ilium, the ischium and the pubis. These subsequently become united to form a single bone, but in the maturer subject the same names are employed to designate the respective portions of this large, irregular and anoma- lous bone. The ilium occupies the side, the ischium the inferior and posterior portion, and the pubis the anterior part of the pelvis. These three bones coalesce on either side, uniting at the acetabulum or cup-shaped cavity for the reception of the head of the femur, and at the ascending and descending ischio-pubic rami, and thus form the os innominatum. It will be more convenient first to describe by itself each of these constituent bones; afterward to consider them as they unite to form one single bone. The Ilium, the largest of the three, presents an external and an internal surface, an anterior and a posterior border, and a crest. The external surface, or dorsum of the ilium, is bounded above by 16 BONES OF THE PELVIS. the crest; below by the acetabulum; and in front and behind by the anterior and posterior borders. It is alternately convex and concave, broad and smooth, forms the external iliac fossa, and is crossed in a curved direction by three lines—the superior, middle and inferior curved lines. It gives attachment, principally, to the gluteus maximus, medius and minimus muscles, which make up the full and rounded contour of the hip. The internal surface is bounded above by the crest, below by a well- marked ridge called the ilio-pectineal line, and in front and behind by the anterior and posterior borders. It may be divided into two parts. The anterior part is a smooth and concave surface, of con- siderable extent, called the internal iliac fossa, or venter of the ilium, and gives lodgment and attachment to the iliacus interims muscle. The posterior portion, lying behind the iliac fossa, consists of two portions; a superior, which is rough, uneven and irregularly shaped, gives attachment to the sacro-iliac ligaments; and an inferior or auricular portion, which is uneven, is covered with cartilage in the recent state, and articulates with the corresponding ear-shaped portion of the lateral border of the sacrum. The crest of the ilium, longer in the female than in the male, is thick, convex, and arched. Its terminations in front and behind form prominent eminences, which are termed respectively the anterior and posterior superior spinous processes. The former, or anterior superior spinous process, gives attachment to Poupart's ligament, and to the sartorius and tensor vaginae femoris muscles. Into the latter, or posterior superior spinous process, are inserted strong ligaments which aid in firmly uniting the ilium to the sacrum. The outer edge or lip of the crest gives attachment to the tensor vaginae femoris, obliquus externus abdominis, and latissimus dorsi muscles, and the fascia lata—a dense fascia which covers in, and by its inner surface gives attachment to, the muscles of the hip and thigh. The inner lip has attached to it the transversalis, quadratus lumborum, and erector spinae muscles; while between the two attachment is given to the obliquus internus abdominis muscle. The anterior border of the ilium extends from the anterior superior spinous process to the ilio-pectineal eminence. It presents two de- pressions, which are separated by the anterior inferior spinous process. To the edge of the upper depression, which is a lunated notch, some fibres of origin of the sartorius muscle are attached, while the external cutaneous nerve passes across it. The straight tendon of the rectus femoris muscle arises from the anterior inferior spinous process. Be- tm THE PUBIS. 17 low this process is a shallow notch or groove, which completes the anterior border of the ilium, and across which the iliacus muscle passes. The posterior border, which is shorter than the anterior, extends from the posterior superior spinous process above to a deep notch be- low—the great sacro-sciatic notch—its termination being marked by a projecting process of bone, the posterior inferior spinous process. The upper portion of this border corresponds with that portion of the dorsum of the ilium which gives attachment to the sacro-iliac liga- ments ; the lower portion to the auricular surface which articulates with the sacrum. The Ischium, the second in size and lowest in position of the bones forming the os innominatum, is divided into a base or body and a ramus or branch. The base is the thickest part, and forms a larger portion of the acetabulum than does the ilium. From the posterior border of the bone arises the spinous process of the ischium, which marks the inferior boundary of the great sacro-sciatic notch. This process gives attachments to the gemellus superior, coccygeus, and levator ani muscles, and the lesser sacro-sciatic ligaments. Below it will be found a smaller notch, the lesser sacro-sciatic notch. The outlet of the pelvic cavity is sometimes materially affected by the ab- normal length and internal inclination of the spinous process or spine of the ischium; which hence becomes an important element in deter- mining the obstetric capacity of the pelvis itself. The tuberosity of the ischium forms the part upon which the body rests in the sitting position. It gives attachment to numerous muscles, and to some of the ligaments of the pelvis. The ramus of the ischium, thin and flattened, extends from the tuberosity upward and inward to join the ramus of the pubis. Its lower border forms part of the outlet, and its inner surface forms part of the anterior wall of the pelvis. The Pubis, the smallest of the three divisions of the os innomina- tum, with its fellow of the opposite side, forms the pubic arch or anterior portion of the pelvis. It may be divided for the sake of description into a body or horizontal ramus and a descending ramus. The horizontal ramus presents at its inner extremity the symphysis, marked on its surface by a number of transverse ridges separated by grooves, which serve for the attachment of the interarticular fibro- cartilage placed between the two pubic bones. The upper surface of this ramus is bounded posteriorly by a sharp ridge of bone, the linea ilio-pectinea, which marks the brim of the true pelvis. The internal surface of the horizontal ramus is smooth, and forms a portion of the 2 18 BONES OF THE PELVIS. anterior wall of the pelvis. The descending ramus is that portion of the bone which extends outward and downward to join with the ascending ramus of the ischium; the point of union is generally marked by a slight ridge. It becomes thin and narrow as it de- scends ; is smooth on its inner surface, and rough externally for the attachment of muscles. The pubic bones are not in actual contact at the symphysis, but are separated by fibro-cartilage, as mentioned above. These cartilages are remarkably adapted to promote elasticity of the pelvis. In some instances the state of this inter-pubic fibro- cartilage is such as to form a false joint, as it were, and to admit so much lateral movement between the pubic bones as to greatly impede locomotion. The acetabulum, or cotyloid cavity of the os innominatum, is the circular, cup-shaped depression for the reception of the head of the femur. The ischium forms something more, and the ilium something less, than two-fifths each of this depression, and the pubis the remain- der. Thus the acetabulum forms the centre of union of the three bones which compose the os innominatum; and these three original bones, which, for distinction's sake, have thus been separately de- scribed, unite to form the os innominatum, which latter must there- fore be regarded as one bone. The obturator, or thyroid foramen, or foramen ovale, as it is some- times termed, large and irregularly oval in the male, but smaller and triangular in shape in the female, is a large aperture situated between and formed by the ischium and the pubis. Formed on the same principle of the double arch which is seen on a larger scale in the construction of the pelvis, it gives lightness to the bone, with strength. Its margins, which are thin and uneven, have attached to them a strong membrane, the obturator ligament or membrane, which covers in the entire foramen excepting at its upper and outer part, at which point, by a notch in the bone and a corresponding hiatus of the membrane, a foramen is formed through which are transmitted the obturator vessels and nerve. A portion of intestine may descend through this opening and become strangulated. It will be perceived that the obturator membrane forms a part of the wall of the pelvis • and by its elasticity more room may be provided for the descending foetal head during parturition. It may be remarked, that the combi- nation of osseous and membranous constituents of the pelvic parietes serves, at the same time, to relieve the fcetal head and the soft parts of the mother from the danger of undue compression. The great sacro-sciatic notch is a deep, lunated depression, formed THE PUBIS. 19 by the ilium and ischium, extending from the posterior inferior spinous process of the ilium superiorly to the spine of the ischium inferiorly. In the recent state this notch is converted into a foramen by the lesser sacro-sciatic ligament Through it arc transmitted the pyriformis muscle, the gluteal vessels and nerve, and the internal pudic vessels and nerve. The os innominatum is formed by the union of the three bones thus separately described; and this bone, considered now as a unit, presents for study an external and an internal face, an anterior, a posterior, a superior and an inferior border. The external face of the os innominatum is occupied, in its upper and posterior portion, by the external iliac fossa. In its respective convex and concave surfaces, this fossa gives origin, insertion and attachment to the gluteus maximus, medius and minimus muscles. Anteriorly and superiorly appears the acetabulum or cotyloid cavity. Still more directly in front and beneath is found the obturator fora- men, already described as being nearly subtended by the obturator ligament. The internal face of the os innominatum is occupied, in its superior portion, by the internal iliac fossa and the auricular facet for articula- tion with the sacrum. Beneath is found the triangular surface which corresponds to the acetabulum and body of the ischium. Anteriorly appear the inner surface of the obturator foramen and membrane, and the internal faces of the ischio-pubic rami and symphysis pubis. The anterior border is concave, oblique above and horizontal in front; marked by the anterior superior and anterior inferior spinous processes and ilio-pectineal eminence, and terminated by the spine and angle of the pubis. The posterior border is irregular in shape, oblique from above downward and from without inward; marked by the posterior superior and posterior inferior spinous processes, great sciatic notch, spine of the ischium and lesser sciatic notch, and terminated by the tuberosity of the ischium. The superior border, or crest of the ilium, is convex and sinuously curved, being bent outward anteriorly and slightly inward posteriorly. It is terminated by the anterior superior spinous process in front, and by the posterior superior spinous process behind. The inferior border, shorter than either of the others, is marked above by the oval articulating surface which forms the symphysis pubis, below by the tuberosity of the ischium, and between the two we find the ischio-pubic rami. CHAPTEK II. THE ARTICULATIONS OF THE PELVIS, AND THE PELVIS AS A WHOLE. THE four bones which compose the pelvis are united by five articu- lations—the junction of the coccyx with the sacrum; the sacro- vertebral junction; the symphysis pubis, and the sacro-iliac symphyses. Each of these articulations is a true amphiarthrosis,—by some authors, however, classed as arthrodia,—a species of articulation in which cor- responding surfaces of bones are united together by an intermediate substance, yet admitting limited motion. These joints are each sup- plied with a partial synovial membrane, and it is supposed that dur- ing gestation the secretion from these membranes is more abundant. During this period, also, all shocks to either or all these pelvic bones are expended upon their elastic interarticular fibro-cartilages and syno- vial membranes, and the contents of the pelvis are thereby preserved from serious injury. In the Coccygeal Junction, or connection of the coccyx with the sacrum, there are found fibro-cartilages which cover each articulating surface. Between these cartilages is placed the synovial capsule. Thus the sacro-coccygeal articulation admits of free motion,__espe- cially backward,—by means of which the inferior outlet of the pelvis may be enlarged at least one inch in its antero-posterior diameter. This movement of the coccyx, so important in obstetric practice, is facilitated by the minor articulations of the small bones which com- pose the coccyx itself. In some rare instances these fibro-cartilao-es become completely ossified; as well at the junction of the coccyx with the sacrum, as at the points of union of the minor bones of the coccyx. In such cases the coccyx forms one continuous bone with the sacrum, greatly extending its curve, and constituting a formid- able obstacle to the passage of the head through the inferior strait in parturition. But ordinarily the mobility of the coccyx as a whole, and of the parts which compose it, increases during pregnancy; and so affords an additional advantage in labor. The anterior and posterior sacro-coccygeal ligaments support this articulation in front and behind. 20 the symphysis pubis. 21 In the Sacro-Vertebral Junction, or articulation of the base of the sacrum with the lower articulating surface of the last lumbar vertebra, is found the wedge-shaped interarticular fibro-cartilage com- mon to the inter-vertebral articulations. This fibro-cartilage is much thicker anteriorily than posteriorly, and assists in the formation of the sacro-vertebral prominence. The oblique processes of the sacrum, in conjunction with similar processes of the vertebra, complete the articulation, and at these points a synovial membrane is supplied. The movements common to the true spinal articulations may be accomplished, but to a limited extent only. The lumbar curve, which begins with the last dorsal vertebra, terminates at the sacro-iliac junc- tion,—the pelvic curve commencing at the same point, and terminating at the extremity of the coccyx. The sacro-vertebral ligament and the ilio-lumbar ligament are those which more immediately connect the spine with the sacrum and pelvis. The Symphysis Pubis, or articulation of the pubic bones in front, is formed by means of two dense oval-shaped fibro-cartilaginous plates, which cover the articulating surfaces of the pubic bones. The surfaces of these plates lying next to the bones are firmly connected to the bones themselves by nipple-shaped processes which fit within corre- sponding depressions on the osseous surface before described; while their opposing surfaces are connected by an intermediate fibrous elastic tissue, especially where the opposing convex surfaces of the pubic bones recede from each other. The interarticular fibro-cartilages vary greatly in thickness in different subjects, and project somewhat beyond the surface of the bones, especially behind. An interspace is left between them at the upper part of the articulation, which is larger in the female than in the male, and especially so during pregnancy and parturition. At this point the surfaces of the plates are lined by epithelium. This articulation is strengthened by several ligaments which traverse it in front and behind, above and below. These are termed, respectively, the anterior and posterior pubic ligaments, and the superior pubic and the sub-pubic ligaments. Their names are indicative of their positions and associations. The inferior surface of the sub- pubic ligament forms the upper boundary of the pubic arch. The strength and variety of these ligaments, which combine to strap the pubic bones together in every direction, and in the firmest possible manner, afford sufficient proof of the error of those obstetric writers who have supposed the symphysis pubis was intended to separate for the sake of enlarging the diameter of the pelvis in par- turition. Except in cases of serious deformity, the head is capable 22 THE SACRO-ILIAC SYMPHYSES. of being moulded (elongated) in its descent, so as to accommodate itself to the size and shape of the pelvis. But neither in such cases of serious deformity, nor in any other, does disarticulation of the pubic or sacro-iliac symphysis enable the pelvis to adapt itself to the size of the descending head. The Sacro-iliac Symphysis, of either side, is formed by the union of the superior, ear-shaped portion of the lateral border of the sacrum with the inferior, auricular portion of the posterior border of the ilium. Each of these articulating surfaces is covered with a layer of cartilage; the sacral layer being much thicker than the iliac. And both the sacral and iliac cartilaginous surfaces are covered by a delicate synovial mem- brane, which,, in the female,—especially in the pregnant state,—secretes a true synovial fluid. Thus,, as in the symphysis pubis, so in the sacro- iliac symphysis, a limited motion is provided for. The sacro-iliac symphysis is strengthened by several important liga- ments, which, without entirely preventing the motion just mentioned, assist in enabling these joints to sustain in safety the whole weight of the body. The anterior sacro-iliac ligament, composed of numerous thin bands, connects the anterior surfaces of the ilium and sacrum. The posterior sacro-iliac ligament occupies the depression between the sacrum and ilium,, behind the edges of the cartilaginous surfaces, and forms the most powerful bond of union between these two bones. This ligament consists of numerous short interlacing fasciculi, which pass in every direction from the sacrum to the ilium, and which from their fibrous and elastic nature are admirably fitted to maintain the necessary stability of this important articulation. In this general name of posterior sacro-iliac ligament are included also those which by some writers are described as superior and inferior sacro-iliac liga- ments. In addition to these, the greater and lesser sacro-sciatic liga- ments, which change th« greater and lesser sciatic notches of either side into foramina, at the same time serve to bind the ilium and ischium still more firmly to the sacrum, and contribute to the construction of the walls of the pelvis. It is doubtless true, as has been asserted by a number of writers that during pregnancy there occurs an increased afflux of fluids to all the parts concerned in that process, inclusive of those which constitute the articulations of the pelvis; and these articulations or symphyses become in consequence relaxed during the period of gestation, and do not return to their normal condition for a longer or shorter period after parturition. To so great an extent, indeed, may this relaxation and softening of the tissues and joints occur as to seriously interfere THE PELVIS AS A WHOLE. 23 with locomotion, which can only be performed with great difficulty and at the expense of considerable suffering. Difficult labor, too, may have a damaging effect upon the symphyses of the pelvic bones while in this relaxed condition, to the extent that standing or even sitting up in bed is rendered wellnigh impossible. The treatment of these disordered conditions, and of others arising during pregnancy and after parturition in consequence of the softening and relaxation of the pelvic joints, will be indicated in another chapter of this work. The Pelvis as a Whole. Having thus studied the separate bones which compose the pelvis, and examined the manner in which they are united and strengthened, and observed the nature of their articulations, we come to the con- sideration of the pelvis as a whole. In general, the pelvis may be divided into an external and an inter- nal surface, each of which needs to be studied by itself. The External Surface of the pelvis presents four regions. The anterior region extends from the symphysis pubis, on the median line, to the edge of the acetabulum on either side, and is principally cov- ered by the obturator externus and adductor muscles laterally, and in front by cellular tissue and the integument of the pubes. The pos- terior region is marked principally by the ridge formed by the spinous processes of the sacrum, the posterior sacral foramina, the inferior opening of the vertebral canal, the union of the sacrum with the coc- cyx, and the posterior surface of the coccyx itself. Each lateral region is formed superiorly by the external iliac fossa, mediately by the acetabulum, and inferiorly by the external surface of the tuberosity of the ischium. In this situation, likewise, is found the great sacro-sciatic notch. In the whole extent of its lateral surfaces the bones of the pelvis are separated from the integument by thick muscles. On its Internal Surface the pelvis is divided into the upper and larger or false pelvis, and the lower and smaller or true pelvis. The line of division extends on a level with the superior border of the symphysis pubis throughout the extent of the linea ilio-pectinea to the promontory of the sacrum. Thus, the superior pelvis is under- stood to include all that part above, and the inferior pelvis all that part below, the ilio-pectineal line. The inferior pelvis is that which is principally concerned in parturition, and which the accoucheur should therefore fully understand in all its parts and relations. Both the superior and inferior pelvic divisions are again divisible into four 24 INCLINED PLANES OF THE PELVIS. distinct regions. In the superior pelvis the anterior region is formed in the living subject by the muscular parietes of the abdomen. The pos- terior presents the sacro-vertebral symphysis and promontory, and extends to the sacro-iliac symphysis on either side. Each lateral region is constituted by the internal iliac fossa, covered by the iliacus internus and psoas muscles. In the lower or smaller pelvis the anterior region is composed of the posterior surface of the symphysis pubis; the posterior region consists of the anterior surface of the sacrum and coccyx. Each lateral region of this division of the pelvis may be again divided into an anterior and a posterior portion. The anterior portion is composed of the bony structure of this part of the pelvis, and corresponds to the inner surface or back part of the acetabulum, and to the interior surface of the body and tuberosity of the ischium. The posterior portion is rep- resented by the greater and lesser sacro-sciatic ligaments, and by the inner surface of the greater and lesser sciatic notches, which, by these ligaments, are converted into pelvic walls. The Inclined Planes of the Pelvis.—Inside the pelvis are found four inclined planes,—one anterior and one posterior on each side. These inclined planes may be demonstrated by dividing the pelvis itself into two lateral halves by vertical section through the symphysis pubis and median line of the sacrum; and by again divid- ing each of these lateral portions into anterior and posterior quarters by a transverse vertical section on the ilio-pectineal line, a little in front of the sacro-iliac symphysis, and terminating in the spine of the ischium. Each of the four quarters thus formed of the pelvis will be found to represent an inclined plane. And each of these inclined planes will be found to look in the same general direction. Thus each of the anterior inclined planes,—that is, the right and the left anterior__ will be seen to look from without inward, from above downward and from behind forward. In like manner both the rio-ht and the left posterior inclined planes will look from without inward from above downward, and from before backward. It was formerlv sup- posed that these several inclined planes, by influencing the rotation of the head of the foetus, through successive changes of direction ex- erted a powerful influence on the mechanism of labor. But, in point of fact, the rotation occurs principally after the head has so far passed through the inferior strait as to engage the soft parts and distend the perineum. And it may be now stated that these inclined planes serve in part to prevent the too rapid descent of the head, and in part to THE SUPERIOR STRAIT. 25 cause it to assume and maintain the most natural and favorable posi- tion in its course. In its general appearance the interior of the pelvis may be said to resemble the inner surface of an irregularly-shaped and truncated cone, tapering downward; although from the strongly-marked de- pression of the hollow of the sacrum the cavity of the pelvis seems larger than either the entrance above or the outlet below. The ilio- pectineal line—already described as dividing the greater from the lesser pelvis—together with the spine and crest of the pubes in front, and the anterior margin of the base of the sacrum and sacro-vertebral angle behind, constitute what is called the margin of the superior strait; and the corresponding border of the apex, bounded by the point of the coccyx posteriorly, by the inferior surfaces of the tuber- osities of the ischia laterally and by the pubic arch anteriorly, consti- tutes wThat is known as the inferior strait. The superior strait corre- sponds to what is by some termed the brim, as the inferior strait cor- responds to the outlet; while the intervening internal portion of the pelvis is indifferently named its cavity or excavation. The engage- ment of the head in the superior strait, its passage through the cavity or excavation, and its subsequent emergence through the inferior strait or outlet, constitute the most important events in the process of parturition. Hence the axes and dimensions, and in fact all the parts and relations of these straits and their intervening cavity, should be thoroughly understood. The Superior Strait. The superior strait or brim of the pelvis presents the shape of a curvilinear triangle with rounded angles,—■ having its base behind and its apex in front. The sacro-vertebral promontory, jutting in, as it were, gives a heart-shaped appearance to what might otherwise have been nearly oval. The psoas muscle on either side, by diminishing the transverse diameter, causes the superior strait to assume a more triangular form in the living subject than it presents in the skeleton; but by flexing the thighs upon the trunk, as during parturition, these muscles are relaxed, and the superior strait thereby becomes more nearly oval in shape and the descent of the fcetal head is facilitated. The boundaries of the superior strait are, the sacro-vertebral angle, the anterior border of the wings of the sac- rum, the linea ilio-pectinea, and the spine and crest of the pubes. The very great obstetric importance of this superior strait arises from the fact that it forms the first part of that bony canal through which the fcetal head must be transmitted, and through the somewhat contracted opening of which it must pass, almost before it acquires 26 ARTICULATIONS OF THE PELVIS. any of that elongated shape which it so often presents on emerging subsequently from the outlet or inferior strait. Fig. 1. c h, the plane of the superior strait prolonged beyond the pubes; c e, the plane of the inferior strait prolonged beyond the pubes; c d, shows the departure of this plane from the horizontal line; a b, the axis of the superior strait; h f, the axis of the inferior strait. The plane of the superior strait, its axis and its dimensions, form the most important points for consideration respecting it. The plane or surface of the superior strait may readily be demonstrated by cut- ting a piece of paper to fit it, making it extend antero-posteriorly from the sacral promontory to the superior border of the symphysis pubis, and transversely from the ilio-pectineal line of one side to that of the other. And when the female is in the erect position, it will be found that this plane presents an inclination of from fifty-five to sixty degrees to the horizon. The axis of this plane will of course be a line which shall fall at right angles upon its centre. Thus the axis of the superior strait must form the same angle with the vertical line that the plane of the strait forms with the horizontal line. And upon examination it is found that this axis extends from a point on the linea alba a little below the umbilicus to the articulation of the second bone of the os coccyx with the third. The inclination of the plane of the superior strait, and of course the direction of its axis, must vary with the changing position of the female; the inclination being diminished when the trunk is bent forward, as in stooping over, and becoming least in the recumbent position. But it is greatly increased when, in the ad- vanced stages of pregnancy, the female straightens up, and even leans backward as it were, in order to maintain her equilibrium. So in THE SUPERIOR STRAIT. 27 parturition, as will be more particularly explained subsequently, the position and flexure of the trunk will greatly affect the entrance of In the dimensions of the superior strait we note its different diame- ters and its circumference. The irregular shape of the figure of this strait renders its various diameters unequal. Different authors have enumerated quite a number; but the three principal diameters are all that are really of practical importance. These are, first, the antero- posterior diameter, which extends from the sacro-vertebral angle to the superior border of the symphysis pubis. This, which is also called the sacro-pubic or conjugate diameter, measures four and a half inches. The second, the transverse diameter, or long diameter, extends across the pelvis at its widest part, and at right angles with the anteropos- terior diameter. This, which is also called the iliac or lateral diame- ter—since it extends from the middle of the rounded border of the iliac fossa of one side to that of the other—measures five inches. The third is the oblique or diagonal diameter. This extends from the sacro-iliac symphysis to the ilio-pectineal eminence of the opposite side, and measures four inches and three-fourths. In consequence Of the space occupied by the soft parts, these dimensions are somewhat less in the living body. And we may allow at least one-quarter of an inch in the antero-posterior diameter, and one-half an inch in the transverse diameter. The circumference of the superior strait—bounded anteriorly by the 28 THE INFERIOR STRAIT. inner margin of the horizontal rami of the pubes, laterally by the 1I10- pectincal line, posteriorly by the promontory of the sacrum—measures from thirteen and a half to seventeen inches. The Inferior Strait.—The inferior strait is smaller than the superior, and in the skeleton much more irregular in form. This latter circumstance arises from the projection of the coccyx behind, and of the tuberosities of the ischia on each side. These projections form three deep notches, one on each side of the coccyx, and one im- mediately beneath the symphysis pubis. Thus this irregular border or periphery of the inferior strait is made up by the symphysis and descending rami of the pubes, by the tuberosities and ascending rami of the ischia, by the lower border of the posterior sacro-sciatic liga- ments, and by the extremity of the coccyx which projects inward. In parturition, however, the coccyx is usually pushed back, rendering the actual obstetric outlet nearly oval. This oval figure of the outlet may be demonstrated by placing the apex of the pelvis on a sheet of paper and tracing its outline with a pencil. And the figure thus obtained, compared with that of the brim of the pelvis, will show a gradual inclination of the wTalls of the pelvis downward and inward. The two lateral projections, the tuberosities of the ischia, extend somewhat beneath the extremity of the coccyx, and, being unyielding, alone support the entire weight of the body in the sitting posture. Hence it happens that transverse contractions of the pelvis at the in- ferior strait are more common than antero-posterior. The deep notch found anteriorly on the inferior strait corresponds to the summit or inferior margin of the arch of the pubes. This notch forms an im- portant feature in obstetric practice, and it is much broader in the female pelvis than in the male. At its base this arch is from three and a half to three and a quarter inches broad, but only from one and a quarter to one and a half inches wide at its apex; its height is from two to two and a half inches. As will be afterward noticed in de- scribing the process of parturition, this notch has very important relations to the fcetal head, affording to it a more ready exit in the first position. The still deeper notches which appear posteriorly on each side of the coccyx are subtended by the sciatic ligaments, Avhose elasticity is capable of materially adding to the pelvic dimensions at the moment of the final passage of the fcetal head. By the combination of double arches, both anteriorly and posteriorly, and from above downward the greatest possible strength has been preserved to the pelvis, with- the inferior strait. 29 out too much increasing; its weight; while at the same time the head is enabled all the sooner to emerge from its bony prison, by reason of these three important notches or arches in the periphery of the in- ferior strait, while the anterior notch—that of the pubic arch—also affords inestimable advantages to the accoucheur, in the introduction of the hand, the forceps or other instruments, when, from irregularity or contraction of the pelvis, from abnormal size of the head, or from other reasons, manual or mechanical interference becomes indispensable. The plane of the inferior strait may be demonstrated by applying a sheet of paper in the following manner. Upon an inverted pelvis in which the sacro-coccygeal articulation is still flexible, and in which the coccyx is retracted as far as possible, we place a piece of paper narrow enough to pass between the tuberosities of the ischium and be closely fitted to the summit of the pubic arch. This paper, thus rest- ing in front upon the inverted surface of the arch of the pubis and posteriorly upon the retracted extremity of the coccyx, will accurately represent the proper plane of the inferior strait. Hence it will be at once obvious that this plane is by no means parallel with that of the superior strait, the angle of inclination of the latter being from fifty- five to sixty degrees, and that of the former but from ten to eleven degrees. And as the planes of the two straits are not parallel, so neither will their axes be in the same line. Fig. 3. c d, the horizontal line; c e, the plane of the inferior strait (during labor) ; a b, the axis of the inferior strait. Thus, as is shown in Fig. 3, the plane of the inferior strait, with the coccyx retracted as it is in the last stage of labor—the only stage in which either the coccyx or in fact the inferior strait itself is particu- larly involved—inclines backward and downward at a very small angle 30 THE INFERIOR STRAIT. below the horizontal line, while, as shown in Fig. 1, the plane of the inferior strait in the ordinary condition of the pelvis—with the coccyx not retracted—inclines at a correspondingly small angle above the horizontal line. And the prolongation of the planes of the supe- rior and inferior straits to their point of union beyond the pubes shows that, instead of being parallel with each other in the human pelvis, they form an angle of not far from 45°, especially when the point of the coccyx is pushed back, as it is by the fcetal head in its passage through the inferior strait. The great advantage which must arise from this apparently irregular arrangement of the pelvic planes and axes, will be evident from a mo- ment's consideration of what must otherwise be the effect of gravity in the upright position, especially in the advanced stages of pregnancy. Even if the head and entire foetus were not impacted in the cavity of the pelvis, premature delivery must necessarily result from the con- stant and directly downward tendency of the'uterus and its contents. This is still further illustrated by comparison with the almost perfect parallelism which appears in the planes of the superior and inferior pelvic straits of quadrupeds. Here the gravid uterus is entirely sup- ported by the abdominal parietes, and the planes of the superior and inferior—or, more accurately speaking, anterior and posterior—straits are nearly parallel, and their corresponding axes nearly identical with each other and parallel with the trunk itself. The axis of the inferior strait is the line which, drawn perpendicular to its plane, falls upon it midway between the symphysis pubis and the extremity of the coccyx. When the coccyx is in its usual posi- tion, this line, extended, will strike the promontory of the sacrum; but when the coccyx is retracted, as in the advanced stages of labor, this line will fall upon the articulation of the first with the second bone of the sacrum. The axis of the inferior strait forms the same angle with that of the superior strait that the plane of the inferior strait forms with the corresponding plane of the superior strait. The diameters most important to be observed in the inferior strait correspond in number and in name to those of the superior strait, First, the antero-posterior or coccy-pubal diameter—extending from the extremity of the coccyx to the summit of the pubic arch—meas- ures four and three-quarter inches with the coccyx pushed back in labor, but only four and a quarter inches when it is not thus retracted. For practical purposes, therefore, the antero-posterior diameter of the inferior strait—taken at any period of labor when the head has not so engaged in that strait as to push back the coccyx—must be con- THE CAVITY OF THE PELVIS. 31 sidered as half an inch longer than the measure shows. The only exception to this will be in those cases in which, from complete ossi- fication of the coccygeal and sacro-coccygeal articulations, the coccyx forms one continuous curve and one solid bone with the sacrum. Fig. 4. A A, the antero-posterior or coccy-pubal diameter; B B, the transverse or bis- ischiatic diameter; C C, the two oblique diameters. The second diameter of the inferior strait is the transverse, con- jugate, or bis-ischiatic. It extends from the inner margin of one ischiatic tuberosity to the corresponding point on the opposite side, and measures four inches. The third diameter of the inferior strait is the oblique. It extends from the point of junction of the rami of the pubes and ischium to the middle of the great sacro-sciatic ligament of the opposite side, and measures about four inches. As previously stated, from the dis- tension of the ligamentous portions of the pelvic parietes the capacity of the inferior strait may be somewhat enlarged in this direction; and some authorities estimate the oblique diameter as practically equal, therefore, to four and a half inches. Naturally there are two oblique diameters to the inferior strait, the right and left oblique; but it is usually mentioned as one diameter, because—except in some not very common forms of pelvic distortion—the one will be exactly equal to the other. The circumference of the inferior strait is very irregular, owing to the projections of the coccyx posteriorly and the tubers of the ischia laterally. It measures about twelve inches. The Cavity of the Pelvis. That part of the canal of the pelvis which consists of the space between the superior and inferior straits is known as the cavity of the pelvis, or the excavation. From its situation, and consequent relation to the movements of the foetal 32 THE CAVITY OF THE PELVIS. head during parturition, it will be obvious that a thorough knowledge of this cavity, of its axes, planes and dimensions, is not only important in all ordinary cases of labor, but indispensably necessary to the suc- cessful management of all those of serious difficulty. This cavity is irregular in shape, contracted in its superior and inferior orifices, and greatly enlarged posteriorly by the concavity of the sacrum. The depth of the pelvis at the symphysis pubis in front is but one inch and a half; at the side, from the tuberosity of the ischium to the linea ilia, it is three inches and a half; and posteriorly, from the promontory of the sacrum to the extremity of the coccyx, the depth is four and three-fourths inches or five inches, according as the coccyx is in its natural position or retracted as in labor. If the curvature of the sacrum and coccyx be followed, this measurement will equal five and a quarter inches. The diameters of the excavation, taken at its centre, correspond in number and in name to those of the superior and inferior straits; and they are all of very nearly the same length of four inches and three-fourths. The antero-posterior diameter, extending from the sub- pubic ligament,—that is, from the summit or under surface of the pubic arch to the middle of the sacrum,—measures four inches and thrcc-fpiarters. But the line drawn from the sub-pubic ligament to the promontory of the sacrum will be found to measure but four inches and a half. The transverse and oblique diameters are each four inches and three-fourths in length. It should be borne in mind that the long diameter of the superior strait is the transverse, but that the antero-posterior is the long diameter of the inferior strait. The common plane and axis of the pelvic cavity ought to be well understood, as they represent the gradual change from the primary plane and axis of the superior strait above to the final plane and axis of the inferior strait beneath. Owing to the concavity of the sacrum, and to the slight convexity of the posterior surface of the pubic wall, the passage through the pelvic excavation represents a curve, which, if continued, would produce a circle. Consequently the plane which commences at the superior strait is constantly changing as we pass from above downward. And as the plane changes, so also must the axis of the plane, to cor- respond to it. Thus the general plane of the excavation will be represented only by a succession of differently inclined planes. So a corresponding series of axes must represent the general axis of the excavation. This general series of planes, and corresponding series of axes, is well illustrated in Fig. 5: thus a b represent the plane THE CAVITY OF THE PELVIS. 33 of the superior strait; i o, the plane of the inferior strait; c, the point of union of these two planes, if prolonged; then p q r s t—c, will represent tjie successive planes which must result from the curvature of the sacrum. It being borne in mind that the axis must Fig. 5. a b, the plane of the superior strait; i o, the plane of the inferior strait; c, the point where these two planes would meet, if prolonged; m n, the horizontal line; e /, the axis of the superior strait; g k, the axis of the excavation; p q r s t, various points taken on the sacrum to show the plane of the excavation at each point. always be regarded as perpendicular to (that is, at right angles with) its plane, the axis of the first plane, or that of the superior strait, will therefore be seen to be at right angles with its plane. And since the sacrum at this upper part of the pelvis forms a straight line, so the plane of the superior strait will form a right angle with it; and the axis of this plane will consequently be parallel with the sacrum. And so in fact in each successive instance; the plane of each succes- sive point of the cavity must be at right angles with the opposite point of the sacrum; and the axis of each successive plane must be at right angles with the plane itself, and of course parallel with the corresponding portion of the sacrum. These successive axes, thrown into a single line, will therefore form a curve exactly corresponding to the opposite curve of the sacrum. This general axis of the exca- vation, g, h, represents the line of direction which the fcetal head must necessarily pursue in its course through the canal of the pelvis. And as this line, in a geometrical point of view, is the result of a union of successive lines, so in a physiological point of view the course followed by the foetal head is the result of a combination of various and successive vital forces, whose progressive development 3 34 THE MALE AND FEMALE PELVIS COMPARED. can take place only in the direction rendered possible by the form and construction of the internal surfaces of the pelvic cavity. It has been remarked elsewhere that a change of position of the individual will effect a change in the direction of the planes and axes of the superior and of the inferior straits; but it is to be borne in mind that no change of position can in any degree affect the general axis or central curved line of the pelvic excavation. This is an im- portant obstetric fact which should be remembered, inasmuch as it is through this excavation and in the direction of its general axis that the foetus passes during the process of parturition, becoming curved upon itself in the passage; and the convexity of its curvature corresponds with the concavity of the sacrum, its concavity with the pubes. The Differences between the Male and Female Pelvis.— The pelvis of the male is smaller, narrower, deeper in its cavity, and more circular in its brim; the bones composing it are thicker and stronger, and the muscular impressions and eminences on their sur- faces more decidedly marked. The symphysis pubis is nearly double the depth of that of the female; the sacrum is straighter, and the sacro- sciatic notches and foramina smaller; the obturator foramen larger and more oval; the pubic arch is straight, much narrower, triangular in shape; its walls and the tuberosities of the ischia are less widely separated; the coccyx is more immovably attached to the sacrum; and in general the articulations are sooner anchylosed than in the female. The pelvis of the female is much wider; the acetabula are farther apart, although the knees approach each other even more than in the male, giving to the movement and gait of the female some distinguish- ing peculiarities. The iliac fossae are broader than in the male pelvis, and the spinous processes of the ilia more widely separated, hence the greater breadth of the hips in the female; and here Nature seems to have sacrificed the facilities of motion to the advantages of pregnancy and parturition. The superior strait is larger and more elliptical; the curve of the sacrum is deeper and more regular; the symphysis pubis is but half as deep as in the male ; and the pubic arch is broader, more rounded, and its lateral walls more widely divided. The entire pelvis is larger and more capacious, and so constructed, in its several arches and ligaments, as to combine the greatest possible lightness elasticity and strength with the most suitable form and dimensions for sustaining the gravid uterus above its brim, or enabling the full- grown foetus to be transmitted through its canal. In early childhood the pelvis seems disproportionably small. It is the uses of the pelvis. 35 narrow and long, and the abdominal protuberance which is seen in the foetus and in newly-born infants, and even still later in the case of rachitic children, is due to its thus forcing upward some of the parts which should be contained within it. But as the female child advances in life the pelvis becomes gradually, although slowly, de- veloped, until, at the period of puberty, it experiences, within a short time, an alteration so extensive and so strongly marked as to change perceptibly the form and contour of the hips. At nine years of age the antero-posterior diameter measures two inches and seven-eighths, and the transverse diameter, two and three-fourths; while at fourteen years of age the antero-posterior diameter measures three inches and three-fourths, and the transverse, four and a half. The Uses of the Pelvis.—The pelvis of the female, as in the male, affords a general support to the abdomen and its contents. In the pregnant female it especially supports the gravid uterus upon its anterior arch and iliac wings. Within the cavity of the pelvis the uterus of the unimpregnated female, the ovaries and Fallopian tubes are safely enclosed, while the delicate and sensitive external organs of generation are securely protected beneath. From its relation to the lower portion of the spinal column, and from the maimer in which it is placed upon its femoral supporters, the pelvis may be regarded as the structural base or foundation of the human body; while, from the study of the functions which it performs in connection with the organs which it contains, it will no less obviously be seen to be the true physiological centre of the entire human system. From improper management in childhood and youth, from too long and too frequent indulgence in unnatural positions, from habitual over-exertion of a particular kind, from accidental injuries, and especially from disease and softening of the bones, the pelvis may become contracted, strained and distorted in every direction, and so more or less incapable of performing its most important uses in the support of the body and in parturition. So also, from similar and corresponding causes, the organs which it contains may become more or less disordered and in- capable of performing their vital functions. In the former case mechanical difficulties and obstructions embarrass the accoucheur. The consideration of these difficulties, and of the appropriate means for overcoming them, we reserve as a sequel to the normal process of parturition. In the latter case the physician has to contend with various forms of functional disorder or structural disease. The con- sideration of these disorders and of their appropriate remedies we shall take up hereafter. 36 the muscular tissues of the pelvis. CHAPTER III. THE MUSCULAR TISSUES OF THE PELVIS. THE study of the bony skeleton of the pelvis forms the only true basis for understanding this most important part of the body, as it exists in life; and it is only now, as we come to the examination of the pelvis clothed with muscular and other living tissues and supplied with organs, that its real study begins. Occupying the middle ground between the upper and lower part of the body, the pelvis affords at- tachment to two classes of muscles. The first class is for completing, enclosing and perfecting the abdo- men. The muscles of this class, by their great power of distension, afford every needful facility for the development and support of the foetus in the pregnant state. These muscles, which form the anterior abdominal parietes, by yielding to the pressure exerted from against PELVIS, WITH SOFT PARTS, SEEN FROM ABOVE. A, section of the aorta; B, the vena cava inferior ; C, the internal iliac artery, aris- ing, together with D, the external iliac, from the primitive iliac trunk ; E, external iliac vein; F, the iliacus internus, and G, the psoas magnus muscles ; H, the rectum . I, the uterus with its appendages; K, the bladder, the fundus of which is depressed, so as to bring the womb into view. the rigid posterior walls, cause the gravid uterus to project over the arch of the pubes, and thus hinder it from settling downward through the superior strait. The muscles of the second class are those which, connecting the pelvis with the lower extremities, are concerned in locomotion. There the muscular tissues of the pelvis. 37 are but four sets of these muscles on the inner surface of the pelvis. The principal of these are the iliacus internus and psoas magnus; next in size and relative importance come the pyriformis and obturator internus muscles. The iliacus and psoas magnus, while being them- selves protected by the iliac fascia, serve to line and cushion the iliac fossse and bones of the upper pelvis, thus preventing the uterus from receiving injury in the latter months of gestation from the shocks and concussions inseparable from active exercise. These two muscles, as they become conjoined in passing over the lateral parts of the superior strait to be inserted into the lesser trochanter of the femur, have the effect to change the base of the curvilinear triangle of the pelvis from the rear to the front, and to lessen the transverse diameter half an inch; these two being the only muscles in the pelvis that do lessen any of its diameters. The iliacus, however, from its thinness, neither too much encroaches upon the concavity of the iliac fossse, nor indeed does it, so much as the psoas, diminish the size of the pelvic cavity. And the shortening of the transverse diameter may be in a great mea- sure obviated by flexing the thighs upon the abdomen in labor, thus relaxing the psoas muscles and reducing the diminution of the pelvic cavity to the smallest possible amount. The pyriform muscles, which arise principally from the outer mar- gins of the sacrum, pass immediately out of the pelvis through the great sacro-sciatic foramina of either side to be inserted into the great trochanter of the femur. The internal obturator muscles arise from the margin of bone which forms the inner side of the obturator fora- men, and from the internal surface of the obturator membrane, and leaving the pelvis through the lesser sacro-sciatic notch, or more properly foramen, are likewise inserted into the great trochanter in front of the pyriformis. These muscles are thin and flattened and project so slightly beyond the bony surface which lies adjacent to them as to encroach but slightly, if at all, upon the capacity of the pelvic cavity. This may be said also of the coccygei muscles, which, arising from the spines of the ischia and lesser sacro-sciatic ligaments and inserted into the margins of the coccyx, do not encroach laterally upon the diameters of the pelvis. Thus we have the entire pelvic cavity covered by fascia and suffi- ciently supplied with muscular tissue for all its uses, without so much diminution of its size as to obstruct the foetus in its descent. Indeed, the obturator internus and pyriformis muscles, covering the obturator and sciatic foramina, afford increase of room by giving way as the head makes pressure upon them in its descent. 38 THE PERINEUM. The antero-posterior diameter is slightly diminished by the attach- ment of the bladder to the posterior surface of the arch of the pubes, and the cellular tissue which everywhere lines the pelvic parietes slightly diminishes the general capacity of the pelvis. When this cellular tissue becomes loaded with fat, as is the case with fleshy women, it may offer a serious obstacle in parturition. The rectum, in passing down over the anterior surface of the sacrum and to the left of its promontory, does not materially hinder the process of labor, un- less loaded with indurated fecal matter, and the uterus, although occu- pying a middle ground between the bladder and rectum, does not diminish any diameter of the pelvis in labor, for at such times it is usually entirely above the superior strait. The Pertxeum may be said to form the floor of the pelvis. It is composed of muscular tissue, fascia, and intervening areolar and adi- pose tissue, and is exceedingly elastic and distensible. The female perineum extends laterally between the tuberosities of the ischia and antero-posteriorly from the apex of the coccyx to the posterior commissure of the vulva. The anus divides the perineum into two portions; that extending between the coccyx and the anus constituting the posterior perineum; that extending from the anus anteriorly to the vulva being the anterior perineum, or perineum proper. It is larger in the male than in the female. The muscles entering into the composition of the perineum are arranged into two layers, the upper of which is concave superiorly and comprises the levatores ani and coccygeal muscles, while the lower, which has its concavity looking downward, comprises principally the transversus perinei, sphincter ani and constrictor vaginae muscles. Of these muscles, the levatores ani are the most important in an obstetrical point of view. They are broad and thin muscles, which arise anteriorly from the posterior surfaces of the bodies and rami of the pubes; posteriorly from the spine of the ischium; while the intervening portion arises between two layers of the descending pelvic fascia. The posterior fibres are inserted into the sides of the lower portion of the coccyx, while the middle and anterior fibres pass downward, converging toward each other, to be inserted into a central line or raphe at the centre of the perineum. In addition to these points of insertion, numerous fibres are blended with those of the sphincter ani, transversus perinei and constrictor vaginae muscles. It will be seen, from this description, that these levator muscles exert a powerful influence by their con- traction upon the entire perineum, and might very properly be called levatores perinei. In a condition of rigidity they may offer a very THE PERINEUM. 39 serious obstacle to the descent of the child, the presenting part of which in its passage downward impinges upon this muscular floor, and must push it downward and forward in order to effect delivery. Fortunately, however, these tissues are usually softened and yielding, and admit of enormous prolongation and distension; otherwise lacera- tion would be a common accident. MUSCLES OF THE PERINEUM. 1, tuber ischia; 2, sphincter vaginae; 3, its origin from the base of the clitoris; 4, vaginal ring of the same muscle, which receives a part of the fibres of the levator ani; 5, intercrossing of the sphincter ani and sphincter vaginae at the perineal centre; 6, erector clitoridis; 7, clitoris; 8, transversus perinei; 9, sphincter ani; 10, levator ani; 11, gracilis; 12, adductor magnus; 13, posterior part of gluteus magnus. The extent of the perineum from the point of the coccyx to the anus is about an inch and three-quarters, and from the anus to the vulva about an inch and a quarter; making three inches in all in its ordinary condition. But at the instant of the passage of the child's head into the external world at full term, it becomes so distended and prolonged downward and forward as to measure about five inches and three-fourths. It must now be evident that the terminal outlet of the obstetric canal in the living subject is not represented by the symphysis pubis and the point of the coccyx, but rather by the symphysis and the anterior commissure of the perineum; and the plane of this outlet 40 THE PERINEUM. will be represented by a line drawn from the lower part of the sym- physis to the commissure. But, in the last moment of labor, as the head is emerging through the vulva, the perineum is prolonged in a forward direction to the extent of passing beyond the lower part of the symphysis pubis, and the plane of the outlet at this moment will be represented by a line drawn from the symphysis to the edge of the distended perineum. Fig. 8. POSITION OP THE PELVIS AND THE DIRECTION OF ITS AXIS IN THE DORSAL ATTITUDE ASSUMED BY THE FEMALE DURING LABOR. a b, total axis of the excavation, being a continuation of d b, the axis of the superior strait; c v, perineum as distended at the moment of the passage of the head ; r, anal orifice; e v, terminal plane of the obstetric canal. The direction taken by the foetal head in its passage through the excavation of the bony pelvis is indicated by the axes of the various planes representing the curvature of that osseous canal. Now, if another series of planes be made, commencing at the plane of the bony outlet, and extending from the symphysis to various points upon the curvature of the distended perineum—the final plane ex- tending from the symphysis to the anterior perineal commissure—and the axes of these planes be ascertained, and prolonged so as to form a complete axis continuous with that of the excavation of the bony pelvis, the line thus indicated will represent the axis of the entire obstetrical canal and the course traversed by the foetus from its en- trance into the superior strait until its final emergence at the vulva. This is well represented in Fig. 8. It will thus be seen that, in the recumbent posture of parturition, the foetus, in following the axis of the obstetric canal, takes a course EXTERNAL ORGANS OF GENERATION. 41 first downward and backward, then downward and forward, then al- most directly forward, and finally, at the moment of delivery, upward and forward. CHAPTER IV. THE ORGANS OF GENERATION. The External Organs and Vagina. THE genital organs of the female, when closely studied and com- pared, will be found to bear a very strong resemblance to those of the male. And in addition to this particular similarity in the struc- ture and functions of some of the parts of the female to those of the male, there will be seen to be a universal and essential correspondence of all the sexual organs of the one sex to those of the other. For as all the sexual organs of the male are structurally and physiologically adapted and intended for giving, so all the sexual organs of the female are, in like manner, structurally and physiologically adapted and de- signed for receiving. Thus they bear to each other the relation of the two halves which are requisite to constitute one complete physiologi- cal whole—of two equally indispensable means for the accomplish- ment, physiologically, of the final end of reproduction. This dis- tinction of structural difference and similarity and of physiological correspondence is the type of the adaptation of the man to the woman in the married state; the highest condition of human life.* And this distinction should be steadily borne in mind in all our study of the genital organs and reproductive system of the female. These genital organs, which as well in structure as in function are much more complicated in the female than in the male, may be divided into external parts, or those without the pelvis, and internal organs, or those situated within the pelvis. The former are the mons veneris, the perineum and the vulva with its appendages. The latter are the vagina, the uterus, the Fallopian tubes and the ovaries. We will proceed to study their anatomy and physiology in the order in which they have just been named. The Mons Veneris.—The mons veneris is situated at the lower margin of the abodmen, just on or above the centre of the svmphysis pubis. Its diameter is usually about three inches; it is half an inch thick at its centre, and tapers off to a thin edge at its circumference. 42 THE MONS VENERIS. It is principally composed of dense cellular or adipose tissue, covered by thick elastic integument, and abundantly supplied with sebaceous follicles. The hair, which makes its appearance at puberty as one of its characteristic signs, is said to diminish in quantity, in many cases, on the cessation of the menses. The growth of the hair varies remark- Fig. 9. EXTERNAL GENITALS. A, mons veneris ; B, labia majora ; C, clitoris; D, labia minora; E, orifice of urethra; F, orifice of vagina ; I, posterior commissure of the vulva; H, perineum ; J, anus. ably in different individuals; and in some cases, where it is very white and scanty, it is supposed to indicate sterility. The excessive growTth of the hair is sometimes accompanied by pruritus, and in those who are subject to the plica polonica this disgusting disease attacks also the hair on the mons veneris, which becomes agglutinated and attains an enormous length. The mons veneris may become the seat of in- flammation and abscess, which should be treated promptly in the same manner that would be appropriate to similar conditions elsewhere. The perineum has already been described in connection with the soft parts of the pelvis. From its peculiar structural formation it ad- mits of very great distension during labor, but is prompt to resume its usual condition when the pressure of the child has been removed. When the last expulsive pains of labor are very violent and the perin- eum is from some cause or other unyielding, or when the woman in the throes of these last expulsive pains straightens herself out instead of remaining in a semi-flexed condition, the perineum may undergo lace- ration. The treatment to be adopted when such an accident occurs will be indicated hereafter. THE VULVA AND ITS APPENDAGES. 43 The Vulva and its Appendages.—The vulva or pudendum is the longitudinal opening between the projecting parts of the exter- Fig. 10. Fig. 11. Fig. 10. Hymen in the form of a crescent.—A, clitoris; B, labia externa; C, labia in- terna ; D, orifice of the urethra; E, hymen; F, orifice of the vagina; G, posterior commissure of the vulva; H, perineum. Fig. 11. This figure exhibits the Hymen in the form of a circle.—E, the hymen ; F, the central opening somewhat enlarged. nal organs of generation, which, situated immediately beneath the mons veneris, is bounded laterally by the labia majora and terminated posteriorly by the perineum. It constitutes the external opening com- mon to the vagina and to the urinary bladder. A more particular description of the vulva will be involved in that of its appendages. These are the labia majora, the labia minora or nymphae, the clitoris, hymen, caruneulse myrtiformes, fossa navicularis, fourchette, vestibule and urethra. The labia majora or labia externa are two prominent folds consisting externally of integument and internally of mucous membrane, which, commencing immediately beneath the mons veneris, diverge from each other, extending downward and backward to again converge and terminate at the perineum. Their junction at the mons is termed the anterior commissure, and that at the perineum the posterior commissure. Between the integument which constitutes the outer surface of these folds, and the mucous membrane which forms their inner lining, will be found a large quantity of areolar tissue, fat, glands, an interlacement of vessels and nerves, and a peculiar tissue which resembles the dartos of the scrotum in appearance and general 44 THE VULVA AND ITS APPENDAGES. * construction. The skin of the labia majora is usually soft and deli- cate, and is studded with hair after puberty. The mucous lining is continuous with the mucous lining of the genito-urinary apparatus. It is moist and smooth and of a rose-color in young women, and well supplied with sebaceous glands and mucous follicles. These glands secrete an oleaginous fluid which serves to moisten the parts and protect them from injury by the motion of the adjacent parts; while the mucous follicles likewise provide abundantly their peculiar secretion—stimulated and increased by exercise—which serves to guard these delicate surfaces, which are not only in apposition but in more or less constant movement upon each other, from the irritating effects of friction and from subsequent adhesions. But although these glands usually pour out a healthful and bland fluid, yet under the influence of some morbid conditions of the system their secretions may be exceedingly acrid and irritating, to the extent of causing severe excoriations and unbearable pruritus; and this acrid secretion, when occurring in a married woman, may produce in her husband a disease analogous to gonorrhoea; a circumstance which should be borne in mind. The arteries of the labia majora are derived from the perineal artery, which is usually a branch of the internal pudic. The veins, which are numerous and often become enlarged during pregnancy, generally accompany the arteries. The nerves proceed from branches of the lumbar plexus. The areolar tissue, or cellular structure of the labia majora, is more loose and spongy than in other parts of the body. Thus the labia frequently become the seat of serous infiltration by which they are enormously tumefied. Sanguineous and purulent engorgements, hernial protrusions, varicose veins, and other abnormal conditions may likewise occur in these parts. In girls and unmarried women the external labia are rounded, thicker above than below, and their inner surfaces are closely approximated; but in married women, and especially in those who have borne children, they are more widely- separated, irregular, pale and flaccid. The labia majora are usually regarded as analogous to the scrotum of the male. And, indeed, by careful comparison this is readily appreciable. The existence of a tissue in the labia bearing a marked resemblance to the dartos of the scrotum; the termination of the fibrils of the round ligament within its tissues—as the spermatic cord enters within the scrotum—the presence within the labia of a pouch or cul-de-sac between the dartos- like tissue and the inner surface of the labial integument, which ad- mits the passage of hernial protrusions or serous infiltrations resem- bling scrotal hernia or hydrocele, together with numerous other points THE VULVA AND ITS APPENDAGES. 45 of resemblance which might be cited, all go to prove the striking similarity between the labia majora and the scrotum. The fourchette is a small, transverse fold of mucous membrane found just within the posterior commissure of the vulva. It is usually ruptured in the first labor. The small space lying .between the fourchette and the posterior commissure is termed the fossa navicularis. Its distinctive presence is usually lost by the rupture of the fourchette. The labia minora, labia interna, or nymphce, are two lateral folds of mucous membrane, interior and parallel to the labia majora, by which they are concealed in the virgin. They are continuous externally with the mucous lining of the labia majora; internally with that of the vagina. Superiorly they commence at the clitoris, and extending from thence downward and outward on each side of the orifice of the vagina, are gradually lost. As each labium converges toward the clitoris to join its fellow, it is divided into two folds, the anterior of which unite and pass in front of or superior to the clitoris, forming a minute fold which has been termed praeputium clitoridis, while the posterior divisions unite with the clitoris itself and constitute, as it were, its fnenum. The nymphse are composed of mucous membrane having a thin epithelial layer, beneath which are numerous sensitive papillae. They are likewise supplied with blood-vessels and nerves, and a large number of mucous follicles which secrete an abundance of sebaceous matter. They are very extensive, and after frequent labor are generally found to project beyond the labia externa. Their use appears to be, chiefly, to enfold and protect the clitoris, meatus uri- narius and superior part of the vaginal orifice. The clitoris arises from the union beneath the pubic arch of two cavernous bodies which spring from the ischio-pubic rami; and its free extremity appears at the superior part of the vulva, a little beneath the anterior commissure of the labia majora. In its internal structure and erectile nature it resembles the corpora cavernosa of the male penis, to which organ it corresponds in sensational and passional function. At its anterior extremity, almost entirely covered and concealed by the prepuce formed by the folds of the nymphae, appears a minute gland which is analogous in texture and use to the glans penis. The clitoris is supplied with blood from the perineal artery, and with nerves from the perineal branch of the internal pudic nerve. Like the male penis, the clitoris has a suspensory liga- ment and an erector muscle. Occasionally it becomes greatly elongated, to the extent, in some instances, of four or five inches, and it then bears 46 THE VULVA AND ITS APPENDAGES. a very marked remcmblance to the penis of the male. Most of the cases of so-called hermaphroditism are referable to an extraordinary growth of this organ. The vestibule is a triangular smooth surface situated at the upper part of the vulva. It is bounded laterally by the labia interna, and extends from the clitoris backward to the orifice of the vagina. The meatus urinarius, or orifice of the urethra, is situated at the back part of the vestibule, just above the orifice of the vagina and about an inch below the clitoris. It is surrounded by a prominent elevation of the mucous membrane. The determination by touch alone of the exact location of the urethral orifice is important as enabling the physician to introduce the catheter in the most delicate manner where this operation is required. It may be effected in this way: the patient being placed upon her back, the point of the forefinger of the right hand should be placed just within the orifice of the vagina, the palmar surface looking upward and resting against the anterior vaginal wall. In this position the finger serves as a guide, along the palmar surface of which the catheter should be slidden until it reaches the tubercle formed by the mucous membrane and which marks the entrance to the urethra; then, by slightly depressing the shaft of the instrument, it may readily be made to pass over the elevation at which it has been arrested and to enter the urethra. Another and very satisfactory method of cathetcrizing the female is, to find the clitoris with the point of the forefinger, and then to pass the finger from this point downward over the surface of the vestibule until an elevation is met with, which is the urethral orifice, into which the instrument may without difficulty be inserted. It may sometimes happen that where great difficulty is experienced in passing the female catheter the use of the male catheter may be successful. The finger having been introduced as before directed, the instrument, with its concave surface upward, should be slidden along the finger, when the desired object will be accomplished by the point of the instrument dropping, as it were, into the orifice of the canal. Where cystocele exists this is the only method that can be crowned with success; it must be remembered, however, that in these cases as the instrument enters within the orifice it must be turned with its convex surface upward. Sometimes in women who have borne many children, or where <>reat tumefaction of the adjacent parts exists, it is impossible to find the urinary meatus by the sense of touch alone; and in such cases it becomes absolutely necessary to expose the vulva and introduce the catheter guided by sight as well as touch. THE VULVA AND ITS APPENDAGES. 47 The urethra itself is larger than its orifice, and may be described as a membranous canal about an inch and a half in length, slightly curved, with its concavity looking upward, passing obliquely upward and backward beneath the symphysis pubis, to which it is attached by loose cellular tissue. More interiorly it passes between the crura of the clitoris and just beneath their junction. It is susceptible of very great dilatation, and opens interiorly into the urinary bladder. It is composed of three tunics—a muscular coat continuous with that of the bladder and composed of circular fibres; a thin layer of erectile tissue intermixed with numerous elastic fibres; and a mucous coat, which is continuous externally with the vulva and internally with that of the bladder. It is surrounded also by the muscular fibres of the compressor urethra?, which assist in controlling the flow of the urine. In the various displacements of the uterus, the urethra, by reason of its structural connection with the vagina, is liable to be changed from its natural direction. This should be especially borne in mind if called upon to perform catheterism to relieve retention of urine caused by such uterine displacements. It is very distensible, in some cases becoming greatly enlarged. Calculi have been' removed from the bladder through the urethra, and large-sized pessaries have been passed through it into the bladder. Orifice of the Vagina.—Immediately below the meatus urinarius is found the much larger and irregularly shaped opening which constitutes the orifice of the vagina. The extent of this opening varies greatly according to the sexual condition of the female. In those who are virgins, and in some exceptional cases in persons who are not, the orifice of the vagina is very small, oval, or crescent-shaped, as repre- sented in Figs. 10 and 11. It is more or less closed in the virgin by a membranous fold called the hymen. The hymen is the delicate membranous structure which covers the greater portion of the orifice of the vagina, and which is usually ruptured at the first successful attempt at sexual intercourse. The rupture of this structure ordinarily occasions a slight flow of blood, and sometimes leads to no inconsiderable haemorrhage. The minute reddish tubercles found near the orifice of the vagina, and called carunculai myrtiformes, are regarded as the remains of the ruptured hymen. Sometimes this membrane, instead of being thin and easily broken, is dense and firm, requiring to be opened Avith an instrument before coition can be accomplished. In other instances the hymen is found entirely imperforate in childhood. And in these cases, unless the abnormal condition has been attended to in childhood, when the 48 THE VULVA AND ITS APPENDAGES. period of puberty is reached it may become necessary to resort to operative interference in order to allow of the escape of the menstrual discharge. When it is suspected that the hymen is imperforate and menstrual fluid is retained behind it, an examination should be made, which may be conducted in the following manner: Place the female upon her back, with the shoulders elevated at an angle of 30°, and the thighs flexed and separated. Then, with the index finger well lubricated, carefully explore the vulva. If no entrance into the vagina can be effected with the finger, a very small blunt probe may be substituted and the exploration very carefully continued. If, on this latter attempt, no orifice can be found, and an accumulation of menstrual fluid be suspected, hold the palmar surface of the index finger against the centre of the hymen with gentle force, and Avith the left hand make sudden and forcible downward pressure upon the abdomen immediately over the region of the Avomb, and if fluid be present within the vagina, it will be made appreciable to the index finger applied against the hymen. If the presence of the menstrual fluid should be made out, operate at once. But if the patient be un- married and not in good general health, an effort should be made to restore the general health by careful medical treatment. This done, if the hymen still remains imperforate, and the menses consequently do not floAV,* an operation should be resorted to in the folloAving manner: The patient should lie on her back, Avith the loAver limbs well flexed and separated, care being taken that as little of the person is exposed as possible. Then, Avith the index finger and thumb of the left hand, separate the external labia, and Avith a bistoury or scalpel make an incision in the mesial line, extending from about one- fourth of an inch below the meatus urinarius doAvmvard for about three-fourths of an inch. A suitable vessel should be at hand for receiving the flow Avhich will folloAV the incision of the hymen and the consequent separation of the vaginal Avails. The hymen is usually crescentic in shape, the concavity looking anteriorly. It occasionally presents a central perforation, or there may be a number of minute holes through it, like those through the top of a pepper-box. It is usually a thin and fragile membrane, and is readily ruptured, as before remarked, during first coition. Sometimes * I once examined a young unmarried lady, whose hymen was found perfectly im- perforate, but the presence of menstrual fluid could not be detected. She was in bad ' health, and her symptoms called for the exhibition of silicia, a single dose of which was given in a very high potency. This was followed by a rapid recovery of her general health, and about two months after the administration of the dose of silicia she menstruated freely and regularly. THE FOLLICULAR AND GLANDULAR SYSTEM. 49 however, it is dense and thick, and when this occurs and there is an opening through its anterior part immediately posterior to the meatus urinarius, a grooved director should be introduced through this orifice, and carried doAvn behind the hymen to the posterior wall of the vagina; then a probe-pointed bistoury should be carefully introduced until its blunt point lies Avithin the groove of the director, and a careful divis- ion of the hymen by cutting doAvnward and outward should follow. Sometimes the hymen lies high up in the vagina. If it be found imperforate in this situation, and section has to be resorted to, the speculum must be used and the cutting instrument introduced through it. When a division of the hymen is necessitated by the presence of menstrual fluid Avithin the vagina, the fluid should be allowed to run off gradually, for fear of shock to the system and subsequent irritative fever. The section of the hymen can be completed when the whole quantity has been evacuated. The presence of the hymen is commonly regarded as the evidence of virginity, but it is well known that the membrane has been found intact by the accoucheur at the setting in of labor, and, on the other hand, that its absence may be attributable to a variety of causes other than coition. Bough nurses, may de- stroy the delicate membrane in the babe, while washing the external genitals. The follicular and glandular system of the external organs of generation require particular attention. They may be divided into two classes: the first consisting of the piliferous bulbs, sudoriparous glands, sebaceous glands, and muciparous glands and follicles; the second including the vulvo-vaginal glands or glands of Bartholine. The piliferous bulbs nourish and support the hair Avhich appears more or less abundantly upon the mons Areneris and labia majora. The sudoripetrous glands are quite numerous upon the labia majora. They are mingled Avith the sebaceous glands and surround the pilifer- ous follicles. The sebaceous glands are more numerous than the rest, and in some situations, as on the mons veneris for instance, are of remarkably large size. They are found on the mons veneris, the external and internal labia, the fourchette, and the glans of the clitoris, but have not been discovered in the vestibule or around the urethral orifice. They se- crete an unctuous substance, thinner than that from sebaceous glands situated elseAvhere, Avhich shields the delicate organs from cold, keeps them moist and supple, and prevents them from being injured by the perspiration, urine, or vaginal or uterine secretions. The muciparous organs are placed at different situations on the 4 50 THE FOLLICULAR AND GLANDULAR SYSTEM. external parts, and are divided into isolated or agminated follicles and the vulvo-vaginal glands. The isolated follicles appear at several different points about the orifice of the vagina, and are variously named according to their Fig. 1~2. situation. The vestibular follicles, some six or eight in number, are found in the vestibule. (Fig. 12, A.) These are very minute; and their small and rounded openings are so oblique to the plane of the mucous membrane as to give them the appearance of being covered by a thin valve. The urethral follicles are situated in the cellulo-vascular tissue of the urethra. They are placed beneath the mucous membrane in a line parallel to the canal of the urethra, and discharge upon the inner margin of its orifice. (Fig. 12, B.) Their function is evidently to prevent the orifice of the urethra from becoming dry, and from being irritated by the streams of hot urine Avhich pass over it. The lateral urethral follicles appear on either side, and at some little distance from the orifice of the urethra. They have a common opening at the mouth of a peculiar conical depression. They are not always to be found, and are small and shallow. (Fig. 12, C.) The lateral follicles of the orifice of the vagina (Fig. 12, D, E), three or four in number and comparatively large, are found usually upon the lateral parts of the vaginal orifice immediately below the hymen or carunculse myrtiformes. They are irregular in their number situa- tion and arrangement, and are not to be found in all females. The vulvo-vaginal glands or glands of Bartholine, one on each side are true conglomerate glands, having a bulbous body and an excretory THE FOLLICULAR AND GLANDULAR SYSTEM. 51 duct. They are situated at about the lower third of the orifice of the vagina, just inside its lateral margins. The bulb (D) and excretory Fig. 13. VTTI.VO-VAGIN'AX GLAND. A A, section of the labia majora and of the nymphse, showing the excretory duct and its orifice; B, the gland ; C, excretory duct; I>, its glandular extremity ; E, its vul- var extremity and orifice; F, bulb of the vagina; G, ascending ramus of the ischium. duct (C), in size and exact position, are on one side, Avell represented in Fig. 13. These glands are comparatively small, acquiring full development only at puberty; are often unequal in size on the tAvo sides; as sympathizing with the ovary, the larger one is found on that side in which the ovary may be more voluminous. The diameter of these glands, Avhen largest, is from four-eighths to five-eighths of an inch. Their secretion is intended principally to lubricate the parts during sexual intercourse, and they are especially active at such times and under the influence of lascivious emotions. During coition the muscles of the perineum and vulva are excited, and the secretion of their glands is discharged in jets. There is a coincidence of action between them and the other muciparous follicles; and the secretion Avhich so abun- dantly supplies the vulva and vagina, especially during sexual inter- course, is the joint production of both glands and follicles. The Vagina. The vagina is the membranous canal Avhich leads from the vulva to the uterus. When distended it is cylindrical in shape, and it is i 52 THE VAGINA. curved in its natural position, with the concavity looking toward the symphysis pubis. Extending from the vulva, or outlet of the in- ferior strait, to the superior strait, the direction of its curvature is the same as that of the general axis of the pelvis. It is capable of great Fig. U. VERTICAL SECTION OF PELVIS, WITH OKGANS IN SITU. dilatation, but ordinarily its anterior and posterior walls remain in apposition. Anteriorly, the vagina is in relation Avith the base of the bladder and the urethra, with Avhich it is connected by condensed cellular tissue. Posteriorly, it is in relation Avith the rectum, to which it is attached by a considerable thickness of looser cellular membrane for the loAver three-fourths of its extent, its upper fourth being separated from the rectum by the recto-uterine fold of peritoneum. Thus, in displacements of the uterus, Avhich necessarily affect the vagina, the rectum is seldom involved, Avhile the bladder, being more firmly bound to the vagina, is ahvays disturbed by such changes in the posi- THE INTERNAL ORGANS OF GENERATION. 53 tion of the uterus. Hence the incessant calls to pass Avater, with pain- ful micturition or more or less complete retention of urine, so often seen in cases of anteversion or prolapsus uteri. The length of the vagina differs in different persons, and in differ- ent states of the same person. It is much longer posteriorly than anteriorly, and may be stated to be from four to five inches long on its anterior wall, and from five to six inches long on its posterior Avail. It is very elastic, and is capable of being distended longitudi- nally, as Avell as of being laterally dilated. In some instances it ap- pears very much shorter than the natural standard. This shortening of the vagina may be accidental, merely the result of partial prolapsus of the uterus, or it may be congenital and permanent. In the former case the womb may be pressed upAvard and restored to its natural position, Avhen the shortening of the vagina will at the same time dis- appear. But in the latter case the uterus cannot be thus pushed up by the finger, and this circumstance conclusively determines the nature of the difficulty. Extreme shortness of the vagina has been put doAvn by some authors amongst the causes of sterility; but it cannot be regarded as necessarily a cause, inasmuch as there is abundance of testimony to prove that conception has taken place from the semen coming into contact with the mucus lining of the vulva and orifice of the vagina. The vagina is narroAvest at its orifice, most capacious midAvay in its course, and again contracted at its uterine extremity. In these re- spects it resembles the superior strait, cavity and outlet of the pelvis. In Avomen who have borne many children its midway capacity is Arery great; its ordinary circumference is about three inches. The parietes of the vagina consist of an external or muscular coat, an internal mucous lining, and an intervening layer of erectile tissue enclosed between two layers of fibrous membrane. The muscular layer is composed of longitudinal muscular fibres, Avhich are continu- ous with the superficial muscular fibres of the uterus. These surround the vagina, and are more abundantly and poAverfully developed in some females than in others. The erectile tissue, Avhich appears to be com- posed mainly of several superposed layers of venous network, is more abundant at the lower than at the upper part of the vagina. The in- ternal or mucous coat is continuous above Avith the mucous lining of the uterus, and beloAV Avith that of the vestibule and vulva. This mucous coat of the vagina is thrown into numerous transverse or oblique folds, called rugos, which are more frequent and distinct near the orifice of the vagina, particularly in women avIio have not borne 54 THE UTERUS. children. These folds evidently constitute a provision for the dilata- tion of the vagina, to alloAV the passage of the fcetal head. The mucous membrane is covered with conical and filiform papillae and numerous glands. These latter, which are especially numerous at the upper part of the vagina and around the cervix uteri, pour out a profuse secretion more abundant during coition, and still more in par- turition. The vagina is abundantly supplied Avith blood-vessels, absorbents and nerves. The arteries are derived from the hypogastric; the veins, which are very numerous and plexiform, communicate with the vesi- cal plexus in front and the hemorrhoidal plexus behind, and its nerve plexus, Avhich contains a large proportion of spinal nerve fibres, arises from the inferior hypogastric or pelvic plexus. The superior portion of the vagina enfolds the neck of the uterus in a manner similar to the attachment of the Zouave pants to the legs, forming an anterior and a posterior cul-de-sac, of which the latter is much the deeper. In its use the vagina constitutes the chief copulative organ of the female, affords an outlet for the escape of the menstrual fluid, and be- comes the channel through Avhich the foetus passes from the uterus through the cavity of the pelvis into the external world. After par- turition it very speedily decreases in calibre and nearly resumes its natural size. The Uterus, The uterus is the organ of gestation in which the fecundated ovum is received, nourished, and supported till the proper period of its ex- pulsion at parturition. In its virgin state the uterus, under the influ- ence of the ovaries, constitutes the pivot around which play all the physical and nervous energies of the female organism; and its func- tional perfection exercises a powerfully controlling influence upon the physical health and social and moral happiness. The generative or- gans constitute the grand centre of the female economy. All the other organisms and functions of the woman are more or less in sym- pathy Avith these. And from the full, healthy, and harmonious de- velopment of the sexual system come the ruddy cheek, the elastic step, the buoyant, Avomanly spirit, and all that constancy of love and affec- tion Avhich so pre-eminently characterize, beautify and ennoble the female sex. And the impregnated uterus becomes at once one of the largest and certainly the most important organ in the body of the female in her highest state of physical development, it being then the THE UTERUS. 55 true physiological centre of the most excited vital activity—the repro- ductive seat of life within life. This distinction of the virgin from the impregnated uterus not only underlies the whole character and constitution and function of the organ, but affects also the entire physiological, social, moral, and even spiritual, nature and condition of the female herself. Both the organ and the individual in the one case are totally different in structure, function and being from the organ and individual in the other. The virgin or unimpregnated uterus has a structure and functions and dis- orders peculiar to itself. The impregnated uterus also has structure, functions, disorders, difficulties and dangers peculiar to it. We give then, in the first instance, an account of the virgin uterus, describing its shape, size, structure, position, relations, appendages and functions, and aftenvard pursue a similar course with reference to the gravid or impregnated uterus. Subsequently, and in the appro- priate place, Ave will detail the various dangers and disturbances to which the uterus—impregnated and unimpregnated—is liable, to- gether Avith the chief characteristic indications for the principal reme- dies required in their treatment. The virgin uterus is a holloAV, pear-shaped conoid organ, Avith its base or larger part turned upAvard and forward, and its apex or smaller extremity looking doAviiAvard and backward. The great im- portance of this organ, and the consequent minuteness of description requisite for its thorough study, have caused it to be divided, nomi- nally and externally at least, into five parts. Of these, the base or upper third is called the fundus ; the middle portion or that part be- tween the fundus and the cervix is called the body ; the loAver third is called the cervix or neck ; the lower extremity of the cervix is called the apex ; and the orifice or opening of the cervix is called the os ex- ternum, os uteri, or mouth of the womb. It has also, externally, an anterior and a posterior face; the anterior being more flat and looking toward the bladder and symphysis pubis, while the posterior face is more extensively covered by the peritoneum, more convex, and looks toward the rectum and promontory of the sacrum. There are also three borders or margins—one superior border, Avhich bounds the summit of the fundus, and one right and one left lateral border. To the two latter are attached the broad and round ligaments of the corresponding sides. Finally, the cervix and body of the Avomb have also an internal surface lined with mucous membrane, which is supplied with numerous follicles and glands. The fundus or base of the Avomb is convex, looking upAvard and 56 THE UTERUS. forward, ordinarily inclining toAvard the arch of the pubis, its summit never rising above the margin of the superior strait, Avhile the supe- rior two-thirds of its anterior and the Avhole of its posterior surface is covered by the reflected folds of the peritoneum. Its superior sur- face is in apposition with the convolutions of the small intestines. Fig. 15. THE INTERNAL GENITAL ORGANS. A, the uterus, seen on its anterior face; B, the intra-vaginal portion of the neck of the uterus; C C, the Fallopian tubes; D, the pavilion or fimbriated extremity of the tube; E E, the ovaries; F, the ligament of the ovary; G G, the round liga- ments ; H, the vagina laid open. On the right, the fimbriated extremity of the tube is seen applied to the ovary. The body of the uterus gradually narrows from above doAvmvard to terminate in the cervix. At the points on either side AA7hich mark the junction of the body with the fundus an angle is formed, Avhich indi- cates the positions of the two Fallopian tubes. A third angle is formed at the junction of the body with the cervix, and hence the uterus has been described as being of triangular shape. The anterior surface of the body is somewhat flattened, and is covered by peritoneum in its upper three-fourths, Avhile its loAver fourth is connected with the bas fond of the bladder by areolar tissue. This connection of the uterus with the bladder accounts in a great degree for the derangements of the urinary functions almost always attendant on displacements of the uterus; as well as for the change in position of the urethra Avhich attends the enlargement and elevation of the uterus during the pro- gress of pregnancy. Between the upper portion of the body and the bladder some coils of the small intestines are interposed. Posteriorly the body of the uterus is convex, separated from the rectum by portions THE UTERUS. 57 of the small intestines, and covered throughout by peritoneum. Its lateral borders are slightly concave, and give attachment to the Fal- lopian tubes and the broad and round ligaments. The cervix is about one inch in length, and is slightly constricted at its point of union with the body of the uterus. At this point take place the flexions which sometimes occur in connection with change of position of the body and fundus of the Avomb. Thus, in cases of anteflexion, retroflexion and lateroflexion the body of the uterus forms nearly a right angle with the neck. The usual position of the virgin uterus is with the fundus inclined toAvard the symphysis pubis. This causes the cervix to incline toward the superior portion of the coccyx (see Fig. 14), and the os uteri to look posteriorly toward the rectum, instead of looking directly downward in the direction of the axis of the inferior strait. The vagina embraces the cervix at its upper third, and hence divides it into two portions—an upper or uterine, which lies above the point of junction of the vagina, and a loAver or vaginal portion, Avhich pro- jects into the vagina as a free extremity of the Avomb. The anterior face of this free extremity is someAvhat shorter than the posterior face, on account of the oblique manner in Avhich the vagina surrounds the cervix. Before puberty the cervix is small, dense and conical in shape, while at puberty there is a considerable increase in its size and a dimi- nution of its density. Pregnancy and parturition still further and very markedly modify the conditions of the cervix in all particulars. From a description of the outer surface of the uterus we naturally come to a description of its cavity and internal surface. And first the cavity of the cervix engages our attention as the entrance to the greater cavity of the body of the womb. The entrance to the cavity or canal of the cervix is termed the os uteri, or, from a fancied resem- blance to the mouth of a tench, the os tineas. In the fully-developed virgin uterus the os uteri presents two lips, separated by a transverse fissure. These two lips are of nearly the same length, although the anterior is the thicker and descends a little lower than the other. In young girls the os is quite small, and sometimes almost undiscoverable. But where it thus seems Avanting or imperforate, gentle pressure of the finger will detect a slight depression which will indicate its exact situation. In women who have borne children, on the contrary, the os uteri is sufficiently open to admit the point of the finger, while the lips of the os are unequal in size and present a number of irregular depressions or notches. The canal of the cervix is from three-fourths of an inch to an inch 58 THE UTERUS. long, extending from the os externum to the os internum which marks the entrance into the cavity proper of the uterus. In its course from the external to the internal os, it first widens and then grows narrower as it merges itself with the os internum, which latter is in a measure a strait or intermediate portion connecting the canal of the cervix Avith the cavity of the body of the womb. The mucous membrane lining the canal of the cervix is arranged in radiating folds, or rugce, on either side; the united radiations of both sides, having an appearance resembling somewhat the arrangement of the branches of a cedar tree, have been called arbor vitm. (See Fig. 16, C, and Fig. 18, A.) The cavity of the body of the Avonih, into which that of the cervix Fig. 16. G CAVITY OF THE UTERUS AND THE FALLOPIAN TUBES. A, superior border or fundus of the womb; B, cavity of the womb; C, cavity of the neck of the womb; D, the canal of the Fallopian tube cut open ; E, the fimbri- ated extremity or pavilion, likewise laid open ; F F, the ovaries, one-half of which has been removed so as to bring into view several of the Graafian vesicles ; G, the cavity of the vagina; H H, the ligaments of the ovaries; G G, the round ligaments. leads, and with which it is continuous, is covered Avith mucous mem- brane, and abundantly supplied Avith muciparous follicles, although these are far less numerous in the body than in the cervix. In the virgin Avomb the Avails are nearly in apposition, there being ordinarily but little cavity in the empty womb. At the same time the walls are much more vascular than the parietes of the canal of the cervix. Still, the cavity of the womb, such as it is (Fig. 16, B), is triangular in shape, its inferior angle corresponding to the os internum, the two superior and lateral angles being situated at the orifices of the Fallo- pian tubes. In Fig. 17 appears a profile view, which conveys a more correct idea of the manner in which the walls of the virgin uterus are approximated in their ordinary condition. At the times of the menstrual excitement they are somewhat more distended. The external dimensions of the uterus vary in different persons—be- THE UTERUS. 59 ing larger or smaller, to correspond with the totality of their physical constitution. We give Avhat may be considered the average admea- surements of the fully-developed uterus at puberty. The entire length Fig. 17. This profile view gives an exact idea of the dimensions of the cavity of the body and of the neck of the womb in a state of vacuity. A, mucous membrane; B, tissue proper; C, cavity of the body; D, cavity of the neck. of the uterus, from the inferior margin of the cervix to the superior border of the fundus, is about three inches, its greatest breadth is about tAvo inches, and its thickness from the anterior to the posterior face is one inch. As the uterus increases in size from childhood to puberty, so from the cessation of the menses it begins to diminish in volume till it becomes more or less atrophied in the second childhood of advanced age. And as in the impregnated condition the womb becomes very greatly and permanently enlarged—that is, during the continuance of pregnancy—so at the accession of each of the monthly periods, in many females, it becomes temporarily enlarged. The Aveight of the virgin uterus may be set down as about an ounce to an ounce and a half, but after child-bearing it remains two or three times as heavy. The structure of the uterus forms a very important element in study- ing its nature and functions. Three distinct tissues, coats or tunics —each possessing a different constitution and performing totally dif- ferent functions—make up this complicated structure. These are the external or peritoneal coat, the middle or muscular coat, and the in- ternal or mucous coat. The external or peritoneal coat.—This membrane is reflected from the posterior surface of the bladder upon the anterior face of the uterus, extends upward, and, covering the fundus, is continued down 60 THE UTERUS. upon the vagina a short distance beloAV the cervix, and is then finally reflected upon the rectum. The peritoneal membrane or serous tissue is thus seen to be identical and continuous Avith the common lining membrane of the abdomen. The fold of peritoneum reflected from the bladder to the uterus is termed the vesico-uterine or anterior ligament, and that which passes from the posterior surface of the uterus to the rectum is termed the recto-uterine or posterior ligament. These, however, are mere subdivisions made for the sake of descrip- tion, of the broad ligaments of the uterus, which are formed by pro- longations on either side of the folds of peritoneum Avhich pass from the bladder to the anterior uterine wall, across the fundus and doAvn the posterior wall, and from thence to the rectum. These prolonga- tions are reflected from each lateral border of the uterus to the corre- sponding side of the pelvis, in the direction of the sacro-iliac symphy- sis. Taken as a whole, they form what are called the broad ligaments of the uterus, and contain the Fallopian tubes, the ovaries and the round ligaments. The middle or muscular coat forms the principal part of the sub- stance of the uterus. This tissue is dense, firm, and grayish in color. It is thickest upon the middle of the body and fundus, thinnest at the orifices of the Fallopian tubes. It consists of bundles of unstriped muscular fibres, disposed in three layers, intermingled Avith areolar tissue, blood-vessels, lymphatics and nerves. The external layer ap- pears principally upon the anterior and posterior surface; its fibres, converging at each superior angle of the uterus, are continued upon the Fallopian tubes, the round ligament and ligaments of the ovary__ some few running backward from the cervix uteri to eonnect Avith the recto-uterine ligaments. The middle layer of this coat is composed of longitudinal, oblique and transverse muscular fibres. The internal layer consists of circular fibres arranged in the form of holloAV cones Avhose apices surround the orifices of the Fallopian tubes, their bases meeting and intermingling at the middle of the body of the uterus. The fibres of this layer are disposed transversely or circularly in the cervix uteri. The womb is a muscular organ of very great power, and a thorough knowledge of the nature and arrangement of its muscular fibres in the cervix, and especially in the fundus, and of their relation to the broad and other ligaments, is essential to a correct understand- ing of its Avonderful action in parturition. The mucous coat of the uterus is so closely adherent to the subjacent tissue that, from the difficulty of separating and demonstrating it its existence has been denied by many authors. But by the aid of'the THE UTERUS. 61 microscope this mucous coat has not only been clearly distinguished, but shoAvn also to consist of epithelium, basement membrane, fibrous tissue, blood-vessels and nerves, like other mucous membranes. This Fig. is. This figure represents the arrangement of the mucous membrane, and of the tissue proper of the uterus, as also their relative dimensions. A, cavity of the neck and arbor vitse ; B, cavity of the body; C, mucous membrane; D, intervening membrane ; E represents the marked thinning ofF of the mucous membrane toward the neck. internal mucous coat of the uterus is continuous with that of the vagina, and also Avith the peritoneum above, through the fimbriated extremity of the Fallopian tubes. It abounds in follicles, whose secretion lubricates the interior surface of the uterus. And the abnor- mal, catarrhal and leucorrhoeal secretions and other morbid products, to be subsequently considered as disorders of the cervix and even of the fundus, conclusively show the mucous character of this innermost tissue of the uterus. Numerous follicles, glands and papilla? appear in the mucous lining membrane of the cervix, the secretions from Avhich serve to maintain the mouth of the virgin uterus in a healthy condition. Much the larger portion of the mucous secretion from the Avomb is in reality the product of the innumerable glands of the cer- vix. This secretion in its normal state is Avhitish, very viscid, almost transparent, and gives an alkaline reaction. It adheres to the crypts and rugse of the cervix, and occupies its canal. The blood-vessels of the Avomb are numerous, and largely developed in comparison Avith the size of the organ. This has reference not only 62 THE UTERUS. to the nutrition of the womb in its ordinary condition, and to its con- gested state at the periods of menstrual excitement, but is provisional also for the necessities of that impregnated condition for Avhich it is designed. The arteries Avhich supply the Avomb form tAvo distinct systems, according to the sources from which they are derived and the parts to Avhich they are finally distributed. The first, or superior system, is composed of the ovarian arteries, Avhich correspond Avith the spermatic arteries of the male, arise from the aorta, and descending along the sides of the womb in a serpentine course are distributed to its upper part, to the Fallopian tubes and to the ovaries. The second, or inferior system, is composed of the uterine arteries, which are de- rived from the internal iliac arteries. These also pass along the sides of the womb, to be finally distributed to the cervix and upper part of the vagina. These arteries pursue a remarkably tortuous course in the substance of the uterus; thus provision is made for their great elongation without danger of rupture in the advanced stages of preg nancy. The numerous branches of these two systems freely anasto- mose with each other. The veins of the virgin uterus are of large size, possess no valves, correspond in name with the arteries, and folloAV their course. The right spermatic vein terminates in the inferior ATena cava, the left in the renal vein; the uterine veins empty into the internal iliacs. They are capable of very great increase in pregnancy, and are then known as uterine sinuses. The lymphatic vessels of the uterus, invested by delicate coverings of peritoneum, are distributed upon all the external surfaces of that organ. They are very numerous, and,, in the virgin'uterus, very small. Some of these ascend, in a serpentine course, from the cervix to the body and fundus of the uterus. Others pass less tortuously, in vari- ous directions, over both these surfaces, communicating with branches ascending from the vagina and with those from the Fallopian tubes and ovaries. The internal as well as the external surfaces of the uterus, Fallopian tubes and ovaries are abundantly supplied with these absorbent vessels. Those of the former, from the interior struc- ture of these organs, communicate with the lumbar ganglia; those of the latter, from their external surfaces, communicate Avith the pelvic or inguinal ganglia. This latter circumstance is important to be borne in mind, since this anatomical and physiological connection is fre- quently the index to pathological appearances. In addition to the general division of the lymphatics of these organs to correspond to their external and their internal surfaces, the mode in Avhich they are THE UTERUS. 63 originally distributed to follow the course of the arteries, arranges them all in two distinct systems of lymphatic circulation. With the exception of the proper menstrual secretion, there is no discharge from the interior of the female organs of generation in their normal condi- tion, the lymphatics sufficing to reabsorb the natural secretions of their internal surfaces, so that no accumulation occurs. The nerves of the uterus and its connecting structures of the gene- rative system are derived, either directly or indirectly, from all three of the great nervous centres of the body, and by their union and concentration serve to render the sexual system of the female the great physiological centre of her entire organism. The nerves which are distributed to the uterus are, in part, derived from the great sympathetic, and in part from the spinal nervous, system. But these latter, as branches of the third and fourth sacral nerves given off from the cerebro-spinal axis, are, indirectly at least, derived also from the cerebral nervous centre, as Avell as from the spinal, although they are not under the immediate control of the will. The nerves Avhich are distributed to- the uterus from the sympathetic system are derived from the aortic and from the hypogastric plexus. The former—variously named as the renal, the spermatic or ovarian plexuses, according to their more immediate relations—are all derived from the great solar or epigastric plexus, and are intimately connected with all the other pelvic, abdominal and thoracic nervous centres. Hence the powerful sympathy Avhich exists between the womb itself and all the other great organs of the female. Hence, too, the intense pain felt at the pit of the stomach in cases of uterine neuralgia, and the nausea and vomiting which are so often associated with peculiar conditions of the impregnated Avomb. The nerves which are distributed to the uterus from the hypogas- tric plexus come directly from the pelvic portion of the sympathetic, and have associated with themselves the filaments from the third and fourth sacral nerves, Avhich connect the womb Avith the general mus- cular apparatus of the body—the former class of nerves having espe- cial relation to the two great functions of nutrition and reproduction, as in the growth of the womb itself and of the ovum Avhich it may contain in the impregnated state; the latter having relation to those muscular powers of the womb by which it is enabled to exert itself so Avonderfully to expel the product of conception at full term, and to combine with its own efforts the muscular powers of all other parts of the body. Unlike other muscular structures, the nervous filaments penetrate 64 THE UTERUS. into the substance of the womb, and during the period of utero- gestation all the uterine nerves are very greatly enlarged. The uterus appears as if supported or suspended in the midst of the pelvis, and is sustained in this position by certain ligaments, which are processes given off from its own substance or from the enveloping peritoneum, and by the peritoneum itself. The ligaments are arranged in four pairs, and are knoAvn as the anterior, the posterior, the round and the broad ligaments. The anterior and posterior, to- gether Avith the broad ligaments of Avhich they are a part, have already been described. Stretching laterally from the sides of the uterus to those of the pelvis, they form a partition wall or septum in the caAdty of the pelvis, Avhich divides it into an anterior portion, containing the bladder, urethra and vagina, and a posterior portion, containing the rectum. The round, ligaments, continuous with the proper tissue of the Avomb, are produced from the anterior and superior part of its body. They are four or five inches long, situated between the layers of the broad ligament, and attached to the superior angles of the uterus, one on each side, a little in front of the Fallopian tube. (Fig. 16, G.) From this point the ligament proceeds outward and forward to pass through the inguinal canal toward the symphysis pubis, Avhere its expanded fibres are distributed to the subcutaneous cellular tissue of the groin, mons veneris and dartoid pouch of the labia. The tubular process in this ligament, called the canal of Nuclc, is analogous to the peritoneal pouch Avhich accompanies the descent of the testes in the male. The womb is apparently maintained in its oblique position by the co-operative agency of all its ligaments, assisted by the support fur- nished by the vagina and the pressure of the intestines. But when Ave come to consider the subject carefully, it undoubtedly appears that it is to the folds of peritoneum the maintenance of the uterus, in its position between the pubes and the sacrum in the ever-varyino- move- ments of the Avoman, is mainly if not wholly due. For, if Ave consider that nearly all the viscera Avithin the abdominal cavity are invested and supported in position by the peritoneum, and that this membrane, reflected from the bladder, covers the entire upper and anterior three- fourths of the uterus, and is thence reflected over its fundus and doAvn- Avard upon its entire posterior length, it will be seen that the organ is invested by, and lies between, as it were, tAvo layers of peritoneum riding upon the anterior and inferior layer, and covered in and held doAvn by the posterior superior layer, the Avhole being anchored in situ to the sides of the pelvis by the reflected broad ligaments. Thus THE UTERUS. 65 while the broad ligaments, the round ligaments, the vaginal walls and the superimposed intestines contribute to keep the uterus in its oblique antero-posterior position, its main support is derived from the investing layers of peritoneal tissue, which almost entirely cover it. These supports of the uterus are not merely extensible, but possess contractile poAver, due to the presence of muscular fibres. Thus a large degree of motion is allowed the womb, particularly in an antero- posterior direction. If the bladder be distended, the uterus will be pushed backward toward the rectum, and if, on the contrary, the bladder be empty and the rectum distended, the viscus will be cor- respondingly pushed forAvard, the contractile power of its ligaments serving to replace the organ when its normal position has been dis- turbed. When these circumstances are borne in mind, and it is like- wise remembered that displacements of the uterus must frequently occur in consequence of the relaxation of these supporting processes of peritoneum resulting from some constitutional disordered con- dition, the rationale of their cure by medication alone becomes per- fectly obvious. " During and after menstruation the uterus is enlarged and more vas- cular, its surfaces rounder; the os externum is rounded, its labia SAvollen, and the lining membrane of the body thickened, softer and of a darker color. " During pregnancy it increases in weight from one pound and a half to three pounds. It becomes enormously enlarged, and projects into the hypogastric and lower part of the umbilical regions. This enlargement, which continues up to the sixth month of gestation, is partially due to increased development of pre-existing and new-formed muscular tissue. The round ligaments are enlarged, and the broad ligaments become encroached upon by the uterus making its Avay between their laminse. The mucous membrane becomes more vascu- lar, its mucous follicles and glands enlarged; the rugae and folds in the canal of the cervix become obliterated; the blood-vessels and lym- phatics, as well as the nerves, according to the researches of Dr. Lee, become greatly enlarged. u After parturition the uterus nearly regains its natural size, weigh- ing from two to three ounces, but its cavity is larger than in the virgin state; the external orifice is more marked and assumes a transverse direction; its edges present a fissured surface; its vessels are tortu- ous, and its muscular layers are more defined. " In old age the uterus becomes atrophied and paler and denser in texture; a more distinct constriction separates the body and cervix. 5 66 THE OVARIES. The ostium internum, and occasionally the vaginal orifice, often be- comes obliterated, and its labia almost entirely disappear."—Gray. The Fallopian Tubes. The Fallopian tubes are the oviducts through which the ovum is conveyed from the ovary to the uterus. They are two in number, one on each side, about four inches in length, and extend from the superior lateral angles of the uterus, lying in the free margin of the broad ligament, outward toward the sides of the pelvis, where they terminate in fringed borders or fimbriated extremities. The canal of these tubes is exceedingly minute. The internal orifice, that within the cavity of the uterus, is termed the ostium internum, or uterinum, and is so small as scarcely to admit the introduction of a fine bristle. From this orifice the tube widens until it is finally developed into a trumpet-shaped extremity, the pavilion. At the base of the pavilion a contracted circle, the ostium abdominale, forms the termination of the tube proper, and from this circle radiate the fringes which com- pose the pavilion or fimbriated extremity itself. The Fallopian tubes are composed of three distinct coats or tunics. The outer coat is derived from the peritoneum. The middle coat is muscular, and consists of two layers of fibres, an outer or longitudinal, and an inner or circular layer, both of which are continuous with the muscular fibres of the uterus. The inner coat consists of mucous membrane, which is continuous at the inner extremity of the tube Avith the mucous lining of the uterus, and at its fimbriated extremity with the peritoneum. Toward the outer extremity of the tube the mucous coat is thrown into folds, which indicates its adaptability for dilatation. It is covered with columnar-ciliated epithelium; the cilia? being arranged in such a way as to facilitate the passage of ova from the ovary to the uterus. The ovules discharged at the menstrual periods pass through the tubes to the uterus. The Ovaries. It is only in a practical or obstetric point of view that the uterus can be regarded as the most important of the generative organs. The ovary, though constituting but a small part, anatomically considered, of these organs, is really the part to which all others are subservient^ inasmuch as it furnishes the element which is essential to the repro- ductive act. And not only can it be claimed for the ovary that it is the essential part of the reproductive system, but that in a very great degree it regulates the growth of the whole female organism—as the the ovaries. 67 testes do in the male—and determines the distinctive characteristics of the sex. " It is the organ upon the presence of which depends the sexual passion and the function of menstruation, whose congenital deficiency is indicated by the absence externally of all signs of a secondary sexual character, whose artificial removal entirely unsexes the individual, and the decline of Avhose functional activity, as age ad- vances, is the cause of the generate faculty being lost in the female long before the ordinary term of life has expired, and at a much earlier period than that at which the power of procreation ceases in the other sex." * In a physiological sense, therefore, the uterus, as well as every other part of the generative apparatus, must be regarded as an ap- pendage of the ovary, and the common formula, " Uterus and its Ap- pendages," might be superseded most appropriately by the title, " Ovaries and their Appendages." The ovaries are the analogues in the female of the testes in the male. They are two in number, lying deeply in the lateral and posterior part of the cavity of the true pelvis, one on each side of the uterus, with which they are so intimately connected as necessarily to take part in all changes of position of that organ, whether normal or abnormal. They lie within the folds of the broad ligament, or, more accurately, within a fold of peritoneum derived from the pos- terior lamina of the broad ligament, and each ovary is in part covered by the Fallopian tube of the same side. In addition to its connection with the uterus by means of the broad ligament, each ovary has an- other and more direct attachment to that organ by means of its OAvn proper ligament of the ovary, Avhich serves as a cord to bind it more securely to the uterus. It is likewise attached by a cord-like process to the fimbriae of the Fallopian tube. In shape, the ovaries are oval, elongated and flattened from above downward. Each ovary is about an inch and a half in length, three-quarters of an inch in width, and about a third of an inch in thickness. They are not usually fully developed until some time after the establishment of puberty, but vary in size, weight and situation in different conditions of the system, increasing in volume at the monthly periods, and in most instances becoming more or less atrophied after the final cessation of the menses. The ovary is composed of protecting parts or tunics, of proper secreting structures containing the ova, imbedded in a parenchyma or stroma, and of vessels and nerves. The tunics of the ovary correspond with those of the testicle, and consist of the peritoneal * Todd's Cyclopaedia of Anatomy and Physiology, vol. v. 68 THE OVARIES. covering derived from the posterior lamina of the broad ligament, and the tunica propria or special covering of the ovary. The peritoneal covering of the ovary is intimately connected with the gland, except at its base. It does not in any way differ from the peritoneal covering of the viscera generally. The tunica albuginea or tunica propria is the covering proper of the ovary, and serves to give it form, as Avell as to protect the stroma and ova from injury. This tunic, which is very tough, forms a complete investment for the ovary except at its lower border, where the fibres are either few or altogether wanting, leaving a longitudinal space or fissure—the hilum—through Avhich the vessels and nerves are admitted to the gland. The parenchyma or stroma of the ovary lies immediately beneath the tunica albuginea, with which it is in contact, and fills up all the intermediate space between the ovisacs, thus giving form to the ovary. It acts as a soft bed for the ovisacs, protects the ova from injury, and serves as a vehicle for the conveyance of the minute blood- vessels to the ova. It is of a pale-pink or bright-red color, owing to the numerous blood-vessels by which it is permeated. The Graafian vesicles, or ovisacs, are numerous small, round, trans- parent vesicles, in various stages of development, imbedded in the stroma, and themselves containing the ova. The number of well- developed vesicles contained within each ovary, and visible to the naked eye, varies in different subjects. They are usually computed to be from twelve to tAventy, and it Avas commonly supposed that when these were exhausted by repeated conceptions the poAver of procreation of necessity ceased. But a more careful and accurate examination of the contents of the stroma has shoAvn that the number of these vesicles greatly exceeds the above computation. During the early development of the ovary the Graafian vesicles are small, and are deeply seated Avithin the substance of the stroma, but as develop- ment progresses they enlarge and approach nearer to the surface; and finally, Avhen mature, they form projections on the surface of the ovary beneath the peritoneal covering. Each Graafian vesicle consists of an external coat, which is fibro-vascular, and which is in connection with the surrounding stroma by means of a vascular network, and an in- ternal tunic, the ovi capsule, which is lined by a very delicate mem- brane, the membrana granulosa. Within these walls is contained a transparent albuminous fluid, in which is suspended the ovum. The human ovum is exceedingly minute, measuring from the T}7 to -j-i^ of an inch, and is made up as follows: an external transparent capsule or envelope, the vitelline membrane, within which, and in con- OVULATION AND MENSTRUATION. 69 tact with it, is the vitellus or yelk, and lying in the substance of the yelk is a small vesicular body, the germinal vesicle, which contains the germinal spot. The vitelline membrane is thick, colorless and transparent, and corresponds to the chorion of the impregnated ovum. The vitellus consists of granules of various sizes lying in a more or less viscid fluid. The germinal vesicle is about yts °f an incn in diameter, and consists of a delicate transparent membrane containing a watery fluid. The germinal spot is opaque, of a yelloAV color, and granular in struc- ture, measuring from ^^ to ^ of an inch. The ovary derives its supply of blood chiefly from the ovarian, but in part also from the uterine arteries, between Avhich vessels there is a very complete and free anastomosis. The veins are very numerous, and form immediately outside the ovary, and between folds of the broad ligament, a plexus termed the pampiniform plexus. The nerves are derived from the spermatic plexus, and enter the ovary through the hilum, along Avith the blood-vessels. CHAPTER V. OVULATION AND MENSTRUATION. THROUGHOUT the entire scale of creation the ovaries form the ultima ratio of generation. The uterus derives its stimulus from the excitation of the external organs of generation, but the^wa^ cause, the true physiological and vital reason of its existence and action, is to be found in the ovaries. It has been amply shown by the success- ful experiments of modern observers that the ovaria are the essential organs of reproduction, and that in them originate the greater propor- tion of those sympathies which have been so long generalized as uterine; and furthermore, that the development of the pelvis, of the uterine system and of the mamma?, the function of menstruation and all the peculiarities of the human female, depend upon the ovaries. These supply the ova Avhich, through the stimulus of the life-impart- ing principle contained in the semen of the male, may be developed into an indiAridual similar to its progenitors. In fulfilling their appro- priate and primary function of ovulation the ovaries determine also that of menstruation, Avhich is secondary and consequent. The ovaries have already been described as containing at puberty 70 OA'ULATION AND MENSTRUATION. the germinal vesicles in different states of development. But these ova are discoverable long before the accession of the period of puberty. They may be seen in the ovaries of the new-born babe, and even in those of the foetus in utero. They form, therefore, an integral part of the ovarian tissue. The ante-pubertal life of the female is one of preparation, of groAvth in stature and in strength, Avith especial refer- ence to the perfect fulfillment of the function of the ovaries. Many of the lower orders of the animal creation arrive at maturity much earlier than man. The human female is longer in arriving at the full measure of her development, as her being and destiny are higher. And the same general principle of greater length of preparation and greater results is seen in the more particular instances of those indi- viduals who commence to menstruate at a period later than the aver- age. Those later in assuming the evidences of maturity are said to be more steadfastly regular in menstruation, and to continue it longer. And the converse is still more evidently true. For, as in general all those Avhose precocious growth, even of the intellectual faculties, at- tracts so much attention, are seen to become exhausted almost before they enter upon the race of life, so in the particular instance under consideration of premature development of the sexual system, the earlier young people arrive at puberty so much the earlier do they grow old. And this is as manifestly true of nations as of individuals. Those races in which, like the Hindoo, the Avomen arrive at sexual maturity at the earlier periods, as in the twelfth year, are effete, emas- culate and doomed to be conquered by those in which the period of puberty is longer delayed. And this is true independently of those influences of climate or temperature Avhich may apparently seem to have conduced to such premature development. Thus the female, after a preparatory period of constitutional incuba- tion, becomes so highly developed in her entire system in general, especially in her sexual organization, and more particularly still in her ovaries, that these minute seminal vesicles, these ova or eggs, ma- ture and begin to burst through the outer covering of the ovary itself. Previous to the final accession of the period of puberty the ova have been but imperfectly developed, and have in consequence remained comparatively dormant. But at this time a new life and vigor spring up in the ovaries, Avhich rapidly develop the external form of the female herself in general, and all the organs of her sexual system in particular. For, as the soul animates the body, so by the interior vital chang«, and new life and vigor of the ovaries, the lank and lean aAvkward and boyish form of the school-girl is transformed into that OVULATION AND MENSTRUATION. 71 full development of neck and bust, that rounded contour of the hips and loveliness of the features which the poet exalts as "beautiful exceedingly." The period of the accession of puberty varies, according to climate and race and hereditary and social circumstances, from the thirteenth to the sixteenth year. But if Ave take the fourteenth year for the average, as is probably the case in this country, half as many more years must be spent before the young woman's constitution and sexual organization will have acquired its fullest development—that is, be- come capable of bearing the most healthy children in the easiest and most healthy manner. Some young women indeed arrive earlier at their highest maturity, as some also do at a still later period ; but in general the average age of the first ovulation being at fourteen, Ave may assume the period of the most perfect and complete development of this function to be at about the twenty-first year. Ovulation, or the functional action of the ovaries, consists in the maturation of the ova and in their extrusion through the ovarian sur- faces. This functional activity occurs in the normal state at regularly recurring periods, usually once in twenty-eight days. And in many women this period returns with great exactness at the same day of the Aveek, or even in some instances at the same time of the day. This increased activity of the ovaries is not far removed from a congestion of these organs, and in many cases the entire system sympathizes in this disturbance of the ordinary sanguineous and nervous circulations. The manner in Avhich the process of ovulation takes place is so ad- mirably described by Dalton* that we quote it in full, and copy the accompanying very elegant illustrations. " In the earlier periods of life, in man and the higher animals, the egg is contained in a Graafian follicle Avhich closely embraces its ex- terior, and is consequently hardly larger than the egg itself. As puberty approaches, those follicles Avhich are situated near the free surface of the ovary become enlarged by the accumulation of a color- less, serous fluid in their cavity. We then find that the ovary, Avhen cut open, shows a considerable number of globular, transparent vesi- cles, readily perceptible by the eye, the smaller of which are deep- seated, but which increase in size as they approach the free surface of the organ. These vesicles are the Graafian follicles, Avhich, in conse- quence of the advancing maturity of the eggs contained in them, gradually enlarge as the period of generation approaches. " The Graafian follicle at this time consists of a closed globular sac * Physiology, p. 567. 72 OVULATION AND MENSTRUATION. or vesicle, the external Avail of which, though quite translucent, has a fibrous texture under the microscope, and is Avell supplied Avith blood-vessels. This fibrous and vascular Avail is distinguished by the name of the ' membrane of the vesicle.' It is not very firm in texture, and if roughly handled is easily ruptured. " The membrane of the vesicle is lined throughout by a thin layer of minute granular cells, A\rhich form for it a kind of epithelium, similar to the epithelium of the pleura, pericardium and other serous membranes. This layer is termed the membrana granulosa. It ad- heres but slightly to the membrane of the vesicle, and may easily be detached by careless manipulation before the vesicle is opened, being then mingled, in the form of light flakes and shreds, with the serous fluid contained in the vesicle. " At the most superficial part of the Graafian follicle, or that which is nearest the surface of the ovary, the membrana granulosa is thicker than elsewhere. Its cells are here accumulated in a kind of mound or 1 heap,' which has received the name cumulus proligerus. It is some- Fig. 19. GRAAFIAN FOLLICLE NEAR THE PERIOD OF RUPTURE. a, membrane of the vesicle; b, membrana granulosa; c, cavity of follicle; d, egg; e, peritoneum; /, tunica albuginea; gg, tissue of the ovary. times called the discus proligerus, because the thickened mass, Avhen vieAved from above, has a somewhat circular or disk-like form. In the centre of this thickened portion of the membrana granulosa the egg is embedded. It is accordingly always situated at the most superficial portion of the follicle, and advances in this way toward the surface of the ovary. " As the period approaches at which the egg is destined to be dis- charged, the Graafian follicle becomes more vascular, and enlarges by an increased exudation of serum into its cavity. It then begins to project from the surface of the ovary, still covered by the albu- gineous tunic and the peritoneum. The constant accumulation of OVULATION AND MENSTRUATION. 73 fluid, however, in the follicle, exerts such a steady and increasing pressure from within outward, that the albugineous tunic and the peritoneum successively yield before it, until the Graafian follicle protrudes from the ovary as a tense, rounded translucent vesicle, in which the sense of fluctuation can be readily perceived on applying the fingers to its surface. Finally, the process of effusion and disten- sion still going on, the Avail of the vesicle yields at its most prominent portion, and the contained fluid is driven out Avith a gush by the re- action and elasticity of the neighboring ovarian tissues, carrying with it the egg, still entangled in the cells of the proligerous disk." OVARY WITH GRAAFIAN FOLLICLE RUPTURED. At a, egg just discharged, with a portion of membrana granulosa. During the earlier life of the female, the ova, or rather their rudimentary and incompletely-developed germs, are formed in the ovaries. But at the full constitutional and sexual development called puberty, with each return of the menstrual period, or ovarian nisus, one or more of the complete ovules bursts through the enveloping membranes of each ovary in the manner just described, and is received into the upper portion of one of the oviducts, called the Fallopian tubes. The fimbriated extremities of these tubes are applied to the ovaries—not, as is supposed by some, under the stimulus of sexual intercourse, but under the wonderful reflex influence of the process of ovulation itself—by which these extremities are led to apply them- selves firmly over the exact portion of the ovaries from which the ova are about making their appearance. This must necessarily be the case, since the ova are conveyed to the uterus whether impregnated or not. At each menstrual period, it is believed that at least one ovum is transmitted through the Fallopian tubes, Avhich passes off and is lost. At the same time those remaining in the ovaries are advanced in their 74 OVULATION AND MENSTRUATION. development. Of the particular manner and time of the transmission of the impregnated ova we shall speak in treating of conception. Suffice it to say here, in general, that the ripening and discharge of the ovum in menstruation is called cestruation. Menstruation requires to be particularly studied in this connec- tion, since it usually forms an important attendant and consequent portion of the process of ovulation, although it is not alA\rays present, even in apparently perfect health. Ovulation we have found to consist in the maturation of the ova, and in their extrusion from the ovaries. By the Fallopian tubes these ova are taken up and transmitted to the womb. The uterus becomes then immediately and directly connected with the ovarian nisus, and at the same time it partakes in a most remarkable manner in the ovarian congestion. And, in fact, all the other parts of the generative apparatus, the vagina and the external organs, and eAren the entire sanguineous and nervous circulations, sympathize in this congestion and excitement. But although thus involving the Avhole system, the menstrual orgasm is entirely dependent upon the ovarian nisus. Where there are no ovaries, there are neither sexual desires nor menstrual periods. And in a remarkable case, in which both ovaries Avere extirpated in removing a painful tumor from each groin, a Avoman Avho before had ahvays menstruated Avith great regularity, immediately and permanently ceased to menstruate; while in some other cases in which the womb Avas either Avanting naturally or had been removed on account of disease, the mammary development and sexual desires remained unabated, and the menstrual discharges took place from the vagina. As long as the ovaries remain intact the Avoman is a Avoman still in external form and inward desires, although, from absence of the uterus or vagina, she may be incapable of conception or even of sexual intercourse. But let the ovaries be removed, and the woman loses at once all the distinguishing traits of the female character; her breasts diminish in size, and she becomes masculine in features, form and voice. Relation of Menstruation to Ovulation.—Thus far we have shown that menstruation is essentially dependent upon the functional action of the ovaries; that it is not an original action of the uterus, since it ahvays fails where the ovaries are Avanting, but does not necessarily fail AA'here the uterus is absent; and that, although there can be no menstruation except in connection Avith ovulation, there may be ovula- tion without menstruation. This latter fact may be, and probably is in consequence of the menstrual fluid being reabsorbed, instead of OVULATION AND MENSTRUATION. 75 passing off as ordinary ovulation occurs and the usual and consequent congestion ensues, but for some occult cause the fluid is again taken up, and this Avithout detriment to the general health. Cases are re- corded of women who have conceived and borne children without ever having menstruated. Let us now examine the physiological relation Avhich menstruation or the quasi function of the Avomb bears to ovulation or the primary function of the ovaries. The orgasm of the ovaries at the period of the maturation and ex- trusion of the ova, and the consequent congestion of the Avomb and other dependent parts of the sexual apparatus, have already been described as very intense and as involving the entire system. This intense orgasm having accomplished its primary purpose in the ma- turation and extrusion of the riper ova, and having at the same time also advanced others to a proportionate degree of development, requires a larger basis for its OAvn critical ultimation. The intense congestion of the blood-vessels and the no less intense excitement of the nervous centres must be relieved, and this relief is obtained through the men- strual discharge, Avhich is simply the excessive blood congested in the uterus and in its mucous membrane, and which oozes from the free surface of the membrane and passes doAvn through the canal of the cervix in greater or lesser quantities into the vagina, and finally through the vulva. And not only does the congestion consequent upon ovula- tion fill the uterine vessels with blood in excess, but the Fallopian tubes likewise partake of the orgasm, in consequence of which their fimbriated extremities approach and are accurately applied over the ovaries, upon that part of the ovarian surface from which the ripened ovules are extruded, and thus receive the ovules, Avhich pass through the Fallopian canals and are discharged into the cavity of the uterus. The first menstruation usually takes place about the fourteenth year. In some individual cases it comes earlier, and in others much later. Delicate and luxurious habits of living, especially in large cities, tend to render the menstrual period earlier in its first occurrence, but less constant and regular in its subsequent appearance. Hereditary consti- tution exerts a poAverful influence in determining the time of the first menstruation. For, while in Calcutta, India, the native females usually begin to menstruate between the twelfth and thirteenth years, the children of British residents, although born in the city, average about the sixteenth year. And different conditions in life, and resi- dence in the country rather than in the city, exert an important influ- ence in determining the period of first menstruation. Thus, in Den- 7G OVULATION AND MENSTRUATION. mark, in the Avomen born in the country, the average period of first menstruation Avill be found to be at sixteen years and five months; those in the larger towns, fifteen years and four months; those in Copenhagen, the largest city, fifteen years and seven months. So in Russia, in fifty-three cases of the noble and rich the average was found by De Boismont to be thirteen years and eight months. In one hun- dred and thirty-five women of the well-to-do classes the average Avas fourteen years and five months. And in one hundred and seventy- one of the poor the average was set down at fourteen years and ten months. In London, of sixty-seven women of the opulent class the average was thirteen years and about six months, while in seven hun- dred and seventy-five Avomen of the Avell-to-do working class the average was fourteen years and four months. The cessation of the menses usually takes place between the fortieth and the fiftieth years, about forty-five being considered to be the aver- age time of the change of life. But this may and often does vary in individual cases to a considerable extent. Some Avomen cease to men- struate soon after thirty, especially those Avho began early, Avhile others have borne children after they Avere fifty years of age, and regularly menstruated to their sixty-second year. Others again cease to men- struate at the usual period, but experience a return of the periodic floAV after some years. In some instances this protracted menstrua- tion or return of the flow may be dependent upon ulceration or other disease of the womb. But in most cases late menstruation, especially if unattended Avith much suffering or other morbid symptoms, may usually be regarded as evidence of remarkable constitutional strength and longevity; since, in general, life is longest and the health most assured in those females who commence to menstruate later, and Avho continue in the exercise of this function later than the ordinary term. In many cases the cessation of the menses does not occur at once, but is arrived at gradually through from one to three or even more years of menstrual irregularities, called by some, " the dodging-time." And the cessation may be by a gradual diminution of the Aoav, by alternate copious and scanty menstruation, or by changes in the character of the discharge itself. The general average duration of the function of menstruation may be stated at about thirty-two years. Symptoms.—"The menstrual discharge consists of an abundant secretion of mucus mingled with blood. When the expected period is about to come on, the female is affected with a certain degree of discomfort and lassitude, and sense of Aveight in the pelvis and more or less disinclination to society." In some instances these symn- OVULATION AND MENSTRUATION. 77 toms are but slightly pronounced, while in others they are more de- cided. If the individual be in a state of perfect general health, there will be, most likely, no premonitory symptoms Avhatever, and but slight derangement during the continuance of the period; but when the general organism is in an unsound condition, the premonitory and the concurrent symptoms of menstruation may be very severe, and to these may be superadded the suffering arising from obstruction of the canal of the uterine cervix or other abnormality of the uterus. " An unusual discharge of vaginal mucus then begins to take place, Avhich soon becomes yellowish or nearly broAvn in color, from the ad- mixture of a certain proportion of blood, and by the second or third day the discharge has the appearance of nearly pure blood. The un- pleasant sensations which Avere at first manifested then usually sub- side, and the discharge, after continuing for a certain period, begins to grow more scanty. Its color changes from a pure red to a brownish or rusty tinge, until it finally disappears altogether, and the female returns to her ordinary condition."—Dalton. The original menstrual flux, as it issues from the uterus, is nearly pure blood; but in its passage through the vagina it becomes mingled with the acid mucous secretion from the vaginal surface, Avhich changes its quality and appearance. The menstrual discharge returns Avith great regularity in perfectly healthy Avomen, but varies in quan- tity in different individuals, being quite free in some and scanty in others. Each menstrual period occupies from two or three to five or six days, and the whole amount of the Aoav may vary from three ounces to eight, according to the temperament and idiosyncrasy of the individual; some plethoric persons having a very scanty flow, Avhile in others, who seem to have no blood to spare, the discharge is much more free; and in some exceptional cases of persons apparently en- joying good health the catamenia may differ from the normal stand- ard in eA^ery respect. Those irregularities Avhich are properly termed morbid will be considered in a separate chapter. During utero-gesta- tion and lactation the menses are usually wanting; there are, however, exceptions, some Avomen menstruating with their usual regularity while enceinte and while nursing; in many others the menses return after the first few months of lactation. The causes of menstruation must be identical with those of ovula- tion, from the intimate connection of these two functions, and from the essential dependence of the former upon the latter. The causes of ovulation must be found in the nerves which supply the ovaries. These form part of the ganglionic system, and are immediately de- 78 OVULATION AND MENSTRUATION. rived from the solar plexus, which is the great centre of vegetative life. All the actions of the human body may be considered as voluntary, as involuntary, or as partaking of the nature of both these conditions. Thus the bodily actions may be distinctly referred either to the cere- bral or voluntary nervous system, to the ganglionic or involuntary nervous system, or to the spinal nervous centre, which is more or less influenced and controlled by each of the others. The involuntary functions, Avith Avhich alone we are at present concerned, may all be classified as belonging either to the nutrition of the individual or to the reproduction of the species. Thus the ante-pubertal period is almost exclusively devoted to the nutrition of the individual, but not without reference to future reproduction, as is seen in the existence and even extrusion of the premature ova during all this period. Dur- ing the child-bearing period the nutrition of the individual is rendered unusually active and vigorous in order that it may subserve the repro- duction of the species, and when both cannot be at the same time provided for, it is the former which gives way to the latter. This is seen in cases of consumptive women who become enceinte; the child flourishes at the expense of the mother and is born comparatively healthy, Avhile the mother dies from inanition. Thus menstruation, as dependent upon the action of the ovaries, must find its immediate cause in the ganglionic nerves which supply these organs. And as forming, with ovulation, one of the important processes preparatory to conception, menstruation must find its final cause in that grand function of reproduction of the species, to the per- fect accomplishment of Avhich all the energies of the individual life are devoted. The above engraving represents the union of the extremes of the sexes. The male, in all respects, is created for giving, even from the very inmost; the female, for receiv- ing, even into her inmost. Hence the fecundating principle, secreted in the testicle from the bosom of his blood is transmitted,—as shown by the dotted line,—to her ovary; where it is received into the ovule, and becomes conjoined with that which is secreted from the bosom of her blood. Thus the extremes meet in the ovule, within the ovary; and thus conjointly united, the male and th« female principle become at once and forever a new creation, a new human being. U.—The Uterus. T.—The Testicle and Appendages. O O.—The Ovaries. L L.—The Ovarian Ligaments. V.—The Vagina. The dotted line represents the passage of the fecundating principle, from the testicle, through the vagina, uterine walls and ovarian ligaments, to the ovaries. REPRODUCTION. 79 CHAPTEK VI. REPRODUCTION REPRODUCTION forms one of the three most general divisions of the functions of organic life, nutrition and innervation con- stituting the others. It includes therefore the aggregate of the more particular functions which concur in organized beings to the repro- duction of their kind. Provision is made in the constitution of the individuals of the human race, as in other orders of the animate crea- tion, for the perpetuation of the species. This is effected by means of generation, Avhich results from the union of the male and female sexes. The act by which this union is effected is termed copulation. The two sexes are differently constituted in the various characteristics of their mental and moral being, and this difference of interior con- stitution becomes the foundation of corresponding differences in ex- ternal form and in sexual organization. The respective mental and moral characteristics of the male and of the female are so constituted as to correspond to each other, so that from the conjunction of man with woman in the married state there results a perfect union, a complete man. Apart, each represents an incomplete moiety—together, they form a whole. In like manner, the sexual organs of the man and of the woman are adapted to each other, and through their conjunction the spiritual and affectional union of man with Avoman is confirmed and consummated. And through this conjunction, in the holy state of matrimony, is accomplished the procreation of off- spring, the perpetuation of the race. In their mutual adaptation to each other, in general and in par- ticular, the male is formed for giving and the female for receiving. Thus the male and the female are seen to correspond, to be adapted and yet opposite to each other. During the act of copulation the male deposits the semen in the vagina of the female, whence the fecundating principle arises, and, entering certain ducts specially arranged for that purpose, passes up through the walls of the uterus, out through the ovarian ligament to the ovary. Here it enters and impregnates an ovule on that side. In the plate opposite this page the semen is represented as passing from the testicle through the penis into the vagina, and from thence the fecundating principle may be traced upward through the uterine parietes and ovarian ligaments to the ovary of either side. 80 REPRODUCTION. It Avill here be observed that it is claimed that the vitalizing principle of the male semen finds its Avay to the ovary of the female through the uterine Avails and ovarian ligaments—a route not generally acknoAvledged as the true one by physiologists; and that impregnation of the ovule occurs within the ovary, which is a point yet in dispute, and by no means agreed to even by a majority of writers. Having prepared an article on the subject of reproduction, as an elaboration of vieAvs concisely set forth in the first edition of this Avork, and which was published in the Hahnemannian Monthly, December, 1868, I take occasion to transfer from that article such arguments as were in it adduced as evidence of the truth of both of the above propositions: " Many years ago Jean Bohn published a Avork on physiology, in Avhich he defended De Graaf. He was decidedly of opinion that the aura seminalis transmitted through the porous structure of the uterus reached the ovary and fertilized the ovum, Avhich then descended through the Fallopian tube..... " Another position assumed by De Graaf, Avhich had been main- tained previously by Warton, and afterward supported by Haller and almost all preceding physiologists, Avas that impregnation was accomplished always in the ovaries.* " Under the head of ' Impregnation of the Ovum while still in the Ovary,' J. Muller says: ' This is the place of impregnation, at all events in man and mammiferous animals. In all cases of extra- uterine pregnancy, in which the ovum is developed in the ovary itself, or escaping into the abdominal cavity is developed there, it cannot be doubted that the ovum was in these instances impregnated in the ovary.' f " A constriction (of a Fallopian tube) may prevent the arrival of the fecundated ovule into the uterus, and may thus give rise to a pregnancy of the tube.J " Haller found it possible to produce artificially an extra-uterine gestation, by tying the corona of the Avomb of a mammalian animal three days after conception. The result of this operation was that tAvo foetuses were discovered in the tube betAveen the uterus and the ovary.§ " Cazeaux, referring to the experiments of Nuck and Hoighton, and * Ritchie's Ovarian Physiology and Pathology, pp. 4, 97 ; London, 1865. f Muller's Elements of Physiology, London, 1842, Vol. II., p. 1491. X Scanzoni, Diseases of Females, New York, 1868, p. 370. § Ritchie, Op. cit., p. 165. REPRODUCTION. 81 the later observations of Bischoff, says: (Such results evidently prove that fecundation sometimes takes place in the ovary.' * "Ritchie—already quoted—mentions cases of ovarian pregnancy. Mr. Stanley has published an account of a case of ovarian pregnancy [British Med. Trans., Vol. VI., Art. 16]; and Dr. Granville a more extraordinary example, the foetus being perfect and four months old [Phil. Trans., 1820]. The celebrated Tyler Smith says: ' Of the occa- sional occurrence of ovarian pregnancy, there can be no doubt.' . . . In the admitted cases the entire foetus has been found within the (ovarian) sac, or escaped from a perforation of the ovarian cyst.f "The instances adduced from these authorities amply prove the fact of the occasional occurrence of true ovarian conception. Now, Avhile no cases can be brought forward to show that conception ever occurs in any other place than in the ovary, I offer the following reasons, among others, for believing that it never does occur any- where else. "I. Extra-uterine pregnancies, Avhether ovarian, tubal, or inter- stitial, all show that the ovule must have been impregnated Avithin the ovary, but failed to be transmitted by the Fallopian tube to the uterus. " II. No embryologist has ever yet found either the germinal spot or the germinal vesicle in an impregnated ovule, even at its first entrance into the Fallopian tube. Both must have been obliterated, as the effects of impregnation, before leaving the ovary; while its gradual and progressive course down through the tube is always marked by a corresponding development looking toAvard the pro- duction of a new human being. "III. The length of time occurring after conception before the ovule can be found in the uterus becomes a still more convincing proof. ' In the present record of our science,' says Cazeaux, (there is no one conclusive fact that proves the ovule to have ever been seen in the Avomb of a woman prior to the tenth or twelfth day after her conception.' " IV. The preparation made in the uterus itself, in the shape of the decidua, for the reception of the impregnated ovule, becomes additional proof when considered from the true physiological point of \Tiew. In accordance Avith the most beautiful economy of nature, this preparation commences immediately and only upon the com- pletion of the impregnation in conception, and occupies the entire time consumed by the product of conception in passing from the * Midwifery, Philadelphia, 1857, p. 97. f Lectures on Obstetrics, Am. ed., p. 343. 6 82 REPRODUCTION'. ovary to the uterus. Thus the impregnated ovule is preparing for the decidua, and at the same time the decidua for the impregnated ovule, each vital process being influenced by the other. "V. It is well known at the present day [see Cazeaux, third American edition, foot-note, p. 98] that the ovule Avhich causes the menstrual flux is never impregnated. After the cessation of the menses, at any time prior to the succeeding nisus, impregnation of an ovule noAV lying Avithin the stroma of the ovary may be effected. This is proven from the preparation made Avithin the uterine cavity, as stated in IV. This preparation could not be effected otherwise than by the evolution of the impregnated ovule. The attendant physiological process proves the event, and the Avhole is confirmed Avhen we consider the length of time occupied by the ovule in passing from the ovary to the uterus after effective coitus. " These considerations will, perhaps, suffice to convince the un- biased mind that the ovary is the seat of conception. " An answer is now demanded to the second question—viz.: What is the course of the semen in its passage to the ovary ? " I am aware that, according to the opinion commonly entertained and supported by the greater weight of authority, this course is through the Fallopian tubes. But while the positive determination of this question is at once impossible, yet, as I have felt entirely dissatisfied with the solutions of the vexed question already offered in obstetrical authorities, I have been led to believe, as above stated, that the semen passes through the Avails of the uterus and out through the ovarian ligament to the ovary. And if the following reasons for this belief appear less convincing to others than to myself, it should be remembered that the whole question is still a matter of opinion rather than of actual demonstration. "I. In numerous cases of extra-uterine pregnancy the cause of the non-transmission of the impregnated ovule into the uterus has been found to be an imperforate condition of the Fallopian tubes. In these cases there could be discovered no sign of an opening ever haying existed through Avhich the semen might have passed to the ovary. The only natural channel Avhich othenvise appears is that through the ovarian ligament. "II. Normal uterine pregnancies have been found where the os uteri was entirely Avanting,* and where not the slightest trace of its ever having existed could be detected. In these instances, as well as * The records of obstetric science furnish several cases of complete absence or occlusion of the os (congenital). The following paragraph, from a source readily REPRODUCTION. 83 in those of an imperforate condition of the tubes, the semen certainly could not pass up to impregnate the ovum through the Fallopian tubes. " III. This modified doctrine of absorption is descriptive of the most simple process that nature could adopt for conveying the semen to the ovary; and while it is true that the assertion that semen is con- veyed ' through the walls of the uterus and out through the ovarian ligament to the ovary' is not predicated upon any anatomical dis- coveries of ducts or passages that I have made in the human uterus, such ducts or passages have been found in the elephant, and, by Dr. Gartner of Copenhagen, in the cow and soav.* " IV. The correspondence of the general affection of the Avhole female organism to that of the male requires that, even as the semen is given from the inmost of the male, so it shall be received into the inmost of the female, even into the OAraries, and there perform its vitalizing function. And here I Avish to remark, that while it is admitted that the actual reception of some portion of the semen into the ovule is necessary in order to impregnate it, still this portion need be no more than the minutest particle, Avhich in organized bodies corresponds to the elementary or primary atom of the inorganic Avorld; and that, in addition to this, the old doctrine of the universal im- pregnation of the blood of the female by means of the seminal aura of the male seems to be confirmed rather than refuted by the later discoveries of modern physiological science. The entire system of the female is influenced most poAverfully, and in a direction highly favorable to reproduction, both by the general magnetic sphere of the male, and by that richly-endoAved secretion Avhich is given off as the representative of his energetic vitality. " V. It is to be remembered that the ovaries are encompassed by, first, the serous peritoneum, and secondly, by the tunica albuginea, a highly-organized and dense fibrous tissue, impervious in a much greater degree than the comparatively porous textures of the uterine accessible to all [Churchill, Theory and Practice of Midwifery, Philadelphia, 1851, p. 256], places beyond cavil the existence of such instances. " Lastly, a few cases are on record of total absence of the os uteri, as in a case which came under the care of my friend, Dr. Ashwell, and which he has described in Guy's Hospital Reports: 'it was found necessary to make an artificial opening with the knife; the labor terminated favorably.' A single well-authenticated instance of pregnancy occurring with an ab.=ent or occluded os entirely uproots the theory of the passage of the semen to the ovary via the Fallopian tube. * See Ryan's Compendium of Gynecology and Paidonosology; also, Cazeaux, Mid- wifery, Philadelphia. 84 REPRODUCTION. Avails and the ovarian ligaments. Thus, though it may be true, as is claimed, that spermatozoa have been observed on the ovary, it does not folloAV that impregnation of the contained ovule is effected through the passage of these spermatozoa through the Fallopian tube. The ovules are within the ovary, at one end of an uninterrupted porous chain, and it is reasonable to argue that the vivifying principle is conducted to the ovule by that way. " Again, it is to be remembered that the Fallopian tubes (oviducts), being lined by ciliated epithelium, have the cilise in a direction to aid movement from the ovary and toward the uterus, and to retard move- ment in the opposite direction." The semen of the male is principally and in the first instance secreted by the testes. In its passage it is commingled Avith the secretions of the corpus Highmorianum, the epididymis and vasa def- erentia. To this are superadded the secretions of the prostate, of Cowper's glands and of the vesiculse seminales. The latter additions appear to protect, and perhaps modify, the original product of the testes. In its mature condition, semen principally consists of an extremely small quantity of a viscid fluid, and of innumerable minute linear corpuscles having a peculiar movement, Avhich are termed the sper- matic filaments, or spermatozoa. As the semen is found in the vas deferens—that is, before admixture with the secretions of the above- mentioned glands and follicles, Avhich give it its peculiar odor—it is whitish, viscid and inodorous, and consists almost entirely of sper- matozoa and connective fluid. In the pure semen these spermatozoa exhibit no movements, or scarcely any Avhen it is concentrated. A peculiar lashing motion of the tail of the spermatozoa is visible in the semen found in the vesiculse seminales. But these bodies, once deemed essential to the procreative function of semen, are now be- lieved to be the products of the formative action of the organs in which they are found, and cannot therefore be ranked in the same category Avith animalcules. The semen, as finally imparted to the female in copulation, consists, then, of three distinct portions: first, the original vital secretion of the superior portion of the testes; secondly, of the delicate fluids which are associated Avith this secretion as it passes through the sec- ondary structures of the epididymis and vasa deferentia; and thirdly, of the more voluminous mucous secretions of the subsequent glands and follicles, which envelop the Avhole as with a natural body. These three diverse and yet harmonizing elements are essential to REPRODUCTION. 85 the healthy condition of the semen; for neither the spermatozoa nor the delicate secretions of the vas deferens, nor the grosser products of the various glands, can accomplish fecundation of the ovum sepa- rately. Nor is it to be regarded that the semen, vieAved according to its physical qualities or chemical constituents as a liquor seminis, can, as such, effect fecundation and the primitive organization of a distinct and vitalized being. But it is upon the vital essence or spirit, so to speak, of the semen that its power to impart life depends. The gross liquor carries Avith it a part of the essential life of its giver, which, meeting a similar vital essence of the female organism in the ovum of the o\rary, the conjunction of these two vital essences or principles is the process of fecundation by and through which a new being results Avhich partakes of the life of the man and Avoman, and which is in that instant made a living soul. The three constituent elements of the semen correspond to the body, soul and spirit. Within the inmost of each seminal nucleus is contained the very highest soul and life of the parent; the deli- cate fluids which immediately surround it are inspired by the animal spirits, Avhile the more gross and exterior mucous envelopments cor- respond to the animal body. This organization of the seminal globule, which makes it correspond to a representative of the body, soul and spirit of the parent, finds in the female ova a corresponding threefold organization, equally repre- sentative of the female constitution. And the semen of the male therefore unites and combines with the ovum of the female, in each one of these three constituent and representative forms, in more or less perfect harmony, according to the more or less perfect adaptability of the male parent to the female. And as in the mingling of different races the stronger takes the lead and predominates in the offspring, so in the union of the seed of the different individuals, the stronger predominates in the moral, mental and physical characteristics im- pressed upon the child. Thus as the lower, more gross and material portion of the male semen meets its counterpart in the grosser organi- zation of the ovum, with Avhich it unites and Avhich it vitalizes Avith its degree of life, so each of the other constituent forms of the semen necessarily unite with and inspire the corresponding representative organization of the ovum. The ovum then receives, cherishes and nourishes the vitality imparted to it by the male semen, and the living form Avhich is the result of such reception partakes of the qualities of the ovum on the one part and of the semen on the other, even as these are but faithful representatives of the various qualities, Avhether 86 REPRODUCTION. orderly or disorderly, of the male and female individuals from Avhich they spring. And even as it was stated in general at the beginning of this chap- ter, that all the sexual organs of the male were for giving and all those of the female Avere for receiving, so here now it is particularly seen hoAV the female ovum becomes receptive of the semen of the male. And at the moment of this vital reception the entire female organism feels its influence, and prepares forth Avith to provide for the protection, sustenance, growth and development of the new creation. This impregnation and fecundation of the ovum is called Conception. And this product of conception usually remains quiet Avithin the ovary for about the space of five days. During this time the first initial stages of subtle and mysterious vital organization and growth are taking place—processes too minutely recondite for successful ex- ploration by the eye of man. Wonderful arcana of nature ! in Avhich, after all our profoundest scrutiny into the mystery of life, we can discern only the means and the ends, but not the manner. We see the minute representative forms of two lives combined to produce a third, in which shall appear, during all the possible threescore years and ten of its subsequent life, the general characteristics of the human race as distinguished from those of other forms of animate nature; the general characteristics of the nation or tribe to Avhich its progenitors belong; the characteristics of the family as distinguished from those of other families in the vicinity; and lastly the personal peculiarities of each of the immediate parents,—all of Avhich are impressed upon the embryonic germ, grow with its groAvth and strengthen Avith its strength. During this time, in which the fecundated ovum remains quiet in the ovary, the interior surface of the uterus is being prepared for its reception. Under the influence of the impetus imparted to the entire system by this event of conception, the mucous lining membrane of the uterus becomes deeply congested, as in spontaneous ovulation. This congested uterine condition is due to the natural evolution of the fecundated ovule, and while the physio-pathological concrestive condition is similar to that occurring with spontaneous ovulation, yet a different evolvement is now to be effected, and, instead of the con- gestion being relieved or carried off in the form of a menstrual flux the decidua is formed as a step in the process of prospective utero- gestation. Very rarely indeed does the congestion after fecundation result in the discharge of the menstrual blood. Thus, by the time the fecundated ovum bursts through its original REPRODUCTION. 87 seat in the ovary and reaches the uterus, it finds prepared for it a thick, rich, soft, vascular and velvety lining, quite different from that Avhich is to be found in the unimpregnated uterus. This hyper- trophied development of the mucous coat of the uterus forms a sort of bed, into Avhich the impregnated ovule is received immediately upon its escape from the Fallopian tube. This, Avhich is the original mucous lining membrane of the uterus, forms Avhat is termed the decidua vera, Avhile the subsequent extension of the same growth, which completely envelopes the ovum, is called the decidua reflexa. The decidua thus constituted and developed form a sort of nidus or nutritious nest, in Avhich the villi of the ovum take root, and from Avhich the development of the ovum itself, already quite advanced, now progresses still more rapidly. Here, then, Avill appear the contrast betAveen spontaneous ovulation and that Avhich occurs in connection with impregnation. In the former instance the disengaged ovum passes from the ovary through the Fallopian tube, only to be swept away by the menstrual flood, which forms the crisis of the menstrual molimen. In the latter instance the fecundated ovum, reposing for a few days in its original bed in the ovary, emerges at length from the ovary, and passes into the uterus, to find, as the result of the uterine congestion attendant upon its fecundation, the beautiful provision already described for its reception under the name of decidua vera. Under the influence of this same congestion the Fallopian tubes become erect, and fix their fimbriated extremities upon the exact portion of the ovaries from which the ova are about to issue. The stimulus which arouses these tubes to their almost instinctive action is to be found not in the orgasm of copulation, as is alleged by many authors, but in the reflex action of the emergence and escape of the ovum itself. The same reflex action of the first birth of the ovum, of its escape from the ovary, causes the exact and timely application of the fimbria? of the Fallopian tubes to the ovaries; and in the case of spontaneous ovulation results only in the critical discharge of the menses, which relieves the uterine congestion; Avhile in the case of impregnated ovulation, conception, it ultimates itself in that congestion of the mucous membrane of the uterus Avhich forms the alma mater of the descending ovum. Hitherto we have attempted to explain the nature of generation, or the reproduction of the species; the nature of the semen of the male and of the ova of the female; their representative character; the mode of their union in copulation; the results of that union in con- 88 REPRODUCTION. ception; and the natural history of the product of conception from its first development and brief stay in the ovary to its arrival at its more permanent but still temporary resting-place in the uterus. There will be seen an analogy between the repose and primary growth of the impregnated ovum in the ovary and its much longer residence and final development in the uterus. The first is the era of concep- tion, the latter is the period of gestation or utero-gestation, to Avhich Ave noAV invite your attention. Gestation, the act of bearing the product of conception, strictly speaking, begins at the moment of conception. As already explained, during a very small portion of this period the fecundated ovum is still retained Avithin the ovary. But after a few days consumed in the vital organization of the ovum itself and in preparing the uterus for its reception, the ovum usually descends into the uterus through the Fallopian tube of that side. From this moment the general term gestation is replaced by the more particular one of utero-gestation. The cases of the so-called extra-uterine pregnancy occur from the failure of the impregnated ova to be properly transmitted through the Fallopian tubes to the uterus. In such cases the ovum may increase in size and development, being nourished in a manner to be subsequently described, Avherever it may finally be deposited, whether in the Fallopian tube, in the adjacent folds of the peri- toneum, or even in the ovary itself. The more general term of gestation Avill, however, continue to be used here, since it is more convenient, and more applicable in some respects, such as in speaking of its period, Avhich, reckoning from its commencement at the moment of conception to its close at partu- rition, is two hundred and seventy days, or nine solar months. This period is, hoAvever, by no means invariable. For, not to speak in this place of those abortions, miscarriages and premature deliveries which are the results of accident or of disease more or less palpably developed, there are many instances recorded of persons Avho from some individual peculiarity have much prolonged this period; while in other instances there seems to have been a disposition to shorten it, independent of any apparent morbid condition. Generally speak- ing, the shorter the period of gestation the less viability has the child after birth. As already explained, conception always takes place Avithin the ovary; and where the embryo, the product of conception, descends regularly into the uterus and there becomes developed, it constitutes what is termed a good, normal or uterine pregnancy. But when it REPRODUCTION. 89 does not thus descend and become developed in the Avomb, if it remain and is developed in the ovary, if it fall into the cavity of the peritoneum, stop in the Fallopian tube, or become engaged in the substance of the womb itself, it forms a bad, extraordinary or extra- uterine pregnancy. Uterine Pregnancy may be simple when the uterus contains but a single ovum; double, triple, quadruple or compound, according as there are two, three, four or more foetuses; and complicated where, in addition to the foetus, there is also found a tumor, polypus, dropsy or other pathological formation in the abdomen. Extra-Uterine Pregnancy may consist of one or the other of the four folloAving varieties, according to the location of the fecun- dated ovum: 1. Ovarian, Avhere the ovum continues its growth in the ovary itself; 2. Peritoneal, Avhere the ovum fails to be received by the fimbria of the Fallopian tube, and thus becomes lodged in the folds of the surrounding peritoneum; 3. Tubal, where the ovum is arrested in its passage through the Fallopian tube, and is there developed; 4. Interstitial, AAThere the ovum penetrates the parietes of the uterus instead of attaching itself to its interior surface. In either of these varieties extra-uterine pregnancy must sooner or later terminate disastrously, unless relieved by the Caesarean section, since normal parturition is impossible, except perhaps in the last. What, by some authors, is termed false pregnancy, consists in an enlargement of the abdomen from the presence of hydatids or other tumors, when in reality no living foetus is present. Simple Uterine Pregnancy.—Upon the occurrence of preg- nancy Ave have to do with two different living beings, which although still united, the one within the other, present two different subjects for our consideration and two different classes of phenomena for our study. The woman, the prospective mother, represents one of these, and the embryo, the future child, represents the other. We will first study the influence of pregnancy upon the woman, and observe the various changes which it introduces into the entire economy. The manner in Avhich the anatomical structure, the physiological func- tions and the intellectual and moral states and sensibilities are affected by this neAv condition of pregnancy must be carefully explained. This account of the natural history of pregnancy will be succeeded, in a subsequent chapter, by a description of the dis- orders incident to pregnancy, and a detail of the principal remedies required for their successful treatment. 90 pregnancy. CHAPTER VII. PREGNANCY. Physiological and Anatomical Changes. HEN fecundation follows copulation, the congestion and tumes- cence of the uterus and Fallopian tubes become continuous, and numerous physiological and anatomical changes are established. Some of these are local, some more general; some are transient, Avhile others en- dure throughout the Avhole period of gestation; some affect the physical economy only, others in a remarkable degree disturb the mental states and moral sensibilities; and finally, some of these changes are purely healthy and normal. These Ave shall consider in the present chapter, while others, being accidental morbid conditions, or the developments of inherent morbid predispositions, will be subsequently described. The Uterus becomes the seat of the most remarkable and first apparent of these changes, in Avhich both the cervix and fundus par- take. Those which occur in the neck are separate from, although simultaneous Avith, those occurring in the body; the former also resulting from the latter. Thus, the ceiwix softens and enlarges from beloAV upAvard, as the body softens and enlarges from aboA^e down- Avard, during almost the entire period of pregnancy. And the altera- tions affect this organ in eA^ery respect—principally in its volume, form, situation, structure and functions. Let us first examine the changes in the body of the uterus. As explained in a previous chapter, the congestion attendant upon a menstrual crisis produces a temporary increase in the uterine parietes. A similar and more permanent result attends fecundation; the congestion attendant on the evolution of the ovum in that case is in some measure perpetuated, and a permanently hypertrophied con- dition of the uterine walls becomes established. Volume, Size.—The mucous lining membrane becomes congested and almost double in thickness; and in consequence of this develop- ment of its vessels, as described by Cazeaux, and especially of the minute glands of Avhich it is partly composed, it has its thickness so much increased in proportion to the size of the uterine cavity as to be throAvn, in a great many subjects, into soft, projecting folds or cir- cumvolutions, Avhich are so .pressed together as to leave no vacant place in the cavity of the uterus. This, as Avill be subsequently ex- plained, constitutes the decidua or enveloping membrane into which the fecundated ovule is received upon its entrance into the uterus w pregnancy. 91 from the Fallopian tube of the side corresponding to that of its ovarian birthplace. Immediately upon its reception of the embryo, the uterus com- mences to increase in size—not uniformly, but in a ratio proportioned to the larger development of the foetus—that is, the larger the foetus the more rapid the enlargement of the uterus. This growth of the uterus takes place in e\^ery direction, and is not a mere mechan- ical distension, as if arising from the outward pressure of the in- creasing ovum, but it is proved to be a true physiological develop- ment, in Avhich both ovum and uterus partake simultaneously and in unison. Form.—The uterus, instead of remaining flattened on its two sur- faces, becomes rounded and then pyriform in the earlier stages of pregnancy, while in the later months it becomes spheroidal, and finally assumes the form of an ovoid which is slightly flattened from before backward, and has its point looking doAvnward. " Of dimen- sions nearly equal in every direction, about the fifth or sixth month the uterus exhibits the figure of a spheroidal vase terminated by a very short neck; it might be compared to a hog's bladder, Avith the urethral extremity surrounded Avith thread for an inch or two; sup- posing some one should umvind the thread by degrees, from aboATe downward, while another blows into the bladder from the fundus, so as to distend it, Ave should acquire a pretty clear idea of the gradual effacement of the cervix of the Avomb."—Velpeau. In the latter months of utero-gestation the shape of the uterus is modified by the exact relatiA^e position of the foetus. That side of the fundus Avhich is occupied by one of its extremities is sometimes more elevated than the other. And since in the most usual presentations the trunk of the foetus is found to incline to the right side, this por- tion of the fundus of the Avomb yvill often be found most elevated. These general statements as to the shape of the gravid uterus are, however, liable to exceptions, Avhich may arise from the number of the foetuses, or from the varieties in the original shape of the uterus itself. In its situation the gravid uterus is subject to important changes. These changes arise in the first instance from the change in size of the organ itself. Remaining in the pelvic cavity during the first three months of gestation, the uterus sometimes becomes at first slightly depressed, so that its cervix approaches nearer to the vulva. This is especially the case in those in Avhom the pelvis is large. Still, this depression of the uterus, when it does occur, is but temporary, and at 92 PREGNANCY. three months the position is in all respects almost exactly the same as before impregnation. From the third and a half to the fourth month, the uterus, finding itself more and more incommoded as it increases in size, gradually forces itself upward from the excavation of the pelvis, rises above the superior strait, then to the level of the umbilicus, and toAvard the close of pregnancy it reaches the epigastric region. But during the last tAvo weeks of gestation the uterus commences to sink doAvn some- what; and this, which is regarded as one of the earliest signs of approaching parturition, is in fact almost the commencement of this process, since in most instances it results from the approximation of the foetal head toAvard the cavity of the pelvis, and in some cases from its actual entrance into the cavity itself. Direction.—The changes in the direction of the womb in pregnancy are no less remarkable than those of size and form. While still re- maining Avithin the pelvic cavity, the uterus, from the greater Aveight of the posterior portion of the fundus or upper portion, inclines back- Avard, as in partial retroversion, and the os uteri looks forAvard toAvard the pubic arch. But this is not ahvays the case in the earlier or first three months of gestation. In many such cases the fundus will be found inclining forAvard more in its natural position, Avhile the os tincse will be reached only by the farthest extension of the finger toA\rard the hollow of the sacrum. As the uterus in the fourth and fifth months rises above the level of the superior strait, two remarkable directions are assumed and maintained, usually till the close of gestation. These are—the in- clination forward, as if leaning over the arch of the pubes, and the inclination to one side, usually the right side. The forAvard inclina- tion of the graArid uterus is the necessary result of the hard, unyield- ing nature of the lumbar vertebra? behind, and of the less rigid structure of the abdominal parietes in front, in combination Avith the constant pressure from above of the contents of the abdomen itself. The line of motion Avhich alone is possible for the gravid uterus on emerging from the pelvic ca\rity being the axis of the superior strait, as guided by the projecting promontory of the sacrum, Avill even from the first have given it a decided inclination forAvard. The lateral inclination to one side or the other is the necessary result of the pro- jecting ridge of the lumbar vertebrae, as it would be little less than impossible to balance Jhe uterus on this high-raised median line. The proportion of cases in Avhich the uterus is found inclining to the right side is stated by various authorities to be as high as eight out PREGNANCY. 93 of ten. But there is less unanimity of opinion as to the causes Avhich produce such a result. Among the various causes proposed to account for this general tendency, no one seems entirely sufficient, nor do many of them unite with any degree of constancy in a given number of cases. Thus, if the inclination is to be attributed to the greater Aveight from the attachment of the placenta, it is found that the placenta is far from being always on the side toAvard which the uterus is inclined. The same is true of the relation of the colon loaded with fecal matter—of the position of the female Avhile at rest on the right or left side. For the present, the most plausible opinion appears to be that of Madame Boivin—that the round ligament of the right side is shorter, stronger and contains more muscular fibres than that of the left, and that to the more poAverful action of this ligament is to be attributed the usual inclination of the uterus to the right side. Still, there is no doubt that the more active physiological influences do much to determine this matter of the lateral inclination of the gravid uterus; and in confirmation of Avhat is here implied it may be sufficient to state that, according to the observations of some authors, the uterus inclines to the left in women who are left-handed. The thickness and density of the uterine parietes form two of the most remarkable changes of pregnancy. The non-gravid uterus has already been described as having Arery thick Avails. After fecundation these walls maintain usually the same relative thickness, although, as the uterus itself increases in size, its parietes become less dense, and instead of being hard and fibrous, are said by Cazeaux to have a clammy softness closely resembling that of caoutchouc softened by ebullition, or that of an cedematous limb. " It is now knoAvn that the Avomb preserves nearly the same thickness during the Avhole course of pregnancy as it had Avhen unimpregnated. This thickness, which is greater at the insertion of the placenta, generally diminishes from the fundus toward the cervix, where it is frequently found to be not more than two or three lines or even less. It increases a little in all parts of the organ at the same time, until the third or fourth month, and then remains rather beloAV its primitive limits, to exceed them again in the last stages of pregnancy, except the cervix, which at that period especially grows thinner." Structure.—The immense enlargement of the Avomb, from its non- gravid size up to that capable of enclosing one foetus or even more at full term, can only be the result of a very great increase in its entire mass. But this great development in substance—in which the weight of the uterus comes to be reckoned by pounds instead of by ounces— 94 PREGNANCY. is accompanied Avith a corresponding development of its proper organization. In its non-gravid condition the uterus exhibits only the type of the Avonderful deA^elopment which it acquires in pregnancy, and Avhich is essential to the proper performance of the important functions with Avhich it then becomes charged. "Its fibres, which were pale, dense and inextricably tangled, soften, become redder and soon represent layers and bundles easy to detect and to follow. The cellular tissue, Avhich was before so firm, dense and elastic, relaxes, becomes supple, and indeed resembles the common cellular tissue, and in this A\ray permits the other elements which it held in bondage, as it Avere, to folloAV the impulse that animates the whole womb. The arterial branches, folded upon each other like the vas deferens, and bridled in this condition by dense elastic laminae, yield to the general relaxation, and gradually become lengthened; their angles, at first so sharp, Avith their doublings, grow blunter, enlarge, and at last exhibit only certain zigzags of greater or less depth—tortuosities which do not impede the circulation. " The veins undergo the same metamorphosis : already in the natural state larger and less tortuous, they are enlarged and developed still more rapidly than the arteries; afterward they are observed to furrow the fleshy layer in eArery direction, and form a network which in some measure separates it into two planes. They are large enough to admit a goose-quill, and in some instances the end of the little finger; near the mucous membrane they dilate so as to constitute cones with inverted bases, Avhich were first termed uterine sinuses, but Avhich are noAV called venous sinuses."—Velpeau. The lymphatic vessels and the nerves are also enlarged in a cor- responding manner in pregnancy. The great change in the texture of the mucous lining membrane of the uterus has already been re- ferred to in describing the formation of the decidua. All the com- ponent tissues of the body of the uterus receiA^e accessions both in structure, size and physiological activity, to correspond Avith the new and most important functions which this organ is called upon to discharge in pregnancy and gestation. The Cervix Uteri is also subject to certain changes during the period of gestation. These occur simultaneously Avith those already described as affecting the body of the Avomb, and are the results of the physiological action by Avhich the entire uterus becomes adapted to its neAv functions. In the consistence of its tissue, in its volume form, situation and direction, the cervix uteri becomes chano-ed in a remarkable manner; and these changes, so far as they are appreciable PREGNANCY. 95 afford valuable indications for determining the fact and the stage of pregnancy. Softening of the tissue constitutes the principal modification of the actual structure of the cervix uteri. The change from a firm, fibrous structure to that of a soft, fungus-like substance begins at the loAver border of the interior surface of the os tincae in the first month of pregnancy, and increases from within outward, and from below up- Avard, till at the sixth month this softening embraces the whole thick- ness of the lips of the os tincse and the lower half of the sub-vaginal portion of the cervix. This softening of the tissue is ahvays from beloAV upward, and proceeds also pari passu with the development of the fundus. And so exactly is this proportion maintained that an experienced examiner can always determine with very great accuracy the advancement of the pregnancy by noting the extent of this upward softening in the ceiwix uteri. It must be borne in mind, hoAvever, that in those Avho have had several children the sub-vaginal portion of the neck of the uterus loses a considerable portion of its length; otherwise the briefer extent of the softening in such cases might mis- lead the examiner to conclude that the pregnancy was less far advanced than it really was. So also in cases of first pregnancy, since this softening of the cervix uteri is less strongly marked and more sIoav in its deArelopment, and therefore more difficult of detection, these circumstances should ahvays be taken into consideration in forming a conclusion in such cases. The increase in volume of the cervix uteri goes on in equal ratio with the decrease in the density of its substance. But the cervix does not shorten: the description given from Velpeau, on a previous page, of the development of the fundus at the expense of the cervix, is applicable only to the last fortnight of utero-gestation. On the contrary, the length of the cervix may begin to increase a little after the commencement of the fifth month; and this elongation, Avhich previously had been rather apparent than real, is continued till the final absorption of the cervix itself in the fortnight immediately pre- ceding parturition. At this period the Avhole neck, having become softened and thickened, becomes more easily distensible, and the development of the body of the uterus from above downward meets the softening and development of the neck from below upAvard at this juncture, which is at the os internum, and the complete fusion of the fundus with the cervix takes place, and the cavity of the womb is one from the fundus to the os tincae or os externum. This fusion causes the sinking down of the fundus from the pit of the stomach 96 PREGNANCY. so often observed in the last weeks of gestation; the fundus must sink as the walls and loAver segment of the uterus are expanded. And upon the occurrence of this depression the female breathes freer and feels better in all respects. The form of the cervix uteri differs in the multiparae from what is observed in the primiparae; this difference is principally to be noted in the varying size and shape of the os tincae and of the cavity of the cervix itself. In the primiparae the os tincae changes from a simple transverse fissure to a circular depression. The cavity, from being conical, becomes spindle-shaped, and the softening of the externally constricted os will not alloAV the finger to penetrate into the cavity. The os tincae never having been ruptured by parturition, its mucous lining membrane rounds it off very nicely, and none of the in- equalities, fissures or puckerings so common in the multiparae are to be found here. Fig. 21. A section showing the neck of the uterus; the anterior and posterior lips are seen in situ, being separated from each other by the fusiform cavity in the neck. In the multiparae the numerous cicatrices and indentations render the os tincae more originally patulous; and the most noticeable effect of the pregnancy upon the orifice in such cases is to cause it to be more easily dilatable. And as the gestation progresses this dilata- bility of the os tincae becomes an actual spreading out of the inferior portion of the cervix, until it reaches the middle part of the cervix uteri about the seventh month, and nearly gains the internal orifice by the ninth month. The cavity of the cervix goes on enlarging simultaneously with the softening of its walls and the advance of pregnancy, and the opening and cavity become thimble-shaped, admitting the finger farther and farther into it as the pregnancy advances. The gradual change in the opening of the os tincae and dilatation of the cavity of the cervix may be seen in the accompanying cuts upon the next page. In the preceding account of the changes in the neck of the uterus incidental to pregnancy we have principally PREGNANCY. 9? followed the very excellent and in some respects entirely original account given by Cazeaux; and for the following summary of these changes we are indebted to the same author. Summary.—From the statements made in the preceding sections we may draw the following conclusions: I. The tissue of the neck begins to soften at the very commence- ment of pregnancy, and the softening, although not very apparent in the early months, and limited to the most inferior part, gradually ascends, so as to invade successively the whole neck from below up- ward, though it is much less marked and less rapid in its progress in primiparae than in other women. II. The cavity of the neck dilates simultaneously Avith the soften- ing of its walls; and, further, this enlargement causes it to be spin- dle-shaped in primiparae, and in Avomen who have already borne children to resemble a thimble, the finger of a glove, or a funnel with its base below. III. The external orifice remains either closed, or else very slightly open, in primiparae up to the very term of pregnancy, whilst in others it is widely open, and constitutes the base of the funnel. IV. The whole length of the neck disappears in the last fortnight, being lost in the cavity of the body. V. Contrary to the opinions hitherto generally adopted, the neck preserves its whole length until the last fortnight; it does not shorten from above doAvnAvard during the last four months, but the fusion of the neck Avith the body takes place only Avithin the last few weeks of gestation. Fig. 22. Fig. 23. Fig. 24. These three figures give an idea of the gradual dilatation which the cavity of the neck undergoes at various periods of pregnancy. This final fusion of the cervix with the body of the uterus causes or is accompanied by a manifest sinking downward of the uterine tumor from the epigastric region, and a corresponding expansion laterally of the abdomen; which phenomena are usually accompanied 7 98 PREGNANCY. with greater freedom of respiration and other evidences of relief from pressure upon the stomach, diaphragm and thoracic contents. The Texture and Properties of the Uterus are also greatly modified by the condition of pregnancy. These changes affect the different tissues and structures of which the uterus is composed. The serous coat or peritoneum, Avhich constitutes the external tissue of the uterus, like the entire substance of the uterine walls, is ex- tended without being diminished in thickness. Just as the uterus itself grows \vith the growth of the ovum it contains, so its perito- neal covering absolutely grows, and in proportion to the whole groAvth of the uterus which it envelops. The mucous coat of the uterus, as already stated in speaking of the formation of the decidua, becomes much more highly developed in pregnancy, and this development belongs to the glands as well as to the mucous tissue itself. This is also the case with the mucous glands of the cervix; these secrete a peculiar dense, semi-transparent, almost insoluble mass of mucus, which fills and closes the entire cavity of the neck during pregnancy. The muscular coat of the uterus also becomes developed in a cor- responding manner during pregnancy; so that the various layers of muscular fibres are much more easily demonstrable at this time than in the unimpregnated condition, and the actual muscular character of this middle coat of the uterus is positively ascertained. The various muscular fibres are noAV seen to cross and intercross in such a man- ner as to secure the greatest possible amount of strength; and the arrangement of the layers and fibres is such that at every orderly con- traction they all act upon one common centre, the centre of the womb itself. The vascular apparatus of the uterus also undergoes very important changes in connection with the advance of pregnancy. These consist in augmented development, which embraces the arteries as Avell as the veins. Through these vessels the blood flows into and through the uterus in greatly increased quantities, and this blood supplies the nutrition for the growth of the uterine walls, and of the'foetus Avhich they enclose. "The augmentation in the size of the arteries only becomes con- siderable as they approach the uterus. Whilst advancing between the peritoneum and the external face of the organ, and before giving off their first divisions, they dilate and swell up, and then they furnish branches to the anterior and lateral parts, Avhich ramify ad infinitum; they are not situated immediately below the peritoneum, but are sepa- PREGNANCY. 99 rated from it by a delicate layer of muscular tissue. All these rami- fications anastomose freely, and penetrate through to the internal sur- face, Avhere they generally terminate; but a large number of those corresponding to the placental insertion traverse the mucous mem- brane and enter the placental deciduous membrane."—Jacquemier. Through these enlarged arteries is conveyed the blood requisite for the growth of the uterine parietes and appendages, and for the supply of the placenta, and consequently of the foetus. The arterial branches become lengthened with the increasing size of the uterus, but do not lose their original tortuosities, Avhich, however, do not appear to impede the circulation through them. The veins undergo similar and no less extensive changes. This will be evident from examining them as they emerge from the uterus; the ovarian veins are nearly as large as the external iliacs, and the uterine veins are but little less in size. In the original state, before pregnancy, they are larger and less tortuous than the arteries; during gestation they become enlarged and de- veloped still more rapidly; and at term they furrow the muscular tissue in every direction, and form a network which lies intermediate between its external and internal face. This muscular tissue or coat of the uterus is traATersed by a great number of venous branches run- ning in every direction, Avhich anastomose and form large sinuses at their junction. Some of the canals of this plexus or network are large enough to admit a goose-quill, or in some instances even the end of the little finger. This is particularly the case at that part of the interior surface of the uterus to Avhich the placenta becomes adherent. Opposite the insertion of the placenta these venous trunks are largest, and they diminish in size as they recede from this vicinity; and in the sub- stance of the mucous membrane, immediately beneath which the placenta is situated, these vessels form, through an enormous dilata- tion of their branches, the long sinuses Avhich exist at the adherent surface of the placenta. These sinuses communicate freely with each other, so as to form a reservoir of blood divided and kept in place by numerous partitions. At intervals may be found a small number of orifices through Avhich this mass of blood communicates Avith cor- responding sinuses in the muscular Avails of the uterus. The veins as well as the arteries are lengthened, growing thus with the growth of the uterus, since even in their greatest extent, in the last months of pregnancy, they still maintain their tortuosities. The areolar tissue which envelops the uterine arteries is not found on the veins, these latter being placed in immediate relation with the muscular tissue 100 PREGNANCY. through which they pass. Neither are there any valves to be found in these veins; probably their numerous convolutions and sinuosities may serve to ansAver the purposes secured by the valves in other venous trunks. The lymphatic vessels of the uterus also acquire an extraordinary development in pregnancy and gestation. These vessels form several distinct layers or planes in the uterine Avails, the superficial being the most fully developed; and, as previously described, they belong to two distinct groups, those of the cervix communicating Avith the pelvic ganglia, and those of the body of the womb terminating in the lumbar ganglia. The lymphatic system forms, with the arteries and veins, a third and no less indispensable set of vessels; and the neces- sities of the circulation, of the nutrition (reparation and growth) of the uterine tissues and their contents, require that the augmentation of the lymphatic vessels should be in some proportion to the increase of those of the arterial and venous systems. The nerves of the uterus during the period of gestation necessarily partake of the same increased activity as the other uterine structures, and it was once supposed that they received also a corresponding augmentation in development. But the more recent researches of physiologists haA^e shown that the proper nerA^e-tissue itself remained unaltered during pregnancy, and that the apparent increase in size of the nerves is due to the augmentation of the tissue composing the neurilemma—a tissue which is almost entirely fibrous, and exhibits no structure specially nervous, its office being to support, protect and bind together the nerve-tubules and ganglionic nerve-corpuscles. Those arising from the ovarian plexus are distributed to the angles of the fundus; those arising from the hypogastric plexus are dis- tributed to the cervix and lower portion of the body, these, by branches from the third and fourth sacral ner\res, being connected Avith the spinal nerves; and finally, those arising from the great sympa- thetic accompany the uterine arteries, and are lost upon the neck and lateral parts of the womb. . Thus the entire structure of the uterus is sure to be supplied with nerves from the nervous system of organic life, a portion only of the nervous filaments distributed to the cervix being in immediate relation Avith the spinal nervous system. The complicated arrangement of the various tissues and organized structures which make up the substance of the Avomb renders it ex- ceedingly difficult to demonstrate the full development of the nervous system of this organ. But there can be no doubt of the fact that the uterus is so abundantly supplied with nervous substance in itself and PREGNANCY. 101 so intimately connected with the great ganglia in its vicinity, that it is endowed, especially in the gravid state, with a vitality peculiarly its OAvn, through Avhich it is enabled not only to support the nutrition of the embryo, but also to exert a controlling influence upon the entire economy of the Avoman herself. These changes in the structures composing the uterus must occasion corresponding changes in the physiological and sensitive conditions of this organ. The physiological properties of the gravid uterus, as to sensibility, irritability and contractility, are very different from those exhibited in the non-gravid condition. The common sensibility of the uterus in the non-gravid state is but slight, but in consequence of the more active development of the nerves of organic life and of their connec- tion, in the cervix, Avith the spinal nerves, this sensibility is much in- creased during pregnancy. And yet in many individuals the uterus shows in this respect a most astonishing power of endurance—a Avon- derful tenacity which enables it to retain and preserve the embryo in the midst of the greatest dangers. Near akin to this increased sensi- bility appears the peculiar irritability of the uterus. This may be defined as a certain morbid sensibility, or a sensibility attended Avith weakness rather than with strength. In the former instance the woman can bear Avith impunity the active movements of the foetus in utero; in the latter, these movements induce the most poignant anguish, or may even threaten a premature delivery. Contractility is but a still farther advance in the direction of sensi- bility and irritability, or, rather, the former is the crisis or reaction Avhich results from the latter. The most important function of con- tractility is, of course, peculiar to the gravid as contrasted with the non-gravid uterus. It belongs to the increased muscular development of the uterine parietes, nourished as they are by the augmented blood- vessels, and inspired by the more active influences of the nerves. This contractility may be excited by the reflex action, from irritation, of the cervix; thus, a common cause of abortion is to be found in repeated and violent coition, and in other disturbances of the os and cervix uteri. The menstrual molimen, in the unimpregnated condition, seems to have the poAver of exciting all the contractility of which the womb is then capable. And even in the impregnated state the same influence is still to be traced in the remarkable tendency to abort at menstrual periods, especially at the third. And it is thus that many drugs Avhich are capable of so irritating the uterus or the adjacent sympathizing structures as to produce a congestion Avhich may simu- 102 PREGNANCY. late that of menstruation, are also capable of directly producing abor- tion. But the grand physiological functional contractility of the gravid uterus is seen only at full term. Then this organ arises in its might in the fullness of time, spontaneously casts off in the most vio- lent manner, even at the blind risk of destroying the mother a\ here deformity may be present, the ovum which it has cherished, protected, nourished and vivified through nine long months. And to the accom- plishment of this contractility the nerves of the uterus summon not only all the various curiously-arranged and poAAerful muscular tissues pertaining to that organ, but through their connections Avith the cere- brospinal nervous system they compel the co-operation of all the inA'oluntary and voluntary muscular apparatus of the entire body, and of all the determined energies of the mind. The efforts of the will, co-operating Avith the involuntary muscular contractions, exert no small influence in maintaining the labor-pain. In some rare instances the contrary has been obseiwed. Mrs. C, living five miles from the city, at a time Avhen the traveling was very bad, was taken in labor, and felt as if she Avould be confined before her physician could reach her. Her pains Avere frequent and vigor- ous, but by a determined effort of her will she had entirely sup- pressed them, and her physician was obliged, after Avaiting in A'ain for some time, to restore them by exhibiting the appropriate remedies. This Avas not a case of fear, but the lady said she exerted herself all she could to suppress the pains. The favorable influence of good hope of a speedy delivery is so well known that the physician instinct- ively encourages his patient all he possibly can. In the state of nature in animals and among the savage tribes this function of con- tractility, even at its final result in the expulsion of the foetus at full term, is attended with little or no pain. But this is very far from being the case usually in civilized life. That function of the uterine tissues by Avhich the Avomb, after being thus emptied, is restored to its original state, is by some authors con- sidered to be distinct from contractility, and termed elasticity. But this seems nothing more than a continuation, into the minute struc- ture, of the same contraction which, in the first instance, had affected the entire organ. In the latter instance, the minutest filaments of the muscular and other tissues seem affected, as in the former the entire muscles and muscular parietes. This identity of contractility Avith Avhat is termed elasticity will be more certainly demonstrated by the consideration of the very similar effects of the same physical and even moral agents in producing or in PREGNANCY. 103 arresting their development. Thus, ergot, Avhich is one of the most efficient agents in producing powerful contraction of the muscular parietes, is no less active in arresting the hemorrhage subsequent to parturition which arises in consequence of a Avant of the proper inter- stitial contractility or elasticity which should close the open mouths of the blood-vessels. In the same manner, fright, from being told there was " something wrong" about the presentation, has been known instantly to arrest the labor-pains and change the labor itself from a natural to an instrumental one. So fear has been seen to stop the normal contraction of the uterus after child-birth, and thus admit alarming hemorrhage. The reflex stimulus of friction to the abdo- men may indifferently produce the pains of labor, or those after- pains by which the continued contraction and final restoration of the Avomb to near its original size are secured. The uterus may be so Avorn out in the actual labor, even if its involuntary contractions have not already ceased before delivery, that it has no longer any tone, and, like an overstretched piece of india-rubber, appears incapable of re- suming its natural form. Such also may easily be imagined to be the case in those in Avhom, whether from failure of the vital forces in general or from organic exhaustion, the foetus has to be removed by force. Nor is it unknown for the last, most violent and successful expulsive efforts of the Avomb to be followed by entire paralysis of the organ. • But, in general, the interstitial contraction would seem to keep pace with the organic, and as the fundus closes in upon the foetus as the head emerges from the os uteri, so the minute interstitial contractility (elasticity) of the tissues already follows on and aids the organic con- tractility in separating and expelling the placenta. Position.—The changes in position of the gravid uterus have already been referred to under the head of direction. But it will not be amiss to again refer to them here, and it will be interesting to note in what Avay the addition of so large a body as the uterus to the already occupied abdomen is provided for, without any of the viscera suffering inju- rious pressure, and without that impediment to the circulatory and respiratory systems, which, in the absence of such a provision, must inevitably take place. " The oblique direction of the uterus upward and forward is deter- mined, firstly, by the corresponding obliquity of the pelvis, the plane of whose brim forms Avith the horizon an angle of 60°. But as the fundus gradually, after three months, emerges from the pelvic cavity, the oblique direction of the uterus is maintained by the symphysis 104 PREGNANCY. pubis in front and the sacral promontory behind. Between these, the superior portion of the uterus continues to ascend, supported most by the abdominal Avails anteriorly and the spine posteriorly. The intes- tines, being bound doAvn by the mesentery, cannot be displaced, and will therefore occupy a position midAvay between the spinal column and the posterior uterine Avail. The pressure of the sacral promontory and of the lumbar vertebrae will still give to the uterus a forward tendency, which, on the other hand, will be prevented from becoming excessive by the elasticity of the front walls of the abdomen. If these have not been previously much distended, the fundus glides upAvard, and ultimately fills the epigastric holloAv; but if the abdominal Avails have been much relaxed, as by frequent child-bearing, or if the pelvis is much deformed, the fundus uteri is usually turned directly forAvard, or even dowmvard. " At the end of pregnancy the whole of the fore part of the abdo- men is occupied by the uterus; on either side lie the ascending and descending colon; the transverse arch, together with the omentum and stomach, fill the space between the fundus of the uterus and the diaphragm, Avhile the rest of the abdominal viscera lie laterally and posteriorly to its hinder wall. " Thus it results that in pregnancy, and especially in its last stages, no injurious pressure is exercised either upon the great vessels, the aorta and vena cava, or upon the intestines, liver or stomach, Avhilst the descent of the diaphragm, and consequently the act of respiration, is not materially impeded, and space is left for the bladder and rec- tum to perform their appropriate acts."—Dr. Farre, in Todd's Cyclo- paedia. Changes in the Uterine Appendages and Adjacent Organs. —Next to the changes which are induced by pregnancy in the neck and body of the uterus, those Avhich are wrought in the uterine appendages and adjacent organs need to be considered. The vagina, Fallopian tubes, round and broad ligaments, the bladder, the rectum, various parts of the trunk, and, finally, the mammae, are all more or less affected in structure or in development during the period of utero-gestation. The vagina becomes shortened with the descent of the uterus in the earlier stages of pregnancy, and lengthened as the uterus subsequently arises above the superior strait. The veins of the vagina experience an enlargement somewhat corresponding, although less in extent, Avith the dilatation of the uterine veins; and these Areins sometimes become varicose. Toward the end of pregnancy the finger will often encounter PREGNANCY. 105 these varicose enlargements, and certain nodosities described by French authors under the name of thrombus. On the superior portion of the vagina, and especially on the infra-vaginal part of the uterus, arterial pulsations may also be detected. This Araginal pulse has been con- sidered an important diagnostic sign of pregnancy. The mucous mem- « brane of the vagina also experiences an extraordinary development Fig. 25. POSITION OF THE UTERUS AT THE END OF PREGNANCY (AFTER MAYGRIER). in pregnancy, analogous to the hypertrophy of the mucous lining membrane of the uterus. This is shown by the innumerable granules or enlargements of the mucous follicles, Avhich about the seventh or eighth month are found covering the interior surface of the vagina, and Avhich are also to be found upon the exterior and interior surface 106 PREGNANCY. of the ceiwix uteri. An increased mucous secretion accompanies this follicular development. This increased secretion of mucus is the nor- mal condition in pregnancy, especially in its advanced stages; and it should never be suppressed by injections. In such cases even cold water injection does harm, since, from the suppression of these vaginal mucosities, the labor is rendered more lingering and severe; Avhat is called dry labor may result. The Fallopian tubes and ovaries are draAvn nearer to the body of the uterus; the former, instead of being on a level with the fundus, now correspond to the upper fourth, or even to the middle, of the uterus. This results from the ascent of the Avomb above the pelvis, by Avhich the folds of the peritoneum, called the broad ligaments, prolonged into the pelvic cavity to reach and support the uterus, are shortened and caused to disappear. The round ligaments are carried forward by the greater development of the anterior than of the posterior wall of the uterus, so that their insertions, instead of being at the sides of the womb, are iioav found at the point of union of the anterior fifth Avith the posterior four-fifths of the antero-posterior diameter. The bladder, during the early months of pregnancy, is gradually pushed above the superior strait; the urethra is elongated, and its orifice concealed behind the border of the symphysis pubis. The anterior projection of the bladder renders the line of the urethra much more curved; so that its course will be more readily followed by the male catheter, with its convex surface backAvard and its con- cave surface forward, than with the nearly straight one ordinarily used for females. The gravid uterus rests doAvn upon the posterior surface of the urethra, and by compressing it against the arch of the pubis often causes an obstruction in its circulation. This may be knoAvn by the tumor to be found in such cases behind the sym- physis, and by the severe and painfully distressing tenesmus, and even strangury, which not unfrequently arise from such compression and irritation of the meatus urinarius. In some of these cases the catheter is requisite in order to afford temporary relief, until, from quiet and rest in the horizontal position, the cause may be removed long enough to alloAV the irritation to sub- side or the proper medicines to be applied for its relief. As pregnancy advances, and the bladder is gradually encroached and pressed upon by the increasing gravid uterus, it becomes more and more flattened, and its capacity for containing the urine is con- siderably lessened; hence the more frequent and more urgent calls to urinate. PREGNANCY. 107 The rectum is pressed upon in a similar manner posteriorly; hence, in part from the mechanical obstruction, there results the constipation so common in pregnancy. A similar obstruction of the blood-vessels and lymphatics in some cases tends to develop hemorrhoids and oedema of the vulva and of the lower extremities. These deviations, partaking of a pathological nature, will be more particularly consid- ered, with the other morbid conditions of pregnancy, in a succeeding chapter. The relaxation of the various pelvic symphyses, especially that of the pubes, Avhich during pregnancy occurs in some peculiar constitu- tions, and which renders locomotion difficult, if not impossible, also results from a morbid condition subsequently to be considered. The abdomen becomes very much enlarged as pregnancy advances, its parietes being thinned, and on the inferior portion often marked by broad or bluish streaks, which form parallel curved lines, Avith the convexity toward the pubes. On the median line, from the pubes to the umbilicus, may be observed a brownish streak, Avhich in primi- parae has been deemed a certain sign of pregnancy; a similar dark- colored line has been seen, however, in non-gravid females and in males. After delivery an oblong tumor is sometimes seen on the median line, especially during any severe exertion. This results from the projection of the boAvels Avhere the abdominal parietes have been permanently thinned and Aveakened by the separation of the aponeu- rotic fibres. With each subsequent pregnancy this enlargement be- comes greater, until, in some instances, it becomes necessary to band- age it. The thorax, with the upward ascent of the large volume of the gravid uterus, experiences important changes. Its base is enlarged, the diaphragm is pressed upward and distended by the stomach and contents of the abdomen; sometimes the croAvding together obstructs the circulation of the heart and great vessels, respiration is visibly affected in such cases, and sometimes the irritability of the distended diaphragm occasions a more or less constant cough. The mammae, both from original sympathy Avith the genital organs and in preparation for the performance of their oavii future function, exhibit remarkable changes during gestation, Avhich may also become diagnostic of the pregnancy itself. These changes are of two kinds— those relating to increase in size, and those which affect the color of the areola surrounding the nipple. Very soon after the commence- ment of pregnancy in many women, the breasts become more full and somewhat tender; they have evidently assumed a more vigorous 108 PREGNANCY. physiological activity. This increase in the volume of the mammae will sometimes diminish toAvard the fourth or fifth month, but to re- turn again and become still greater toAvard the close of gestation. The nipples also become turgid and more prominent; the same in- creased activity already mentioned as apparent in the mammae in general is particularly evident in the nipples; their erectile tissue be- comes more permanently developed, as if in sympathy Avith the corre- sponding hypertrophy of the mucous coat of the uterus. The areola around the nipples becomes much darker. And in the centre of the areola, immediately surrounding the base of the nipple, may be seen quite a number of minute glands, from Avhich may be squeezed a serous, and in the advanced stages of pregnancy a sero- lactescent, liquid. These changes in the size of the nipples, in the color of the areola and in the development of the glandules make their appearance in the course of the third month. About the same time with these, blue veins begin to make their appearance over the surface of the bosom, from Avhich numerous branches are given off to the areola. In connection with these venous trunks may sometimes be seen certain shining silvery lines, linea cdbicantes; both the enlarged veins and the silvery streaks are more prominent in the breasts of primiparae. The change of the areola from the delicate pink tinge of the virgin to a more or less darker shade in the first pregnancy remains permanent thereafter, the color becoming darker at the accession of each subsequent pregnancy. But a more particular statement of the changes in the structure and ap- pearance of the mammae will be given when we come to study them in the chapter on the Diagnosis of Pregnancy. Generally speaking, these changes in the external form of the Avoman in pregnancy but partially disappear after parturition. Where the abdomen has been so greatly distended, certain folds or Avrinkles will still remain as consequences. So the hernia-like protrusion of the boAA^els along the median line below the umbilicus, Avhich has been mentioned as resulting from the separation of the fibres of the aponeurosis on that line, unless remedied by appropriate treatment, Avill tend to increase rather than to diminish. Neither does the dis- coloration of the areola ever entirely fade away; it always remains as evidence that pregnancy has existed; and yet not as of itself affording conclusiA^e eA'idence, for this discoloration may be the result of uterine irritation in Avomen Avho have never been enceinte, just as the breasts may enlarge from sympathy Avith enlargements of the uterus which are caused by the development of tumors or other morbid groAvths. THE DIAGNOSIS OF PREGNANCY. 109 CHAPTER VIII. THE DIAGNOSIS OF PREGNANCY. rnHE determination of pregnancy at the earliest possible period JL forms one of the most frequent, difficult and important problems in the practice of medicine. The physician will often be called upon to decide this question where strong feelings are aAvakened and great interests are at stake of the most opposite character. " The honor, and therefore the happiness, of a female may depend upon his decis- ion ; the peace of families may rest upon it, and the inheritance of property be controlled by it." For some to be enceinte is the grati- fication of their highest hopes and most ardent desires; by others it is regarded as a most serious inconvenience—as something to be dreaded on account of health, or, in the unmarried, as threatening a disgrace- ful exposure of their want of chastity. All these different states of mind and various social relations must always be considered in esti- mating the value of evidence for or against a supposed pregnancy, since those earnestly desirous of children Avill naturally magnify eA^ery new sensation, Avhile in some other cases there may be a disposition to suppress or overlook the signs of an actual pregnancy. " In all such eases the physician must remember that he may not merely be re- quested to investigate a case of doubtful pregnancy Avhere no shame is involved, but that he may be consulted in cases Avhere pregnancy is concealed by unmarried women, or by married Avomen under certain circumstances, to avoid disgrace, and on the other hand, Avhere it is pretended in order to secure an inheritance, to extort money or to delay punishment." And the very circumstances Avhich tend to ren- der the question more difficult to decide, at the same time seriously increase the responsibility attached to such decision. Hence, the physician can neATer be too cautious or too discreet in these matters, especially where the question relates to the unmarried; his acknoAV- ledging himself to have been mistaken Avill afford but a poor repara- tion for shocking the feelings and insulting the \rirtue of the pure- minded and the innocent. Such a blunder were Avorse than a crime, and its consequences might be irreparable as Avell for the physician himself as for his patient. The signs of pregnancy may be divided into two classes—those earliest observed, which are called rational or presumptive signs, and those subsequently appreciable, which are termed sensible or positive 110 THE DIAGNOSIS OF PREGNANCY. signs. From one or more of the first class a presumption of preg- nancy may arise, and from all that the case affords in its early stages a rational conclusion may be draAvn; but this is not positive know- ledge: this can be derived from the positive or sensible sighs alone, and of all these there is but a single one that is entirely incapable of being mistaken, and that is the beating of the foetal heart. The signs of pregnancy increase in number and become accumulative in value as the case advances. Thus, the diagnosis Avhich in the first instance had been possible pregnancy becomes presumptive, probable, and, finally, certain or demonstrable pregnancy. We will study, therefore, these signs as they arise in order of succession, proceeding from the rational to the sensible. Rational Signs are derived from the circumstantial history of the case, from the related experience and sensations of the Avoman, and from our own observations of such changes as may appear. Among these may be classed the general effects observed in the female econ- omy—such as greater rapidity of pulse and of respiration ; greater activity of the circulation and secretions, especially those of the genital organs; greater sensibility of the nervous system. But from indica- tions so general as these no rational inference can be draAvn; they are only important Avhen taken in connection with other more particular signs. Suspension of the catamenia is generally the first indication which leads the Avoman in Avhom impregnation has been possible, to con- sider herself enceinte. But the importance of this symptom will very greatly depend upon the attendant circumstances: if the woman has been very regular, and if the cessation of the menses promptly occur after some particular sexual intercourse, the presumption of preg- nancy Avill be ATery strong indeed. But if she has always been very irregular, the mere fact of the menses failing to make their appearance at a particular monthly period will carry with it but little weight. Where the entire absence of the menses for two or three months occurs from no other assignable cause, and Avhere this suspension is attended with good health and appetite, and some perceptible increase in the size of the abdomen, the rational conclusion of pregnancy may be considered to be Avell founded. And yet even these circumstances are far from affording infallible evidences of pregnancy, since thev haAre been knoAvn to arise in this combination from other causes. In newly-married Avomen the catamenia are sometimes suspended from irritation of the sexual organs where no conception has taken place • and at the same time there may be an increase in the size of the THE DIAGNOSIS OF PREGNANCY. Ill abdomen and in the sensibility of the breasts; so that even this very strong combination of symptoms cannot be positively relied upon. The attendant circumstances must be borne in mind in other re- spects ; for Avhile conception may take place in women who have never apparently menstruated, so the catamenia may still continue even after conception and through all the months of utero-gestation. Cases have been recorded in which menstruation appeared only during pregnancy; but such cases are anomalous. Thus while the cessation of the menses, under favorable circumstances, becomes the first and one of the most important signs of pregnancy, it is by no means decisive, since on the one hand the catamenia may be suspended without preg- nancy, and on the other pregnancy may occur without the suspension of the catamenia. The general rule Avill be all the more valuable, if Ave constantly bear in mind the possibility of the exceptions Avhich, though far from being common, may occur in any given case. Morning sickness forms in very many women the next sign of pregnancy. As its name indicates, it is a morbid symptom, but on that account none the less valuable as a diagnostic sign. It arises from sympathy of the cceliac or solar plexus with the organic nervous system of the uterus. This morbid irritability may commence im- mediately after conception, but it generally sets in about the fifth or sixth Aveek, and ceases soon after the third month. It may become in individuals a positive indication of their being pregnant, since these persons learn by experience that these symptoms occur with certainty and regularity at a particular time after conception. Thus in different persons the presence or absence of morning sickness "will have a very different diagnostic value. In those who have had it in former pregnancies, its non-appearance will be tolerably conclusive evidence against the existence of pregnancy; while in primiparae its non-appearance Avould scarcely be considered worth noticing as an evidence that they were not enceinte. Still, where morning sickness makes its appearance persistently attended by suppression of the cata- menia, and in circumstances where there is a liability to impregnation, it can scarcely be attributed to any other more probable cause than pregnancy. And this indication will be strengthened by the character of the sickness itself. The appetite improves and is good through the day, in spite of the nausea, vomiting of a peculiar watery fluid and sinking at the pit of the stomach, which occur and continue for a short time only on first rising in the morning. The sickness and the fluids Aromited up are different from those accompanying any other disorder, such as gastric or bilious fevers, for example. While morn- 112 THE DIAGNOSIS OF PREGNANCY. ing sickness, from its peculiar character, brief daily appearance, usual temporary continuance and final sudden and perhaps unexpected dis- appearance, becomes, Avhere it occurs, a valuable indication of preg- nancy, its absence is hardly to be regarded as a negative sign, as functional or organic disturbances of the uterus apart from pregnancy may occasion it, and it sometimes follows suppression of the monthly flux from other causes than conception. The morning sickness which exists during the earlier months of pregnancy is a physiological occur- rence, Avhereas that Avhich occurs during the latter months is due to mechanical causes. Certain other derangements of the digestive organs, such as eructa- tions, heartburn, remarkable longings for some particular article of food or other substances not used as food, and corresponding aversion to some one or more of the common varieties of food, which occur separately or in connection with morning sickness, or even subse- quently to it, may also be regarded as among the rational signs of pregnancy. The same may be said of salivation, which occurs in some Avomen about the fourth or sixth Aveek; in such cases the frequent spitting will be equally diagnostic Avhether the quantity be large or small. This salivation, differing from that which results from mercurial influences by the absence of the fetid breath, sore gums, and great prostration, becomes truly characteristic of pregnancy, just as the morning sickness above described does, by reason of its being a sympathetic rather than a primary and idiopathic affection. Spitting of " feathers" or " fippenny bits" is with some Avomen a marked signal of the existence of pregnancy, and with such women is of course of greater diagnostic \ralue than with others. There is in some cases an irresistible impulse to spit at any time and under any circumstances when pregnancy is advancing. The abdomen, by its changes in size and form, affords some rational signs of pregnancy even in the early stages. The enlargement of the abdomen may indeed occur from many other causes; but no other cause can simulate the shape and manner of development of the enlargement of pregnancy. A careful study of all the successive appearances of the abdomen in pregnancy will therefore enable the practitioner to estimate at their proper value the changes Avhich may present in any given case. Sometimes even in the first month the abdomen will seem larger than it does in the second, which arises from the co-operation of two distinct causes. First the abdomen seems larger because it is rendered tympanitic by the reflex influence THE DIAGNOSIS OF PREGNANCY. 113 of the newly-begun pregnancy itself. After three or four weeks this tympanitic condition passes off, and the abdomen loses its apparent increase in size. In cases in which this tympanitic condition has disappeared, as well as in those in Avhich it had not occurred, the abdomen becomes flattened. This flattening of the abdomen is usually •attended Avith a draAving inAvard and doAvnAvard of the umbilicus. These appearances, the very opposite to what might naturally be expected, are due to the sinking of the uterus a little loAver down in the pelvis, as described in the preceding chapter. And in connection Avith these changes there may be more frequent calls to urinate. But after the second month the uterus begins to rise Avithin the cavity of the pelvis, and the abdomen soon recovers from this depressed condition. About the third month the abdomen is seen to be visibly enlarged, and the enlargement steadily goes on till toward the close of pregnancy, the uterus still continuing to ascend Avithin the pelvis. After the third, fourth or fourth and a half month, according to the capacity of the pelvis to give it room, it rises above the superior strait, either suddenly or gradually, according as it has been more or less impacted in the pelvis. This rising out of the cavity of the pelvis into the abdominal cavity constitutes what is called quickening, and sometimes it occurs so sud- denly as to quite alarm the mother. It was at one time erroneously supposed that no life Avas present in the foetus till the occurrence of quickening, but it is now Avell known that at the very earliest mo- ment of conception a living human soul is there. Motion probably takes place at a much earlier period than it is perceptible to the mother, but it is not usually sensibly recognized till the uterus has finally risen from the smaller into the larger or abdominal pelvis. Usually after the beginning of the third month the enlargement begins to show itself just above and behind the symphysis pubis, being ahvays more considerable on the median line. After the commencement of the fourth month, if the woman be not too corpulent, by placing her upon her back with her thighs flexed upon the abdomen, the enlarged uterus can be felt like a half moon rising behind the symphysis pubis; and this ascent of the uterus goes on regularly, and usually at the rate of about tAvo fingers' breadth per month, until Avithin two weeks of the full term. But this enlargement is not always so regular in its development, since it may be varied by dropsical accumulations, multiple pregnancies, a greater or less projection of the spinal column, breadth of the pelvis or other individual peculiarities. An important means of distinguishing the enlargement of the abdo- 8 114 THE DIAGNOSIS OF PREGNANCY. men Avhich results from pregnancy from that caused by dropsies, tumors or other morbid conditions, will be found in observing the manner in Avhich this enlargement is developed, very nearly on the median line and always proceeding from below upward. Just above the symphysis pubis the tumefaction begins to show itself, at first being more considerable on the median line than elseAvhere; the sides' are flattened and the middle portion projects considerably. And the constant, steady and uniform enlargement of the abdomen, in the manner just described, and under favorable attendant circumstances as to health, appetite, etc., affords substantial ground for a conclusion in favor of the existence of pregnancy. The umbilicus also affords some indications of A^alue among the rational signs of pregnancy, since the changes which occur here are almost ahvays present and can ahvays be obserA^ed. During the first two months of pregnancy the depression of the umbilicus is greater than usual, OAving to the descent of the uterus into the pehTis and to its dragging doAvn the fundus of the bladder, by Avhich tension is made upon the urachus. This umbilical depression continues and gradually increases during the continuance of the descent of the uterus, and during this period the woman may be seen to walk stooping, in order to relieve the dragging sensation experienced by this strain upon the umbilicus. This descent of the uterus upon the bladder occasions frequent micturition, and the dragging upon the urachus sometimes gives rise to a distressing pain at the umbilicus, Avhich disappears, together with the too frequent urination, when the uterus commences its ascent. As soon as this sinking doAvnAvard is arrested, and the uterus begins to rise again, the umbilicus is gradually restored to its normal condition. It next begins to lose its depression, groAving decidedly superficial during the fifth and sixth months, becoming entirely flattened out in the seventh month and on a level Avith the surrounding integuments, and during the last two months the umbili- cus really pouts or protrudes beyond the general surface of the abdo- men. This course of changes in the umbilicus during pregnancy is the general rule; there may be some deviations, but usually the phenomena afforded by the umbilicus are regular and of great value. Tumors or ascites may cause appearances someAvhat similar, but these do not arise in the same regular order of time. When the three suc- cessive and Avell-defined stages of umbilical depression, restoration and projection occur as above described, they constitute a rational sio-n of pregnancy very easily observed and of very great value. The mammce, about two months after conception, begin to afford THE DIAGNOSIS OF PREGNANCY. 110 indications of much ATalue. Although from various causes some of these indications, except in primiparous Avomen, are less reliable in the early stages than many others, still, taken in connection with other signs, they cannot but haAre some Aveight. As described by Tyler Smith, these indications consist in a certain sense of fullness and Aveight and shooting pains in the breast; subsequently the circu- lation becomes more active, and there is an actual increase of volume; the gland becomes hard, knotty and tender to the touch, and large blue veins may be seen meandering over its surface just beneath the integument. About the end of the second month the nipple SAvells, becomes more erectile, sensitive and projecting; its color is also deeper. The surrounding skin assumes an emphysematous appear- ance, and becomes also a little darker. By the end of the fourth month a dark-broAvn areola is seen to surround the nipple in every direction, at a distance of three-quarters of an inch from its base. In blondes, or in feeble, delicate women, this appearance is not so well marked as in those Avho have black hair and eyes and in brunettes. "As pregnancy advances, especially if it be a first pregnancy, the de- posit of pigment in the areolae increases, the areolae themselves become moister, and the follicles studding their surface are prominent, dis- tended and bedeAved Avith transuded fluid. These follicles or little glandules which appear near the base of the nipple Avithin the areola attain an eleA^ation of one or two lines aboAre the surface of the skin. Each little gland has an excretory duct, and by pressing upon its base a little serous or sero-lactescent fluid is made to escape. In several instances I have seen this fluid flow in considerable quantities during lactation." Sometimes these glandules become very sore, Avhen Calendula Avill effect a speedy cure. About the fifth month a sort of shadoAV of the first areola makes its appearance outside the first, very pale, although quite similar to the first; and outside of these again, somewhat later, or about the seventh month, are often seen dark veins running across the breasts in various directions. Minute streaks, glistening like silver threads, are also observed running near these darker vessels. These appearances of the mammae, occurring in regular order, par- ticularly when taken in connection Avith other rational signs, afford almost conclusive evidence of the existence of pregnancy. But it should be borne in mind that the discoloration of the areolae, from never entirely disappearing when it has once taken place, is of little value as a sign of pregnancy except in primiparae, and also that both the enlargement of the mammae and the discoloration of the areolae 116 THE DIAGNOSIS OF PREGNANCY. may be occasioned by distension of the uterus from other causes than pregnancy. Quickening, Avhere it can be distinctly recognized, becomes of course a conclusive evidence of pregnancy; but it cannot be thus posi- tiA^ely determined except in those Avhose previous experience leads them to interpret aright the sensations which compose it. The term was originally applied to the supposed period at Avhich the foetus in utero first became possessed of the living principle, or Avas united to its physical soul, Avhich " quickening" of the foetus Avas believed to be the cause of the changes and unusual sensations experienced by the mother at that time; but not only is it true that from the moment of conception the embyro is " a living soul," but equally a fact that it may move within a feAV hours after the conception has taken place. It is curious to note hoAV the advance in physical science is equaled by that in psychical knoAvledge—hoAV physiology and psychology go hand in hand. Thirty years ago Davis wrote, in this connection, " It is now well knoAvn that the foetus in utero possesses some of the most important attributes of life from the earliest pulsations of the first speck of organization called the punctum saliens." By quickening, therefore, we merely understand those sensations which indicate the escape of the gravid uterus from the pelvic into the abdominal caATity. It is not the result, as formerly supposed, of movements of the foetus itself, but rather of the intrusion of the uterus itself among the other organs of the abdomen, and perhaps of the removal of the pressure hitherto exerted by the uterus upon the large vessels in the pelvis. " The sudden intrusion of the volume of the uterus among the abdominal viscera, organs of high sensibility, accompanied by a sudden removal of pressure from the iliac vessels, is quite equal to the production of the sensation called quickening. The sensation is felt in the transit at the moment Avhen the uterus, upon quitting its residence in the pelvis, enters the abdominal cavity." —Davis. This sensation, AArhich occurs at various periods in Ararious Avomen, is to be distinguished from those arising from the actual movements of the foetus in utero, Avhich are only subsequently experi- enced. Quickening may occur as early as the tenth Aveek, or it may not be observed till the sixteenth, the eighteenth or even the twenti- eth Aveek; the average period is probably about the sixteenth week. Changes in the Urine. Much valuable time and a great amount of labor have been spent in attempting to render the alterations of the urine useful as a rational sign of pregnancy; and A\*hile, for reasons subsequently to be stated, Ave attach e\ren less importance to these THE DIAGNOSIS OF PREGNANCY. 117 changes in the urine than do the Allopathic Avriters, we will briefly describe them, folloAving principally the account given by the cele- brated Dr. Elisha Kent Kane.* These changes consist briefly in the formation of a gelatino-albu- minous product in the urine of pregnant females subsequent to the first month of gestation, which is separated from the other elements of that fluid by rest alone, and to Avhich is given the name of Kiesteine. This consists of certain globules held in suspension in the urine Avhen secreted, and which rise to the surface and there form a pellicle which resembles in appearance the thin scum of fatty substance covering soup as it cools. When thick this pellicle is said to give off a strong cheesy odor. This pellicle usually makes its appearance upon the second day, or in the course of the third; though it is sometimes not observed till the urine has stood longer, even till the eighth day. The experiments of Dr. Kane and others prove that the Kiesteine is by no means peculiar to pregnancy, but that it has more especial rela- tion to lactation, either prospective or actually present; since it makes its appearance either where the milk is but imperfectly withdraAvn from the breasts, or in those cases in which, as in pregnancy, nature is pre- paring for the future function of lactation. Finally, Kiesteine can- not be regarded as an unerring diagnostic of pregnancy, since it may occur under other conditions of the system, and is not always observ- able where pregnancy actually exists; but its presence in the urine of an othenvise healthy woman is stated by Cazeaux to be an important rational sign. It remains noAV to state Avhy we attach little or no importance to this phenomenon as an indication of pregnancy in the homoeopathic practice; and this is from the fact that those changes of the urine Avhich ultimate in the formation of this peculiar pellicle, if not purely pathological, are at least but the consequences of the imperfectly per- formed physiological processes. These imperfections are also mani- fested in other more positive morbid symptoms, Avhich being cured by appropriate homoeopathic medication, the pellicle entirely fails to make its appearance. Still in cases of supposed pregnancy the experi- ment could easily be made as a matter of curiosity. Sensible Signs.—The sensible signs of pregnancy are observed through the medium of the senses of touch and hearing. By the touch Ave examine the condition and position of the uterus and its relations to the adjacent parts, externally, through the vagina, and, if necessary, through the rectum. By auscultation Ave ascertain the * See American Journal of the Medical Sciences, New Series, vol. iv., July, 1842. 118 THE DIAGNOSIS OF PREGNANCY. probable existence of pregnancy from hearing the bruit de souffle, or belloAVS murmur, and, at a little later period, its positive existence by detecting the pulsations of the fcetal heart. The term " towc/i" signifies the means wThereby knoAvledge is ob- tained of the condition of the woman as to health or disease, or whether she be pregnant or other Avise—by vaginal or anal examination Avith the finger, or by external examination Avith the hand, called palpa- tion. By vaginal touch we may be able to diagnose the stage of gestation, the stage of parturition, or Avhether the Avoman is in that state, the progress of labor, the presentation and position of the child; in fact all normal and abnormal conditions Avhich have ultimated themselves in material products. In order to be able to use the touch with certainty and advantage, the finger must be educated to recognize all the normal conditions, then it will be able to readily de- tect disease or any important change in material or structural mani- festations. The vaginal touch may be practiced Avith the woman standing, lying upon her back or upon either side. If she be standing the physician should place himself toAvard her left and upon his right knee, his left hand upon her abdomen exter- nally, and his right hand, the index finger being well lubricated Avith oil, should be carried under her clothes and directly between her limbs, —great care being taken not to touch her skin—the back of the hand upAvard, Avith all but the index finger closed. The index finger should be slightly flexed, and if carried directly between the limbs Avithout shocking her by touching the skin, the back of the finger will come directly in contact with the hairy portion of the vulva; now press Avith a little firmness and straighten the finger and its point Avill pass directly into the vagina. Noav drop the A\-rist and pass the finger upAvard and forAvard and it Avill exactly trace the canal of the vaoina, and by rotating the hand on the Avrist the interior cavity of the smaller pelvis can be explored and all the abnormities and deviations in that vicinity may be noted. If the Avoman be lying upon her left side, with her thighs flexed upon her abdomen, Avhich is the most usual position for the exami- nation, the physician will sit at her back and use his right hand. In this case also the thumb and all the fingers should be closed except the index, Avhich should be Avell lubricated and slightly curved, as before directed. The hand should be carried to the parts Avith great care to avoid touching the bare skin unnecessarily. As the back of the finger comes in contact with the A^ulva, press firmly thouo-h care- fully, straighten the finger and its point at once enters the A'ao-ina. THE DIAGNOSIS OF PREGNANCY. 119 Let the finger now be carried backward and upward and the canal of the vagina Avill be traced, and by rotating the hand as before, all parts of the canal can be well examined. If the patient be lying upon her right side, the physician will seat himself at her back as before, but Avill touch with the finger of the left hand. Anointing the finger with lard or oil, not only facilitates its introduction into the vagina, but serves to protect it from any disease that the woman may have. The physician should accustom himself to examine Avith both hands; since it may be necessary sometimes to use the left hand from the peculiar condition of the patient herself, or from experiencing a tem- porary injury to his right. In like manner it may be desirable to examine both in the erect and in the horizontal position. In the earlier months the recumbent position, Avith the extremities flexed and separated, will give a greater degree of relaxation of the abdominal muscles and render the uterus more completely accessible. In the standing position, ballottement may be more readily accomplished. But in all doubtful or difficult cases, the Avoman should be examined in both positions. When about to be examined standing, the patient should be placed Avith her back against the wall, a chair should be placed at each side to support her hands, and the upper part of her body should be a little bent over and forward. When it becomes necessary to make an examination per vaginam, all the parts of the perineum, vulva, vagina and cavity of the pelvis should be carefully exjflored, in order to detect any existing abnor- mities or diagnostic indications. If the patient be a supposed primi- para, the condition of the vagina as constricted and presenting the evidences of increased activity of the circulation will be carefully noted. The position and direction of the os uteri will then be ascertained. If in the early Aveeks of pregnancy, the uterus may be found some- what settled doAvn in the pelvis, and the os looking toward the holloAV of the sacrum. Or the supposed greater advance in the pregnancy will prepare him to find the uterus in its usual position Avhen unim- pregnated, or still higher, above the superior strait. Thus, on the one hand, the indications given by the rational signs will be either confirmed or invalidated by these sensible evidences; and on the other, the rational signs and history of the case Avill direct the physical exploration. The impregnated uterus is heavier than in the ordinary state; and its loAver segment, at about the third month, will be found so distended as to occupy nearly the whole cavity of the lesser pelvis. 120 THE DIAGNOSIS OF PREGNANCY. Its mobility is Arery slight; when, if unimpregnated, it Avould be very movable in every direction and much easier to raise on the point of the finger. One of the surest of the sensible signs of pregnancy at this stage consists in the softening of the extreme point of the neck. The sensation is that of a sort of velvety softness, only deeper, beyond Avhich may be felt a certain hardness, as of a board. No other state than pregnancy can either produce or simulate this feeling of softness. And this softening, as well as a corresponding dilatability of the neck, increases from beloAV upward, from month to month, in almost exact proportion to the development of the pregnancy. Palpation is a means of obtaining knowledge of the condition of the womb by placing the hands upon the > abdomen externally; and this method is much pleasanter to the woman than the former, although not so satisfactory. If the abdominal integuments are not too thick and fleshy, by placing the patient upon her back, Avith her head raised and her thighs flexed, and pressing the points of the fingers gently downward and backAvard above the pubes, a hard, round tumor will be found on the median line rising out of the pelvis. This can be felt as early as the third month, if the walls of the abdomen are not too thick. In two or four weeks later the increase is much more strongly marked and the true state of the case more certainly an- nounced. We must bear in mihd that, as pregnancy advances, the tumor loses more and more of its hardness and becomes more and more elastic, like a cyst filled Avith Avater. Percussion is also useful in deciding as to the existence of pregnancy. In such cases the uterine tumor Avill invariably afford a dull sound, unless a mass of intestines should intervene, Avhile all around may be distinguished the usual clear abdominal resonance. But, in pursuing this method of examination, care must be taken not to confuse all the indications by percussing over a full bladder. Tumors of the abdomen or womb would also give a similar dullness on percussion ; but such tumors are irregular as to the time of their development. In doubtful cases, Avhere decided enlargement of the abdomen is present, the exploration per vaginam becomes of very great import- ance, since the softening of the os uteri and even of the loAver end of the neck does not occur from any other cause than pregnancy. By the end of the sixth week this softening can be detected, like a piece of velvet drawn OATer a table. But Avhere tumors occur in the abdominal cavity, unconnected with pregnancy, they may be more easily detected by simultaneous palpation and vaginal touch. This THE DIAGNOSIS OF PREGNANCY. 121 is accomplished with the finger applied to the cervix uteri, and the other hand placed upon the abdomen externally, in order to find the fundus uteri. The finger may be brought in direct apposition with the lower portion of the uterus, Avhile the other hand presses down its upper portion, so that, Avith the exception of the abdominal walls, nothing but the uterus itself intervenes between the two hands. In this manner a judgment may be formed as to the size of the organ, as Avell as of its relations to the surrounding parts. And thus, any tumor Avhich may have occasioned the abdominal enlargement may be distinguished from the uterus. If unconnected with this organ, the tumor will remain stationary Avhen the uterus is moved; if it is attached to the uterus, moving the latter will, of course, be attended with corresponding movement of the former. And, in addition to any other tumor in the pelvis or rising above it, the actual size of the Avomb Avill also be ascertained, since the presence of any adven- titious groAvth in the pelvis, whether connected with the uterus or not, by no means precludes the possibility of pregnancy also. The greatest caution should be observed, as Avell in making the exami- nation as in giving a final opinion. It is not many years since the profession, in a certain city in New England, were greatly amused at the denouement of a case of uterine tumor in the wife of a Avell-knoAvn practitioner. The poor woman, Avho had sons groAvn up, and was supposed to have passed the change of life, during a course of several months endured all the severities of the most orthodox allopathic treatment at the hands of her anxious husband, assisted by a much older and more eminent practitioner than himself, in which injections of solution of nitrate of silver and large and frequent doses of the most powerful drugs performed an active part. The case advanced in spite of the treatment; and, the symptoms becoming more urgent, a third physician was called in consultation, who presently relieved the patient from her dangerous condition by delivering her of a full- grown child, Avhich had finally succumbed to the tours deforce of the latest injections. The patient had had no other disease than this tumor (pregnancy) ; but it required many months for her to recover from the effects of the protracted treatment she had undergone.* During: the first three or four months it is a difficult matter to de- termine the existence of pregnancy; up to this time the most certain * This statement is simple fact; the circumstances were well known at the time to the public, as well as to the profession, and are by no means forgotten now. The account is given here simply to show how men of the largest experience may not only be mistaken,but remain so. 122 THE DIAGNOSIS OF PREGNANCY. sign is the unmistakable softening of the cervix or os tincae. By taking into consideration, together, all the rational and sensible signs and the time of their appearance, Ave may in most cases be able to announce pretty confidently the existence of pregnancy by the third or fourth month, but not Avith absolute certainty. On the other hand, from being able to ascertain that the uterus still retains its natural size Ave can Avith much more positiA^eness determine that pregnancy does not exist in a given case. The uterus may, indeed, be enlarged or distended by some other cause than pregnancy; but if it is not found enlarged at what should be the third month, Ave may be sure there is no pregnancy. During the last five months the active and passive movements of the child reveal the fact of pregnancy Avith sufficient certainty. The active movements are felt by the Avoman at about four and a half months, sometimes earlier. In accordance Avith the strength of the child they are at first very slight and uncertain. We can easily imagine how delicate must be the sensations experienced by the woman from the motions of a foetus of four months, and trace them to the bounding and springing of a viable child of eight or nine months. It might be imagined that these sensations experienced by the mother would be quite infallible as indications of pregnancy. But other sen- sations, the result even of morbid changes in the abdomen, have been mistaken by women for those occasioned by a foetus in utero. In- stances are given by Avriters in Avhich the sensations produced by an incipient dropsy, in connection with the enlargement of the abdomen from the same cause, have been mistaken in this manner, to the seri- ous disappointment of all concerned. But the physician is not liable to such misinterpretation of sensations. By placing his open hand upon the abdomen the motions of the child may easily be perceived if the Avoman be pregnant, and these movements are unmistakable, since no pathological conditions can simulate them, although cases are recorded in which foetal movements Avere simulated by persons who had acquired complete control over the abdominal muscles. When from the inactivity of the child it becomes desirable to provoke its movement, this may be done by placing one hand upon one side of the abdomen and Avith the other hand gently striking the opposite side; the child will move quickly as if to get out of the way. By some Avomen the motions of the foetus are felt about the end of the third month, usually at about four months and a half. Some are conscious of these movements only after six, seven, or eight months, and some do not experience them at all. This, Avhich is OAving to the THE DIAGNOSIS OF PREGNANCY. 123 great passiveness of the child, is particularly apparent in Avomen of an inactive, sluggish temperament. After the motions have been dis- tinctly recognized for some days, if they then evidently become weaker and Aveaker, or entirely fail, the physician should at once understand that there is danger. All the mother's symptoms should be at once sought out, for some condition threatens the destruction of the life of the child. The proper remedy will remove this abnormal condition of the mother and restore the motions of the child. In plethoric women aconite will often do this, but we must be guided here, as else- Avhere, by the symptoms. The passive movement, or ballottement, is obtained by the manipula- tions of the examiner. The foetus swimming in the amniotic fluid is nearly of the same specific gravity; being a little heavier, it just swims in the fluid, touching the loAver internal surface of the amnion at inter- vals. Consequently, if Ave suddenly press upon the most dependent portion of the uterus, and then retain the finger steadily at that point, the foetus, having been forced to rise in the fluid by the sudden pres- sure, Avill soon return, and its Aveight will be felt as it again strikes the finger of the operator. The proper method of performing this operation by the vaginal touch is to place the woman either in the sitting or the erect posture, then Avith the finger upon the Avail of the uterus, either in front or behind the cenrix, curve the finger suddenly upward and forAvard, hold it there for a moment, Avhen the foetus, having been displaced and made to rise in the fluid, will rebound and impinge upon the finger Avhich displaced it. There results an unmis- takable dowiiAArard shock, and a sensation upon the finger Avhich no other condition of the Avoman can possibly produce. The same ex- periment Avith a stone in the bladder might seem to simulate this, but the sharp, strong bloAV which would be giA^en by a stone would con- vey a very different impression from that of the gentle, momentary touch of the foetus rebounding in the amniotic fluid. The accoucheur should be careful, in the effort to detect ballotte- ment, to press from below upward, and at the same time from behind forward. Pressure simply from beloAv upAvard may not be sufficient to cause the desired momentary ascent of the foetus, and the experi- ment may therefore fail. The force exerted upon the floating foetus in utero should be in the direction, as nearly as possible, of the axis of the uterine cavity. The same ballottement sensation may also be obtained by placing the woman upon her side, Avith the palmar surface of all the fingers applied to the most dependent part of the abdomen, forcibly flex them against 124 THE DIAGNOSIS OF PREGNANCY. the abdomen and hold them there; the foetus, thus suddenly displaced, will rebound from the upper side of the uterine cavity, where its movement may be felt against the other hand there applied, and settle doAvn again upon the fingers with a certain gentle, subdued, unmis- takable shock. The most favorable time for obtaining this sign of pregnancy is at any time after the period of quickening and before the first of the ninth month, for then the child becomes too large to be easily displaced or to descend upon the finger. At six months and a half or seA^en months is the most satisfactory time for making this diagnostic experiment. Where, from the presence of the hymen or the partial obliteration of the vagina, the examination per vaginam is inexpedient or impossi- ble, it may be made through the rectum. But the unpleasantness of the operation to the physician, as Avell as to the woman herself, Avould preA'ent resort to the rectal examination, except in cases Avhere no other method was available, or Avhere there existed an urgent necessity for a positively correct diagnosis, and the conjunction of all other means failed to afford a satisfactory result. Auscultation as applied to pregnancy consists in listening for the beating of the foetal heart. If the stethoscope be applied to the abdo- men Avith care at any time after the period of quickening, the heart of the foetus may be heard to beat nearly twice as fast as that of the mother, Avith a sound faint indeed, and muffled, but still unmistakable. These pulsations generally become perceptible in the course of the fourth or fifth month, and they range from one hundred and thirty to one hundred and sixty per minute. They are sometimes faster and sometimes sloAver Avithout any assignable cause, apparently not in the least influenced by the changes in the pulse of the mother. The foetal pulsations Avill be most distinctly perceptible in that region of the abdomen Avhich corresponds to the dorsal surface of the foetus. They are more frequently heard over the left iliac fossa than over the right, less frequently on the median line above the symphysis pubis. There is ahvays a point over Avhich these sounds are most distinct, and they diminish in intensity as Ave recede from this point. In their intensity these pulsations vary Avith the age of the foetus, increasing in strength usually up to the full term. But the number of the pul- sations is very much the same from the period of their being first distinguished up to the full term, except in some anomalous cases. When in the progress of labor the membranes are ruptured, the escape of the liquor amnii, by bringing the ear still nearer the foetus, renders the beating of the heart more distinct. The pulsations be- THE DIAGNOSIS OF PREGNANCY. 125 come less regular as the labor advances, and they are more sIoav and feeble during the contractions. Hence it becomes evident that the health of the child must ahvays be more or less seriously compromised during difficult and protracted labors. When the dorsal surface of the foetus is toward the abdomen of the mother, the pulsations are more distinctly heard; but after the sixth month they may be heard in any position of the foetus. There are two distinct sounds observable in the beating of the foetal heart, corresponding to those of the adult heart—a first and a second sound, of Avhich the first is more distinct. In those cases where at first but a single sound is heard, the other may often be distinguished by examining in some different position. As a sign of pregnancy the beating of the fatal heart is conclusive, since no other conditions can produce a similar sound. Aneurisms or other abnormal pulsations of the mother must be synchronous Avith the pulse at the Avrist, which is ne\Ter the case with the pulsations of the fcetal heart. Double or tAvin pregnancies may be detected by hearing the pul- sations of the foetal heart at two distinct parts of the abdomen, the sound becoming more and more distinct as you approach each part; while at the same time there is a perceptible Avant of harmony between the two sounds. Still, the apparent absence of the sounds of two hearts does not preclude the possibility of a tAvin pregnancy, since one foetus may be so directly behind the other as to mask its sounds. The position of the foetus in the uterus can be determined to a limited extent only by auscultation. The pulsations heard most dis- tinctly on the left of the median line, Ioav doAvn, just above the horizontal ramus of the pubis, indicate the first position. When they are heard in the same situation on the right side, they indicate the second position. The sounds being heard on either side on a leA^el with or even above the umbilicus indicate a breech presentation. If there be any truth at all in the statement that Pulsatilla, by reason of its action upon the muscular fibres of the uterus, can produce a change in the position of the foetus from an unfavorable to a favorable one, then the ascertaining of the position of the foetus by means of the stethescope becomes a matter of moment in all cases of pregnancy, as touching the welfare of both mother and child during parturition. A careful study of the sounds of the foetal heart, both during the continuance of utero-gestation and at its period in labor, enables us to determine the health of the child. Thus, after the sixth month, when Ave have had sufficient evidence of the existence of pregnancy, 126 THE DIAGNOSIS OF PREGNANCY. the absence of the sound produced by the pulsations of the foetal heart, ascertained by repeated examinations made at different times, will prove the death of the foetus. And during labor, if after the rupture of the membranes the pulsations of the foetal heart become irregular, more and more feeble and more and more rapid, Avith irregularity of rhythm, absence of the second stroke, complete cessation of the beats during the pains and sloAvness of their return after these have ceased, the life of the child is evidently threatened by further delay, and the labor should be terminated as promptly as possible. Still, it should be remembered that just in proportion as from auscultation Ave have reason to conclude that the child is no longer living or viable, we should give our principal attention to the mother and govern our conduct by indications derived from her condition. For in many cases of protracted labor, in Avhich the pulsations can still be distinguished at the moment of birth, the child has already suffered so much that respiration cannot be established. While the positive evidence of the death of the foetus in utero Avhich may be afforded by auscultation, leaves us at liberty to resort to craniotomy under circumstances in Avhich it might not be justifiable if the child Avere still living. The bellows murmur, bruit de souffle, although capable of being distinguished before any of the other intra-uterine sounds, before the beating of the foetal heart can be heard, is here mentioned in the second place, since it possesses little or no diagnostic value. This sound may generally be heard as soon as the uterus has risen out of the pelvic cavity—that is, a little earlier than the sound of the fcetal heart can be made out. From the supposition that it was produced in the utero- placental circulation, it has been called the placental murmur. From being supposed by others to be produced by pressure of the developed uterus upon the iliac arteries and aorta, in the posterior plane of the abdomen, it has been termed the abdominal souffle. From being sup- posed to originate in the enlarged vessels Avhich ramify in the walls of the uterus, it has received from others the name of uterine souffle. The fact that this sound has been distinctly heard for a short time after delivery is conclusive against the placental theory. The double fact that this sound is heard as distinctly in the same position, Avhen the pressure of the gravid uterus must be supposed to be removed from the posterior abdominal arteries, and that it disappears under pressure made upon the anterior of the uterus directly toAvard the spine, proves no less conclusively that it is not caused by obstruction of or pressure upon the iliacs and the aorta. There remains only the hypothesis of the uterine sinuses; and here the following circumstances THE DIAGNOSIS OF PREGNANCY. 127 may be considered as decisive of the question : the bruit is# heard in the earlier part of the second moiety of utero-gestation, nearer the pubes, and it gradually ascends Avith the upAvard advance of the uterus; it is most distinctly heard in that portion of the uterus where its A^essels are largest; and finally it may be heard through an instrument (the metroscope of M. Nauche) applied to the cervix uteri, Avhen it cannot be distinguished by the ordinary abdominal examination. The bruit de souffle, uterine murmur, then, is produced in the walls of the uterus itself and is synchronous with the radial pulse. It can be heard in chlorotic Avomen in whom no pregnancy exists, in cases of fibrous tumor and vascular tumor of the uterus, and in males. As a sign of pregnancy its value is A^ery differently estimated by different authors, some giATing it much more importance than others do. It can only serve to render probable the existence of pregnancy, since it may exist independently of pregnancy and does not always accompany it. No proof of the life or death or position of the child can be obtained from the uterine murmur, nor whether the uterus contains one or more than one foetus. Where Ave are certain the woman has no disease, the bruit de souffle becomes of some importance as a sign of pregnancy. In auscultating the abdomen for the purpose of discovering the signs of pregnancy, it should be remembered that the uterine murmur may be first distinguished at about the fourth or fifth month, or at Avhatever time the uterus rises out of the pelvic cavity, and that the beating of the foetal heart may be discerned in the course of the fifth month, so that in most cases the examiner may expect to meet Avith both classes of sounds. The bruit de souffle, coming first in order of time, may senre to render pregnancy probable, Avhile the clearly dis- tinguished beating of the foetal heart not only renders absolutely cer- tain the presence of a living foetus, but affords some indications as to its position in the Avomb and its healthy condition. Auscultation in the earlier months of pregnancy can only be ac- complished by placing the woman upon her back; later she may lie on her side, sit, or be examined standing. It is always best to use the stethoscope, Avhich should be placed at once, first on the left side, low down, then in the same region on the right side if necessary. Thus by applying directly to the place where the pulsations are most usually to be found, Ave escape annoying the woman by searching at random. It is important for the physician to avoid stooping too much, Avhich in many cases will cause such a pressure of blood in his head as to prevent him from hearing at all. By using the stethoscope the exam- 128 THE DIAGNOSIS OF PREGNANCY. iuer Avill avoid all danger of confusing the uterine sounds by the fric- tion of his ear upon the abdomen, and at the same time relieve his patient from the close personal contact Avhich to many Avomen is a very serious annoyance. In cases in which the mother has already recognized the foetal movements, the stethoscope should be applied exactly opposite to the side where these are most distinctly felt. For the upper and lower extremities of the foetus which cause the " mo- tions" being folded upon the abdomen, and the pulsations of the fcetal heart being most distinctly perceived from the back, it Avill be evi- dent that if the motions are felt in the left side of the abdomen of the mother, the sounds of the fcetal heart will be plainest on the right side, and Arice versa. Before the fifth month, however, the pulsations are usually most plainly discernible on the median line, from the pubes to the umbilicus. In addition to the uterine murmur, or uterine souffle, as, it is more properly termed, and the beating of the fcetal heart, certain " sounds of the displacement of the foetus" have been distinguished by auscul- tation, and at a period even prior to the uterine murmur. These sounds consist of shocks, sometimes quick, like a light tap, and at other times more like a heavy plunge, and there are also friction- sounds Avhich are evidently produced by the gliding of the surface ' of the foetus over the inner surface of the uterus. Some have even believed they could distinguish the pulsations over the funis itself— in cases where the parietes of the abdomen were extremely thin. But both these classes of sounds, Avhile they possess at the least very little of practical diagnostic value, require for their successful discovery more protracted opportunities for auscultating the particular case, and greater skill and more extended experience in auscultation in general, than usually fall to the lot of the young physician, at least in private practice. Statement of the Principal Signs in Pregnancy, Showing the time and order of their appearance; condensed from Cazeaux. First and Second Months.—Suppression of the menses, usually from the first of conception, some exceptions, which however are less numerous in the later months. Morning sickness, nausea and vomit- ing, and other gastric disturbances, sometimes flattening of the hypo- gastric region, depression of the umbilical ring. Enlargement and tenderness of the breasts, increase in the size of the uterus. It slightly descends and becomes less movable. Third and Fourth Months.—ToAvard the close of the third THE DIAGNOSIS OF PREGNANCY. 129 month the fundus uteri rises to the level of the superior strait. About the end of the fourth month it reaches midway in the space between the umbilicus and the pubes. Vomiting and other gastric derange- ments. A small protuberance in the hypogastric region. By abdom- inal palpation a round tumor may be detected of the size of a child's head. Less depression of the umbilical cicatrix. Increased enlarge- ment of the breasts; the nipple appears more prominent and the areola slightly discolored, especially in primiparae. In the fourth month the cervix uteri appears elevated and directed backward and to the left side. The orifice of the os tincae is more softened; in multiparae it is patulous, admitting the finger; in primiparae it is closed and rounded. Kiesteine in the urine. Fifth and Sixth Months.—ToAvard the close of the fifth month the fundus uteri is one finger's breadth below the umbilicus, and the" same distance above at the end of the sixth month. The gastric dis- turbances generally disappear. The sensation of " quickening" may be experienced about the sixteenth or eighteenth week—that is, about the beginning or middle of the fifth month. Then the movements of the foetus itself begin to be noticed. The abdomen becomes still more enlarged. The umbilical depression is nearly effaced. The uterine murmur may be heard, and soon after the beating of the foetal heart may be distinguished. Ballottement may be detected. The discolora- tion of the areola becomes deeper. Kiesteine in the urine. The infe- rior half of the intra-vaginal portions of the cervix uteri is softened. In multiparae the finger can penetrate the cavity of the neck, which in primiparae remains closed at its orifice, though softened. Seventh and Eighth Months.—Increased size of the abdomen. The fundus uteri is four fingers' breadth above the umbilicus at the seventh month, and fi\Te or six at the eighth. Dilatation of the um- bilical ring, pouting of the navel. The movements of the foetus are more sensibly felt. The sounds of the foetal heart are more clearly distinguished. Ballottement, Avhich is easily detected in the seventh month, becomes somewhat more obscure in the eighth. The soften- ing of the cervix uteri extends above the vaginal insertion ; in primi- parae the cervix is ovoid and shortening; in multiparae it is conoidal, and so patulous as to admit the whole of the first phalanx of the finger, while at the upper portion of the neck it still remains closed. The mammary areolae become darker. The breasts become more fully developed, and there is a show of milk. Kiesteine still appears in the urine. Ninth Month.—First Fortnight.—The fundus uteri reaches the 9 130 development of the ovum. epigastric region and (on the right side) presses the inferior margin of the false ribs. Difficulty of respiration. The abdomen is still more enlarged, the skin is stretched and very tense. The fcetal move- ments are active. The sounds of the fcetal heart are heard. In primi- parae the cervix is softened and its external orifice slightly opened. In multiparae the finger may penetrate its entire cavity to the os inter- num, which remains closed. Ballottement indistinct. Second Fortnight.—The fundus uteri sinks down a little, in conse- quence of the body and neck becoming one and constituting the uterus one rotund cavity. Vomiting is less troublesome and the respiration easier. Walking becomes difficult. Frequent and sometimes ineffec- tual efforts to urinate. In multiparae the internal orifice is dilated, and the finger may reach the naked membranes. In primiparae the "entire cervix is expanded, the os externum remaining closed. Hem- orrhoids, varices and oedema of the lower limbs, and even of the vulva. CHAPTER IX. DEVELOPMENT OF THE OVUM. The Unimpregnated Ovum. THE ovary is principally composed of Graafian vesicles or follicles imbedded in areolar tissue and abundantly supplied Avith blood- vessels. Each vesicle contains a single ovule and consists of two membranes, the outer of which is in contact with the stroma of the ovary, while the inner tunic, or membrana granulosa, forms the im- mediate covering of the ovule and of the liquid in which it floats. For the ovule occupies but a very small part of the cavity of the Graafian vesicle, the remainder being filled with albuminous fluid, granules and oil globules, Avhich, from their greater gravity, support the ovule upon its surface near the upper portion of the vesicle. Here the ovule comes in close relation with the inner surface of the mem- brana granulosa, and at this point there is found collected upon the o\nile a zone of granules called the discus proligerus. The ovule is composed externally of an envelope, the vitelline mem- brane, sometimes called the zona pellucida, which after fecundation is known as the chorion; internally the ovule is composed of the vitellus, or yolk, a spherical, semi-solid mass, or granular, organized liquid. development of the ovum. 131 The ovule is very small, measuring from the two hundred and fortieth to the one hundred and twentieth of an inch in diameter. Within the vitellus, and situated almost immediately beneath the vitelline membrane, is found a clear, colorless, transparent yesicle of a rounded form, called the germinal vesicle. This may measure from the eight-hundredth to the five-hundredth part of an inch in diameter. Whether this vesicle is developed from the ovisac or exists before the ovisac is formed is a point not yet decided. Upon the surface of the germinal vesicle may be seen a dark spot, like a nucleus, called the germinal spot. While the rest of the contents of the vesicle is transparent, this is opaque; and its diameter may be stated to be not more than the two-hundredth or three-hundredth part of a line.* Such is a succinct description of the human ovum in its unimpreg- nated condition. But if we examine the same ovum some three weeks after it has become fecundated, we shall find it so wonderfully changed that, Avere it not for the fact that all the various steps and stages of this remarkable transformation may be traced in the development of the ova of fishes, of birds and of the lower orders of the mammalia, Ave might entirely fail of being able to recognize and prove the identity of the one Avith the other. In fact, as the human ovum corresponds with that of the chick, ovology may be conveniently studied compara- tively. By carefully breaking the egg of a chicken, it will be found that there exists a delicate transparent membrane Avhich contains the fluid parts of the egg, and which constitutes the vitelline membrane, while the yellow portion or yolk is the vitellus. Upon this may be observed a Avhitish vesicle—the germinal vesiele; and in the centre of this the dark germinal spot. The albuminous fluid surrounding the vitellus or yolk is similar in quality, though greater in quantity, to that found in the human ovum. The external tunic becomes the chorion, whose cellular surface is extended into a number of villous prolonga- tions, which form the channel through which the embryo is nourished by the fluids of the parent, until a more perfect communication is subsequently formed. The internal tunic, above described as the membrana granulosa, becomes separate and distinct from the outer one, and is called the amnion. Between these tAvo membranes now intervenes some considerable space, Avhich is occupied by an albumi- nous liquid, in the midst of which is situated the umbilical vesicle. * For a more complete elucidation of this interesting subject, see Dr. Arthur Farre's article on the " Uterus and its Appendages," and Dr. Allen Thomson's article on the "Ovum," in Vol. v., Cyclopaedia of Anatomy and Physiology. 132 development of the ovum. Within the amnion is found another fluid, the liquor amnii, in which is supported the ovum. In the ovule itself the germinal vesicle disappears, and a new cell, the embryo cell, arises in its place. And finally, the entire ovum, Avith its external covering, is enveloped by a double covering, the deciduous membrane, which is developed and reflected from the inner surface of the uterus. The manner of the escape of the unimpregnated ovule from the ovary has already been described, on page 73 of this work, to which reference is now to be made. The description of the manner in Avhich impregnation is effected will be found on page 80 et seq., Avhich see. The changes which occur in the uterus immediately after conception, and the attendant condition of the ovary and Fallopian tubes, have been recounted on pages 86 and 87 ; these should be carefully revieAved. It remains now to describe the changes that occur in the ovum from the first possible moment of observation after impregnation, to the full development of the new being at the period just preceding par- turition. No- change lias ever yet been observed immediately after fecunda- tion, until the escape of the ovule from the ovary into the abdominal extremity of the Fallopian tube. No ovule has yet been observed in the Fallopian tube still presenting either the germinal vesicle or the germinal spot. At what time exactly these features of the ovule become transformed has not yet transpired. But it is certain that the ovule, either while still remaining in the ovary or on its way out from it, gradually loses both the germinal vesicle and the germinal spot. It may be possible that the spot disappears first, the ATesicle subsequently; and it is certain that the space occupied by them becomes filled with granules. This single circumstance alone is sufficient to prove that conception must take place before the ovule enters the Fallopian tube, and that the ovules that have just caused the menstruation cannot be the same that are impregnated. The same circumstance also proves that there is one ovule for menstrua- tion and another for conception. The only change observable in the OA^um during its passage through the first half of the Fallopian tube is the thickening of the A/itelline membrane. During the passage of the ovum through the second por- tion of the. tube, the vitellus evidently becomes more consolidated; and in concurrence with this change a thin Avhite fluid escapes, entirely surrounds the vitellus, and fills the interval between the vitelline mem- brane and the vitellus, occasioned by the condensation of the latter. Other and very remarkable changes take place in the ovule as it development of the ovum. 133 descends through the second portion of the Fallopian tube. One of the more remarkable of these constitutes what is termed the segmen- tation of the vitellus, Avhich, Avith its immediate consequences, may be thus described. The vitelline membrane continues to thicken, and the vitellus becomes divided into two distinct spheres, each of which Fig. 26. Fig. 27. A, the layer of albumen; V, the vitelline membrane. Fig. 28. THE FECUNDATED OVUM AT A MORE ADVANCED STA/JE. A, the albuminous layer surrounding the vitelline membrane V, which is seen to be thickened, and to contain within its cavity the mulberry-like mass. is again divided into two others; these again into others, and so on, during the Avhole course of the descent into the uterus, each minute sphere dividing and subdividing until the ovum reaches the uterine cavity. The vitellus is thus completely dissipated, and what in the first instance Avas its exterior surface comes to resemble a mulberry- seed in its appearance; Avhile its cavity or interior is filled with a liquid containing an infinite number of minute granules. (This process of segmentation is illustrated in Figs. 26, 27 and 28.) These are termed vitelline spheres; they have a somewhat firmer con- sistency than the original substance of the vitellus, and this consist- ency appears to increase as they successively multiply in number and diminish in size. At last they become so abundant as to be closely crowded together, compressed into polygonal forms and flattened 134 development of the ovum. against the internal surface of the vitelline membrane. They have by this time become converted into true animal cells, Avhich, adhering together by their adjacent edges, form a continuous organized mem- brane, called the blastodermic membrane. This constitutes the germ- mass, or plastic material, out of which the entire organization of the foetus is gradually evolved. This blastodermic membrane is subsequently divisible into two dis- tinct layers, which are known as the external and the internal layers; and as the blastodermic membrane, as a Avhole, represents all the foetal organization in its totality, so these tAvo layers represent the com- mencement of all the particular organs of the foetus, and the subse- quent division of all these organs into two distinct classes—those of the vegetative life and those of the animal life respectiA7ely—finds its foundation in this pre-organic stage of organization. For the internal layer of the blastodermic membrane produces the intestinal canal and all the organs of vegetative life; while the external layer is developed into the spinal column and the organs of animal life* As nearly as can be determined, the time occupied by the human ovum in traversing the Fallopian tube is twelve days, and the move- ment is always much more rapid in the first than in the second half of its descent, when the nearer it approaches the uterus the slower it moves, probably on account of the increasing narroAvmess of the tube. The ovum is knoAvn to enlarge decidedly during its continuance in the tube, during which time the. product of conception must be nourished by the granules contained in its interior fluid. When the ovum ap- proaches the uterine cavity, we find in it simply the vitelline mem- brane much thickened and surrounded by a dense layer of albumen which it has collected in passing through the tube, and the vitellus containing some granulations remaining from the decomposition of the mulberry-like body. The vitelline granulations, as they disap- pear, give place to a perfectly Avhite, transparent liquid. In their disappearance these granulations seem to be condensed, and by ad- hering to one another they form a neAv vesicle which lines the first. This fact may be easily demonstrated by macerating the ovule in water, when the neAv vesicle will be thrown off by the water percolat- ing through the vitelline membrane, and be seen to lay corrugated in distinct folds in the above-mentioned transparent liquid. This neAV membrane, or vesicle, is called the blastodermic vesicle. Whilst this process is going on the albumen collects as above stated, becomes ab- sorbed and the vitelline membrane is much thinned. The ovule now for the first time begins to be fixed. development of the ovum. 135 In sixteen or seventeen days after fecundation a rounded, whitish speck is perceptible on some portions of the blastodermic vesicular Fig.. 29. THE OVULE SHORTLY AFTER ITS ARRIVAL IN THE WOMB. A, the diminished albuminous layer; V, the vitelline membrane; B, the blasto- dermic membrane. membrane, and really stands out in relief; this is called the embryonic spot. This embryonic spot is composed of granulations, like those of the blastodermic vesicle, only they are more numerous and more con- crete. It is very evident that the embryonic spot and the blastoder- mic membrane are each developed from processes of a double lamina; which may be separated by means of fine needles. Fig. 30 portrays the doubling of the blastoderm, the embryonic spot assuming an elon- gated form. Finally, the blastoderm exhibits a convex and a concave surface, as in Fig. 32. The concave surface is divided into tAvo dis- Fig. 30. Fig. 31. Fig. 30. The blastoderm with the embryonic spot seen in front; V, the vitelline membrane ; E, the external layer of the blastoderm; F, the embryonic spot. Fig. 31. The same figure in profile, to show the two layers of the blastoderm; V, the vitelline membrane; E, the external, and I, the internal or intestinal layer of the blastoderm. tinct portions, one embryonic, the other becoming the umbilical A7esi- cle. The tache embryonnaire becomes the embryo. The margin of the embryo exhibits a tendency to double over, leaving a cavity (as well as the extremities) of considerable depth. The extremity Avhich 136 DEVELOPMENT OF THE OVUM. is most fallen is called the cephalic, the other the caudal extremity. As the development of the embryo goes forward, numerous minute elevations appear scattered over the external surface of the ovum; these become the villosities which subsequently appear on the chorion. At the same time the external layer of the blastoderm is raised in Fig. 32. Fig. 33. E i Fig. 32. A section of a more developed ovum, in which the two portions, the em- bryonic and the umbilical vesicle, begin to appear; O, the umbilical vesicle ; I, the internal layer of the blastoderm ; E, the external layer; V, the vitelline membrane. Fig. 33. A section showing the origin and first traces of the amnios; O, the umbili- cal vesicle; I, the intestinal, and E, the external layer of the blastoderm; V, the vitel- line membrane; C C, origin of the cephalic and caudal amniotic hoods. folds around the central or embryonic portion. (See Fig. 33.) Figs. 34 to 37 exhibit the continuous approach of the embryo toAvard the cen- tre of the ovum, until the blastoderm has become united over the dor- sal surface of the embryo, their union absorbed, and the embryo sur- rounded by a complete fold of the external or serous surface of the blastoderm, which seems to be a continuation of that upon the abdo- men of the embryo. This fold gradually increases in size at both the cephalic and caudal extremities, and between these points to form, as it were, hood-shaped investments of the embryo. To these Cazeaux has given the name of amniotic hoods. The new membrane thus formed is called the amnion, and becomes distended and separated from the external surface of the embryo by the amniotic fluid. The external or serous lamina noAv forms a rins or membrane by itself, which surrounds the whole. This contains the liquid in which the embryo, with its amnios, swims, and which, as the foetus develops, is forced onward to join the vitelline mem- brane and chorion. Immediately after the formation of the amnios, the doubling in of the cephalic and caudal extremities increases and forms more and more the abdominal cavity of the embryo, and finally DEVELOPMENT OF THE OVUM. 137 a mere canal leading out of the abdominal cavity into a large vesicle, called the umbilical vesicle, and this canal, as it finally closes up, forms the umbilicus of the nine months' child. •Fig. 34. Fig. 35. THE AMNIOTIC HOODS MORE DEVELOPED. Fig. 34. O, the umbilical vesicle; I, the internal or intestinal, and E, the external layer of the blastoderm ; E/, a portion of the external layer converted into the am- nios ; E//, the embryo; C, the limit of the amniotic hoods; V, the vitelline membrane. Fig. 35. This figure shows the amnios almost completed, and likewise the origin of the allantois. 0, the umbilical vesicle; I, the intestines; E, the amnios ; W, the external layer of the blastoderm, or the non-vascular chorion; V, the vitelline mem- brane; C, the amniotic hoods ready to close up; A, the allantois. In the cuts 34, 35, 36, 37 blood-vessels may be seen running from the embryo into this vesicle and again returning, one artery from and two veins returning to the embryo; these are called the omphalo-me- senteric vessels. As this doubling of the embryo goes on (see Fig. 35), we find a slight elevation springing up at the spot Avhere the rectum and bladder are confounded in the earlier days of embryonic life, under the name of cloaca. This begins to take place about the time the em- bryo has nearly exhausted all the nourishment contained in the um- bilical A^esicle, and the embryo Avould inevitably perish at this stage from want of nourishment but for this wise provision of nature, by Avhich a connection is formed Avith the parent; for this little eleva- tion rapidly extends to the villi of the chorion, passing out from the abdominal canal alongside of the umbilical vesicle, and is called the allantois. The allantois is composed of two arteries and one vein, the arteries arising from the primitive iliacs, carrying arterial blood of the embryo, seeking a fountain for allaying its thirst for material wherewith to sustain the little being over which it presides; for the blood always contains all the material elements for upbuilding and for repairing tissue. 138 DEVELOPMENT OF THE OVUM. These arteries seem to compel the growth of the allantois, and Avith the accompanying vein plunge into and take root in the villous coat of the chorion, when the desired nourishment is found in the blood of Fig. 36. Fig. 37. Fig. 36. This figure sliows the rapid progress of the allantois, and how it spreads over the fetus, the umbilical vesicle and the amnios. This latter begins to unsheath the pedicle of the umbilical vesicle and that of the allantois in such a way as to form a commencement of the cord. According to some writers the vitelline membrane dis- appears more and more. O, the umbilical vesicle; W, the amnios; E", the external layer of the blastoderm; C, the point where the two hoods come in contact; V, the vitelline membrane almost entirely atrophied; A, the allantois. Fig. 37. in this figure the allantois has spread over the whole internal surface of the ovum, and but very slight traces are left of the continuity between the amnios and that part of the external layer of the blastoderm which formed the non-vascular chorion; the latter has a tendency to be confounded with the chorion, and the amnios encloses the umbilical cord more and more. O, the umbilical vesicle; E/, the am- nios ; C, the point where the two hoods are fused into each other and form but a single membrane; W, the external layer of the blastoderm; A, the allantois; V, the vitelline membrane. the mother. This is quickly carried back by the vein to the famish- ing embryo, and delivered through the liver, as will be seen farther on. In the subsequent pages, also, it will be shoAvn that the first circuit in the embryonic circulation constitutes the beginning of the placental mass to be afterAvard described. In some animals, and perhaps in the human female, the allantois in its development spreads out like an umbrella; but for all practical purposes it is sufficient to describe it as taking root in a single villus of the chorion, and spreading out more and more as more ample means of supply are demanded till the full time is accomplished. The closing up of the abdominal or umbilical canal brings the DEVELOPMENT OF THE OVUM. 139 amnios in close juxtaposition to the remaining minute stem of the um- bilical vesicle (as seen in Fig. 37), and as this canal closes up the amnios sheaths over the allantois and the small stem of the remain- ing umbilical vesicle, which vesicle is thereby forced out, and is found finally to be a little yellow body lying between the chorion and the amnion, next to the placental mass, and the allantois stem is found to be one and the same thing as the umbilical cord entirely sheathed over by the amnios. With this description of the development of the allantois concludes the principal parts of the ovum; which are therefore: 1, The em- bryo ; 2, the liquid in which it swims; 3, the amnios, filled Avith the liquor amnii, and forming a sheath over the umbilical A^essels ; 4, the umbilical vesicle with the omphalo-mesenteric vessels still to be seen communicating Avith the embryo; 5, the allantoid vesicle; 6, the space betAveen the amnios and the umbilical vesicle, filled Avith liquid; and 7, the chorion, the outer envelope over all. The Development of the Decidua.—The decidua, from first to last, is simply the mucous membrane of the uterus hypertrophied by the influence of conception and gestation. This hypertrophied develop- ment, Avhich constitutes the deciduous characteristic, as previously stated, has already commenced Avhen the impregnated ovule is about to make its escape from the ovary; so that upon its arriAral in the cavity of the uterus, the ovule finds a soft, velvety bed in readiness to receive it. And as the mucous membrane of the uterus is con- tinuous Avith that of the Fallopian tube, so in cases of extra-uterine fcetation, the deciduous development has sometimes, although not ahvays, been found in the uterus; and in one case of development of the ovum in the Fallopian tube, referred to by Miiller, the decidua was observed both in the uterus and in the tube. Into the vegetative bed above described the ovule becomes fixed by the villi of the Aatelline membrane (which becomes the chorion) taking root and growing into it in every direction. The decidua at the same time grows up all around the ovum, which latter thus be- comes implanted in a living cyst, attached to one portion of the Avail of the uterus, usually that of the fundus. When thus encysted the ovum is not only completely covered by the mucous membrane, but by means of the villi of its own membrane, the chorion, it becomes attached to the decidua, growing into it Avhenever they thus come in contact. In the earlier months of embryonic development the decidua is formed of two 'apparently distinct layers, the one being in approxi- 140 development of the ovum. mation Avith the internal uterine surface, and the other enveloping the embryo. The uterine layer has been called the decidua vera, or parietal decidua, Avhile the embryonic layer has been termed the decidua refiexa. The decidua vera presents upon its external surface a rough or shaggy appearance, Avith numerous projecting filaments, Avhich are doubtless due to the separation of the decidua from the proper tissue of the uterus and the remains of uterine glands. The internal surface of this layer, hoAvever, is smooth and shining, and eleArated, according to Dr. Arthur Farre, into numerous projections which may be roughly compared to the convolutions of the cerebrum. It contains numerous minute apertures Avhich are continuous Avith similar apertures on the outer surface of this layer. The inner layer, or decidua refiexa, Avhich invests the embryo, is, so far as histological elements are concerned, composed of the same material as the decidua vera, and it is, indeed, but a part of the same structure. It received the name decidua refiexa from Dr. William Hunter, Avho believed that it was formed by the ovum in its passage into the uterus from the orifice of the Fallopian tube thrusting it before it away from the uterine wall and enveloping itself, so to speak, in it as a covering; in a manner similar to the investiture of the heart by the pericardium. This view of Hunter's has been combated by other investigators, but the mode of formation of the decidua refiexa may be regarded as a question still in doubt. If the intimate structure of the decidua be examined at about the sixth week of embryonic life, it Avill be found to consist of large round and oval cells, nuclei, fat granules and elongated fibre-cells, the Avhole so bound up that if a portion of the membrane be spread out and examined with the microscope, " it is observed to be readily separable into irregular portions or fragments, with clear interspaces, very much, in fact, like a Aveb or netAvork formed by the superposi- tion of several layers of a cribriform membrane one upon another." (Meadows, " Manual of Midwifery," p. 69.) There can be but little doubt now that the opinion of William Hunter in regard to the formation of the decidua is correct—viz.: that it is " an efflorescence of the internal coat of the uterus itself. the internal membrane of the uterus." It assumes in the first in- stance the triangular shape of the cavity of the uterus, and although these are not constant, there are commonly three openings Avhich cor- respond with the orifices of the tAvo Fallopian tubes and the internal os of the cervix. At parturition it is thrown off, either as a whole or in part, as a useless appendage, and replaced by a new formation. DEVELOPMENT of the ovum. 141 The Further Development of the 0\rUM.—Having thus de- scribed the provision made for the primary reception and support of the ovum in the changes Avhich occur in the interior surface of the uterus, we Avill noAv proceed to the more particular examination of the further development of the ovum itself. We have briefly traced this development from the original ova to the production of the embryo, and noticed in a cursory manner the umbilical and allantoid vesicles, the amnios and the chorion. These appendages to the em- bryo, Avhich at the same time protect it and administer to its groAvth, require noAv to be more particularly considered. The allantois, as before partially described, is usually observed to arise as a minute tubercle from the inferior portion of the canal about the tenth day; it then rapidly shoots forward and takes root in the villi of the chorion. This organ is also called the urachus, and is accompanied by, or rather principally composed of, two arteries pro- ceeding from the iliacs and called the umbilical arteries, and one vein. The allantoid vesicle, as such, disappears very rapidly; after a feAV days no trace of it can be found, excepting a cord of no definite length which connects the embryo with the chorion and contains the um- bilical vessels. That portion of this vesicle which is contained Avithin the abdomen of the child is, hoAvever, more persistent in its duration, becomes converted into the urinary bladder, and in the rudimentary state terminates in the rectum and constitutes the temporary cloaca; all of Avhich is capable of demonstration in the human subject. It is here easy to understand what is meant by the urachus, Avhich is really that portion of the allantois which extends from the bladder to the umbilicus; hence anything that is capable of causing descent of the uterus must drag on the bladder from this attachment, and thus re- sults the dragging sensation felt in the umbilicus in such cases from the attachment of the urachus to that part of the body. The umbilical vesicle, Avhen first seen, seems to occupy the Avhole of the cavity of the ovum. Subsequently the embryo is seen on the blastoderm, its back corresponding to the serous external surface, and its abdomen to the mucous or interior surface, of the blastodermic membrane. Thus, at this early period the abdomen is open to the entire umbilical Aresicle. As development goes on the embryo seems to rise more and more toAvard the umbilical vesicle, and to be devel- oped forward and imvard upon the abdomen. In consequence this vesicle loses more and more of its bulk, and assumes the appearance of a long narrow stem. This vesicle contains a yelloAvish and highly nutritious fluid, which, through the intervention of a vascular appa- 142 DEVELOPMENT OF THE OVUM. ratus, seiwes to nourish the embryo until it can provide for itself by other means. This vascular apparatus is supplied Avith two trunks for the transmission of blood—one venous, the other arterial; both, Iioav- ever, accompany the pedicle and form an important constituent part of it. (See large figure on plate facing 143.) " The first, N, called the omphalo-mesenteric vein, enters the abdomen, Avinds around the duode- num, and then opens into the umbilical vein at the point O, just as the latter emerges from the liver. As it passes the duodenum, branches are given off to the stomach and intestines, and when it discharges into the umbilical vein it sends a voluminous trunk to the liver. That portion Avhich furnishes the branches just described persists in the adult under the name of ventral or hepatic-portal vein, Avhilst all the rest Avill disappear Avith the umbilical vesicle and its pedicle. The arterial trunk, P, accompanying the pedicle, has been designated as the omphalo-mesenteric artery. Arising from the aorta, it gains the summit of the intestinal convolution, and gives off branches to the mesentery and to the intestine itself; then it reaches the pedicle and folloAvs the latter to the umbilical vesicle, upon Avhich it ultimately ramifies. The part that supplies the mesentery is converted in the adult into a mesenteric artery, all the rest being effaced. From all which it appears that the Avascular system of the umbilical vesicle rep- resents the primitive circulation in the embryo, corresponding in it to the sanguiferous apparatus of the yolk of fowls."—Cazeaux. The amnion, as before stated, becomes developed by the embryo rising into the umbilical vesicle, thereby completely developing the blastoderm about itself; Avhen the doubled parts unite the bridge unit- ing this neAv ring Avith the former becomes absorbed, leaving tAvo dis- tinct circles formed out of one—the former being the chorion, the latter the amnion. Now, as the amnion becomes distended more and more Avith liquor amnii, of course the umbilical vesicle becomes en- croached upon and grows smaller and smaller; at the same time the abdomen of the embryo curves up more and more, and the pedicle of the umbilical vesicle becomes longer and smaller, being now found on the outside of the amnion, between it and the chorion. At the end of six Aveeks after conception this is seen to be a small yelloAvish point about as large as a coriander seed. The umbilical vesicle is of vital importance to the embryo until after the formation of the allan- tois and its union Avith the villi of the chorion; after which it is no longer of any particular account, and with the exception of the above- mentioned remnant of its artery and vein it becomes entirely atro- phied. '^«—,4-' _• ^* * A- ■ "A. K O M S P EXPLANATION OF THE FIGURES IN PLATE OPPOSITE. No. 1, the human ovum, of its natural size, at about the thirtieth or thirty-sixth day. No. 2, the same ovum, of its natural size, laid open to show its constituent parts. A, A, the chorion ; B, the amnion ; C, the foetus ; D, the umbilical vesicle. No. 3, the same ovum highly magnified and opened in such a way as to exhibit the principal relations existing between the embryo and its appendages. The walls of the abdomen and chest have been cut away so as to bring the viscera into view, and the umbilical cord has also been split up for the purpose of showing how the ap- pendages of the foetus are brought into relation with this latter. A, A, the chorion, consisting of two layers, placed back to back, and confounded with each other, but which have been dissected apart for a limited extent at A' A7. B, B, the amnion laid open so as to show how it is continuous with the umbilical cord, along which it is reflected, thereby forming a sheath which, under the form of the canal B'' W, is directly continuous with the umbilicus or the umbilical walls C C of the embryo. D, the umbilical vesicle, and D', its pedicle. D//, the point where this pedicle communicates with the intestine E. E, the loop of the intestine prolonged into the cord. F, the urachus, continuous by one extremity, g, with the chorion, and by the other with the rectum at the point H. ii, the umbilical arteries. j, the umbilical vein. j', the part of the right auricle from which the umbilical vein comes off. K, the vena cava inferior. M, the inferior surface of the liver. N, the omphalo-mesenteric vein. 0, the point where this vein empties into the umbilical vein. P, the omphalo-mesenteric artery. 1, the heart; 2, the arch of the aorta; 3, the pulmonary artery; 4, the lung of the right side; 5, the Wolffian body; 6, the branchial fissure which is converted into the external ear; 7, the lower jaw; 8, the upper jaw; 9, the nostril of the right side; 10, the nasal canal still forming a kind of fissure, which extends from the eye to the nostril; 11, the caudal extremity, or coccyx, projecting like a tail; 12, the upper extremity; 13, the lower extremity. 143 144 DEVELOPMENT of THE OVUM. The amnion is thus seen to be the most internal membrane of the embryo, and that it is formed by folding the blastoderm over the em- bryo in every direction, which latter is accomplished apparently by the rising of the embryo toward the centre of the umbilical vesicle. When the folding over is complete, and both portions have grown together so as to form a complete shut sac around the embryo, then we have the amnion containing the embryo, the umbilical vesicle, and a quantity of fluid, thick and gelatinous, between the amnion and the chorion, Avhich becomes less and less as the amnion itself becomes dis- tended Avith its OAvn proper fluid. This fluid sometimes exists up to the period of parturition, and is called spurious liquor amnii, or liquor allantoidis. Its escape at an early period of labor gives rise to the opinion, sometimes, that the membranes have ruptured. The amnion consists, structurally, of a fibrous membrane, covered Avith a layer of oval nucleated epithelial cells, but contains neither vessels nor nerves. Its inner surface resembles a serous membrane, and in the opinion of many authors it secretes the liquor amnii ; its outer surface presents a rough and reticulate appearance. The doctrine, however, that the amniotic fluid is a secretion from the surface of the amnion appears to be a mistake, since this liquid is most likely an efflux from the em- bryo itself. From the moment of the complete formation of the am- nion as a shut sac, there is no longer any outlet for the escape of the efflux from the embryo; and that there must be such an efflux must be evident, since there are certain portions of the nourishment flowing into the embryo that are not entirely assimilated—some material car- ried thither from the mother, Avhich, although it has served the pur- pose for Avhich it had been imbibed, must be in part rejected in the form of sensible or insensible perspiration. In fact, there can be little doubt that there is enough of what we may call offal from the embryo and foetus to account for the quantity and quality of the liquid found Avithin the amniotic membrane. As the embryo develops and the liquor amnii increases, the amnion is forced to recede more and more from the foetus; of course it must eventually be forced to join the outer membrane or chorion, and thus form a covering to the umbilical cord all the Avay from the navel of the foetus to the outer membrane or chorion, into which its maternal end is inserted, and all the parts thus enclosed constitute Avhat is called the umbilical cord. Consequently the Avhole abdominal cavity must be in connection with the canal represented by this cord, that the fcetal appendages may communicate with it through the opening thus prepared for them. It is in this manner that the pedicle of the urn- DEVELOPMENT OF THE OVUM. 145 bilical vesicle becomes united to the ileo-csecal fold of the intestine, while the allantois connects with the rectum by the intervention of the urachus. The liquor amnii itself varies in appearance with the time at which it is examined. At the earliest period it is clear, transparent and limpid; at later periods it becomes thicker, more opaque, sometimes flaky, green, yellow, or of almost any other color, according to certain states of the foetus itself, which it demres from corresponding condi- tions of the mother. Its odor varies also; sometimes it is like that of spermatic fluid, with saline taste. The proportionate quantity of the liquor amnii also varies according to the time; in the earlier periods it is much greater than the weight of the foetus. At the middle of the term the relation may be about equal, and after that time the liquid lessens in proportion as the foetus increases; so that at full term the quantity of Avater is usually about a pound and a half, sometimes more and sometimes much less. Its specific gravity is somewhat above that of Avater, and it pre- sents an alkaline reaction. Careful examinations have shown that in addition to Avater it consists of a small quantity of albumen and gelatine, Avith traces of chloride of sodium, ammonia and phosphate of lime. The formation of the embryo involves the formation of the amnion as a matter of course, as a reservoir for the reception of effete matters from the foetus. The amnion also affords protection to the foetus by surrounding its body with an aqueous shield, impervious to bloAvs and shocks, since the embryo floats freely in its centre. The foetus, thus floating in the liquor amnii, is at liberty to accommodate itself to all the movements and varying positions of the mother, and to yield, Avith the least possible disturbance, to all the influences of her mental and moral states. The accoucheur finds in the ballottement practiced by the aid of this fluid an important diagnostic sign of pregnancy; and at the period of parturition is able to correct any malpositions with greater ease before than after the Avaters have been discharged. Again, it serves other useful purposes during labor, by diminishing and equalizing the pressure of the foetus upon the womb, and by distending the membrane into an elastic and conical plug or Avedge affords material assistance in the dilatation of the os uteri. The chorion lies next in order to the decidua, between it and the amnion. " The chorion begins to be formed in the Fallopian tubes as an albuminous layer enveloping the ovum; but as soon as it reaches the uterine cavity a number of small tubular projections, the chorion 10 146 DEVELOPMENT OF THE OVUM. villi, start from every point of its outer surface. At this time no vessels exist in it, but at about the second month the vascular sac of the allantois comes into contact with the inner surface of the chorion, forming its inner layer, or endochorion, and then capillary twigs are sent into the hollow villi; these now take on a rapid development; they become compound branching tufts, enclosing capillary vessels, which are brought into closer interdigitating communion with the capillaries ramifying in the decidual membrane. During the first three months of gestation every part of the chorion remains covered with villi, giving it the appearance, when placed in water, of a beauti- ful white shaggy or Avoolly membrane. After this time, however, a great number of the villi begin to disappear, so that a large portion of the external surface becomes smooth, except within the site of the placenta, where they increase enormously, becoming at the same time more convoluted, and constituting the foetal portion of that organ, their trunks helping to form the umbilical vessel." The Placenta, or After-birth.—In order to obtain a proper idea of the placenta, so named by Fallopius from its fancied resem- blance to a flattened cake, it is necessary to commence its description at the very commencement of its formation. It will be recollected that the allantois shoots from the embryo at a very early period of its existence, and very soon takes root in the villi of the chorion. Examination and experiments prove that this process is adapted to furnish nourishment to the embryo by means of arteries and one vein passing from the embryo to the mother and back. The arteries carry the impoverished arterial blood from the foetus toward the mother, seeking aeration and nourishment in the mother. The vein brings it back, purified and laden Avith all that the embryo needs for its growth and nourishment. In this first circuit there is made the beginning of the placenta, or the placenta itself so far. The next circuit adds to its size by the larger demand made by the increasing embryo; and so it goes on, constantly enlarging, circuit after circuit, until it has attained a full and sufficient size. The placental mass, at its full size, is about six inches in diameter, three-fourths of an inch thick in its centre, tapering to a thin edge at its circumference. In different persons the placenta will often be found to vary in form and size; but the above are about the average dimensions. The cord is usually attached in the centre, but it is sometimes found attached to one edge, constituting what is termed a battledore placenta. The placenta presents an internal or fcetal sur- face, and an external, maternal or uterine surface, and a border. At development of the ovum. 147 full term the internal surface is found covered by the chorion and the amnion. The foetal surface is smooth and shining, from being covered with the amnion—concave and transparent, showing the rami- fications of the blood-vessels of the cord most beautifully at full term. Immediately beneath the amnion is found the chorion, which enters largely into the formation of the placenta, giving it strength and transmitting the ramifications of the placental vessels. The maternal surface is convex, rough, and subdivided into a variable number of lobules, held together by an albuminous tissue, which is so easily torn off that it is very difficult to retain it in separating the placenta.. These lobules, or cotyledons, are the original villi of the chorion very much enlarged and compacted together, although even these are also very easily ruptured and separated into loose, disorganized masses. Fig. 38. Fig. 39. Fig. 38, the internal or foetal surface of the placenta. Fig. 39, the external or uterine surface of the placenta. The villi have been described as compacted together; this results from their having groAvn into the mucous membrane of the uterus, between that organ and the ovum. At the same time the mucous membrane has also gro\vn into the villi and the chorion; so that there is a mutual groAvth of one into the other, each supplying its own share in the formation of the placenta; the villi and their growth forming the foetal side, and the mucous membrane and its groAvth forming the maternal or uterine side of the placenta. Thus, in the very first circuit of the foetal blood in its vessels on the inner side of these villi, it becomes aerated and supplied with all things needful from the maternal blood on the outer side of these villi. In this way the process goes on, hour after hour, day after day, the demand and the supply alike increasing, till large quantities of blood are formed 148 DEVELOPMENT OF THE OA^UM. on each side; their banks, hoAvever, never breaking, while the foetal blood constantly communicates, but never commingles, Avith the ma- ternal blood. This is proved by injecting the vessels on the foetal side; not a particle, even of the finest material, is ever found to pass beyond the foetal side, while on the other hand it is found equally impossible to cause a particle of the finest injection to pass from the maternal to the foetal side. The foetal portion of the placenta, that to which the umbilical cord is attached, receives the branches of the tAvo umbilical arteries, each of which divides into two branches at the point of juncture with the placental surface, and these branches again divide and subdivide until the vessels are reduced considerably in size, and thus pass through the chorion and ramify within the substance of the foetal portion of the placenta. The blood is taken up by the venous radicles and returned by sixteen chief venous branches, Avhich folloAV the course of the main arterial subdivisions, and finally form the single umbilical vein of the cord. The maternal or uterine portion of the plagenta is divided into lobules or cotyledons as before described. Over these is spread a thin and pulpy membrane, the placental decidua, or decidua serotina, which dips down into the sulci of the cotyledons in a manner similar to the dipping doAvn of the pia mater into the sulci of the brain. In exam- ining a placenta cast off during parturition " numerous valve-like apertures are found upon all parts of its surface (uterine). They are the orifices of the veins which have been torn off from the uterus. A probe passed into any of these, after taking an oblique direction, enters at once into the placental substance ; small arteries, about half an inch in length, are also everywhere obsenred imbedded in this layer. After making se\^eral spiral turns they likewise suddenly open into the placenta. These are the uterine vessels Avhich carry the maternal blood to and from the interior of the placenta."—Dr. Arthur Farre. It will thus be seen that the placenta is coArered upon its maternal or uterine surface by a membrane (decidua serotina), and on its fcetal surface by another membrane (the amnion). These give firmness and consistence to the placental mass, and at the edge or circumference they unite and spread out to form the envelope of the foetus and liquor amnii. In regard to the manner in which nutriment is conveyed to the em- bryo through the maternal blood without a commingling of that fluid with the blood of the embryo, we quote the folloAving passage DEVELOPMENT OF THE OVUM. 149 from Dr. John Reid : " When the blood of the mother flows into the placenta through the curling arteries of the uterus, it passes into a large sac formed by the inner coat of the vascular system of the mother, which is intersected in many thousands of different directions by the placental tufts projecting into it like fringes, and pushing its thin walls before them in the form of sheaths, which closely envelop both the trunk and each indiAridual branch composing these tufts. From this sac the maternal blood is returned by the utero-placental veins, Avithout having been extravasated, or without having left her OAvn system of vessels. The blood of the mother contained in this placental sac, and the blood of the foetus contained in the umbilical vessels, can easily act and react upon each other through the spongy and cellular walls of the placental vessels and the thin sac ensheathing them, in the same manner as the blood in the branchial vessels of aquatic animals is acted upon by the water in which they float." Thus it Avill be percei\red that there is no direct vascular intercom- munication between the foetus and the mother, and hence all changes Avhich take place in the blood of the foetus, whether of depuration or of nutrition, must take place by endomosis. There is probably no nervous connection betAveen the foetus and the mother, since no nerves have been discoA^ered in either the placenta or the umbilical cord. The placenta is usually attached to the fundus of the uterus—more frequently to the left than to the right side—but it may be implanted upon any part of the interior uterine surface, and is sometimes found near to or even over the os itself. The umbilical cord, or funis, connects the foetus in utero Avith the placenta, and is the bond of union between the mother and her child. The product of a somewhat advanced state of development, it is not found in the early weeks of pregnancy. The umbilical cord takes its origin in the embryo, in the form of the allantoid vesicle. And as soon as this vesicle has taken root in the villi of the chorion, it is found to consist of tAvo arteries arising from the bifurcation of the abdominal aorta in the embryo, and of one accompanying vein Avhich arises from the vena cava ascendens and the hepatic portal vein. The arteries carry the embryonic blood away, to be replenished and nourished by that of the parent. This is accomplished through the medium of the placental A'illi, as above described. From them the blood is returned by the vein to the embryo; and thus is established the living connection of the foetus with the mother. As the abdomen of the foetus closes up with the advancing de- velopment, it is found that the stem of the allantoid vesicle and the 150 DEVELOPMENT OF THE OVUM. umbilical vesicle are embraced in one common sheath, the amnion. And when the abdomen fails to close up firmly and tightly around the cord, there remains what is called a congenital umbilical hernia, which continues till the child is perfectly formed. The urinary bladder is formed on the abdominal portion of the urachus or allan- toid vesicle. Hence it appears that the bladder is on a line AVith the cord; and Avhen the child has been separated from the mother and the fcetal circulation cut off, the two arteries arising from the bifurca- tion of the aorta are converted into suspensory ligaments of the bladder, which terminate in the umbilicus. The umbilical cord at full term differs very much in length iu different cases; it may be but a few inches, or even five or six feet in length, but it is usually from twenty-one to tAventy-three inches. The existence of nerves has not been demonstrated in the cord, but lymphatics have recently been discovered. Thus, as the waters of the amnion serve to protect the foetus as far as possible from external violence, by allowing it easily to float aAvay and evade any direct attack, so the entire absence of direct neiwous connection be- tween the foetus and the mother prevents the former from being too injuriously affected by any sudden mental emotion or moral ex- citement of the latter. The child must indeed be poAverfully affected in such cases, but through the circulation only; and thus not so rapidly or so violently as if there were direct nervous communication. Fig. 40. An anomaly, described by Benckiser: a division of the cord, just within the mem- branes, into five or six branches. The greater part of the body of the umbilical cord is made up of the arteries and vein, which are imbedded in a gelatinous material consisting of a very delicate cellular structure infiltrated with albu- minous matter; but, what is very curious, the arteries Avind around the cord from left to right through its Avhole length, the vein con- DEVELOPMENT OF THE FCBTUS. 151 stituting the central axis of this regular spiral. The cause of this— for it must have a determinate cause—has not been satisfactorily ex- plained; a similar phenomenon may be observed in pouring fluids through a funnel; they will always gyrate in a single direction. It is very common to find the cord Avound round the child's neck at parturition, requiring to be slipped off upon the emergence of the head; in such cases there is probably an abnormal length of the cord. Other cases are reported in Avhich the cord is tied in knots, but not so tightly as to compromise the foetal life by impeding the circulation. The umbilicus usually constitutes the point of origin of the cord, but it has been knoAvn to arise from the head, the chest, the shoulder, etc.; such anomalies result from some peculiarly disordered condition of the mother during this period of the incipient development of the embryo. It will be observed that as the interior or abdominal portion of the blastodermic membrane represents the organs of the vegetative life, so the umbilical cord, arising from this very portion of the embryo, and connecting with a corresponding portion of the mother, through the placental mass attached to the uterine walls, directly unites the vegetative organization of the mother with that of the child; this organization being thus seen to underlie the whole organic life, and thus to involve all that we understand by hereditary con- stitution. The same ideas are also no less plainly suggested by the fact that the whole life of the child is absolutely dependent upon the vital circulation of the mother, the movement of which is entirely under the control of the vegetative, organic or ganglionic nervous system. CHAPTER X. DEVELOPMENT OF THE FCETUS. HAVING thus described the primary development and organiza- tion of the ovum with its appendages, we now come to the study of the foetus as a whole, with particular reference to its safe delivery from its gestative Avorld to a more independent state of existence. But before proceeding to trace the intra-uterine life to the full term, it Avill be proper to review the ground already surveyed; this will be best done by a careful examination of the Plate (after Cazeaux) facing page 143, in Avhich are delineated the embryo and appendages up to the already described state of development. 152 DEVELOPMENT OF THE FCETUS. Successive Dimensions and Weight of the Farrus.—The first indications of the formation of a neAv human being that it is possible to discover, even by the help of a microscope, consist in an oblong figure, obtuse at one extremity, SAvollen in the middle, blunt-pointed at the other extremity. This rudimentary embryo is slightly curved forward, is of a grayish-white color, of a gelatinous consistence, from two to four lines long, and Aveighs one or two grains. Here a slight depression, representing the neck, enables us to distinguish the head; the body is marked by the SAvollen centre, but there are no traces of the separate extremities. So much can be observed about the end of the third Aveek after conception. At about the fifth week the embryo is found much more distinct. The head is very large in proportion to the rest of the body; the eyes are represented by two black spots; and the upper extremities are represented by small protuberances on the sides of the trunk. The embryo is now nearly two-thirds of an inch in length, and Aveighs about fifteen grains. The umbilical cord can now be distinguished in its rudimentary stage, and the loAver extremities begin to appear in the shape of two minute rounded tubercles. Minute depressions may now be discerned between the vertebrae, and the embryo is so much curved forward that its caudal portion very nearly approximates the head. Till about this time a straight artery has been observed to beat with the regularity of the pulse, but now it appears doubled somewhat in the shape of an adult heart, although as yet it has but one auricle and one ventricle. But as the time advances we find at length the perfect heart, with its two auricles and two ventricles, all developed from the original straight artery. The division of the first cardiac cavity into others is effected by partitions thrown up, or by contractions accomplished in the course of the same natural and orderly development. The septum Avhich divides this primary ven- tricle into two is developed from the apex toward the base between the pulmonary artery and "the aorta, so that we shall open the pul- monary artery from the right ventricle, and the aorta from the left ventricle. At this period the lungs appear to exist in five or six different lobes, and Ave can barely distinguish the bronchial tubes, terminating apparently in minute cul-de-sacs. Along the vertebral column may be perceived tAvo large glandular structures, which extend from the lung to the bottom of the pelvis. These structures, termed the Wolffian bodies, are constituted by an excretory canal which runs through their whole length, and perform the functions of the kidneys DEVELOPMENT OF THE F03TUS. 153 until the latter are developed. By means of numerous caeca which appear on one side only of their surfaces they secrete a fluid Avhich is poured into the canal and thence transmitted into the temporary cloaca. The Wolffian bodies disappear upon the development of the kidneys, and leave no traces of their former existence.—Cazeaux. A second canal, perfectly distinct, although lying alongside of that of the Wolffian body, is also to be discerned, which presents in the adult, and, according to the sex, becomes either the oviduct or the vas deferens. At about the same period of embryonic life may be distinguished four transverse fissures upon each side of the neck, which open into the pharynx. These are separated by fleshy par- titions that correspond with the branchial arcs of fishes, and they may for a time serve some similar or corresponding purpose. In the course of the subsequent development these fissures are dispersed and disappear, with the exception of one on each side (see the Plate), which are converted into the external ears. At about the same period, upon what appears to be the face appear two isolated tubercles, Avhich gradually approach the mesian line as development goes on, and form the upper jaAV. The double hare-lip, so often seen in children, results from the failure of development of the upper jaw and nose, as the nostrils originally constituted one cavity on a mesian line with the mouth. At about the seventh week the first centres of ossification appear in the clavicle, and subsequently in the lower jaw. The intestines still extend some distance along the interior of the umbilical cord; the omphalo-mesenteric canal is nearly obliterated, although it may still be traced as far as the umbilical vesicle, Avhere it is reduced to a mere thread. The anus is not yet opened or formed. The kidneys now begin to be formed, and soon after the genital organs. The urinary bladder is first seen in the form of a small tumor continuous with the urachus. The embryo is about one inch in length. At two months the rudiments of the extremities become more promi- nent. The forearm and hand can be distinguished, but not the arm; the hand is larger than the forearm, but it is not supplied Avith fingers. The cord has not yet become spiral, and still contains a large quantity of intestine; it is four or five lines in length, and is found to proceed from the lowest point of the abdomen. The formation of the placenta commencing, a minute tubercle may be distinguished between the cord and the termination of the spine, marking the locality of the genital « organs, but the sex cannot yet be determined. The length of the embryo is now from one inch and a half to two inches, and it weighs 154 DEVELOPMENT OF THE F(ETUS. from three to five drachms. The eyes are discernible, but still un- covered by the rudimentary lids. The nose forms an obtuse eminence, the nostrils are rounded and separated; the mouth is gaping, and the epidermis can be distinguished from the true skin. At ten weeks the embryo is from one and a half to two and a half inches long, and its weight is one ounce or one ounce and a half; the eyelids are more developed and descend in front of the eyes; the puncta lachrymalia are visible, and the mouth begins to be closed by the development of the lips. The walls of the thorax are now more completely formed, so that it is no longer possible to see the move- ment of the heart. The fingers become distinct, and the toes appear like small projections, Avebbed together like a frog's foot. The um- bilical cord now assumes the spiral form, still contains a portion of the intestine in its base, and its place of attachment appears higher up in the abdomen. At the end of the third month the Aveight of the embryo is from three to four ounces, and its length from four to five inches; the eyeballs are seen through the lids, the pupils of the eyes can be discerned, the forehead, nose and lips can be clearly made out. The neck now ap- pears between the head and shoulders; the cord contains no intestine, and its spirals are more numerous and apparent; the finger-nails re- semble thin membranous plates; the cerebro-spinal axis is divisible into its leading parts; the ventricles of the heart are separate, the pla- centa is separate, and the allantois and umbilical vesicle have dis- appeared. The skin shows more firmness; although apparently Avith- out fibrous structure, it is still rosy-hued, thin and transparent. At the end of the fourth month the product of conception is no longer called the embryo, but the foetus. The body is from six to eight inches in length and weighs six or seven ounces. The sutures and fontanelles are now very large, and little Avhite hairs may be seen scattered OA^er the scalp. The development of the face is still imper- fect. The eyes are now closed by their lids, the nostrils are well formed, and the mouth is shut in by the lips. The sexes are now distinguishable, and meconium is present in the upper boAvel. The tongue may be observed far back in the buccal cavity, and the loAver angle of the face is rounded off by Avhat a little later will be a Avell- formed chin. The umbilical cord is attached to the abdomen still higher up, though as yet much below the centre of the body. A foetus born at this time may survive for several hours. At the end of the fifth month the body of the foetus is from seven to nine inches long, and Aveighs from eight to eleven ounces. The skin DEVELOPMENT OF THE FCETUS. 155 has noAV a fairer appearance and is more consistent; the eyes can no longer be distinguished through the lids, owing to the increasing thickness of the latter. The head, heart and kidneys are large and well developed. The movements of the foetus are usually plainly felt by the mother. At the end of the sixth month the fcetus is from eleven to twelve and a half inches in length, and weighs about sixteen ounces, more or less. The hair upon the scalp is thicker and longer, the eyes remain closed, and very delicate hairs may be seen upon the margins of the eyelids and upon the eyebrows. The nails are solid, the scrotum small and empty; the surface of the skin appears wrinkled, but the dermis may be distinguished from the epidermis. The liver is large and red, and the gall-bladder contains fluid. At the end of the seventh month the length of the fcetus is from twelve and a half to fourteen inches, its weight is about fifty-fiA^e ounces, and it is both well defined and well proportioned in all its parts. The bones of the cranium, hitherto quite flat, noAv appear a little arched, and as the process of ossification goes on the arching increases till the vault is quite complete. The brain presents greater firmness, and the eyelids are opened. The skin is much firmer and red. The gall bladder contains bile. At the end of the eighth month the fcetus seems to thicken up rather than to increase in length, since it is only from sixteen to eighteen inches in length, while its weight increases to four or five pounds. The skin is red, and characterized at this period by a fine doAvny covering, over which is spread a quantity of thick A'iscous matter, called the sebaceous coat, which has been forming since the latter part of the fifth month. The lower jaw has noAV become as long as the upper one, and in the male the left testicle may be found in the scro- tum. Convolutions appear in the brain structure. At nine months the anxious time has arrived; the foetus is from nine- teen to twenty-three inches in length, and Aveighs from six to eight pounds, on an average. Some children weigh very much less; some as much as fourteen pounds; but such extremes are very rare. In most instances the child is covered with a whitish, sebaceous matter, which is really a secretion from the child's skin, Avhich may be dis- solved and removed from the surface after birth by rubbing with some unctuous material, such as oil or lard. At this period the white and gray matter of the brain are dis- tinct, and the convolutions are Avell marked; the nails assume a horny consistence; hair is more or less abundant; the testes are 156 DEVELOPMENT OF THE FCETUS. in the scrotum; the umbilicus is situated midAvay between the head and feet. Upon a careful review of the preceding account of the growth and development of the foetus, it will be seen that this growth is much more rapid in the first and in the last three months of its intra-uterine life than during the middle of this period. The following brief though graphic account of the development of the different parts and organs of the foetus is taken from Meadows' Manual of Midwifery, condensed by the author from Carpenter's Physiology: " The alimentary canal is formed from the vitelline sac or umbilical vesicle, with which a communication is kept up for some time. At first it exists as a narroAv straight tube, having no division of parts and no orifices ; subsequently, the mouth, oesophagus, stomach, large and small intestines are formed; and it is at the junction of the two latter that the vitelline duct exists. " The liver is formed upon the small intestine, and makes its ap- pearance first, at about the third week, by the aggregation of a num- ber of cells at the spot Avhere the hepatic duct afterward opens; this increases, and gradually removes farther from the canal; ducts begin to appear in it, starting first of all from the intestinal Avail; and so rapid is the groAvth that by the fifth Aveek the organ is about one- half the weight of the embryo itself. The subsequent changes which take place consolidate it and adapt it to Avhat Ave see at birth. "The pancreas and salivary glands are similarly developed as offshoots of the alimentary canal. It will be remembered that all the organs of vegetative life arise from the original inner or mucous layer of the area germinativa. " The lungs arise at about the sixth week, as a pair of bud-like processes, from the oesophageal portion of the alimentary canal; their surfaces soon become covered Avith numerous little wart-like projec- tions, caused by corresponding enlargements of their cavity. This goes on increasing; the parenchymatous tissue is developed in the spaces betAveen the bronchi, vessels are deposited in it, and by degrees these organs separate from the tube from which they spring, and as- sume more and more the natural state. " The urinary organs begin as two large tubes situate one on either side of the spinal column; little csecal appendages, the corpora Wolff- iana, are developed on their outer sides; the ducts then enter the allantois, there being at present no proper urinary bladder; this takes place about the fifth Aveek, and by the end of the second month they DEVELOPMENT OF THE FCETUS. 157 have disappeared. These take no part AvhateArer in the deArelopment of the kidneys, Avhich begin to form at about the seventh Aveek, behind the Wolffian bodies. At first as separate lobules, they afterward coa- lesce : for some time the supra-renal capsules equal in size the kidneys, but at the sixth month the former rapidly decrease, Avhile the latter as quickly increase in growth. The ureters at first open, Avith the duct of the Wolffian bodies, into the allantois; but as these bodies disappear a portion of the allantois is nipped off, and thus the urinary bladder is formed. " The generative organs are developed later than the other vegeta- tive organs, and at first they present no essential sexual difference. This applies to both the internal and external organs until at least as late as the fourteenth week. " The internal generative organs appear first at the inner side of the Wolffian bodies. As development advances, the testes become round, thick, vertical in direction, and are united to the vasa defcrcntia ; the ovaries, on the contrary, become long, flat, transversely situate, and remain unconnected with the Fallopian tubes; the former subsequently enter the scrotum, beginning the descent about the middle of preg- nancy ; the latter descend into the pelvis. The uterus is formed by a coalescence of the inner extremities of the Fallopian tubes; it remains bifid or bihorned (the normal condition of some animals) up to about the fourth month. "The developmental changes of the external generative organs are interesting, from the light they throAv on some malformations incident to these parts. So early as the fifth or sixth week a common cloaca exists for the termination of the intestine, the urinary and generative organs. At about the tenth week the former is separated from the two latter by a band, and subsequently these are shut off from one another by a similar band. Then the labia majora or the tAvo hal\Tes of the scrotum, as the case may be, are developed on either side of the orifice of the genito-urinary canal; and above and betAveen these a small body protrudes, being surrounded with a glans and fissured on its under surface. This becomes the clitoris in the female, and, by future groAvth, the penis in the male. The margins of the fissure are, in the former, developed into the nymphce; in the latter they unite and form the urethra. It will noAv be readily understood how, by arrested or morbidly augmented development of these parts, herma- phrodism or other deformities may result. " Turning now to the organs of animal life, a few words upon the development of the cerebrospinal axis may fitly terminate the con- 158 DEVELOPMENT OF THE FCETUS. sideration of the embryological changes affecting indiA7idual organs. This, as has already been stated, takes its origin in the external serous or animal layer of the germinal membrane by a contribution from each side of the primary groove formed by the rising up of the laminae dorsales; it is, in fact, from a portion of these latter, at first separate, but aftenvard united, that the central nervous system arises. The encephalic portion consists at first of three vesicles : out of the first is formed the greater portion of the cerebral hemispheres, the corpora striata, optic thalami and third ventricle; out of the second, the corpora quadrigemina and crura cerebri ; and out of the third, the pons varolii, the medulla and fourth ventricle. At first, all these vesi- cles are arranged in a straight line, very much like the permanent condition of the brain in fishes, but a curve is formed about the seventh Aveek, the hemispheres arching over the thalami and corpora quadrigemina. The lateral sinuses are formed about the third month, the corpus callosum in the fifth, and convolutions appear at the fourth. The membranes of the brain are formed at about the sixth or seventh Aveek, the arachnoid rather later. They are developed from the primary encephalic mass." Ossification sets in in the embryo at an early period, commencing about the sixth Aveek at a point of the clavicle; nearly simultaneously Avith this primary point of ossification bony formation commences in the inferior maxilla; then follow, successively, the vertebrae, humerus, femur, ribs and occipital bone. At the commencement of the third month it occurs in the superior maxilla, frontal bones, radius and ulna, tibia and fibula, and the scapula; and toAvard the close of the third month it has commenced in the metacarpal, metatarsal and phalangeal bones, and the remaining bones of the cranium. During the fourth month the bones of the pelvis and the sacrum begin to ossify, together with the minute ossicles of the inner ear. During the fifth, sixth and seventh months the astragalus and os calcis, the ethmoid bone, the pubis and the ischium commence to ossify. At the eighth month ossification sets in in the last bone of the sacrum. At full term many of the bones still remain in a cartilaginous con- dition, as the carpus, the smaller bones of the tarsus, part of the coccyx, the patella, the epiphyses of the long bones, and usually the os hyoides. The Fcetus at Full Term.—It must be evident that all the mechanical difficulties attending childbirth increase Avith the develop- ment of the child; hence the necessity of particularly studying the most voluminous portion, in order that we may intelligently adapt it DEVELOPMENT OF THE FCETUS. 159 to the passage in the pelvis through Avhich it must pass. The most voluminous, the least yielding and compressible, and by far the most difficult part to manage in parturition, is the head, and of course where this may pass, the remainder of the body can follow with comparative ease. The shape of the foetal head is ovoidal, the posterior part being larger than the anterior. The cranium, Avith which as accoucheurs we are principally interested, is composed of the os frontis, the occipi- tal, the two parietal and the two temporal bones. These are articu- lated by means of sutures, Avhich in the foetus at full term are usually cartilaginous. Angular spaces, called fontanelles, are left at the cross- ing of these sutures. Each suture and fontanelle has its particular designation. The sagittal suture arises from the root of the nose, dividing the frontal bone on the mesian line, runs across the top of the head to the occipital bone, and sometimes divides that bone to its very base. Tlie coronal suture crosses the sagittal at right angles, uniting, the os frontis to the parietal and temporal bones. The lambdoidal suture also crosses the sagittal, although at a more acute angle, uniting the occipital bone to the parietal and temporal bones. Where the coronal suture crosses the sagittal suture there is left a large quadrangular space called the anterior fontanelle. The crossing of the lambdoidal suture with the sagittal leaves a three- sided space, smaller than that of the anterior fontanelle, and called the posterior fontanelle. There are other sutures and fontanelles, formed in a similar manner, between the bones which compose the foetal head, but those mentioned above are the only ones of prac- tical importance to the accoucheur. By means of these sutures and fontanelles the head may be compressed so as to require less space during parturition, thus rendering this function less frequently in- jurious to both mother and child than must othenvise be the case; and these sutures and fontanelles serve as guide-marks for deter- mining the exact position of the foetal head relatively Avith the cavity of the pelvis during labor. The diameters of the fcetal head at term may be reduced, for all practical purposes, to seven in number. The occipito-mental (a b, Fig. 41), extending from the occipital protuberance beloAv the pos- terior fontanelle, to the chin, is five and one-fourth inches. The longi- tudinal or occipitofrontal, d e, extends from the occipital protuberance to the frontal protuberance, and is four and one-fourth inches. The mb-occipito bregmatic, c f extends from the central point between 160 DEVELOPMENT OF THE FCETUS. the foramen magnum and the occipital protuberance to the anterior fontanelle, and measures three inches and three-fourths. These are called antero-posterior diameters. The transverse diameters are, the Fig. 41. Fig. 42. bi-parietal, a b (Fig. 42), extending from one parietal protuberance to the other, three inches and three-fourths; the other, the bi-temporal, c d (Fig. 42), extending from the zygomatic process of one side to the same point on the other, measures three inches. Finally, there are also two vertical diameters: First, the vertical diameter, i g (Fig. 41), extending perpendicularly from the highest point of the vertex to the anterior boundary of the foramen magnum, measures three inches and three-fourths. Second, the fronto-mental, d a (Fig. 41), from the frontal protuberance to the lowest point of the chin, meas- ures three inches. While it is absolutely necessary for the accoucheur to have a perfect knowledge of these various and varying diameters of the foetal head, yet the most important in an obstetrical point of view undoubtedly are, the occipito-mental, five and one-fourth inches; the occipito- frontal, four and one-fourth inches; the bi-parietal, three and three- fourths inches. NoAAr, it will be readily seen that the antero-posterior diameter is quite too long to pass any diameter in the Avell-formed pelvis, even in the dried state, Avhere the largest diameter is only five inches. Hence it must be apparent that in order for the head to be capable of pass- ing in parturition, the longest diameter must lead the way—that is, the long diameter of the head must be made parallel to the axis of the pelvis by making either the occiput or the chin lead the Avay. When this is accomplished it is evident that all the other diameters of the head will be permitted to pass through a well-formed female pelvis. And the more perfectly the antero-posterior diameters of the head are made parallel with the general axis of the pelvis, the easier —other things being equal—will the child be born. A great difference exists between the heads of male and female DEVELOPMENT OF THE FCETUS. 161 children, in the greater size and more complete ossification Avhich are found to obtain in the former. As a proof of this Ave may adduce the one observed fact, that the proportion of stillborn boys to stillborn girls is one hundred and fifty-one of the former to one hundred of the latter. And even of those born alive a much larger number of boys than of girls die in infancy from injuries received during birth. And finally, of the mothers who succumb to consequences of childbirth a majority have given birth to boys. Thus, it appears that the groAvth of the male portion of the race costs much more suffering and a greater loss of life than does that of the female portion. One more fact needs to be studied in this connection, and this is the articulation of the child's head to its trunk. The occiput is articu- lated Avith the atlas in such a manner as to admit of great flexion and extension, while at the same time the atlas is so placed upon the axis as to admit of great rotation—much more freedom of movement in either articulation than is possible in the adult. Hence it makes little difference, so far as the child's neck is concerned, Avhether the occiput or the chin lead the way in parturition. It is, hoAvever, much better, as is usually the case, for the occiput to lead the way; for, as the chin thus rests upon the sternum of the foetus, the long diameter of the head corresponds more exactly with the long diameter of the body of the fcetus, and consequently the Avhole long diameter is more in harmony Avith the axis of the cavity of the pelvis. Thus, the direct force of each contraction of the uterus is received by the propelled body in a mass, none of the force being lost, as would necessarily be the case if the chin were to lead the Avay. For here every contrac- tion Avould tend to throAV the occiput back upon the spine, in which case it Avould not find a firm base, as in the natural position of the chin upon the sternum. The Presentation and Position of the Fcetus at Full Term is a thing of much interest, and the true causes which influence and determine these must noAV be stated and explained. At the earli- est period at which the embryo is seen, it has ahvays been observed to be curved fonvard, and in all orderly developments this position con- tinues as the groAvth increases, until at full term of gestation the head is found flexed so that the chin nearly touches the sternum, the arms are flexed upon the chest, and the forearms upon the arms, so that the palm of each hand is applied to its side of the face and chin. The in- ferior extremities are also flexed in a similar manner, the thighs upon the abdomen and the legs upon the thighs; the feet lying together and within the thighs, the knees and elbows touching each other. 11 162 development of the fcetus. This is found to be the position most economical of space; it forms the body into a compact and ovoidal mass, similar in shape to that of the head, and most convenient for expulsion from the pelvis. Upon a little reflection it must be evident that the same influences that give shape to the embryo and foetus must also shape its position in utero. And furthermore, that the same influences must also deter- mine the presentation of the foetus, not at once, but as it is gradually developed so it is gradually made to assume its best possible position and gradually to present itself at the superior strait with its head dowmvard, the occiput turned to the left ilio-pectineal eminence, its back—relative to the mother—to the left and in front, and its face looking back to the mother's right. This position and presentation is assumed by means of the all-pervading influence of the mother more frequently than all the others put together, simply because it is the most favorable for an easy expulsion from the generative organs, and is consequently the most orderly and natural one. When the fcetus deviates from this it assumes the next most favorable position for an easy delivery, and so on; the greatest number of presentations and positions being by far the best, and the least number being the most difficult. The causes of all these different presentations and positions may be much more rationally accounted for by referring the Avhole matter to Nature's formative process than by attempting to explain them as the effects of gra\rity or of any other mechanical influence; since the same result is obtained where women maintain the horizon- tal position during the entire period of utero-gestation. If the forma- tive poAvers of Nature in the mother are adequate to the folding of the limbs in the compact and symmetrical manner just described, Avhy should they not be deemed sufficient to determine the presentations and the precise position? It is contended by many Avriters, however, that the fact of the foetal head being usually found at the outlet of the uterus is due to gravity. " The reason," says William Hunter, in his work on the Human Gravid Uterus, " Avhy the child's head is com- monly doAvnward may be supposed to be this : the child is specifically heavier than the liquor amnii, and therefore in the various attitudes of the mother is ahvays in contact with and supported upon the de- pending part of the uterus. This in the more common attitudes is the cervix uteri. The child's head and upper part of the trunk con- tain more matter in proportion to their surface than the lower part of the body; hence the head will more generally fall doAvn to the lower part of the uterus." It may be asked, Why, then, are there so many different presenta- development of the fcetus. 163 tions and positions ? The head is sometimes extended upon the back, as in the face presentation, and sometimes the loAver extremities are throAvn over toward the back. All these various attitudes, presenta- tions and positions result from corresponding variations in the vital energies of the mother. Should she be well, in an orderly and happy condition, both mentally and physically, her child will haA^e only natural and orderly presentations and positions. The truth of this is proven by daily experience in practice. For Avomen Avho, for instance, invariably have face presentations of their children, and Avho have always been ill in some particular manner themselves, after the re- moval of their malady have as inArariably had their children present naturally. Hence the great importance of making the most strenuous and persevering efforts to remove the various disorders Avith which Avomen are afflicted, and to advise happy and orderly modes of life in order that the distresses of childbearing may be entirely overcome; Avhich indeed is not only possible, but under the prevalence of the homoeopathic regime quite probable in the course of time. It should be remembered here that the embryo or foetus is not suspended in the uterus by the umbilical cord, but that it floats in the liquor amnii; hence it is free to obey any influence brought to bear upon it by the mother. By presentation we mean the part that presents at the superior strait, as the vertex, the face, the breech, etc, By position Ave mean the particular posture in presentation, as the occiput in the left half of the pelvis, anterior, transverse or posterior. But the further con- sideration of this subject Avill be postponed until Ave come to treat of the mechanism of labor. The development of the foetus needs also to be studied Avith especial reference to the three great functions of Nutrition, Respiration and Circulation, by Avhich this development is accomplished. Each of these functions is evidently maintained during intra-uterine life in a manner altogether different from that after birth. Nutrition.—At no instant in the history even of the unimpreg- nated ovule is it Avithout the support of the mother, from the earliest moment of its existence Avithin the OA^ary till it is ruthlessly washed aAvay by the menstrual flux or broken and destroyed by some other means. But Avhen impregnated the ovule becomes still more espe- cially the object of the particular care of the mother. Hence, imme- diately upon the occurrence of conception the entire natural, spiritual and vital organism of the mother is aroused to provide for Avhat is really a new creature, already a new human being. From this moment, 164 DEVELOPMENT of the fcetus. therefore, commences the nutrition of the embryo. And at the very first this is accomplished in a manner similar to the nutrition of a seed in the earth; which, although in a general manner supported by the external influences of the mother-earth, is in a still more immediate and particular manner sustained by itself, the sprout flourishing upon the remaining substance of the seed till that is consumed. So the impregnated ovum, even after it has left the ovary, is sustained in a general way by a sort of endosmosis from the mother, but in a more immediate and particular manner its primary development is main- tained by, and the embryo itself subsists upon, the vitellus; a substance most nutritious and especially provided for this very purpose. When this original resource is exhausted, the embryo throAVS out the allan- toid vesicle in search of other supplies. These are found by coming in contact Avith the mother's blood in the villi of the chorion. In this great life-fountain the embryo finds a bountiful supply of all things needful for its present wants and future growth and development, The vitellus is indeed very small, but the embryo itself is correspondingly minute; it wants but little. Sufficient proof of these statements may be found in the fact that the umbilical vesicle is entirely constituted from the vitellus, or from what remains of it after the formation of the blastodermic membrane, and in the further fact that the omphalo-mesenteric vessels are found to circulate blood to and from the embryo in a manner altogether similar to that in which it is subsequently done in the umbilical cord. And, finally, the umbilical vesicle and the omphalo-mesenteric vessels soon become obliterated after the nutritious root has become Avell es- tablished by means of the allantoid vesicle, its arteries and veins. Pure arterial blood contains all the needful materials for growth, and for the separation of the waste and decomposition of tissue; these must be first accumulated in the blood, then distributed as needed. For this supply of the elements necessary for growth and repair there is a constant yearning, of Avhich the blood, as a living body, is conscious, and to Avhich it continually seeks to respond. Blood is found in the embryo at the earliest possible period of examination; a circulation has already been established in the embryo and in the omphalo-mesenteric vessels by the time the supply is exhausted which was contained in the umbilical vesicle, into which these vessels ramify in search of nourishment for the blood itself. Upon the failure of the supplies from the umbilical vesicle a new route must be opened up to furnish the demand. This is done by the embryo throAving out the allantois supplied with the tAvo arteries aris- development of the fcetus. 165 ing from the internal iliacs, and containing impoverished blood which must be renovated and returned to the embryo. These arteries are accompanied by a vein. The Avhole apparatus soon takes root in the villi of the chorion, and forthwith a return of nourishment is made to the already famishing embryo. The impoverished blood from the embryo, by endosmosis through the coats of the villi of the chorion, is reneAved and regenerated from the maternal blood. And the arteries anastomosing with the vein, the aerated and revivified blood is imme- diately returned to the embryo for its especial benefit. Now is formed the first nucleus of the placenta; and in this manner is accomplished the continued nutrition of the foetus, by its famished and exhausted blood being thus supplied Avith all things needful by endosmosis from the maternal blood, through the blood in and about the villi of the chorion. From this time the foetus, the cord and the placenta grow pari passu till the completion of the full term. And by no other means is the nutrition of the embryo and fcetus provided. All the plants, and, indeed, the Avhole animate creation, is nourished by a kind of endosmosis from the parent earth, or mother; but the material thus supplied is appropriated by each receiver in its own Avay, in accordance with its own form of life. A positive proof that the nutrition is supplied by means of the cord, and in no other Avay, is found in the Avell-knoAvn fact that compression of the cord so as to arrest the circulation, although but for a very short space of time, is certain death to the child. What change the nutritious material obtained from the mother undergoes before it is fitted for appropriation by the foetus, or where that pre- paratory change is made, Avhether in the foetal placenta or in the foetal liver, is not yet known. Nor is it knoAvn where or hoAV the plant transforms the nutriment derived from the earth into its peculiar sap, fibre and bark. Respiration.—This function is essential to the existence of all the animals of creation, and for every individual thereof; for this is the process by Avhich the effete blood becomes aerated, and gives up the excess of carbon and other useless matters Avith which it is loaded. This, as just above described, is accomplished by the foetal blood coming in contact with the maternal, in a manner not unlike that in which the blood of fishes is decarbonized by being exposed, by means of the gills, to the air contained in the Avater Avhich passes through them. The blood of the mother serves exactly the same purpose for that of the foetus that the water does for the blood of fishes; the Avater contains an appreciable amount of air, or rather of 166 development of the fcetus. oxygen, and so does the mother's blood. In proof of this, it is only necessary to compress the cord so as to prevent the blood of the fcetus from being exposed to that of the mother, and the child turns black and dies, as from asphyxia. Secretion.—As development advances all the secretions are suc- cessively established. The liver secretes bile, the gall-bladder is found full, and there is reason to believe that bile is steadily supplied to the intestines. Even prior to the fifth month the alimentary canal con- tains a substance called meconium, Avhich is principally composed of biliary matter and the detritus of the mucous membrane. There is no positiAre evidence that this meconium is ever evacuated into the amniotic sac, but it sometimes passes off freely during labor, and in other cases not long after delivery. Urine is secreted, and usually passes in considerable quantities after birth; and it is thought by some that the fcetus in utero discharges the urine into the amniotic cavity. But Ave have no positive evidence that the urine is ever discharged from the bladder till after delivery. Circulation.—The lungs of the fcetus in utero not being employed, are small and collapsed, and bear a striking resemblance to the liver in appearance. A very small portion of blood passes through them, and that which does so pass neither gives up impurities nor receives vivifying material, as after birth. In consequence of this the pul- monary arteries are small, and the passage of blood from the right side of the heart would be impeded in consequence of their lack of development were it not for the existence of the foramen ovale, or foramen of Botal, as it is likewise termed, an opening in the septum of the right and left auricle and through Avhich a proper quantity of the blood flows from the right into the left auricle. But not- withstanding the fact that a portion of the blood received by the right auricle is thus conveyed away, there is still too great a quantity to be transmitted through the minute pulmonary artery; and hence a supplementary short and thick vessel is provided, the ductus arte- riosus, Avhich passes between the pulmonary artery and the aorta, and gives free escape from the right ventricle. The right and left ven- tricles thus become in a measure one, and the blood from each enters directly into the aorta; while it will be seen that the right and left auricles are likewise one through the medium of the foramen ovale. Now, in the pelvis of the foetus the common iliac arteries divide into two branches, an external and an internal. The latter go to supply the extremities of the foetus, Avhile the former pass directly upward to the umbilicus as the umbilical arteries, and reach the placenta anomalous pregnancy. 167 through the medium of the cord. Here the blood receives its vivify- ing properties from the maternal blood, as has been already described, and is returned by the venous branches which unite to form the umbilical vein. The blood thus changed. and purified enters again the body of the foetus at the umbilicus, passes upAvard along the anterior edge of the suspensory ligament of the liver, and supplies that organ Avith blood. The current then passes onward to be emptied into the ascending vena cava by means of another short supplementary trunk, the ductus venosus, and is conveyed to the right auricle of the heart. The course of the foetal circulation, then, may be thus stated: start- ing from the placenta, the blood passes through the umbilical vein, along the cord, into the fcetus at the umbilicus, and thence to the liver; part goes to that organ, and the remainder passes onward through the ductus venosus into the ascending vena cava, and through it to the right auricle. Part of the blood recei\red by the right auricle comes through the descending vena cava, and of this a portion passes into the left auricle through the foramen ovale, and thence to the left ventricle, Avhile another portion passes into the right ventricle, is forced by its contractions into the pulmonary artery, and into the ductus arteriosus, Avhich conveys it to the aorta. The blood in the left ventricle is also forced into the aorta, and through the aorta the blood passes upAvard to the head and superior extremities and doAvn- ward to the trunk and inferior extremities. Having reached the internal iliacs in its downward course, it passes through the umbilical arteries of the cord to the placenta again. CHAPTEK XL ANOMALOUS PREGNANCY. Multiple Pregnancy. TTAVING described normal pregnancy, the product of Avhich is -■-J- a single foetus, Ave noAV advert briefly to that form of gestation in Avhich there are two or more. It is by no means an uncommon occurrence for a Avoman to give birth to twins; triplets are produced less frequently; and yet there are well-authenticated instances on record in Avhich four and even five children have been brought forth during a single labor. TAvin pregnancy occurs about once in seventy- 168 ANOMALOUS pregnancy. five cases. Madame la Chapelle records that in 37,441 births there were 444 instances of twins and but five of triplets. Churchill states that in 257,935 births recorded by British practitioners there were 3431 cases of twins and 43 cases of triplets. A great variety of theories have been promulgated by various Avriters regarding the causes of multiple pregnancies. These theories, however, may be summed up into the general opinion that the cause lies in an. extra- ordinary reproductive power, possessed in some instances by the male and in others by the female. As a general rule, in plural pregnancies each foetus has its OAvn set of membranes and its own placenta, although there may be an inos- culation of the blood-vessels of the placentae. It sometimes happens, hoAvever, that there is but a single placenta. This may be, and doubtless is, attributable to there being but a single ovule impregnated, which has contained two yolks and two germinal vesicles, as is some- times observed in the eggs of birds. Twin pregnancy is, as is shown above, the most frequent form of multiple pregnancy. The foetuses in such cases are usually smaller than Avhere there is but a single product of conception, and in after life they are usually marked as " delicate " children; but this is by no means the case in every instance, for twin children are frequently fully and largely developed at birth, and are quite as healthful in after life as are other children. The signs of plural gestation prior to delivery may be regarded as uncertain and unsatisfactory. The disproportionate size of the abdo- men, as compared Avith the period of gestation, Avhich has been ad- vanced as a sign of twin pregnancy, may be due to other causes, such as an excessive quantity of liquor amnii, an unusually large develop- ment of the foetus, dropsy, either ovarian or abdominal, tumors, etc. The appearance of the abdominal tumor as though it Avere divided into halves is equally untrustworthy as a sign, for it may be due to other causes, such as those enumerated above. The only sign that can be regarded as at all reliable is that derivable from auscultation. If two distinct foetal pulsations, not synchronous, can be detected in dif- ferent parts of the abdomen, almost conclusive evidence is afforded of the existence of more than one fcetus. Extra-uterine Pregnancy.—Impregnation is effected within the ovary, as has been described in a preceding chapter. But Avhere the fecundated ovule fails to reach the cavity of the uterus, it may lodge, adhere and become developed in some other place, constituting extra-uterine pregnancy—a very disastrous and happily infrequent ANOMALOUS PREGNANCY. 169 occurrence. Of the causes of this failure to reach the uterine cavity we know but little; the most plausible view being that it is due to a constriction or other morbid condition of the Fallopian tube. Sometimes the impregnated ovule remains in the o\rary and is there developed, constituting ovarian pregnancy. The autopsy of a Avoman dying suddenly has revealed, as the cause of her dissolution, an en- larged ovary rent in twain by a fcetus of four and a half months. Sometimes the ovule is arrested in its progress through the Fallo- pian tube, becomes attached to its walls, and development there pro- gresses. This is called tubarian pregnancy, and is the most frequent form of extra-uterine gestation. The ovum may be arrested in any part of the tube, the Avails of Avhich, becoming distended around the ovum, envelop it in a sort of sac or cyst, In other instances, on account of some abnormality of structure, the ovum slips in between the interstices of the uterine tissue in that part where the Fallopian tube traverses the uterus. This anomaly is termed interstitial pregnancy, and is the rarest of all the forms of mis- placed gestation. OAving to the yielding and distensible character of the uterine walls, gestation may here go on for a longer period than in other abnormal situations, and even exceed full term; but in such cases labor sooner or later sets in, with disastrous consequences to the woman. In some recorded cases of this form of extra-uterine preg- nancy the placenta Avas found to be normally attached Avithin the uterine cavity. In some instances the impregnated ovum either does not enter the Fallopian tube at all, or, having entered it, drops out again and falls into some part of the abdominal cavity, fastens to some portion of the peritoneum and develops there for a longer or shorter period. When the foetus dies shortly after conception in these cases, it may remain Avithin the abdominal cavity in the form of a cyst for years, or an ab- scess may form and discharge either externally or internally. In the latter case this would necessarily result fatally; not so, however, should the contents of the abscess discharge externally, or even into the intes- tines, uterus, bladder or vagina. This form of extra-uterine preg- nancy has been termed ventral or abdominal. The mode of development in these abnormal cases is similar to that m others. Internally, the ovule goes on developing as in normal pregnancies, in the formation of the amnion, chorion, placenta, um- bilical cord, etc. It is doubtful, however, whether a true decidua is formed in these cases, though a substitute for that membrane exists. Externally, to Avhatever point the ovule may become attached, it be- 170 ANOMALOUS PREGNANCY. comes so attached by means of the villi of the chorion groAving into Avhatever structure they are brought into contact with. Simultane- ously Avith this growth on the part of the ovule, the maternal struc- ture grows to correspond and to furnish its part in the reproduction, by growing upon these villi and throwing out blood-vessels to meet those coming from the embryo. Thus the placenta is formed pre- cisely in a similar manner here as in the uterine cavity—only Avith far less present security to the embryo, and Avith almost certain fatal consequences to the mother. After the ovule has thus become fixed in its unnatural bed for de- velopment, its groAvth goes on for a longer or shorter time, according to the strength of the membranes—usually till about the middle of the ordinary term of utero-gestation—sometimes even to the full term. At last, the membranes, from want of sufficient protection, burst and their contents are poured out into the abdominal cavity, and there re- sults a rapidly fatal inflammation of the peritoneum of the ill-fated mother. Sometimes the maternal surface of the placenta becomes ruptured, so as to produce fatal hemorrhage. In other instances the first shock is Avithstood, the contents of the cyst become absorbed or again encysted—as any foreign body may be—and the Avoman not only surviAres, but may even enjoy good health for years. In some cases the foetus itself perishes at about the full term, and makes its exit by means of fistulous openings through the abdominal parietes or other- wise. The diagnosis of these cases will be most easily effected by obser\T- ing that in vaginal examination the os and cervix uteri will be found little, if at all, altered in size, and generally higher than usual. A tumor may also be felt above the vagina, either in the recto-vaginal pouch or on one side of the uterus. This tumor generally pushes the uterus against the pubes or to one side of the pelvis, or draAVS it up into the pelvis almost beyond reach. Little satisfaction is derivable from auscultation, but palpation may reveal the fcetal outlines if the abdominal parietes be sufficiently thin and relaxed. Where the preg- nancy is of the interstitial variety, the uterus will be found irregularly enlarged. Super-Fcetation.—The question as to whether conception can take place while the uterus is carrying the product of a previous con- ception has given rise to a vast amount of argument pro and con. At one time a belief in the possibility of super-fcetation occurring was almost universal; but a careful scrutiny of the so-called facts of the case, together with the plausible arguments advanced in opposition, LABOR. 171 succeeded in engendering an almost universal disbelief in the doctrine. Now, however, there appears to be no bar offered to a belief in the possibility of the occurrence of conception during the earlier months of embryonic life by any anatomical or physiological fact connected with gestation. Dr. MattheAVS Duncan is of the opinion that, Avhile ovulation is suspended during the greater part, if not the whole, of pregnancy, yet there may be exceptions to this rule, particularly dur- ing the earlier months. If, then, ovulation be not suspended, it is of course possible for super-impregnation to take place. It is difficult to understand in the ordinary vieAv of the case how impregnation can occur Avhile the uterine cavity is filled Avith an embryo and the decidua is closely adherent to the inner uterine Avail. Dr. Duncan says that the " decidua refiexa does not become adherent to the decidua vera till after the third month, prior to Avhich sufficient space exists to ad- mit of the passage of the semen, and consequently to allow of a subse- quent conception." This special pleading is not demanded to explain the occurrence of super-fcetation if the views entertained by the writer in regard to the passage of the semen to the ovaries, as laid down in a previous chapter of this work, are taken into consideration. CHAPTER XII. LABOR. T ABOR, or parturition, completes the grand function of reproduc- -*-* tion, and by it, either by nature, by art, or by both conjoined, the new being is ushered forth to assume an independent existence with all other isolated existences. Labor is considered natural Avhen it is accomplished by the unaided poAvers of nature, and unnatural when manual or other assistance is found necessary. Labor is also considered at term when it occurs at about the expiration of the ninth month of utero-gestation, and prema- ture Avhen it occurs at any time betAveen the first part of the seventh month and full term. ProAroked labor is one which has been pro- duced by some mechanical cause, either accidental or designed. A re- tarded labor is one that is delayed beyond nine and a half or ten months of gestation. Premature Labor.—Premature labor may result from a great variety of causes—accidents of any kind, diseases incidental to the 172 LABOR. pregnant condition, etc. For the precautions and remedies to be em- ployed in case of threatened premature labor we refer to the chapter on Abortion. It may be stated here, however, that all Avomen should use extra precautions at about the seArenth month of gestation. In premature labors the first stage is usually longer in proportion than the second, Avhich latter is generally longer than a labor at full term. Also vertex presentations are far less frequent than in natural labor at term, and cross, breech or irregular presentations are much more fre- quent. There is great danger from hemorrhage in premature labors, consequently more need of quiet rest, from the first symptoms and ever after till all danger is past, and so much the more need of care- fully selecting the proper remedy. Retarded Labors.—The ordinary time for gestation is tAvo hun- dred and seventy-five days, but as there are exceptions to all other rules, Ave might naturally conclude they Avould be found here also. Accordingly, investigation has been made, and out of forty-three in- stances of conception after a single coitus, collected by Dr. Reid—all of them resting upon testimony as credible as can be obtained in such cases—of which the average duration of gestation Avas two hundred and seventy-five days—three Avere delivered at the 280th day, two on the 283d day, one each on the 284th and 286th days, tAvo on the 287th, one on the 291st, two on the 293d, and one each on the 296th and 300th days. Natural Labor at Term.—In the study of this subject two orders of facts must be separately considered—the one regarding the physiology of labor on the part of the mother, the other consisting of the movements Avhich the child must execute in order to promote its passage from the uterus through the organs of generation. The former is to be regarded as purely functional, the other as simply mechauical. Let us first consider the subject functionally Avith refer- ence to the vital action of the mother. Causes of Labor.—The causes of labor have been divided into the efficient and the determining causes. The efficient causes are un- questionably the vital energies of the mother, brought to bear in every possible manner upon the child for its expulsion, and at the same time to open up the way as much as possible for its exit. The uterus itself, acting involuntarily, is an agent in the expulsion, aided more or less by the voluntary efforts of the mother, while at the same time an involuntary dilatation is effected of the os uteri, vagina and exter- nal organs. All these processes on the part of the mother are purely functional and involuntary—as much so as are the processes of concep- labor. 173 tion, gestation, digestion, nutrition, etc. The efficient cause of the labor is in fact only the last part of the grand function of reproduc- tion. Hoav important, then, that this most sacred function should not be disturbed by any influences Avhatever, but should be sedulously Avatched over by a careful and skillful homoeopathic physician, ready to administer the proper remedy for Avhatever deviation from the nor- mal condition may occur! Hoav different when the blood is poisoned and the senses stupefied by anaesthetics ; 1ioav impossible then for the mother to give the alarm, or for nature to respond and furnish the symptomatic signs of danger till it is too late! The determining cause may be any influence by which the efficient cause is set in motion. At the full term, Avhen the woman should be delivered, the determining cause becomes spontaneous, the grand func- tion of reproduction is about to be completed ; and here, as in all other vital processes, there is no delay; the work constantly advances till parturition terminates and completes to the very last the great process of reproduction. At the full term, or even a few days before, various kind of accidents, diseases or mechanical means may become the de- termining cause by arousing the efficient cause in the contractive and expulsive action of the uterus; but this function of parturition will not be so safely or so easily accomplished when thus excited by exter- nal influences as Avhen it begins in a perfectly natural and spontaneous manner. As to Avhat it is that immediately excites labor, hoAvever, very little is definitely knoAvn. Various speculations have been indulged in by obstetrical Avriters. By some it has been attributed to the direct ac- tion of the fcetus; others have thought it due to the uterus having attained its utmost limit of distension; Avhile still others have thought that labor sets in at that period at which a menstrual period would have occurred had conception not taken place. Sir James Simpson believed it to be due to the disintegration of the decidua at full term, and a consequent separation between that membrane and the uterus. It is undoubtedly referable to a natural law which at present is not understood or explainable. The Physiology of Labor.—The phenomena of labor may be arranged in three distinct groups or successive stages—the first including the Avhole period from the commencement of the labor to the complete dilatation of the os uteri; the second extending from the dilatation of the os uteri to the expulsion of the child; the third terminating with the final delivery of the placenta. 1. The First Stage.—The approaching termination of gestation is 174 labor. indicated usually by various symptoms cal led precursory or premonitory signs of labor. About the last two weeks a change becomes percep- tible in the form of the abdomen. Its sides become more projecting as the uterine tumor sinks from the region of the stomach and epigas- trium, so that respiration becomes easier and food can be taken with less discomfort. And in many respects the Avoman feels lighter, better and easier. This change results from the cavity of the body and of the neck of the uterus being blended into one by the softening and giving way of the os internum uteri, and by the sinking doAvnward of the uterus, the fundus of Avhich is noAv found to lie midAvay be- tween the ensiform cartilage of the sternum and the umbilicus; at the same time the uterus is projected forward. The calls to urinate now become rather more frequent, owing to increased pressure on the blad- der and its lessened capacity; sleep is more broken by restlessness, and Avalking becomes more difficult. The woman becomes more clumsy, and a little later glairy discharges take place from the vagina, which simply show an increased action of the muciparous glands prepara- tory to the final act of parturition. Finally, the first stage is ushered in by painless contractions, which after a Avhile become someAvhat painful, and finally more and more so. The mucous discharge often becomes more or less tinged Avith blood from the rupture of small vessels about the cervix, due to com- mencing dilatation and separation of the membranes. This, in the parlance of the lying-in chamber, is called a " show." The os uteri dilates more and more Avith every orderly contraction, the parts be- come bathed Avith moisture, and the upper portion of the vagina gradually dilates simultaneously with the os uteri. During this stage the Avoman may walk" about, sit or lie doAvn, as she finds most comfortable. Her respiration is usually continuous with every pain; there may be a sort of shiA^ering-like respiration; at times violent shiArerings and shudderings seize upon her, although she does not feel cold, and she Avonders why it is she shakes so. This shivering is one of the phenomena most usually Avitnessed during an orderly first stage of labor. The pains of this stage of labor are of a "cutting" or "grinding" character, and although they are of shorter duration than those Avhich occur Avhen labor is more advanced, they are, in many Avomen, less easily borne, and give occasion to expressions of impatience. They usually begin in the back, extending around into the abdomen, but are unaccompanied Avith any bearing-doAvn effort on the part of the LABOR. 175 woman. Vomiting sometimes occurs at this stage, but is usually re- garded as a favorable sign. These pains indicate the gradual dilatation of the os uteri. This dilatation of the os is due not only to the pressure dowmvard of the membranes and the presenting part of the foetus, but chiefly, according to Dr. Rigby, to the contraction of the longitudinal fibres of the uterus, which, overcoming the action of the circular fibres, have a tendency by their action to open the os in every direction. This state of things continues for a longer or shorter period until the dilatation of the os uteri is completed, which marks the termination of the first stage of labor. "As a general rule, it may be stated that regular and genuine contractions of the uterus sufficiently powerful to produce pain seldom require more than six hours to effect the full dilatation of the os uteri; in many cases a much shorter time will be sufficient; Avhereas, in others the first stage of labor may last for more than quadruple this period before it is completed; in neither can it be considered abnormal, and Ave usually find that Avhere the pains of the first stage have been slow and lingering, they become remark- ably quick and active during the second stage."—Dr. Rigby. If the hand be placed upon the abdomen during the continuance of a pain, the uterus will be found to be hard and tense, as though it were drawn up into a knot. An examination per vaginam will re- veal a greater or less dilatation of the os, which will be found during a pain to be hard, tight and circular, Avhile the membranes protrude through the aperture, are tense, and communicate a feeling of firmness to the finger, Avhich passes aAvay and they become relaxed again as the pain subsides. Usually in primiparae, at this stage, the os will be found to be high up, Avhile in women who have already borne children it Avill be loAver down and nearer to the pubes. At the same time, if any considerable progress has been made, the vagina will be found to be flaccid and dilatable, hot and moist. II. The Second Stage.—The os uteri is noAV fully dilated, and a marked change takes place in the character of the pains and in the condition and appearance of the patient, Generally at the completion of the first stage, or quite early in the second stage, the membranes are ruptured and a portion of the liquor amnii is discharged. This fluid still farther moistens the parts, and its escape gives rise to a sense of relief to the Avoman, which is very grateful to her. There is quite frequently at this time a suspension of active uterine operations for a longer or shorter period, Avhich likewise adds materially to her com- fort, and gives her an opportunity to gather her strength for the try- 176 LABOR. ing ordeal she has yet to encounter. Soon, however, pains return, and these are of a different character and serve a different purpose from those that preceded them. The efforts of the uterus are increased, the pains are longer, and the intervals between them are shorter; and yet, although there is absolutely greater suffering at this period than during the first stage, the Avoman bears up more heroically and gives less evidence of suffering. This is doubtless due to the fact that her attention is directed to the bearing-doAvn efforts which attend the pains of the second stage of labor. These pains have been termed voluntary, but it is a question Avhether they are entirely so, for there is an undoubted sympathy between the uterus and vagina on the one hand and the muscles of the abdomen and other parts on the other, Avhich gives to them an involuntary or irrestrainable character. To aid this bearing-down or expulsive effort the woman holds her breath, generally grasps something to aid her in bringing into play the necessary muscles of the trunk and extremities, her face becomes red or even dusky-hued, the respiration is quickened, the voice is hoarse, and she replies to questions in a short and spasmodic manner. When this is noticed in a Avoman in labor, it is certain that the second stage has set in and that the os uteri is fully dilated. As the pains come on the presenting part of the fcetus advances, and as they go off it recedes; thus, by this wise provision, the vagina is gradually distended and dilated, acted upon and relieved. An ex- amination per vaginam noAV reveals the disappearance of the os uteri, the cavity of the uterus and the vagina constituting a single channel, in the lower part of Avhich the foetal head is found completely filling up the passage-way. Occasionally the finger will encounter the an- terior lip of the os uteri, for it is sometimes forced down by the ad- vancing head and becomes distended over it. As the pains and the quasi-involuntary muscular efforts continue the head advances more and more, and as it passes along the utero-vagi- nal channel pressure is made on the rectum, the contents of Avhich are expelled, and even a part of the intestine itself in some instances. Finally, the floor of the pelvis is reached, and pressure upon and dis- tension of the perineum and dilatation of the vulva folloAV. The head advances still farther under the operation of the combined mus- cular exertions, the perineum and vulva are distended, while the head of the foetus is moulded to accommodate itself to the channel and outlet, and begins to be extruded through the vulva. Finally, at the moment when the expulsive efforts are at their greatest, and the woman is in a condition of intense mental excitement, the head is LABOR. 177 born. This is usually folloAved by a moment of relief and rest, but frequently the efforts of the uterus are continued, and the child is forced into the world, one shoulder coming out under the pubic arch and the other passing over the floor made by the distended perineum. As soon as the body of the child is born the remaining portion of the liquor amnii, that Avhich was dammed up by the occupancy of the channel by the foetus, is discharged, and the uterus contracts upon itself. This completes the second stage of labor. III. The Third Stage.—After the termination of the second stage of labor in the birth of the child there is usually a lull, as though the uterus Avere resting from its exertions. Soon, hoAvever, there is a return of pain, Avhich is slight and excites no bearing-down effort on the part of the mother. This usually marks the detachment of the placenta and its extrusion into the vagina, or even its expulsion through the vulva. This is commonly followed by a slight gush of blood. The uterus will then be found low down in the pelvic cavity, hard and globular, and contracted to about the size of a foetal head. The subsequent pains—or after-pains, as they are called—serve the im- portant purpose of completing the contraction of the uterus, and by thus closing the mouths of the uterine sinuses, rendered patulous by the detachment of the placenta, preventing hemorrhage which would otherAvise occur. A pain, in labor, signifies the contraction of such muscular fibres as are concerned in giving birth to the child, and the sensation of pain produced in such contractions results from pressure upon the nerves distributed in the tissues, especially of the uterus itself, thus contracting, the forcible distension of the os, and the dilatation of the utero-vaginal channel. The sensation of pain is felt in the back, abdomen and elseAvhere by virtue of reflex action, by which the seat of the pain is located at the central origin of the nerves themselves, rather than at their peripheral terminations. During the entire course of the parturition the child takes no part in its delivery ; it is entirely submissive, as it has been during its entire stay in the uterine cavity; it is entirely neutral and passive, and is expelled entirely by the last act of reproduction on the part of the mother. The more active the muciparous glands in this vital act the more easily is the child brought forth, the abundant glairy discharges rendering the labor a moist one and comparatively easy. Where little or none of this mucus is secreted the labor is called dry, and is con- sequently more painful and tardy. The bag of waters, known as such, is simply the amnion and cho- 12 178 LABOR. rion distended in advance of the presenting part of the child by the bulging of the liquor amnii in consequence of the pain. The Duration of Labor is exceedingly variable—even Avhen no obstacle seems to oppose the delivery—lasting from one hour to a Aveek, and between these two extremes there is every intermediate grade. In general, labor is longer in primiparae than in those Avho have had many children or are nearer the climacteric period of life. As a general rule, the average length of time may be set doAvn at from six to twelve hours. The duration of the labor is expected to be an- nounced as soon as an examination is made per vaginam. But much caution should be used in this matter, for it is discouraging to the patient to overrun the specified time. After the first stage is passed, the second will be two or three times shorter, other things being equal, the diameter of the straits all being normal and there being no undue rigidity of the soft parts. In other cases the time will vary according to the changed conditions. It is, after all, utterly impossible to pre- dict the time of delivery with certainty. The Effect of Labor upon the Mother and Child.—On the part of the mother there is often much despondency at the com- mencement of labor, and during the first stage there is apt to be more or less distress of body and mind—a feeling of despair, as if she could not endure to the end, or a feeling of fretfulness or irritability. But as soon as the second stage sets in the patient nearly always is in better spirits,; she becomes more hopeful and bears her pains, and vol- untarily exerts herself, with greater confidence that she will be deliv- ered all right. She often perspires profusely and becomes much exhausted during labor. The whole process of parturition is apt to be a great shock to the nervous system, and there is danger of great prostration during delivery, similar in effect to that produced in persons sustaining a severe mechanical injury; even a complete col- lapse may sometimes occur. Great care is needed, immediately after the completion of this great event, that the patient get quiet sleep as soon as possible. She should not be allowed to talk, and much less should the accoucheur try to have a little pleasant conversation with her after the labor is over. Such a course cannot be too severely cen- sured, since it may be attended with fatal consequences. A little sleep goes very far toward making all safe. On the part of the child the effect of the labor varies with its severity and its duration; and the shock of the compression of the uterine contractions is more severely felt upon male than upon female children, as before stated. In many cases the sad effects are LABOR. 179 immediate; in others more remote and proportionally more in- jurious. In regard to the force possible to be called into operation during the progress of labor, the experiments and calculations of Professor Haughton are certainly very interesting. He has shown that the ex- pulsive force of the uterus during the first stage of labor in accom- plishing the dilatation of the os amounts to about 3.4 lbs. on the square inch. In addition to this, Dr. Haughton has calculated the force capable of being exerted by the mother in her expulsive efforts to be equal to 38.6 lbs. to the square inch. So that, taking the uterine and abdominal forces together, we have a total of 42.0 lbs. to the square inch as representing the force capable of being exerted in the expulsion of the foetus. It is not to be supposed that this great power is neces- sary, or that it is brought into operation in any stage of labor. The immense power dependent upon the action of the muscles of the woman apart from those of the uterus, is more or less dependent on the will, and hence, it will be perceived, the use of chloroform must interfere Avith labor to the extent that it lessens the power to cause voluntary muscular effort. The Mechanism of Labor. The mechanical phenomena of labor have relation strictly to the child. It is very evident, from the knowledge we possess of the form and mechanism of the pelvis and also of the child, that there must be a mechanical adaptation of the latter to the former, in order that it can be born, and that in order to secure this result there must be certain presentations and positions at the superior strait. Almost any part of the child may present at the superior strait, making almost an infinite variety of presentations, but for all prac- tical purposes it will be sufficient to describe only five; for when the accoucheur recognizes either of these he will be able to deter- mine Avhat, if any, mechanical means may be needed to produce relief. These five presentations are: I. Vertex Presentation; II. Facial Presentation; III. Presentation of the Pelvic Extremity; IV. Pres- entation of the Right Lateral Plane of the Trunk; V. Presentation of the Left Lateral Plane of the Trunk. Each of these five presentations may have one of six positions— as, for instance, in vertex presentations the occiput must lead the way in labor, for it is, as it Avere, one end of the head. Then the occiput is described as being in the left iliac region, anterior, transverse or V 180 LABOR. posterior; or in the right iliac region, anterior, transverse or poste- rior. That is to say, the position is left occipito-iliac anterior, left oc- cipito-iliac transverse or left occipito-iliac posterior, according as the occiput is in the left half of the pelvis and at the ilio-pectineal emi- nence, transversely across the pelvis, or at the sacro-iliac symphysis. And the position is right occipito-iliac anterior, right occipito-iliac transverse or right occipito-iliac posterior, according as the occiput is in the right half of the pelvis and at the ilio-pectineal eminence, trans- A^ersely across the pelvis, or at the sacro-iliac symphysis. In facial presentations the chin would lead. Then the position Avould be styled right mento-iliac anterior, right mento-iliac transverse or right mento-iliac posterior, if the chin Avere in the right half of the pelvis and at the right ilio-pectineal eminence, transversely across the pelvis, or at the sacro-iliac symphysis. And they would be styled the left mento-iliac anterior, left mento-iliac transverse or left mento-iliac posterior, if the chin occupied corresponding positions in the left half of the pelvis. In presentations of the breech the sacrum is regarded as the point determining the position, and the positions are called, according to circumstances, the right sacro-iliac anterior, right sacro-iliac transverse, right sacro-iliac posterior, or left sacro-iliac anterior, left sacro-iliac transverse, left sacro-iliac posterior. In presentations of the trunk, when the right lateral plane presents, the head must be either in the right or the left half of the pelvis, and hence we have the right cephalo-iliac anterior, right cephalo-iliac trans- verse or right cephalo-iliac posterior, and the left cephalo-iliac anterior, left cephalo-iliac transverse or left cephalo-iliac posterior positions. In presentations of the left lateral plane the same terms, according to circumstances, must express the positions with sufficient accuracy for practical purposes. , Each of these presentations will iioav be particu- larly explained. The Vertex Presentation.—This occurs very much more frequently than all the others put together; as, for instance, of twenty-two thou- sand five hundred and thirty-seven carefully observed cases, only eight hundred and fourteen were found to be of any other presentation. And of the vertex presentation the very much larger proportion of cases is found to be in the left occipito-iliac anterior position. This position, which occurs the most frequently, is found to be the most natural of all, and the one by Avhich delivery is most easily accom- plished. The diagnosis of the vertex presentation is made out by feeling a LABOR. Igj large, round, hard, smooth tumor, while examining per vaginam either at the superior strait or descending into the cavity of the' pelvis. The stethoscope will also reveal with much certainty the presentation of the vertex, by the beat of the foetal heart being heard low down in the abdomen. The vertex presentation being made out, it remains to define the position by means of the position of the fon- tanelles and sutures. By carrying the finger a little backward and upAvard on the head the sagittal suture will be encountered, and if it runs from before backward, from left to right, and if the anterior fontanelle is toward the right sacro-iliac symphysis, the position must be left occipito- iliac anterior. But if the anterior fontanelle is found to be at the left ilio-pectineal eminence, the position must be right oftcipito-iliac posterior. Either fontanelle, anterior or posterior, may be ascertained by tracing along on the sagittal suture each way, backward or for- ward. In this manner are all the positions of the vertex presenta- tion ascertained. The mechanism of labor where the position is Avith the occiput in the left half of the pelvis is usually the same in all cases. The occiput being left anterior, transverse or posterior, the contractions having begun and the liquor amnii having partially escaped, the first effect upon the child is to flex the head more perfectly upon the chest, which constitutes the first stage in the mechanism of labor. This has the effect to bring the long diameter of the head in harmony with the axis of the superior strait. The second stage is completed when the head descends into the cavity of the pelvis till its crown presses upon the floor of the pelvis. The third stage and rotation is accomplished from left to right till the progress of the head is arrested by the back of the neck resting upon the symphysis pubis. While the third stage is in progress the shoulders rotate into the long diameter of the supe- rior strait and engage therein. During the fourth stage the shoulders and chest descend to the floor of the pelvis, extension of the head upon the neck takes place, and the head is born by the occiput slip- ping up in front of the symphysis pubis and the perineum retracting from over the forehead, face and chin of the child. (See Fig. 43.) Now the fifth and last stage in the mechanism of labor is accom- plished by the shoulders rotating into the long diameter of the inferior strait, which produces external rotation of the head, and the child is delivered. It will be observed that the external rotation of the head is not an isolated fact, but that it is in consequence of the shoulders rotating 182 LABOR. into the long diameter of the inferior strait, and that this corresponds to the previous rotation of the shoulders into the superior strait sim- ultaneously with the rotation of the long diameter of the head into the inferior strait. The face in these positions ahvays appears on the right thigh of the mother. The right or anterior shoulder is the first to appear in the fissure of the vulva, but the left or posterior shoulder is the first to be set free by means of the perineum retracting from it, and it is thus in reality born first. Fig. 43. In Figure 43 the relative positions of the head are seen in the various degrees of disengagement and extension, the nape of the neck resting first behind and then under the symphysis pubis. The mechanism of labor, the occiput being in the right half of the pelvis, whether it be anterior, transverse or posterior, is all the same usually as that just described. The same stages are passed through, but the rotations are now all from right to left, and consequently the face will appear at the left thigh of the mother instead of the right as in the former case. When the occiput is at the right sacro-iliac sym- physis it should always rotate to the front and appear under the arch of the pubes, precisely the same as when it is at the left sacro-iliac symphysis; which it sometimes fails to do, but slips into the hollow of the sacrum and remains behind till the completion of the labor, when the forehead appears under the arch and the occiput is first dis- engaged at the posterior commissure of the vulva. (See Fig. 44.) It may happen that when the occiput is in the hollow of the sacrum the head becomes gradually extended by the vertex being detained in the sacral depression, and the presentation becomes converted into one of the face. LABOR. 183 Inclined or irregular vertex presentations are usually aided in re- covering a regular presentation by changing the mother's position upon the same side as the inclination; thus, if the sagittal suture is inclining far upon the right side, by turning the patient upon the right side the child's body will fall down upon that side and the inclina- tion will be rectified at once; and if inclined upon the left side, by turning the patient upon that side a similar result will be attained. Fig. 44. In Figure 44 is portrayed the disengagement of the head, it having failed to rotate to the front, as usual, to come under the symphysis pubis. After the birth of the child, if inspection is made at once, it is always easy to tell the position it occupied from the sero-sanguineous tumor upon that part which presented; for the presenting part not being in contact with anything and pressure being made upon all other parts of the child, the fluids are forced into this part; all of Avhich soon subsides after the birth of the child. This sero-san- guineous tumor need not be mistaken for cephalsematonia, for the former exists at birth, the latter does not appear for some hours after; the former is large and purple, the latter smaller, the skin not dis- colored ; it is fluctuating or pulsating and has an osseous border. The sero-sanguineous tumor does not exist if the child perishes long before birth; from which fact a medical jurist can draw an important infer- ence in fixing upon the time of death of a newly-born child. Facial Presentation.—According to standard authorities this pre- sentation occurs about once in three hundred labors. The head, in- stead of being flexed upon the chest, is extended upon the neck, so that the face looks right down into the superior strait. In vertex presentations the occipital end of the long diameter leads the way in parturition; now in facial presentations the other end of the long diameter must lead the way—that is, the chin; of course, then, the 184 LABOR. chin must become the point of departure. Then we have the left mento-iliac, anterior, transverse or posterior; or the right mento-iliac, anterior, transverse or posterior. The cause of this unnatural presentation, except when it is produced by the accidental exchange of other presentations, can only be ac- counted for as the result of some previous conditions of the mother, which may be beyond our power to designate exactly. This presentation of the face is diagnosed by feeling the depression of the eyes, the prominence of the nose, the mouth and the chin, and more especially by feeling the upper and lower gums and the inter- vening tongue. The relate position of the chin will also determine the exact position in this presentation. Mechanism.—As the right mento-iliac transverse position is the most frequent of any of the facial presentations, we will describe the mechanism in this for all the others—since they are similar—only it should be remembered that the rotation will be from right to left, or the reverse, according as the chin is in the right or left iliac regions. After the liquor amnii has been discharged and the expulsive pains begin to operate, the first effect is to produce forced extension of the head upon the trunk, so that every pain has a strong tendency to throw the child's neck backward. (See Figs. 45 and 46.) Descent noAV goes on, the chin leading the way, till its farther progress is ob- structed by the breast coming in contact with the superior strait. Noav, rotation must commence and continue till the chin comes round in front sufficiently for the length of the neck to span the depth of the pelvis, and the chin to pass under the arch. By this time complete descent and rotation have taken place, for the depth of the pelvis is here so shallow as to allow the neck to span it completely, and the croAvn of the head rests upon the floor of the pelvis; and this is the only point at which such a result can be obtained. Flexion now begins to take place slowly around the symphysis as a centre, and finally the chin rises up in front of the symphysis pubis, and the crown of the head descends on the anterior face of the sacrum and coccyx, and is finally disengaged at the posterior commissure of the vulva. (See Fig. 43.) External rotation is effected by the shoulders rotating into the inferior strait. Internal rotation causes the shoulders to place themselves in the long diameter of the superior strait. By no other means can a viable child be born in facial pre- sentations than that rotation shall bring the chin under the arch of the pubis, unless the presentation itself should be changed into one of the vertex or some other. Sometimes this actually does spontan- LABOR. 185 eously take place by the chin, when it is posterior, engaging in the sciatic notch; the progress of the child continuing gradually flexes the head upon the trunk, and the vertex appears under the arch of the pubis, as in original vertex presentations. Inclined or irregular facial presentations—when the chin or one cheek is found in the centre of the superior strait—by continued contractions gradually regain the normal face presentation. Fig. 45. Fig. 46. Figure 45 exhibits the face in the right transverse mento-iliac position, after the forced extension. Figure 46 shows the face in the same position, although more fully engaged. Figure 47 exhibits the passage of the chin under the symphysis, the head descend- ing on the anterior face of the sacrum and coccyx, and the occiput departing more and more from the shoulders. Facial presentations are by no means so safe for mother or child as are those of the vertex, yet in a very large majority of the cases they terminate favorably to both. The position is such that at every con- 186 LABOR. traction the expulsive force upon the child is much diminished by the rolling back of the head upon the spine. Dilatation and rotation are not effected so rapidly on this account, and the child must of course remain, as a general thing, much longer in the pelvis. Presentations of the Pelvic Extremity.—We class as such presenta- tions all those of the feet, knees and breech, since in labor the same mechanism pertains to all alike. In the breech presentation the sacrum forms the point of departure for determining the relative position; the anterior face of the tibia in presentations of the knees; and the heels in footling cases. As in the vertex or face presenta- tions the positions may be left sacro-iliac or right sacro-iliac, and of the anterior, transverse or posterior varieties. Presentations of the breech are much more frequent than those of the face, and very much less frequent than those of the vertex; thus, of sixty thousand four hundred and twenty-tAvo cases reported, two thousand and eighty-two Avere breech presentations. A breech presentation may be recognized, on digital examination, by feeling the cleft between the nates, instead of the sagittal suture as in the vertex; in addition we find in the anus with its sphincter, instead of the fontanelles, a positive and not to be mistaken charac- teristic. The coccyx and sacrum will enable us to decide as to the part of the pelvis they occupy, and consequently to determine the position exactly; when the feet or one foot presents, the heel will enable us to decide as to the position. It must be recollected that a foot is articulated at right angles with the leg, Avhich fact alone will enable us to decide between the hand and foot, since the hand is in a straight line with the arm. The knees seldom present, but when they do it is easy to make them out by recognizing the popliteal spaces. The Mechanism of Breech Presentations.—-The position being the left sacro-iliac anterior, and the membranes ruptured, the first stage is one of descent to the floor of the pelvis, the child's legs, arms and chin being folded in the same position as in the vertex presentation. The next stage is one of internal rotation, where the left hip comes under the arch of the pubes, and at the same time the shoulders are made to come into the long diameter of the superior strait. The next stage is the expulsion of the breech, during which time the child is strongly flexed upon its left lateral border, to correspond to the curve in the excavation of the pelvis. As the breech is delivered the body descends with the arms folded up, and the chest and shoulders rotate into the long diameter of the inferior strait; the long diameter of the LABOR. 187 head passes through that of the superior strait, and finally rotates itself into the long diameter of the inferior strait; and the head is born with the chin still strongly flexed upon the chest, and the back of the neck and occiput under the pubic arch. (See Figures 48, 49 and 50.) Fig. 48. Fig. 49. Figure 48 exhibits the presentation of the breech in the left sacro-iliac anterior position. Figure 49 exhibits the same position after internal rotation is accomplished. Fig. 50. Fig. 51. Figure 50 illustrates the delivery of the breech. Figure 51 exhibits the delivery of the head in the sacro-iliac posterior position. The faint outlines show the successive stages of the flexure of the chin upon the already delivered chest, which may be greatly assisted, if need be, by the pressure of the operator's finger introduced into the child's mouth. 188 LABOR. If the breech is in the right sacro-iliac posterior position, the mech- anism is the same, only rotation occurs from right to left. If the feet appear first, or the knees, the mechanism is still the same as in the former breech positions. Sometimes it occurs that rotation is re- versed, so as to bring the occiput into the hollow of the sacrum, in Avhich case the face will appear under the arch of the pubes, and if the chin remain flexed upon the chest all will go on well. If not, the chin may be flexed by placing a finger in the child's mouth and pulling it doAvnAvard. (See Fig. 51.) Presentations of the feet, knees or breech are more tedious, and con- sequently rather harder for the mother, than are those of the vertex. The largest part escaping first, the smaller quite easily folloAvs; but the smaller escaping first, there is less remaining in the uterus with which to force out the most difficult part. For instance, if all but the head escapes, it often becomes a difficult matter to expel that for Avant of leverage or purchase-power in the uterus itself. The child itself is much safer in vertex presentations. This is true in the first place on account of the cord, Avhich is more likely to be- come compressed and strangulated in breech presentations—an acci- dent from Avhich the child necessarily perishes. For after the breech and abdomen are born up to the navel, the cord must be more or less compressed till after the delivery of the head, since the placental ex- tremity of the cord extends of course far above the head, even to the fundus of the uterus. Another danger to which the child is exposed in breech presentations arises in this manner: the smaller part escap- ing first, the uterus becomes sufficiently emptied to allow the contrac- tions to detach the after-birth before the head is expelled, and the child perishes from asphyxia. Thus, it is evident that it is very much safer for the child to have the head expelled first. It is not safe for the accoucheur to leave a breech presentation, even for a brief period, after the os is well dilated, as it may happen that during an expulsive pain the cord is prolapsed and expelled beyond the vulva. In such a case delivery at once is necessary to save the life of the child. Presentations of the Trunk.—These are all comprised under present- ations of the right lateral plane or of the left lateral plane, either an- terior or posterior. The head is always taken as the point of depart- ure, it being either in the left or in the right half of the pelvis, consti- tuting the left cephalo-iliac anterior or left cephalo-iliac posterior, or the right cephalo-iliac anterior or right cephalo-iliac posterior. In each case the back is either anterior or posterior. It is quite common to find LABOR. 189 the hand or the hand and arm in the A7ulva in either of these posi- tions ; but this is of no account, as it neither alters nor complicates the matter at all. This presentation occurs rather more frequently than do those of the face; many estimates have been made, but a fair aver- age Avould be about one in one hundred and fifty cases. A failure on the part of Nature to place the child in a more auspicious position is the only assignable cause for so unfortunate a condition. The shoulder is usually the first point touched in making a digital examination. The acromion process is distinctly made out, and then the claAricle, the spine of the scapulae and the axillary space, all com- bined and always within reach of the finger, confirm the presentation to a certainty. All these being made out, Ave can tell the position of the child, for the axillary space always looks aAvay from the head, and the clavicle will also tell where the face is, as the scapula Avill tell Avhere is the dorsal region of the child. When the elbow alone is accessible to the finger, it can be recog- nized by three protuberances, the olecranon process and the two con- dyles, and also by the transverse space in the bend of the elboAV, and by the vicinity of the chest and the intercostal spaces, for the arm is always found lying upon the chest. The elbow ahvays points away from the head, and-the forearm is always on the anterior plane; thus we at once know where the head and face are Avhen Ave diagnose an elbow. If the forearm is not doubled up, but lies in the vagina, by turning the palmar surface upward and in front, the thumb Avill ahvays indi- cate which hand it is by its being next to the corresponding thigh of the mother, and then to determine where the head is it Avill be neces- sary to slip the finger up to the axillary space. When the hand comes out of the vulva its dorsal surface will always correspond Avith the direction of the head, and the little finger with the dorsal surface of the child. The presentation of the trunk at the superior strait is ahvays an in- dication for manual treatment. Still, under certain circumstances a spontaneous delivery may take place, and this is effected either by spontaneous version or by spontaneous evolution. Of spontaneous version there are tAvo varieties—one cephalic, the other pelvic. In the former, where the shoulder presents, the trunk ascends under the in- fluence of the uterine contractions and the vertex comes into the supe- rior strait; in the latter the head ascends into the fundus under the same influence, and the trunk comes into the superior strait; and in either case of course a spontaneous delivery is effected. 190 LABOR. Spontaneous Evolution*—" The mechanism of spontaneous evolu- tion is much better understood, and in its description we shall find all the divisions of the mechanism of natural labor in the presentations of the vertex and face. M. Velpeau admits a spontaneous cephalic and a spontaneous pelvic evolution. But since we can conceive of a spontaneous cephalic evolution only in abortions, or in cases where the fcetus is completely putrefied, we shall speak of the pelvic evolu- tion alone. "Take, for example, the first or left cephalo-iliac position of the right shoulder. In this variety we find the cephalic extremity is placed in the left iliac fossa, the breech in the right iliac fossa, the dorsal plane of the foetus being in front, the sternal plane behind; so that its long axis is almost exactly in the direction of the transverse diameter. " Immediately after the rupture of the membranes the waters almost entirely escape; the uterus forcibly contracts, and pressing in every direction upon the trunk of the foetus tends to engage the presenting part in the excavation. " A. Under the influence of the uterine contractions the fcetus in its long axis is strongly flexed upon the side opposite to that which pre- sents ; in the case proposed the head is turned toward the left side and the breech toAvard the hip of the same side. This first change in the situation of the foetus may be designated as the movement of lateral flexion. " B. Then begins a second period, which we may term the period of descent; that is to say, as the contractions are renewed the shoulder tends more and more to approach the inferior strait, and the trunk, bent double, engages itself deeply in the excavation. But here appears the same difficulty as in presentations of the face (see position of the face), that it is impossible for the shoulder—the trunk being thus placed transversely—to reach the inferior strait unless the head at the same time engages with it in the excavation, or unless the neck should be long enough to reach the Avhole length of the lateral wall of the ex- cavation, Avhich AA-e have already seen to be impossible. The descent of the shoulder is governed, then, by the length of the neck. " C. Then follows a movement of rotation, by means of which the long axis of the child, originally transverse, assumes almost exactly an antero-posterior direction, so that the head rests above the hori- zontal ramus of the pubis near its spine, and the breech above, or rather in front of, the sacro-iliac symphysis. The movement of rota- tion being accomplished, that of descent may now be completed, since * Translated from the French of M. Cazeaux. LABOR. 191 the side of the neck is placed behind the symphysis pubis, equaling its Avhole length. Thus the forearm and arm make their appearance at the vulva, the arm and shoulder having passed under the arch of the pubis. " D. Under the powerful efforts of the uterus the trunk, bent double, is pressed into the excavation, but the shoulder can descend no farther, because it is arrested by the shortness of the neck. The expulsive force acts upon the pelvic extremity, forcing it more and more toAvard the floor of the pelvis, and causing it to traverse the anterior face of the sacrum, till finally it reaches, depresses and drives the perineum before it. Presently the vulva dilates, and—the acromion remaining fixed under the symphysis—the superior and lateral portion of the chest, the inferior part, the loins of that side, the hip, the thighs, and finally the whole extent of the lower limbs, success- ively make their appearance at the posterior commissure of the vulva; and the head and left shoulder only remain in the excavation, and these parts are extracted or expelled without difficulty. This last movement may be considered the fourth stage of the labor, and may be named the stage of deflexion or disengagement. This movement has for its centre the shoulder engaged beneath the symphysis; and if from this centre we extend lines to all the points of the side of the foetus, we shall have here the radii which subtend the antero-pos- terior diameter of the inferior strait. " This is, very exactly, the mechanism of the spontaneous evolution in those cases in which the posterior plane of the child Avas primarily in front; that is, in the first position of the right shoulder, and in the second position of the left. For in this latter there is this difference only, that the movement of the rotation must be in the opposite di- rection, that is, the head must turn from the right to the left, and from behind forward; and the breech must, turn from left to right, and from before backAvard. " But where the sternal plane of the foetus is originally turned for- ward—as in the first position of the left shoulder and in the second position of the right—the movement is somewhat different. M. P. Dubois, Avho had an opportunity to see tAvo such cases, states that at the moment of the disengagement of the breech at the anterior perineal commissure the entire trunk of the child experienced a movement of torsion that brought the dorsal plane of the foetus still farther forAvard and upAvard, which, without this movement, would have been directed toAvard the anus. Thus it happens—and we cannot but declare it a very remarkable circumstance—that even here we find 192 THE CARE OF THE WOMAN DURING LABOR. the same general law that Ave have already seen to regulate every natural labor, that whatever may be the primitive situation of the pos- terior plane of the foetus, it ultimately places itself in relation with the anterior parts of the pelvis. " As Avas observed at first, it is easy to submit the mechanism of spontaneous eA^olution to the same divisions as the delivery by the face. We have, in fact, a first period of flexion of the trunk of the fcetus toAvard the side opposite to that which presents; a second one of descent, interrupted by the third movement or stage of rotation; a fourth period of deflexion or disengagement; and according to the ob- servations of M. Dubois for the dorso-posterior positions, we may add a fifth movement, or period of exterior rotation." Such is the account given by M. Cazeaux. Of course no one at the present day Avould think of allowing any of these unnatural pres- entations to continue for the sake of observing a possible spontaneous evolution. Speedy interposition should be instituted for the humane purpose of saving both mother and child. CHAPTER XIII. THE CARE OF THE WOMAN AND OF THE CHILD DURING AND AFTER LABOR. The Care of the Woman During Labor. HEN summoned to attend upon a case of labor, it is better to go provided with a male and a female catheter, a pair of forceps and a blunt hook. Emergencies may arise requiring in haste the use of one or more of these instruments, and no time should be lost in sending for Avhat might so easily be taken in the first instance. A case containing medicines should likewise be taken to meet any emer- gency demanding the exhibition of the appropriate homoeopathic remedy. Before entering the room our arrival should always be announced, that we may not shock our patient by our unexpected entrance. We should take especial care to appear in an easy, unaffected manner; and Ave should have no other thought in our mind than to attend strictly to our business in as agreeable a manner as possible. W THE CARE OF THE WOMAN DURING LABOR. 193 First Ave should inquire into the nature of the pains, with a view to prescribe for any abnormality that may appear in the sufferings of our patient. When this grand function commences, the pregnant Avoman comes into a new physiological state, and if harmony exists throughout her entire organism, her labor will be comparatively free from suffering, and parturition will be accomplished as speedily as is consistent Avith safety. If a want of harmony should exist, symptoms Avill be devel- oped and manifested in some way, by means of which the follower of Hahnemann will be guided to make that selection from the great storehouse of the Materia Medica Avhich shall at once relieve and re- move the disarray and re-establish harmonious action. Anaesthesia should not be resorted to ; oblivion should not be courted at the risk of safety; for the symptoms masked and suffering suppressed, crushed under the ponderous action of chloroform or ether, what guide has the physician to the selection of a remedy for disorder, or to a knoAvledge even that disorder has arisen ? After observing attentively, without seeming to look at the woman, the nature of her pains, we may, Avhen we think it necessary, propose an examination per vaginam, in order to observe the condition of the internal organs, the presentation, etc. This vaginal examination should be conducted in the following manner: The woman should lie on her left side upon a couch or bed, with the thighs drawn up toward the abdomen. The forefinger of the right or left hand of the accoucheur should then be introduced into the vagina, and passed up- ward and backward in a direction toward the promontory of the sacrum, to reach the uterus and detect the os. The finger and even the hand used in making the examination should be anointed with lard or some other innocuous grease, for the double purpose of facili- tating the examination and protecting the hand against possible poisoning. It may not seem out of place to observe that the first object of search Avill be to see if the woman be pregnant, for it has sometimes happened that every preparation has been made for parturition Avhen no pregnancy existed. The Avriter has met Avith such cases Avhere the real facts were not revealed until examination Avas made per vaginam as if to ascertain the presentation. Having, then, determined the existence of pregnancy, AA'hich may be ascertained by noting the condition of the os and cervix, and other signs of pregnancy laid doAvn in a preceding portion of this work, the next thing is to learn if the patient be in labor, or Avhether she 13 194 THE CARE OF THE WOMAN DURING LABOR. have not, instead, certain abdominal or lumbar pains called " false pains." If she be really in labor, we shall find, on retaining the finger in the os uteri during a feAV pains, a rigidity and tenseness of the os accompanying every contraction, and folloAved, after the pain, by a corresponding looseness and state of relaxation. Or if the mem- branes are entire and become tight and firm under the contraction, relaxing as it passes off, the woman is certainly in labor. The next step is to inquire if she is at full term. This inquiry will of course be settled in our own minds affirmatively if Ave find the neck of the uterus absolutely blended or spread out into the globe of the uterus. The internal os will not be felt, the orifice leading to the membranes now being simply that of the os tinea. If the internal os still remains closed or partially so, and the cervix uteri be found still capable of being distinguished, the full term has not arrived; and we must hasten, as in threatened abortion or premature labor, to arrest all further progress by means of quietness and the exhibition of the proper homoeopathic remedy. The accoucheur should determine the position and presentation as early as possible; and if it be one of the usual and natural ones, he has little to do but watch and wait—watch the conditions, note the symptoms, and apply the homoeopathic remedy when needed; and wait for Nature to complete the process she has incepted, in her own best manner. It is Avell to cheer the patient at this period by telling her that "all is right" (if so it really be), as such a communication rarely fails to add to her comfort of mind and her contentment to bear the pangs to come. The next question to determine is, Are the membranes ruptured? And this is not always an easy task, since they are sometimes so closely draAvn over the scalp as to deceive a novice. But during a pain, unless the head has already descended low down in the excava- tion, so much water will be forced down between the membranes and the scalp as to make it quite apparent that the former are still intact. And besides, there is a certain greasy smoothness perceptible in the touch of the unruptured membranes Avhich differs from the sensation experienced in feeling the hairy scalp of the child. Bearing these things in mind, we never need be mistaken if Ave press firmly down upon the scalp, for the rough, hairy condition of the uncovered scalp is never simulated by the unbroken membranes. Next we Avish to determine how far the labor has advanced and what part of the child presents. In primiparae particularly it is not ahvays easy to find the os uteri, for sometimes it is not discoverable THE CARE OF THE AVOMAN DURING LABOR. 195 till we carry the finger far upAvard and backAvard upon the anterior face of the sacrum, nearly up to its promontory. In such cases it may be necessary for the Avoman to lie on her back till the anterior obliquity disappears; and this can be aided by the accoucheur elevat- ing the fundus with one hand applied externally, and with a finger of the other hand in the os to draAV it doAvn. If it now appear that Ave have a timely labor to treat, it will be necessary to provide for it accordingly. Where we can have our choice the Avoman should be placed in a large, airy chamber, exposed to the sunny side of the house, and as much retired as possible, if the above more important points can likewise be secured. The tem- perature of the room should be about sixty-five degrees during labor, about seventy degrees afterward ; the covering should be sufficient for the comfort of the patient. While labor is at its height the covering should be reduced as much as possible, according to existing circum- stances, thus compensating in some degree for the accumulating heat of labor. Bright light should not be permitted to strike the eye, as being liable to induce nervous irritation. Particular care should be taken that the feet are comfortably warm, not alone for the sake of personal comfort, but the pains of labor will be more apt to be natural. A strict adherence to these rules may prevent fatal or at least dangerous accidents, such as hemorrhages, chills, metastases, etc. If the boAvels have not been freely evacuated within twelve hours, she had better take a large injection at once, that no accumulation of feces remain in the rectum. She should noAv be suitably dressed for the occasion. Let her be arrayed in the dress she intends to wear in bed, but so adjusted that it cannot slip down below the Avaist. Next to this let an old sheet or something of the kind be pinned around her, so as to cover all the loAver part of the body, hips and legs. Next the bed must be suitably prepared for its OAvn protection and for the comfort of the patient. An india-rubber sheet about one yard wide should be placed across the middle of the bed upon the mattrass. A clean sheet should now be spread over the Avhole bed. Across the foot of the bed an oil-cloth or another piece of india-rubber a yard Avide should be placed, and this covered with a thick doubling of blanket. The patient should lie upon this, on her left side, with her feet placed against the foot of the bed as a purchase during the expulsive ef- forts of labor. She should lie Avith the breech near the edge of the bed, with her thighs flexed at right angles with her abdomen, and the legs at the same angle Avith the thighs. During the expulsive pains an assistant may hold her hands, or a toAvel may be so attached that she 196 THE CARE OF THE WOMAN DURING LABOR. can assist herself by draAving A\rifh her hands in the direction of the support of her feet. The rule to observe in relation to attendants is to have in ordinary natural labors only the nurse and the doctor. The doctor should be in and out from time to time, as his judgment may dictate. It is better to be absent as much as possible, and keep due surveillance over the case, till toward the close of the labor. In the first stage the woman may make herself as comfortable as she best can by Avalking about, sitting in her chair, or changing from the one to the other. Unless the labor be very protracted, cold Avater or other beverage of a cooling and refreshing nature is the only refreshment required. When the head has commenced descending into the cavity of the pelvis, and the os uteri is fully dilated, the accoucheur should not absent himself from the patient long at a time. It Avill be better for him to take his seat at the patient's bed, in a position to Avatch the appearance of her face, place the finger on the presenting part, mark well its progress, and be ready for any emergency that may arise. Some women are troubled Avith a terrible shhTering during the early part of labor or at its commencement, and sometimes it follows im- mediately afterward, but it is of no account. When it occurs as a first symptom the labor is apt to be quick. No obstetric apothegm carries with it greater Aveight of truthfulness than this, that " meddlesome midwifery is bad" when applied to natural labor. All fingering and manoeuvring, with the hope of bettering the process of nature, is uncalled for and injudicious. Parts that under the severest tax laid upon them by a provision of nature quickly rally to a normal condition and tone, may be seriously in- jured and give rise to much after suffering by being subjected to " manipulation." Interfere judiciously where interference is neces- sary, but trust to Nature where she is sufficient of herself, seeking aid from homoeopathic remedies where aid seems requisite. Women in labor are apt to be frightened at the noise of the rup- ture of the bag of Avaters, so that it is best to forewarn them in time to prevent any alarm. When the labor seems delayed by the tardy discharge of the Avaters, and the os is fully dilated, and yet the head is evidently kept back by something, it is better to rupture the sac during a pain and let the Avaters escape; then the labor will advance much faster. When the membranes are tightly draAvn over the head they can be scratched through by means of the finger-nail, and then they may be torn up each Avay by forcing the finger betAveen them and the scalp. Care should be taken, however, during the examina- THE CARE OF THE CHILD DURING LABOR. 197 tions made in the earlier part of the labor, Avhen the os uteri is not fully dilated, not to rupture the membranes, as such a mischance as the premature discharge of the liquor amnii is apt to render the labor more tedious than it othenvise would be. Sometimes the child is very movable at the superior strait, and several portions present in alternation; in such cases when the head presents the membranes may be ruptured and the head thus caused to engage in the superior strait. Where there is evidently an over- distension of the uterus by excessive amount of liquor amnii, Aveak- ening the contractions, the membranes may be punctured at any time Ave are certain of such a complication. If the membranes should be found to be too dense to be ruptured by the finger-nail, a probe may be introduced into the vagina, carefully guarded by the finger, by means of Avhich a puncture can easily be made during a pain. During the first stage of labor the woman should never bear down, since her strength must be exhausted in making such useless efforts. It is only in the second stage, when the expulsi\re pains occasion a sort of involuntary forcing, that advantage can be taken of this effort, for then only is it useful. Too much voluntary exertion should not be used at the very last, for fear of lacerating the perineum. Nor should a Avoman be alloAved to rise to the chamber near the close of the second stage, for fear of accidents, however much she may desire to eATacuate the bowels, for it is far easier to remove such discharges from the bed than to extricate a new-born child from the chamber, as has sometimes been necessary in such cases. As the head is about to escape from the vulva the accoucheur should bear his right hand upon the perineum, in such a manner as to encircle the labia as much as possible with his thumb and fingers; and Avhile he is draAving doAvn with these upon the labia, he must press gently forward and upward upon the perineum with the palm of the same hand. The Care of the Child during Labor.—Immediately after the expulsion of the head Ave should feel with one finger about the child's neck to ascertain if the cord is around it; if this is the case, a slight elevation of the cord upon the finger will cause the placental extremity to yield; thus the loop Avill become large enough to slip over the head. Should the cord prove too short for this purpose, when the next pain occurs it may still be loosened sufficiently to enable the child to pass through it in safety Avithout becoming stran- gulated. When the head is delh'ered it should be carefully supported and 198 the care of the child during labor. protected from the clots and other discharges from the uterus, the accoucheur patiently waiting for the subsequent contractions of the uterus ,to complete the delivery. The more Ave trust to nature in this respect, the better it Avill be for the mother, and the less Avill she suffer from subsequent hemorrhage and after-pains. No interference should be attempted at this stage unless demanded by the child seem- ing to be in danger of strangulation or apoplexy, Avhich Avill be evi- denced by its face becoming livid, congested and SAvollen. In such cases the child should be delivered at once, even at the risk of hem- orrhage from want of uterine action. Gentle traction may be made by the head; or, better still, if the finger can be passed iip and hooked into the axilla, traction may be made in that Avay. When the occiput remains posteriorly, we should not interfere any more than Avhen it rotates to the front, all the instructions of other accoucheurs to the contrary notAvithstanding. After the expulsion of the child it is better to turn its back to the mother and let her covering fall between the child and herself, thus at the same time bringing the child to our full view and completely protecting the mother from cold or exposure. A soft napkin should now be used to wipe the child's face, eyes and mouth. It usually cries lustily as soon as it is born, but it should be permitted to lie undis- turbed for some five minutes, or until respiration is fully established. By that time, in most cases, the cord will have ceased to pulsate until within three inches and a half of the abdomen. It should then be cut about three inches from the abdomen, care beine: taken that the blood does not spurt over the bed or one's own clothing if pulsation still continues. The child should then be permitted to lie for about five minutes longer, to alloAV the remainder of the effete blood to ooze away—just such quantity as would othenvise have been returned to the placenta. This blood is loaded with effete and noxious material, and on its way to the placenta for such purification as it could there receive Avas arrested in its course, and if permitted to enter into the general circulation of the child, or to lie congested in that part of the cord betAveen the ligature—when applied—and the bifurcation of the iliac arteries, may do great harm to the general health of the child, and I am convinced often does. In one minute the flow from the cord Avill have ceased. For the sake of cleanliness during the Avash- ing of the child, it will be more satisfactory to apply a ligature to the cord after the gush of effete blood has fairly ceased; for in some cases blood continues to ooze for some time, thus keeping the child constantly soih d during washing. The child should then be handed the care of the child during labor. 199 to the nurse, wrapped in a blanket. This may be neatly done by seizing the feet with one hand and placing the other under its shoul- ders and neck, and thus depositing it carefully in its blanket, Avhich should be handily laid for its reception. The mother should not see the newly-born babe until it is washed and dressed. As soon as con- venient it should be washed and rubbed dry. Should the cord seem large and tapering from the abdomen, care should be taken not to wound the intestine, a portion of which may be Avithin it. In such a case the cord should be cut beyond the extruded intestine, and the gut should be returned into the abdomen and retained there by means of the belly-band. After it has been properly Avashed and thoroughly dried, a piece of raAV cotton or cotton batting of the size of the palm of the hand should be laid on the abdomen just above the navel, the remnant of the cord laid on it with its cut end pointing upAArard—the cotton being arranged so as to embrace the base of the cord—and another piece of cotton of the same size placed over the cord, the whole being kept in place by the usual belly-band. So Avell con- vinced am I that this is the best plan of treatment for the navel that I do not think I shall ever change my practice to'go back to old methods. When the breech presents great care should be obsen^ed not to interfere further than to watch the condition of the cord after the lower part of the body is born. We should take hold of the cord Avith the thumb and finger, and draw it down a little to prevent it from being dragged upon at the navel. Then it should be examined to ascertain if pulsation still continues; if not, try to disengage it from compression by slipping it sideAvays or by draAving it a little loAver doAvn; for as long as the cord pulsates there is no danger to the child. But there is danger in this breech presentation of making so much traction upon the child as to pull the body aAAray from the flexion of the head, and thus cause the chin to hang upon the superior strait or to become fixed in the caArity of the pelvis. Great care should be observed till the head has descended into the pelvic cavity, and then, if there is need to hasten delivery, the finger can be intro- duced into the child's mouth, by which means extension may be pre- vented and the child delivered at once. The death of the child in breech presentations is nearly always due to the compression of the cord; therefore when its pulsations are seriously interfered Avith it will be better to make traction upon the loAver extremities during a pain, but with great care; and as soon as the finger can be introduced into the child's mouth a good deal of 200 THE care of the AVOMAN AFTER LAB )R. pressure can be applied to keep the chin down upon the chest, and then almost any amount of force can be exerted upon the shoulders with safety. As already stated, it is better as far as possible to avoid manual interference either with mother or child during labor. The more perfectly Nature can be helped by the use of homoeopathic reme- dies Avhere assistance is required, the better will it be for both parties —much less suffering will be entailed and much better health will be enjoyed in after life. Diet and Regimen of the Woman in Labor.—Cold Avater or lemon- ade is all the refreshment usually required during labor. The use of fermented liquors of any kind should be dispensed with. If the patient is in the habit of taking tea, a small quantity, either cold or warm, Avill sometimes be found very refreshing. A little broth or some other light food may be allowed in case the labor proves tedious, but no spices. It is necessary that the enema should not be forgotten Avhere it may be needed, in order that the rectum may be as free from obstruction as possible, and for other obvious reasons. The patient should be encouraged to evacuate the bladder occasionally during labor, and if there be reason to apprehend an accumulation of urine Avhich she can- not void, the male catheter should be at once employed. Much danger and inconvenience is avoided by such precautions, the over-distended bladder often becoming so paralyzed that the urine cannot be volun- tarily passed for days. Therefore always beware of an over-distended bladder during parturition. After the discharge of the liquor amnii a distended bladder can be detected by the fluctuation betAveen the pubes and the umbilicus. In order to introduce the catheter the patient should lie flat on her back, and the presenting portion of the child should be pressed backAvard and upAvard as much as may be necessary. On the Attentions to the Woman Immediately after Labor. Delivery of the Placenta. After the child has been handed to the nurse the next care of the accoucheur should be for the delivery of the placenta, for until it is removed and the uterus has contracted firmly the woman cannot be regarded as altogether free from the danger of flooding. In most cases there is a momentary suppression of the pains immediately after the expulsion of the child; upon which the pains return in a dimin- ished degree, and the placenta usually becomes entirely detached from its uterine connections, and either lies free in the vagina or is expelled delivery of the placenta. 201 without the vulva. It often happens, hoAvever, that the detachment of the placenta and its extrusion into the vagina folloAvs immediately after the expulsion of the child. If upon introducing the finger into the Angina the insertion of the cord into the placenta can be reached, it may be taken as evidence that the placenta is detached and that it may be extracted. Should the placenta be found to be still attached to the uterus after a delay of about twenty minutes, or should hemor- rhage occur, proper remedies should be administered to promote the expulsion of the placenta, Avhen the hemorrhage will be arrested by the normal contractions of the uterus. This may be aided by apply- ing the palm of the hand to the abdomen immediately over the fun- dus uteri, and making gentle pressure upon that organ as though attempting to clasp it. If the placenta has been detached and is found lying in the vagina, it^ delivery may be facilitated by making gentle traction upon the cord, in a direction toAvard the lower part of the curve of the sacrum, and afterward toAvard the outlet of the vulva, guarding the cord against being ruptured by being drawn over the symphysis pubis. Especial care should always be observed, hoAvever, not to draw too forcibly or too violently upon the cord, for fear of tearing it aAvay from the placental mass. Traction is facilitated by Avrapping the cord several times around the fingers or by enclosing it in a napkin. (See Fig. 52.) Fig. 52. MODE OF EXTRACTING THE PLACENTA. Sometimes the placenta is entirely detached from its uterine adhe- sions but is detained in the mouth of the uterus. In such a case the forefinger should be passed up into the vagina so as to pass above the edge of the placenta; the finger then being hooked into the placenta, it is easily draAvn dowmvard, and aided by traction on the cord is readily delivered. Should the placenta remain attached to the uterus, the question 202 the care of the woman after labor. arises, Should any mechanical measures be resorted to to secure its detachment? According to my personal experience, I should say quite decidedly, No ! The placenta may remain attached for hours without doing any actual harm to the Avoman. Such cases should be carefully Avatched, the indicated remedy selected and administered, and the result is usually a speedy detachment and expulsion of the mass. Cases must be very rare, indeed, in which other means than the above need to be resorted to. Friction over the uterus or pressure upon that organ may bring about uterine contractions and the expulsion of the placenta, but if the end can be secured through homoeopathic medicines it must be much more satisfactory. Nevertheless, should there be hemor- rhage—which may result from a partial adhesion—which we cannot control, we must not wait till our patient is hopelessly sacrificed, but after relying upon the selected remedy as long as Ave may feel safe in doing so, the hand should be introduced into the uterus and the at- tempt carefully made to insinuate the fingers between the placenta and the uterus until the placenta'is, if possible, entirely separated from the uterine surface (see Fig. 53), Avhen it should be carefully scooped out. Fig. 53. THE MODE OF BREAKING UP THE ADHESIONS OF THE PLACENTA. Sometimes the placenta is found to be retained by a spasmodic con- traction of the neck of the womb, so that it is impossible to extract it until this spasm has abated. Sometimes, again, and more frequently, Ave find what is called the hour-glass contraction, as shoAvn in Fig. 54. Other abnormal contractions may occur Avhich Avill render utterly impossible the delivery of the placenta until the proper remedy ha? been giA'en to relieve the morbid irritability which gave rise to the abnormity. All these anomalies have a vital origin, and Ave have only to interpret rightly the symptoms Avhich they present, exhibit the corresponding remedy, and the whole difficulty Avill be removed. the care of the woman after labor. 203 The remedies most usually appropriate for these occasions will be mentioned in the therapeutical portion of this Avork. Fig. 54. THE HOUR-GLASS CONTRACTION OF THE WOMB. When some portions of the placenta are retained and cannot be removed, Ave must treat the symptoms as they arise, and thereby ward off any danger that may accrue from putrid absorption. When any difficulty appears in relation to the delivery of the pla- centa, Ave should ahvays examine through the abdominal walls in order to ascertain Avhether the uterus presents its regular globular form, or whether there may not be a depression in its fundus, shoAv- ing a tendency to inversion; for it sometimes occurs that a complete inversion takes place in this manner. If a tendency in this direction be discovered, and if a remedy can- not be found Avhich will cause a return of the uterus to its natural condition, the hand must be used for this purpose. If there be discovered already a complete inversion, Avith the placenta attached, the latter should first be peeled off, and the uterus returned by seizing it with both hands and very carefully and steadily pressing it upward and backAvard until Avithin the vulva; then with one hand press it gently upAvard, and finally upward and forAvard. " An unfailing test by which we may judge Avhen the placenta has become detached from the uterus, and consequently when it may be removed, even though still in the uterine cavity, is the presence or ab- sence of pulsation in the cord, for Avhile it remains attached to the Uterus pulsation Avill still be felt; the cord Avill also be full and elastic under pressure betAveen the finger and thumb. When, hoAve\Ter, sepa- 204 THE care of the woman after labor. ration has taken place, the elasticity and fullness disappear, the cord gets flabby, limp and cold, and no pulsation can now be detected in it."—Meadows. When the placenta finally begins to emerge from the vulva it should be received into the palm of the left hand, and rotated with the right hand, in order to secure the twisting up and removal with it of the membranous shreds, since even a small portion left behind may occasion serious annoyance to the patient, even if it does not give rise to more serious complications. When any shred thus left behind aftenvard appears at the A^ulva, it may be removed by being seized Avith a dry napkin and extracted. The placenta, with its cord and attached membranes, should then be placed in a vessel conveniently placed to receive it, and removed from the lying-in chamber as soon thereafter as possible. Other Attentions to the Woman.—The woman should then be made comfortably dry, and a soft dry cloth should be applied to the vulva. She should then be straightened out a little in bed, and in all respects made as comfortable as possible. No bandage should be ap- plied. Since this doctrine is so entirely opposite to the usual practice, it Avill be proper to state the reasons which have led to the adoption of this method. First: It Avill be evident, from a moment's consider- ation of the natural position of the fundus uteri, inclining forward, that the application of a bandage could not but change this position, so as to render the uterus itself nearly perpendicular to the plane of the superior strait. This must of course bring the uterus into a line Avith the axis of the superior strait; this position must evidently be more favorable to prolapsus, and it may even lead to retroversion. Second: The great object intended to be secured by the bandage is to promote the contraction of the parietes of the abdomen, both for the safety of the patient and for the symmetry of her form. Now, avo believe not only that this is better accomplished by Nature in her own way, uninterfered Avith by mechanical and compulsory appliances, but that such appliances actually Aveaken the Avails of the abdomen, and so in reality tend to defeat the very object sought to be secured. Third: The omission of the bandage, as we have found by much experience, by allowing free circulation in the adjacent parts and avoiding unnatural compression of the peritoneum and uterus, in many cases removes much of the danger from peritoneal inflam- mation, and greatly facilitates the speedy recovery of the patient. There is also less liability to prolapse of the Avomb occurring after the woman gets about, or of leucorrhoeal discharge. An abundant THE CARE OF THE WOMAN AFTER LABOR. 205 personal experience of the superiority of this non-use of the bandage or binder since the first edition of this work appeared, coupled A\nth the assertions to the same purport of numerous medical men in all parts of the country who have adopted it, warrant me in emphasizing the direction above given. The mother should be enjoined to remain perfectly passive, and she should not be subjected to a disturbing influence of any kind. A pleasant chat Avith the patient after "all is safely over" is very enti- cing, and apt to be indulged in by the nurse and friends, and some- times even by the physician ; but too much cannot be said against this most cruel and injudicious practice, and it is almost impossible to calculate the amount of mischief that has been done by a deviation from the rule enjoined. It is to be remembered that the mother has just emerged from a condition of the highest mental and physical excitation, and if this be borne in mind the necessity for perfect pas- sivity becomes at once apparent, The room should be darkened somewhat moTe than during parturition, and talking and Avhispering should not be allowed. Perfect quietude should be maintained, if possible, in order that she may sleep, AA'hich will prove very advan- tageous and refreshing. Additional covering should at once be ap- plied, and if she desires water she should be allowed to have it in plentiful quantities. After an hour or tAvo, when she may have thus rested, the nurse may safely proceed to place her in bed by gently moving her up to her position, rolling the soiled clothes up into a lump and removing them. Thus the patient will be at the same time ren- dered neat and comfortable, her clean clothes being brought doAvn from her Avaist as the others are removed, and her loAver limbs made dry and Avarm. The nurse Avill, of course, understand her duty of keeping the patient clean and comfortable by constant attention to the lochia and in other respects; but the physician should exercise the greatest care in seeing to it that the nurse does her duty fullv in this particular, as very serious complications have arisen solely through the carelessness of nurses in not giving proper attention to cleanliness. If all goes perfectly Avell with the patient, there is no need to resort to medicinal means. A dose of arnica may be given, however in case the woman complains greatly of soreness or a bruised feeling resulting either from the extrusion of the child or from the general muscular effort incidental to parturition. The accoucheur should not leave his patient for at least a half hour after the birth of the child, until he is assured that there is no danger of subsequent flooding. 206 THE CARE OF THE AVOMAN AFTER LABOR. He should carefully note the patient's pulse, Avateh her countenance Avithout exciting observation, and be governed accordingly. The relief experienced immediately after parturition is in a great majority of cases truly remarkable; according to her own expression, the patient feels " as though she Avere in heaven." Afterward, it is no uncommon occurrence, hoAvever, for the patient to be seized Avith a shivering or chattering of the teeth. With the addition of a little covering this soon passes off; she begins to feel a gloAV of heat, her skin becomes moist, and there is no more trouble. After a little sleep—which, as already suggested, she should seek to obtain as soon as possible—she seems to recover from the shock of delivery and once more appears in a natural, healthy condition. The Avoman should be visited again within from twelve to twenty- four hours. At this visit the folloAving points demand attention: First. The condition of the pulse. Second. The condition of the bladder and Avhether urine has been voided or not. Third. The degree of uterine pain or abdominal tenderness. Fourth. The cha- racter of the lochia. The general condition of the patient, the pres- ence or absence of headache, and Avhether she has had a nap or not, are likewise matters of importance to be ascertained. The pulse of the lying-in Avoman should not reach a hundred beats per minute. If it goes beyond that number there is something Avrong, and if it greatly exceeds one hundred, rising to one hundred and twenty or higher, adwe measures will be necessary to secure a restoration to health. These active measures will consist in the prompt adminis- tration of the appropriate and homoeopathic remedy; and it is some- times almost marvelous Avith Avhat benignity and with what prompti- tude the remedy thus selected acts in restoring the lost equilibrium of the system. If no 'inclination to urinate has been felt, the bladder is probably ^emi-paralyzed and needs help to resume its proper function. This help it Avill get from arsenicum, causticum or hyosciamus, accord- ing to the indications for each, as given elsewhere. All other de- rangements from the line of the true physiological lying-in state should be met Avith the proper homoeopathic remedy. At this second \'isit directions may be given for having the child applied to the breast, should all be going on well. This procedure not only serves to stimulate the mammary glands into action, but it fur- thers the neee.-sary uterine contractions. Dr. Rigby advises that the child should be applied to the breast very shortly after delivery. He says: " Even if the child sucks fairly well for only five minutes, we THE CARE OF THE WOMAN AFTER LABOR. 207 feel satisfied, for Ave cannot call to mind a single case of hemorrhao-e after the effects of this operation." There does not seem any necessity, hoAvever, for subjecting the mother in her weakened and exhausted condition at this early period to what must of necessity in most cases prove an annoyance. Unless spontaneously mo\%l, the patient's bowels should not in any way be disturbed for eight or nine days. The custom—formerly much more general than noAv in allopathic practice—of giving a pur- gative on the second or third day after confinement, is exceedingly pernicious, and sometimes gives rise to very serious consequences. Until after the secretion of milk has been well established the diet should be very simple and the room should continue to be well shaded. During convalescence, commencing after the secretion of the lacteal fluid has been Avell established, the diet may be made more generous in both meats and vegetables (eggs, oysters and fish being strictly pro- hibited), and the light of day should be allowed to enter the chamber freely, rejoicing the Avoman's sight and strengthening her in every way. The bed-covering and her OAvn clothing should provide a sufficient degree of Avarmth, and yet be so light as not to be burdensome. Heavy, close and thick material not only weighs down and swelters her, but prevents the carrying off of the effluvia arising chiefly from the profuse transpiration of the effete material, so desirable to be got rid of at this period. Let the accoucheur, at a subsequent visit, turn down the covering in cases Avhere he finds the patient heavily blank- eted, and the heat and stench escaping from the bed will suggest to him its occupancy by some offensive carrion, rather than by a living human being, and perhaps by two—the mother and her child. Can it be wondered at if such cases make a sIoav recovery ? The room should be ventilated every day, the thermometer never rising above 70° Fahr. The patient should be allowed plenty of pure cold Avater to drink, and her lavements should be sufficient for clean- liness, but always performed under cover. The feet should be sponged almost daily, one foot at a time, which should be rubbed perfectly drv and covered before the other foot is touched. The water for external use should be tepid, and free from alcohol, bay rum, cologne or any- thing of that kind. The patient's clothing and the bed-linen should be changed fre- quently, having been previously Avell aired before a hot fire in an- other room than the lying-in chamber. For two Aveeks she should keep the recumbent posture, using a bed-pan when required, changing frequently from one side of the bed to the other to rest herself and 208 THE CARE OF THE AVOMAN AFTER LABOR. permit the vacated side to be shaken up and prepared for her return to it Avith increased satisfaction; or she may be transferred to another bed or a lounge for a feAV hours daily after the first few days. At the end of the third Aveek she will be the stronger and better for hav- ing spent the first two weeks in a recumbent posture. Physicians should be particular in urging this point, as very much of the comfort, health and happiness of a Avoman's after life depends on the care >he takes of herself during convalescence after parturition. After the second Aveek, other things being equal, the woman may take a sitz-bath, the water being at a temperature of 65° or 70° Fahr. While sitting in the tub, water may be poured over her shoulders and washed doAAm for a few moments, Avhich should then be rubbed dry and covered Avhile the limbs are being Avashed and rubbed dry. The process being completed, she should go at once to bed. In no case should she go out immcdicdely after a bath. Extra caution must be observed in bathing in cold Aveather. During the third Aveek she may drive out in fine Aveather—in cold weather during the fourth Aveek, other things being equal. During the entire nursing period the diet should be plain and sim- ple, but abundant and nourishing. All abnormal conditions should be carefully attended to and the proper remedy given. The room of a lying-in Avoman should be light and airy, and Avhen the proper time comes she should walk out every day in the air and sun Avhen the weather is suitable, riding being entirely insufficient. The underclothing should not in any instance be allowed to hang upon the hips, but should be suspended from the shoulders. No Avoman can hope to remain Avell Avho allows the weight of her skirts to drag upon her hips and loins, and complaints of great magnitude may arise from this apparently trivial cause. If a Avoman should feel Aveak " after she gets about the house," she should not be recommended or permitted to fly to stimulants of any kind for relief, but the physician, being consulted, should seek the ap- propriate remedy, Avhieh may be found under the laAV of the similars. The After-Pains and the Lochia. The uterus by alternations of contraction and repose gradually re- turns after parturition from its enormous distension to its natural size. Its complete restoration in size and position generally occupies about six weeks. Sometimes, on the contrary, it suddenly grows larger from some abnormal condition, and may be felt rolling from side to side as the patient turns in bed. This condition need excite no alarm the care of the woman after labor. 209 —since the uterus will soon subside to its normal size—except in some few instances in Avhich it still remains large, with a sensation of bounding as if it contained a foetus; in such cases a dose of crocus will soon set all things to rights. As the uterus regains its normal size, the new mucous membrane becomes completed, and the spot from Avhich the placenta was peeled off is also supplied Avith a new mucous membrane by a process of granulation. As the uterus returns to its normal state the vagina also groAvs shorter, its transverse rugae return, and in the course of six Aveeks it is in all respects as before pregnancy, except that the subA^aginal por- tions of the neck may be more or less permanently shortened on ac- count of the extreme stretching upward during gestation. The uterus and vagina return to their usual condition by virtue of the elasticity of their tissues, and where this is sufficient the process is unattended with pain. But if necessary, organic contractility is also brought to aid, and this is always attended with more or less pain, constituting what are called the after-pains. During all this time a discharge from the vagina is taking place?__ first of pure blood for a day or two, which groAvs paler and paler till finally it appears as a sero-purulent liquid, often of a pinkish color; then it becomes lighter, watery, and at last entirely disappears. This discharge is called the lochia. The After-Pains. Of the after-pains it is proper to state more particularly that they are really the organic contractions of the uterine fibres, where the elasticity of the general uterine tissue is insufficient to expel the liquids with which the walls of the uterus are engorged, or the clots or shreds of membrane which are contained Avithin its cavity. When they make their appearance at all—which is sometimes not the case—these pains usually come on soon after delivery, and continue with greater or less severity from two to eight days. Fluids o.r coagula, in greater or less quantity, are discharged with each pain. It is very important to diagnose between the after-pains and those which indicate the acces- sion of puerperal inflammation; but this is an easy thing to do, since the former contract the uterus, while the latter do not, and in the former case there is usually considerable abdominal tenderness, which increases, Avhile in the latter this is absent. After-pains are commonly absent in primiparae, but almost always present in a greater or less degree in multipara?. They are generally salutary, as before remarked, but sometimes they become excessive, 14 210 the care of the woman after LABOR. unbearable, and give rise to distressing accompanying symptoms. When they assume this character, they should be checked by the ad- ministration of the appropriate remedy as laid down under its proper heading in the portion of this work devoted to therapeutics. The Lochia. The lochia constitute the discharge from the genital organs which commences soon after the expulsion of the placenta, and continues until the complete restoration of the uterus to its normal condition. This discharge results from the disgorgement of the uterus in its return to its usual size, and it is principally derived from that por- tion of the uterine surface to which the placenta had been adherent. During the first twenty-four hours the lochial discharge is quite san- guineous, and sufficient in quantity to soil ten or twelve napkins. After the first few hours this discharge gradually becomes less and less, as it passes through its four or five successive stages: first, san- guineous ; second, serous; third, milky; fourth, puriform: and when it has nearly subsided it is not an uncommon occurrence for it to freshen up and assume a pinkish hue, and then, resuming the appear- ance of a delicate, limpid pus, rapidly disappear. In about six days after parturition the sanguineous discharge should disappear entirely, and in two or three weeks more the patient should be completely Avell. In severe cases the lochia will cease sometimes earlier, sometimes later, either as a natural consequence of the attend- ant conditions or as an exception merely to the general rule; and in all such variations the accompanying sensations and conditions of the patient will indicate the treatment. During the milk fever the lochial discharge lessens or ceases en- tirely, and returns more abundantly as the fever subsides. In quan- tity this discharge varies in different individuals; some have very little, others have much ; in either case no interference is necessary, unless symptoms arise which shoAv that the unusual quantity results from some abnormal state. The lochia has a peculiar odor, differ- ing in individuals both in character and intensity. The presence of even a small shred of the membranes, Avhich may have become detached and left behind in delivering the placenta, may render the lochial discharge exceedingly offensive. In all cases the fetid nature of the discharge, or any other deviation from its normal character, will go far to indicate the proper remedy for the general morbid con- dition of which this peculiarity is one of the evidences. Throughout the lying-in period the condition of the lochia, if treatment of the child after birth. 211 abnormal, forms one of the surest and soundest indications for treat- ment. The selected remedy must always cover the condition here manifested. Every day the physician should inquire of the nurse as to the state of this discharge, and the first abnormal condition should place him on his guard against other serious disturbances which may result. We should always be watchful for the beginning of mischief, but this one of abnormality of the lochia should be especially guarded against, since it is ATery apt to be overlooked till a late hour. In such cases all the symptoms should be carefully collated and the remedy selected in accordance, but it must always cover the abnormal condi- tion of the lochia. In the treatment of cases in which there is derangement of the lochial discharge such medicines should be carefully studied as are recommended elseAvhere. Hygiene and Treatment of the Child immediately after its Birth. After the cord has been cut and the child has been given to the nurse, it should be Avashed and dressed as soon as may be convenient. Some unctuous matter, such as lard or oil, should be rubbed into all those places covered Avith the caseusa, which latter will then be entirely removed upon being Avashed Avith tepid or warm water and soap. The navel should then be dressed as directed on page 199, and the belly-band applied; then may be added the diaper, the shirt, the flannel petticoat and the outer dress or slip. This constitutes the babe's dress for the bed; Avhen it is taken up it should also have a shaAvl or blanket proA^ided for that purpose, to be laid aside upon its return to the bed. During the process of washing and dressing—which should be conducted Avith as much expedition as possible—the child usually becomes quite cold and blue. It should therefore be quickly placed in bed and covered to that degree that warmth will soon return. At his daily visits the physician should observe that the infant is not smothered Avhile lying in bed, but has an opportunity of breathing like other human beings. Its pilloAV should not be more than two inches and a half thick, and it should be made of hair, untufted, so that it may be pulled apart and made light and airy every feAV hours. Should the child be troubled with retention of urine, aconite will be the remedy most likely to afford relief. (See Dysuria.) If the meconium does not pass off naturally, mercurius, nux v., bryonia or Pulsatilla may be resorted to. (See Constipation.) The child is not ahvays born in so healthy a condition as to be ca- 212 TREATMENT OF THE CHILD AFTER BIRTH. pable of undergoing promptly the treatment above described. Some- times it comes into the world in a state of apparent death. This condition, may result from three distinct classes of causes, and may present corresponding differences in the appearance of the child. I. Apparent death of the child may result from shock to its ner- vous system in general, or from some special lesion of a particular portion of it. In the former class may be instanced the severe com- pression Avhich the brain undergoes in certain cases of contracted pelvis, and from the application of the forceps under difficult circum- stances, especially in the superior strait; in the latter class may be instanced the still more serious lesions of the medulla oblongata which may result from extreme rotation of the head, from undue traction upon the head after it is delivered, or from too much force applied to the body in order to delh'er the head still detained Avithin the pelvis. This latter is one of the most frequent causes of the fatality so commonly attendant upon breech presentations. The injury to the brain, not necessarily preventing respiration, may pass away and the life of the child still be preserved. Such, liOA\e\Ter, is not the case with serious lesion of the medulla oblongata, Avhich renders respiration impossible. HoAvever, as it may not be knoAvn that such injury exists—unless the child's neck should have been distorted by some remarkable ATiolence—every case of apparent death in the neAv-born babe should be treated as if there Avere a possibility of recovery. II. Injuries of the placental circulation may have been the cause of the apparent death of the child. These may ATariously arise from compression of the umbilical cord between the sides of the pelvis and the head or body of the child; from winding of the cord so tightly around the neck as to obstruct the circulation in the umbilical vessels; from the premature separation of the placenta, Avhich may occur in cases of delivery by the breech Avhen all but the head has been delivered, or from great retraction of the uterus itself Avhen only the head remains Avithin it, such retraction preventing the admis- sion of fresh blood into the uterine sinuses in sufficient quantity to supply the child. By either of these causes a real asphyxia may be produced. A similar condition may result from" such an accumulation of mucus in the nose and mouth as Avill prevent the introduction of air into the bronchia. In addition to the breathlessness this condition will be indicated by discoloration of the skin, Avhich may exhibit a violet or blackish-blue color; the muscles are motionless, the limbs flexible and the body warm; but the pulsations of the cord, of the treatment of the child after birth. 213 radial artery, and even those of the heart, are faint or impercep- tible. III. Lesions of the foetal circulation constitute a no less dangerous class of causes of apparent death. These may consist in rupture of the placenta or of the umbilical cord, which affects the life of the child while yet unborn; or if the hemorrhage should be arrested in any way before proceeding to so fatal an extent, the child may be born alive, but in a state of syncope. In these cases the child is very pale, the muscles are relaxed; it may make a feAv short respirations and utter some feeble cries, but unless saved by the administration of the proper remedy, it soon perishes. Treatment.—From Avhatever cause the apparent death or suspended animation of the child should result, no time should be lost in making proper efforts to establish respiration. In cases Avhere the breathing is simply deficient, and there is not a complete suspension of animation, one or the other of the folloAving remedies may be administered in accordance Avith the given indications: Aconite.—The child is hot, purple-hued, pulseless and breathless, or nearly so. Belladonna.—The face is very red and the eyeballs are greatly injected. China.—In cases Avhere profuse hemorrhage has been the apparent cause. Tartar Emetic—When the child is pale and breathless, although the cord still pulsate-. Camphor a may be given a feAv minutes after tartar emetic, if the latter shouW fail. If the child does not soon respond to internal remedies, or in cases of so grave a nature that it is apparent that these remedies can have no effect, it should be immersed suddenly in very cold water, or, better still, cold water, even iced water, should be poured over it. In some pale and apparently lifeless children pouring cold water upon the head and allowing it to run down over the body establishes the circulation and respiration ; the child should then be at once Avrapped in Avoolen blankets until quite restored. Of course in all those cases Avhere respiration is prevented by an accumulation of mucus in the nose and mouth these obstructions should be at once removed. Any or all of the above methods failing, artificial respiration should at once be resorted to by either Marshall Hall's or Sylvester's methods, Avhich are so Avell known that they need not be described here; or the lungs may be filled directly from the accoucheur's lungs, by his closing 214 TREATMENT OF THE CHILD AFTER BIRTH. the child's nostrils betAveen the thumb and forefinger of his hand, ap- plying his mouth accurately to the mouth of the child, bloAving air into the child's lungs, and, Avhen filled, by gradually and carefully compressing the thoracic Avails, emptying the lungs again. This manoeuvre shall be repeated again, not oftener than from ten to fifteen times in a minute. This artificial respiration, and all other methods resorted to to restore suspended animation, should be persevered in for some time, life having returned after even an hour had elapsed, from judicious and continued treatment. Secretion of the Milk. This function is one of the most interesting and at the same time one of the most remarkable of the phenomena transpiring during the lying-in period. While the child is still in utero the maternal prin- ciple and all that pertains to the mother unite to effect its nourish- ment, growth and development there. Suddenly all this is inter- rupted : the child is expelled from the little Avorld Avithin, and has to find nourishment elsewhere. It is supplied as before from the mater- nal blood through the medium of the mammary glands. The reac- tion upon the organism from this change from the uterus to the breasts causes what is called the milk fever, in consequence of Avhich there results a disturbance in the system more or less well marked according to the obstacles to be overcome. Hence appear chills, fevers, headaches and a great variety of pains and sufferings; even intermittent fevers are sometimes developed in consequence of this great physical change. Some women appear to have milk before the babe is born or at its birth, but this is not the real milk, since it is devoid of the true milk- globules, and is called colostrum. The change already referred to has yet to be made, and presently the real milk comes, exhibiting the true, full and plump milk-globules. The quantity of milk varies greatly; in some Avomen it is quite scanty but rich in quality, while in others it is poor in quality but abundant in quantity. Every woman in a perfectly healthy state Avill yield nourishment enough for her own babe, and when this is not the case remedial agents must be administered to bring about this much- to-be-desired result, for no child can possibly do so Avell as Avhen sup- plied with its own maternal aliment. As a general thing, all the dis- turbances incident to the coming of the milk are less when the child is applied to the breast as soon after delivery as practicable. Much advantage is gained both to the mother and babe by this method, DYSTOCIA. 215 since it serves to lessen the suffering of the one from hunger and the danger of the other from fever. When the fcetus perishes near the full term the child is still carried for a while—it may be till term. In general no milk secretes in such cases, certainly not till after the delivery of the dead child. At no time should the milk flow from the breasts except when drawn. In those cases in which it is constantly flowing spontane- ously remedies should be sought to remove the abnormality. In order to relieve the disorders incident to lactation Ave should always rely upon homoeopathic medicines. No bathing or even rub- bing of the breasts should be resorted to. Rubbing the breasts in in order to " rub out lumps" often bruises the breasts and lays the foundation for abscesses. External applications are altogether un- necessary. The remedies to be given for these varied disorders Avill be pointed out under an appropriate heading in the latter part of this work. (See Disorders of Lactation.) CHAPTER XIV. DYSTOCIA. BY dystocia is meant unnatural, " laborious, morbid or difficult labor." Labor does not always take place in what may be re- garded as a truly normal manner. It may become, by a combination of circumstances, difficult, dangerous, and even impossible. In such cases the intervention of art is demanded. These circumstances are exceedingly various and numerous, and they give rise to three dis- tinct classes of difficult labor, viz.: 1. "Those rendered difficult, dan- gerous or impossible by a defect or an excess in the action of the ex- pulsive forces. 2. Those rendered difficult, dangerous or impossible by obstacles to the expulsion of the foetus. 3. Those complicated by accidents liable to endanger the life or health of the mother and child." * In respect to the first of these classes, it should be observed that the pelvis, as Avell as the organs of generation, may be perfectly natural, and the diameters of the child may all be in harmony Avith the pas- sage, and yet the expulsive force may be wonderfully deficient, and at length may cease to act entirely. In deciding on the duration of * Cazeaux. 216 DYSTOCIA. labor, it may be adopted as a general rule that where more than twenty-four hours have elapsed since its commencement serious acci- dents may be feared either to the mother or child, and these should be anticipated by removing the cause of the excessive slowness. The fact Avhich requires particular attention in the prognosis is, that the period of dilatation of the cervix is to that of the expulsion as two or three to one. Noav, the delay may occur either in the first or the second of these stages. The first stage may be prolonged Avithout danger either to the mother or the child unless there be hemorrhage or convulsions, but Avhen the second stage, or the period of expulsion, is extended beyond ten or tAvelve hours, the uterine pains may become irregular in their return and intensity, and the foetus seem to retro- grade rather than advance—there is no expulsion. The condition of the patient at this crisis is thus described by Cazeaux: " The local disorder is accompanied, or at least soon followed, by a violent trembling; the patient has an inclination to vomit, and even throws up bilious matters; she is uneasy, excited and changes her position every moment; the skin is hot and dry , the pulse runs up to a hundred or a hundred and fifty per minute the tongue is dry, and both it and the teeth are covered with a dark coating. The vagina and cervix are hot and sensitive to the touch, and a yellowish liquid escapes from them, which occasionally has a fetid odor; the pressure of the child's head on the cervix vesicae prevents the emis- sion of urine, and the parts that line the superior strait and the pel- vic excavation being compressed for a long time by the head, may become inflamed or even gangrenous, which complications may sub- sequently prove a source of the most serious accidents. " If the Avoman still remains undelivered, these symptoms increase in intensity in a frightful manner; the vomitings become more fre- quent and the abdomen more distended; the excitability of the patient knoAvs no bounds; the pulse is more and more feeble and frequent, and she falls into a half-stupid or a semi-delirious condi- tion, Avhich is soon terminated by death. It is scarcely necessary to remark that in the latter case the life of the child is also most seriously compromised." There are numerous causes Avhich may operate to bring about this condition, some of Avhich are vital, Avhile others are mechanical. Among the former may be mentioned general debility, plethora of the uterus, inflammation of the uterus, mental emotions, various dis- eases, etc.; among the latter, over-distension of the uterus by an excess of liquor amnii, too early rupture of the membranes, etc. DYSTOCIA. 217 When the cause appears to be a vital one, the pains, too Aveak from the first, groAv Aveaker, are irregular or cease entirely, the appropriate homoeopathic remedy will almost always bring about a normal con- dition, and labor Avill go on to its completion in a proper manner. The medicines to be resorted to under these circumstances will be mentioned, together Avith their indications, in a subsequent chapter. A Avoman Avho has had a difficult labor from deficiency of uterine action in consequence of some general disease, such as gout, rheuma- tism, disorder of the digestive organs, etc., and has again become pregnant, should be very carefully treated during pregnancy, that the cause may be abated or removed, in which case she will not be apt to have a return of the uterine atony when she is again taken in childbed. Mechanical Causes of Dystocia.—Over-distension of the Uterus from Excess of the Liquor Amnii.—Cases of this kind can be recog- nized from the fact that the membranes do not bulge into the mouth of the uterus as it dilates; during the contractions the membranes are felt to be tense and to retain the globular form of the uterus. In this case the only plan of relief and of rendering the pains efficacious is to rupture the membranes, which may be readily done by plunging the finger through them during a uterine contraction. Premature Rupture of the Membranes.—In cases of this kind the early escape of a small portion of liquor amnii allows the head to descend upon the undilated mouth of the uterus, so as to hinder the escape of any more of that fluid, and of course it is all retained in the fundus above the child. The contractions gain nothing by forcing out more fluid either through the ruptured membranes or by causing the bulging of a pouch; consequently, the pains are liable to become more and more feeble. The mode of action noAv to be adopted is to introduce a finger and in the absence of a pain raise the head and hold it up during a pain, Avhen the liquor amnii will escape freely. Repeat this process, if necessary, again and again, and the pains Avill strengthen rapidly. Sometimes the child's head becomes engaged in the loAver segment of the membranes and they fit close to it, and there is no opportunity for the membranes to bulge through the os, the consequence of Avhich is that the liquor amnii is all retained above the body of the child and in the fundus of the uterus. In this case the membranes must be stretched through and the head eleA^ated, in the absence of a pain, and held there until the next pain, when the Avaters will gush out and the pains Avill gain in strength. This process may be repeated again and again if necessary, and the pains will become more and more effective. 218 DYSTOCIA. Impaired action of the abdominal muscles, occasioned by the exist- ence of some disease, such as asthma, pneumonia or dropsy, may like- wise be the cause of difficult or retarded labor. In such cases, should it become evident that nature is entirely unequal to the task of emp- tying the uterus, resort must be had to mechanical means for effecting deliA'ery. The pains may be rendered inefficacious from an over-distended bladder, the reflex from Avhich painful condition will cause the uterine contractions to cease. This may be determined by the history of the patient's case, and by great sensitiveness of the bladder when pressed, or by a dullness on percussion if she has not voided urine for a long time. In this case a catheter must be used, the male being preferred, for obvious reasons. A loaded rectum may have the same effect as the bladder in the state above described, in Avhich case it must be washed out with injections. In precipitate labor the chief danger lies in a liability to the rup- ture of the uterus from too poAverful contractions, or of the vagina or perineum. The umbilical cord may be torn asunder by the child falling on the floor, or the child may receive other injuries consequent on sudden and violent action. Some women are always troubled with too rapid labors, and, knowing from experience Avhat to expect, should adapt themselves to this condition by preserving a recumbent posture from the first pain, and restraining themselA/es as much as possible. In some cases the disposition to too slow or to too rapid labor seems to descend hereditarily from mother to daughter. The treatment of precipitate labor is usually unsatisfactory, inas- much as it generally occurs in the absence of the accoucheur. Should, however, the accoucheur be present, and the force and rapidity of the pains be in excess of what may be regarded safe, they may be miti- gated by the administration of coffea, secale, belladonna, conium, nux vomica or chamomilla. The patient should likeAvise be cautioned to refrain from expulsive efforts. Dystocia from Malformation of the Pelvis. We next come to the second group of causes Avhich render labors difficult, dangerous or impossible. The causes are mechanical, and refer themseh^es to the mother or the child. We shall first treat of those Avhich depend on the mother, and the first of these which Ave shall notice are the malformations of the pelvis. A pelvis is malformed, in the sense in which Ave here use the word, when it too greatly ex- ceeds or falls short of the average size. Excess of amplitude or of dystocia. 219 retraction, too great size or narrowness, are productive of notable obstacles in the exercise of the child-bearing function. If the ampli- tude is too great the Avoman is exposed to serious accidents in all the three states, the non-gravid, the pregnant and the parturient. In the non-gravid, because the uterus, being free and movable in an over-spacious cavity, is much more liable to the various displacements of descent, anteversion and retroversion. In the pregnant, because " during gestation the Avomb, finding more space than usual in the pelvic cavity, remains there until a much more advanced period of pregnancy, and the volume of the organ, by com- pressing the rectum and the bladder, often occasions an excessive tenesmus in these parts, Avhich proves very distressing to the patient; sometimes even the discharge of the urine and fecal matters is im- peded ; besides Avhich varices, hemorrhoidal tumors, and a considerable infiltration of the lower parts are found to be developed in conse- quence of the mechanical obstacle to the circulation of the inferior extremities."* In the parturient state, because during labor the too great amplitude of the pelvis exposes the patient to all the dangers resulting from a too rapid delivery, which we do not propose to treat of here. A woman subject to this malformation should be kept in the recumbent posture during labor, and she should be instructed not to aid the pains in any Avay, and not to bear doAvn until the os uteri is fully dilated; and even then as little voluntary effort should be made as possible. But the most terrible deformities of the pelvis are those arising from its contractions; for it must at once be obvious that a just pro- portion must exist between the dimensions of the canal and those of the body Avhich is to traverse it, and that where this relation does not hold, either through the contraction of the pelvis or the abnormal size of the child, delivery by any natural process becomes impossible. The contractions of the pelvis, according to Velpeau, are either absolute or relative—absolute when, although greatly retracted in all its dimensions, it notwithstanding is properly formed and presents no irregularity in its exterior aspect; relative, Avhen only one or more of its diameters is affected by the contraction (the others preserving, or very nearly so, their normal length), and the form is completely changed by this partial alteration. The last group of contracted pehres —viz., the relative—is the only one Avhich Avill engage our attention in this place. This deformity is referred by M. Dubois to one of three principal types—viz., either to a flattening from before backward, * Cazeaux. 220 DYSTOCIA. to a compression on the sides or to the depression of the anterior and lateral parts. The flattening from before backward, or shortening of the antero- posterior diameter, results from a more or less marked approximation of the anterior and posterior pelvic Avails; and of this species of mal- formation there are several varieties, all resulting from the extent of contraction either in height or Avidth. An example of this kind is presented when the superior strait alone is contracted, the excavation retaining its normal capacity. This phenomenon is due to an unusual curvature of the sacrum, Avhich sometimes makes an obtuse angle at A PELVIS IN WHICH THE CONTRACTION OF THE SACRO-PUBIC DIAMETER IS PRODUCED BY THE UNCSUAL PROMINENCE OP THE SACRO-VERTEBRAL ANGLE. its middle part, so that the sacro-vertebral angle is increased to an unusual degree. Sometimes the reverse happens, and the sacrum, instead of affording an anterior cavity, is quite plane, or even convex in front, and then the antero-posterior diameter of the excavation is contracted simultaneously Avith that of the superior strait, and the sacrum seems to lose its natural curvature and project forward in its whole length. Sometimes the shortening of the antero-posterior diameter of the superior strait is accompanied by an enlargement of the corresponding one at the inferior strait. This indeed is the arrangement most usu- ally met with, and this is Avhat generally happens Avhen the sacrum, yielding to the Aveight of the trunk, transmitted to it by the spinal column, tilts—that is, projects forward its base—Avhile pushing back- Avard its coccygeal extremity. Sometimes the coccy-pubic and the sacro-pubic diameters are short- ened at the same time. This happens Avhen the sacrum, instead of DYSTOCIA. 221 performing the tilting movement just mentioned, yields in such a way that its tAvo extremities are thrown fonvard, and two consequences are the result of this action—viz., the anterior curvature is greatly Fig. 56. THE SHAPE OF THE SUPERIOR STRAIT IN THE FIGURE-OF-EIGHT PELVIS. increased, and there is an enlargement of the corresponding diameter of the excavation. Another case of pelvic contraction is thus described by Cazeaux: " In the approximation of the antero-posterior Avails the sacrum is nearly always the displaced bone; but, although much more rare, a flattening of the anterior Avail is also met Avith, and then the sym- physis pubis, instead of presenting a convexity in front, is perfectly flat, or even (as in one instance represented by Madame Boivin) pre- sents a depression, Avhich seems to protrude inwardly toAvard the prominence of the sacrum. This double inclination of the pubis and sacrum toAvard each other gives to the superior strait the form of a figure of eight—that is, its plane is divided into two rounded portions on the sides, corresponding to the iliac fossse, and is separated in the middle by a restricted part of variable Avidth. If the depression is considerable, the antero-posterior diameter of both straits and of the excavation must evidently be affected by it." Or again, the extent of the symphysis pubis may be much greater in its vertical direction than usual, giving rise to Avhat is termed the bar pelvis, or it may have an excessive inclination backward at its lower end; in both these cases the pelvis is narrowed. Sometimes the coccyx is elongated, and it takes a nearly horizontal direction. This, as Avell as an immobility of the sacro-coccygeal articulation, may, it is alleged, contribute to the shortening of the coccy-pubic diameter. Compression of the lateral walls, by Avhich the transverse diameter is shortened, is the rarest of all pelvic malformations—that is, so far as the superior strait and upper part of the excavation are concerned. As regards the inferior strait, the approximation of the two ischial 222 DYSTOCIA. tuberosities, by which this species of deformity is produced, is quite as frequent as the shortening of the coccy-pubic diameter. The pubic arch, in this case, assumes the triangular form peculiar to the male sex. Moreover, the inAvard projection of the spines of the ischia mav produce a sensible diminution of the lower part of the excavation in the transverse direction. "Another variety of transverse contraction is OAving to the fact of the pelvis being less developed in one of its halves than in the other, and consequently to its exhibiting a less degree of curvature in that part than upon the opposite side. In this case the articulation of the spine with the sacrum no longer corresponds to the middle of the pelvis, and the A^ertebral column is found nearer to the hip of the con- tracted side; the transverse diameter is likeAvise diminished at the in- ferior strait by reason of the obliquity of the entering part of the coxal bone. The antagonism before alluded to as existing between the an- tero-posterior diameters of the superior and the inferior straits, Avhereby the elongation of one most frequently coincides with a shortening of the other, rarely exists in the transverse direction ; the deformity pro- duced by a congenital displacement of the femurs is probably the only condition in which the transverse diameter of the inferior strait aug- ments at the same time that the bis-iliac one diminishes, the en- largement in the lower part of the pelvis in this instance being marked by an unusual Avidth in the pubic arch, a great obliquity of the ischio-pubic ramus, a separation of the ischial tuberosities, etc."— Cazeaux. Depression of the Antero-hderal Walls.—The effect of this depres- sion is the diminution of the oblique diameters. It occurs more fre- quently than the preceding, but not so frequently as the first variety. The essential characteristic of this deformity is the flattening or the inward projection of the coxal bone at the part corresponding to the cotyloid cavity and the junction of its three constituent pieces, where- by the curve described by the pelvic circumference is more or less diminished, even Avhen carried to a high degree to the reversal of the curvature, its convexity being turned toward the sacrum, and the pubis pushes almost directly forward, the coxal bones assuming the form of an italic S, instead of presenting a regular arch. We next proceed to describe the oblique-oval pelvis, a malforma- tion produced by an arrest of development on the part of one lateral half of the pelvis, Avhile the other maintains its normal condition. The effect of this, as will readily be seen, is to throw the symphysis pubis to one side of the mesial line of the body, while the sacrum seems to DYSTOCIA. 223 be on the other side. The consequence of this is, that the cavity of the pelvis will be oval, and will occupy one or the other lateral half. A very rare form of pelvic deformity is the funnel-shaped pelvis, in Fig. 57. A PELVIS IN WHICH THE SINKING IN OF THE ANTERO-LATERAL WALLS EXISTS ON BOTH SIDES. which, Avhile the brim is normal, the cavity and outlet are contracted gradually from above downward in all diameters. Fig. 58. K FIGURE TAKEN FROM M. NAEGELE's WORK, WHICH EXHIBITS THE CHARACTERS OF THE OBLIQUE-OVAL PELVIS IN A HIGH DEGREE. The influence of these deformities on the pregnant state is rather un- favorable, from the fact that in the latter half of pregnancy the gravid uterus is not so easily and safely supported, and in the earlier period it is often more easily displaced, or it more slowly rises above the superior strait. These and other similar circumstances have a con- stant tendency to produce abortion or premature labor. It is of the utmost importance that distortion of the pelvis be de- 224 DYSTOCIA. tected as early as possible. Naegelk gives the folloAving conditions as presumptive evidence of the existence of malformation : " The lower jaAV projects beyond the upper, the chin is very prominent, the teeth are grooA^ed transversely, unhealthy appearance, ashy-pale color of the face, diminutive stature, unsteady gait; Avhen the Avoman Avalk> the chest is held back, the abdomen projects, and the arms hang be- hind ; there is deformity of the spine and breast, one hip is higher than the other, the joints of the hands and feet are remarkaBly thick ; curvature of the extremities, especially the inferior, even Avithout dis- tortion of the spine, is a very important sign; wherever the lower ex- tremities are curved the pelvis is mostly deformed. It is well to ascertain also if, Avhen a child, it Avas a long time before she could Avalk alone; Avhether she had any fall on the sacrum; whether, as a girl, she Avas made to carry heavy Aveights or to work in manufac- tories." If, in making an examination per vaginam, the top of the sacrum can be reached Avith the index finger, there is good reason for believ- ing that there is deformity at the brim of the pelvis; Avhich may be the case elsewhere, however. But it does not folloAV that because the top of the sacrum cannot be thus reached there is no deformity. If the deformity exist at the brim, and is great, the fcetal head cannot engage in the inferior strait; but the brim may be normal and the deformity may exist in the cavity, in which case the head may enter the cavity and be unable to proceed farther ; or, again, the outlet alone may be deformed, in which case it is obvious that the head may de- scend to the outlet, and then remain fixed until extricated through mechanical measures. In regard to deformity at the brim, Dr. Rigby Avrites: " Besides the general appearance of the patient, Ave frequently find that the uterine contractions are very irregular; that they haATe but little effect in dilating the os uteri; the head does not descend against it, but remains high up; it shoAvs no disposition to enter the pelvic cavity, and rests upon the symphysis pubis, against Avhich it presses very firmly, being pushed fonvard by the promontory of the sacrum." A great variety of circumstances are to be taken into consideration in regard to the course to be pursued by the accoucheur Avhere he meets with pelvic deformities during labor; for it must be evident that unaided nature is able to do very much more in some cases than in others; and in addition to this, the period of pregnancy at Avhich labor takes place, the size of the child's head, its compressibility and its degree of ossification, the presentation, etc., should all receive due DYSTOCIA. 225 consideration before resorting to any measures to effect delivery by artificial means. It is a good rule, and one that holds good in a very large majority of cases of this kind, to give nature a fair chance to effect expulsion unaided. At the same time it should be borne in mind that there is great danger in waiting until symptoms either of exhaustion of the vital forces or of powerless labor have shown them- selves. The mode of treatment Avhere cases of deformity occur does not differ in the first stage from that pursued in the case of well-formed women. Where the os uteri is sufficiently dilated or dilatable, so as to permit the escape of the head, the experienced accoucheur, by a careful comparison of the presenting part with the passage, will be able to decide on the possibility of a spontaneous delivery. When the vertex presents itself, sufficient time should be allowed for its engagement, descent and final expulsion. The contractions should be supported by means of such remedies as the case may seem to require. But should no advancement be perceptible, the forceps may- be applied and extraction effected if possible; but if there is no reasonable hope of delivery by this means, craniotomy must be re- sorted to. And should the distortion of the pelvis be so great that even craniotomy would not avail, the Cesarean section must of neces- sity be resorted to. When the pelvic extremity presents, the same rules apply as in natural labor; but if the deformity is too great to allow a sponta- neous expulsion, the blunt-hook must be used, as hereafter to be described. When the body is in the act of being delivered, intro- duce as soon as possible the index finger into the mouth of the child and force the chin down upon the sternum as much as possible Avhilst traction is being made upon the shoulders. In this way the longest diameter of the head will be made to occupy the shortest possible space in the pelvis. If then it is not found possible to deliver the head, the forceps must be applied. When the face presents an effort should be made to convert it into a vertex presentation, as described hereafter; and then, if necessary, apply the forceps. Every effort should be made to change the face presentation to one of the vertex, as it would greatly increase the chance of the child's life, afford relief to the mother and contribute to our satisfaction. When the child presents by the trunk, an effort should always be made to convert this into a presentation of the vertex; and if we discover that one part of the deformed cavity is broader than any other, the occipital diameter should be directed to that part as much 226 DYSTOCIA. as possible. If the labor has already continued so long as to make it impossible to bring the vertex into the superior strait, the foot must be seized and the malpresentation converted into one of the breech, Avhen we may proceed as in all breech presentations. It may be stated m general terms that if there be an antero-poste- rior diameter of not less than three and one-fourth inches, the forceps may be successfully used. If this diameter, however, should be less than the above, the forceps Avould not be likely to avail, and if it should be very much less, their use would be altogether out of the question. With an antero-posterior diameter ranging between three and one- fourth inches doAvn to tAvo and one-half inches, it is possible that by turning and bringing the lower part of the wedge that the foetal head forms—according to Sir James Simpson and Tyler Smith—down first, the thicker part of the head may be extracted. If this diameter should be less than two and one-half inches, but should exceed one and three-fourths, craniotomy is available, and may be resorted to with a good hope of success; but craniotomy need hardly be performed with a smaller antero-posterior diameter than one and three-fourths inches, and in such cases the Csesarean section alone remains. It is to be borne in mind, hoAvever, as before remarked, that much more may be done by nature in some cases of pelvic deformity than in others. If we could secure a full knowledge of the existence and the extent of pelvic deformity before gestation has gone on to the full term, it is obvious that a resort to the Caesarean section and craniotomy could be prevented by inducing premature labor. To determine the existence and extent of pelvic deformity has led to the invention of a great variety of instruments, termed pelvimeters, for the purpose of measuring these deformities. French accoucheurs have been especially prolific of these inventions, some of which are quite complicated and apparently useless. A very simple instrument, the invention of an English practitioner, Dr. Greenhalgh, is thus des- cribed : " It is intended for measuring internally the antero-poste- rior diameter at the brim. The principle of the instrument is to assist the finger in measuring this diameter. It consists of a band of flexible metal one inch broad, Avhich forms a ring. This band en- circles the hand, passing across the centre of the palm, the size of the ring being adapted to different-sized hands by a piece of elastic india- rubber webbing. On the surface of the band, corresponding with the centre of the palm of the hand, is a projecting pivot perforated so DYSTOCIA. 227 as to allow a small metal rod to traverse it. The rod is seven and a half inches long, graduated along its central third; at its distal ex- tremity it is bent at right angles into a form which admits of its gliding along the index or examining finger. It is to be thus used : The right hand having the instrument fitted to it, the forefinger or two first fingers are to be introduced so as to reach the sacral promontory. The curved extremity of the rod lies noAv on the radial side of the index finger. The promontory having been reached, the rod is draAvn outward until the ring-shaped extremity is arrested against the arch of the pubis. The distance at which the rod is thus stopped is shown in the index, and Avhen the hand is withdrawn, the antero-posterior diameter of the pelvis can be obtained by measuring the length be- tween the end of the finger and the extremity of the rod." If the hand alone be employed, the tip of the index finger should be made to touch the promontory of the sacrum, and the distance from that point to the posterior surface of the pubes can be estimated, although no very accurate measurement can be taken in this way. Or, again, the index and second finger may be introduced, and while the palmar surface of the index finger is placed against the pubes, the second finger may be stretched across toward the sacral prominence and an effort made to touch it. Yet a third plan is to introduce the four fingers within the cavity of the pelvis, and place them on a line between the pubes and the sacrum. The necessity of overlapping these fingers or extending them to fill up the space, will give a fair idea of this diameter. The greater the deformity the more readily is it made out, and hence Avhen there is great difficulty in ascertaining the existence and the extent of the malformation, in skillful hands, it may be accepted as negative evidence of a favorable character. Causes of Pelvic Deformities. We now pass to the causes and mode of production of the pelvic deformities. For a long time these, together Avith other deformities of the skeleton, Avere referred to a single cause—viz., rachitis—but modern researches have clearly proved that the pelvis may be de- formed in the absence of rachitis, and from purely mechanical causes, operating at a time Avhen, on account of tender age or feebleness of constitution, they could meet but little resistance. From this view of the causes which produce changes in the form of the pelvis, we might collect deformed peh^es into three groups—viz., (1) Those which are deformed from a softening of the bones, either by rachitis or mollities ossiura; (2) Those deformed in consequence of a previous deformity 228 DYSTOCIA. of some other part of the skeleton; (3) Those deformed by absolute narrowness. (1) The Pelvis deformed by Rachitis or Mollifies ossium,—These two diseases, however differing from each other, yet produce the same result—viz., they soften the osseous tissue and thereby weaken its poAver of resistance. But the mere fact of softening the bones, and their consequent Aveakness, is not of itself sufficient to account for the various deformities presented by the pelvis; for it is very evident that the bones, unless reduced to a gelatinous state, would maintain their general conformation unless acted on by some external force, for rachitis diminishes the solidity of the bones, but does not of itself produce any alteration of shape. This exterior force may be looked for in the muscular action, and still oftener in the Aveight of the parts which the pelvis has to support; for the pelvis, interposed between the spine Avhich it supports and the loAver extremities on Avhich it rests, is most favorably conditioned for the action of deformity. The weight of the trunk in its erect position being transmitted from the lumbar vertebrse to the heads of the femurs in the direction of two lines intersecting the sides of the superior strait, evidently tends to increase the curvature of the posterior part of the ilium, and to depress the osseous circle of the pelvic cavity. In this A\ray the sacrum receives a tendency, by almost insensible degrees, to push forward. By considering the action of the pubic bones under this pressure we may see how it is that the superior strait is oftener affected by the contractions of the pelvis than other parts, and Avhy at this strait the antero-posterior and oblique diameters and the sacro-cotyloid inter- vals are more frequently contracted than the transverse ones. When the Aveight acts more particularly on one side of the pelvis, the collapse is more marked in that direction, because in this case a change in the centre of gravity takes place from the inclination of the spine; and there is also a very unequal pressure of the Aveight of the body on the two sides of the pelvis, where, on account of a difference of length in the loAver extremities, one of the coxal bones is more depressed than the other. In this Avay the acetabulum of one side is throAvn almost directly under the sacrum, and at the same time receives the weight very obliquely. The customary attitude of the individual and the nature of her occupations must be taken into account in con- sidering the irregularity of figure in the pelvis. Sometimes there is a complete fusion of the sacrum and ilium, and the sacro-iliac articulation on the contracted side disappears. We simply state this fact without attempting any explanation of it. DYSTOCIA. 229 In estimating the respective influences of mollities ossium and rachi- tis on the bony tissue, the distinctive characteristics of each should be carefully noted. Mollities ossium affects all parts of the skeleton indifferently, and it occurs in the adult only. The softening pro- duced by this disease is very distinctly marked, and the most consid- erable retractions must be referred to it Rachitis affects the bones of the loAver extremities and ascends gradually to the upper parts; it proceeds from below upAvard, so that a deformity of any part by rachitis almost necessarily implies a deformity below. It is peculiar to infancy, and its effects on the skeleton are twofold—it softens the bones and it arrests their development; and as this arrest of develop- ment particularly affects the loAver extremities, it is a necessary con- sequence that the ossa innominata should be much less developed in those subject to this disease than in others, and the limits of the pelvic cavity more or less contracted by it. It is here that Ave may see the difference again between rachitis and mollities ossium, or rachitis adultorum, as it is sometimes called; for the first, exerting its influence at an early age of the patient, at a period when the pelvis has not yet reached its full development, permanently arrests the groAvth of this part of the skeleton; but the last, not occurring until after puberty, at a time Avhen the ossa innominata have reached their full development, may soften the bones, but can- not arrest their groAvth. Moreover, the development and growth of the bones of the skeleton are not only arrested absolutely by rachitis, but their growth is retarded, even after a cure has been effected, dur- ing the Avhole term of development. (2) The Pelvis deformed in consequence of a previous Deformity ofso-me other part of the Skeleton,—These deformities are: (a) Deviations of the Vertebral Column.—Rachitis is not the only cause of this deformity. It is now admitted that several other dis- eases may produce abnormal curvatures in this column. It is thus we establish a line of distinction between those deviations which nearly ahvays attend pelvic malformations and those which often exist Avhen the pelvis is Avell formed. The form'er must be referred to rachitis, the latter to some other affection. The shape and direc- tion of the pelvis are subject to the influences of other deviations of the spine than those Avhich depend on rickets, but it is only in sub- jects of an advanced age that cun'atures occurring after the age of infancy exert an influence of this kind. Curvatures produced by rickets, even when not the essential cause of deformity in the pelvis, heighten the degree of contraction and affect the shape of the pelvis. 230 DYSTOCIA. The aged and the young are alike affected by the spinal deviation, but the effects are brought about more rapidly Avith the young than with the old. The malformation is more or less similar to that de- scribed under the name of the oblique oval pelvis. (b) Congenital Luxations.—These may cause an arrest of develop- ment and subsequent pelvic deformity. (c) Non-congenital Luxations.—A luxation remaining unreduced, and which occurred early in life, is sufficient cause for an atrophy of the iliac bone corresponding to the dislocated femur ; and it is evident that the malformation of the pelvis will be proportionately great as the luxation occurred at an early age. (d) Lesions of the Inferior Extremities.—The curvatures of the lower limbs do not always diminish in length equally, and the pres- sure which they make on the bottom of the cotyloid cavities is not the same for both sides; the consequence of this is that the pelvis may be affected on that side where the pressure is the greater. The loAver extremities may often be curved without injury to the pelvis, provided they maintain the same length, and where they are unequal in length there must result pelvic deformity. The pelvis may be deformed by a shortening of one of the legs from any cause, particularly if the accident occur in early life, when the pelvis is but partially developed. Where one leg is affected Avith chronic disease, and the person is obliged to use crutches, bearing the Avhole length of the body on one leg, or where the thigh has been amputated in early childhood, the pelvis is in either case liable to deformity. (3) Pelvis Deformed by Absolute Narrowness.—The most generally accepted opinion on this topic is, " that we have no positive data con- cerning the causes that give rise to the general narrowing of the pelvis; and that such pelves, as Avell as unusually large ones, should rather be considered as a freak of nature, belonging to the same cate- gory as a want of proportion in the head, which is not unfrequently found too large or too small relatively to the rest of the body." The practitioner of homoeopathy should bear in mind, in consider- ing these various pelvic deformities and their proximate or remote causes, that a majority of them commence very early in life—some of them perhaps even before birth—and that they are due to a morbific influence which lies even beyond the apparent causa occasionalis, per- haps beyond our ken. But, taking into consideration the gravity of these cases on the one hand, and the wonderful efficacv of homoeopathic medicine on the other, it becomes a solemn duty of the practitioner, DYSTOCIA. 231 in treating such cases in infancy or childhood, to spare no efforts to bring about a complete effacement of the dyscrasia, if such it be, that has given rise to the abnormal manifestation, as Avell as a removal of that local manifestation itself. The so called " antipsorica" of Hahnemann act with a benignity almost divine in the various forms of scrofula, and by affecting a radical cure through their instrument- ality in these cases, not only is present good done, but prospective suffering and even death in childbed may be averted. Dystocia from Malformations of the Vulva, Vagina and Uterus. Adhesions of the vulva may occur, hindering the expulsion of the child. In a case of this kind it is only necessary to divide the adhering portion with the scalpel at the moment that the presenting part is pressing down upon the adhesion, if the pressure of the pre- senting part is not of itself sufficient to break up the adhesion. The hymen also may be so persistent as to hinder the expulsion; this also should be divided Avith the scalpel if it does not give Avay under the repeated manual examinations or from the pressure of the presenting part. Contractions and rigidity of the vulva quite frequently delay the expulsion very much, but I have never found it necessary to operate in cases of this kind. Aconite most usually, or some other remedy, has aided the dilatation, and a little patience has always sufficed, and I believe always Avill suffice, in such cases. Rigid perineum.—Remarkable cases of resistance on the part of the perineum are met with when the labor has been much delayed. Aconite or some other remedy has invariably supported the contrac- tions and aided in the dilatation, and the delivery has been satisfac- torily accomplished. In some cases the whole perineum has appeared to fit in such a manner the child's head, and to sink down so low, that it has been found necessary to apply the forceps and simply lift the head directly out of the little sulcus it has seemed to make for itself there. There may be cases, however, in Avhich interference would be ab- solutely required to admit of expulsion of the head taking place without laceration of the perineum. It has recently been advised to make small incisions a little on either side of the median line, upon the principle that an incised wound will heal more readily and nicely than a laceration will. It is barely possible that such a procedure might be necessary. If the perineum be properly supported, and the 232 dystocia. downward pressure of the head be thereby delayed someAvhat, it will be found that the perineum will yield gradually and the danger of laceration will be aATerted. The vagina may be found malformed or adherent, or the hymen may be double or triple, and thrown across high up in the vagina; or there may be a complete septum in the vagina. These cases should all be treated with the knife if necessary, and according to circumstances present; these will indicate the proper treatment. Vaginal cicatrices offer a formidable bar to the progress of labor. These may exist from previous disease of the vagina or in consequence of operations performed thereon. They are hard and unyielding, and seldom give way to the pressure of the head. If their existence is known prior to labor, they may be relieved by the use of sponge tents, etc., but during labor, if they exist in any degree, recourse must be had to the knife. The knife should be well guarded, and should only be used on such parts as are on the stretch during a pain, and but little cutting at a time should be done. It may be necessary finally to use the forceps to effect delivery. Inversion of the vagina sometimes takes place during labor, Avhen the protruding portion from prolonged pressure becomes gangrenous. When this is likely to occur, the forceps should be used at once and the expulsion accomplished. When this condition is apprehended or observed in its incipiency, the accident can be averted by care- fully crowding the descending parts back continually as the labor progresses. GZdema of the labia and nymphee, so far as my experience goes, presents no formidable obstruction to the progress of parturition. Patience and the administration of remedies will assist the Avork of nature, and surgical interference will not be required. The parts are liable to become inflamed and slough if puncturing be re- sorted to. Tumors are also liable to obstruct the passage, so as to cause great and even fatal delay. These may be osseous tumors or they may belong to the soft parts. Exostoses may exist, and form some of the most formidable obstacles to a safe delivery. These usually arise from the anterior face of the sacrum, sometimes from the ischium and the pubes. They may be recognized by hardness, immobility, roughness aud adherence to the bone. These forms of tumor continue to grow in size from year to year, and consequently to become more and more formidable at every successive pregnancy, unless cured by the proper homoeopathic reme- dystocia. 233 dies. The only plan of treatment is that to be pursued in deformed pelvis. Osteosarcoma is another type of malformation, quite similar to the one just mentioned. The only difference is that it is somewhat com- pressible, a mixture of the osseous, fibrous and cartilaginous matter. Even the osseous crepitation can be felt on pressure. The plan of treatment is the same as that in the last case. Fortunately, the exist- ence of both these forms of tumors is of rare occurrence. Other bony formations are sometimes met Avith in the pelvic cavity, obstructing the progress of labor. These arise from the imperfect coaptation of fractured bones, or from the head of the femur being forced in upon the acetabulum. If the resistance offered by these should be very great, the plan of delivery must be conducted as in similar cases of pelvic deformity. Sanguineous tumors sometimes form in the soft parts—in the labia, among the muscles of the pelvis, or even in the neck and lips of the uterus. If the size of these tumors increase gradually, the case should be treated by the administration of aconite, hammamelis, erigeron or any other remedy strongly indicated by characteristic symptoms, which will then be sure to arrest the difficulty and facilitate parturition. Various other tumors are found in and about the track Avhich the child must pursue in its passage to the light of day; many of which need no attention during parturition if they are not obstacles to the expulsion of the child; if they are, they may need' to be punctured, incised or removed, as the nature of the case may indicate. It is always best to Avait and allow Nature to do her own work, if possible. Many of these tumors are not discovered until the hour of parturi- tion arrives, and note should be made of them and the proper treatment resorted to after the lying-in period has passed. Ovarian tumors sometimes offer a very serious obstacle to parturition, and at other times do not. Numerous cases are recorded in Avhich labor occurred naturally, the tumor occasioning no serious accident either to mother or child. If their presence is detected early in the first stage of labor, and the size be not too great, the tumor may be pushed up above the brim of the pelvis, and kept there until the head engages in the superior strait. Under such circumstances labor may terminate naturally and Avithout further trouble. Or if this cannot be clone, and the size of the tumor admits, it may be pushed to one side and the forceps applied to the head. If the tumor contain fluid, a trocar and canula may be pushed into it through the vagina or rectum, and the fluid contents draAvn off. If the tumor should be 234 dystocia. large, hoAvever, and the above methods should fail, craniotomy or the Csesarean section will have to be performed. Sometimes, though rarely, the soft character of these tumors allows of their giving to the pressure of the fcetal head in its descent, and labor is terminated without diffi- culty. Mr. Spencer Wells Avrites, in the Obstetrical Transactions: " 1 know one Avoman Avho during the slow progress of an enlarging ovarian cyst, has gone through five pregnancies, has borne five living children without unusual difficulty, and has never yet had the cyst tapped, nor has labor ever been prematurely or artificially induced. . . . Another patient, upon whom I performed ovariotomy with success in the fourth month of pregnancy, after rupture of the cyst and peritonitis, had borne six living children during the progress of the cyst before its rupture." These cases are of course to be regarded as exceptional. Polypi and other uterine growths are sometimes found obstructing labor. They are usually recognizable by their pyriform shape, and are generally found attached to the os or cervix by a pedicle. The safest and simplest course to be pursued in such cases is to remove the growth. This may be done by torsion if the polypus and its pedicle be not too large, or a ligature may be throAvn around the pedicle and secured, and the growth removed with scissors; or again, the ecraseur may be used and the polypus removed at once. The hemorrhage is not usually great. Fig. 59. POLYPUS PRESSED DOWN BY THE ADVANCING HEAD IN PARTURITION. Ramsbotham mentions what he terms scirrhous glands as a cause of obstructed labor. They are found in the holloAv of the sacrum, and are to be recognized by " their situation, irregularity and hard- ness; by their being very sensitive; by their forming a chain of indurated tubercles, external to the vaginal coats; and by their being more or less firmly attached to the surrounding structures." They DYSTOCIA. 235 are not likely to form any serious obstruction, and should they do so may be pushed out of the way, or the forceps may be applied. Abscesses situated within the pelvis may likewise obstruct the descent of the foetal head and retard labor. The evacuation of their contents might be necessary. Accumulations of feces in the rectum may sometimes seem a very formidable obstruction to labor, but an injection or two of tepid water soon dissipates them. Sometimes, however, it is necessary to use a scoop or spoon. Vaginal hernia, which consists in the descent of a portion of the in- testine into the cul-de-sac behind the uterus, is mentioned by Churchill as a cause of delay during parturition. If it be possible, it should be pressed up above the brim of the pelvis; long-continued pressure upon the intestine should not be allowed, hoAvever, if this cannot be done, and the forceps should be promptly resorted to to effect a speedy delivery. Over-distension of the bladder may usually be remedied by the catheter and when it is prolapsed it must be crowded up into its place. If stone in the bladder exists, an effort should be made to push it up out of the way should it prove an obstacle to labor. This may be done with greater facility in the early stage of labor, before the child's head has advanced. If this should not succeed, the choice will then lie between vaginal lithotomy and craniotomy. Vesical hernia, or cystocele, is occasionally found during labor. It gives rise to great suffering if the bladder is full of urine, and the Fig. 60. VAGINAL CYSTOCELE, TAKEN FROM RAMSBOTHAM. pressure of the child's head may occasion its rupture, Avith fatal results. The male catheter must be introduced at once, and after the urine has been discharged the bladder must be crowded up into its place, and kept there until the head descends and forms a support for it. The 236 DYSTOCIA. tumor will be found posterior to the pubes, fluctuating and free except at its pubic side, and the os uteri will be found above, in its natural place. The introduction of the catheter makes the case clear and unmistakable. Its correct diagnosis is important. Dystocia from Morbid Conditions of the Uterus. Tumors of the Neck and Body of the Uterus.—If encysted tumors prove an obstruction to delivery, they may be punctured and the con- tents draAvn off, or if they contain cheesy matter an incision will allow it to pass out, especially from the pressure during a pain. But unless their size prevent the expulsion of the child they need not be interfered Avith. Pedunculated fibrous tumors, or polypi, have already been treated of. (See page 234.) Ceudiflower Excrescences.—These cancerous or syphilitic growths seldom cause delay, unless their size is very considerable. But when they are large the condition is much more serious. Several cases are quoted by Cazeaux from Puchelt: " In one it was necessary to make incisions upon another part of the hard or scirrhous neck, so as to secure the introduction of the hand; and in a second, to remove the tumor that Avas attached to the anterior lip and occupied all the vagina by the scissors; gastrotomy was resorted to in a third, on account of a rupture of the womb, and not even the child Avas saved ; in another, the extraction of the child was impossible, notwithstanding the per- foration of the cranium, and the woman died before delivery.. Only a single mother survived." As these fungous growths are liable to bleed freely, they may be mistaken for placenta preevia. Carcinoma Uteri.—In this complication much depends on Avhether the child be alive or dead. The mother has a necessarily fatal dis- ease, and if the child be living all care should be bestowed upon pre- serving its life; although the mother should be spared from suffering. Either incisions should be made into the os, turning may be resorted to, or the forceps may be applied. In case the child should be dead, the mother may be saved much suffering by resorting to craniotomy or other procedure to reduce the size of the head. Other Abnormal Conditions of the Uterus affecting Labor. Rigidity of the Os Uteri.—When this exists it may offer a formidable bar to the progress of parturition if not removed by proper treatment. It occurs more frequently in primiparae than in multiparae. The orifice becomes dilated to a certain limited extent, and beyond that it does DYSTOCIA. 237 not yield, notAvithstanding the continuance of the proper pains; and hence the strength of the patient becomes gradually exhausted and untoward symptoms set in. It usually depends upon some functional derangement inducing a spasmodic action, but it may be due to organic lesions of the cervical tissues. In the latter case the measures to be resorted to have already been pointed out. Incisions will probably be required, which may be made by using a probe-pointed bistoury carefully guarded by the fingers from injuring the surrounding tis- sues; and if after these have been made, if dilatation does not progress, india-rubber dilating bags may be used to effect it. But in the ordi- nary form of rigid os arising from some functional disturbance, homoe- opathy furnishes a certain relief, and the measures resorted to by the old school of practice—such as bleeding, opium, chloroform and topi- cal applications—are rendered altogether unnecessary. The properly- selected homoeopathic medicine restores order to the disordered sys- tem, the parts are relaxed and softened, dilatation proceeds as usual, and a happy termination to the labor is the reward. The remedies called for in such cases will be laid down in a subsequent chapter of this volume, in treating of the therapeutics of Labor. Obliquity of the uterus Avould throw the orifice of the neck to one side of the axis of the pelvis—either too far posteriorly, anteriorly or yet to the right or to the left laterally. In such cases the first and possi- bly the only thing the accoucheur has to do is to wait patiently on the operations of nature. Should it be evident that parturition will not be accomplished unaided, the woman should be subjected to " perfect rest on the back when the obliquity is anterior, or on the side opposite to the one occupied by the fundus uteri when it is lateral, and the employment of the hands to support and maintain the deviated organ, or of a large bandage properly applied to produce the same effect. The patient should be advised not to bear doAvn until after the dis- placement is remedied. If these means are not sufficient, it will be necessary Avhile thus operating externally on the body to act at the same time on the neck, for that purpose introducing two fingers into the uterine orifice and taking adA'antage of an interval betAveen the pains to draw it gently toward the centre of the pelvis, while the other hand is employed in pressing the fundus of the organ in the opposite direc- tion."—Cazeaux. In the posterior obliquity the woman ought to re- main seated or standing, or, if possible, even inclining a little forward. Agglutination of the external uterine orifice sometimes occurs, even at the hour of labor. Such a state will be recognized by feeling the outlines of the lips apparently covered over by a thin membrane. 238 DYSTOCIA. At every contraction the line of demarcation between the lips will become more and more apparent, and allow the thin membrane to sink a little betAveen the lips. Now during a pain the thinnest and most yielding spot must be found out, and the finger forced Avithout much violence through the membrane. If the finger is not sufficient, a more potent agent must be used, great care being taken not to wound the child or the mother needlessly. The sioclling and elongation of the anterior lip is a frequent cause of delay in labor. The anterior lip from some cause may not dilate. It may swell and become paralyzed, and hang down upon the head of the child, Avhilst the posterior lip kindly dilates, and the presenting part is ready to pass through but for the stubbornness of the anterior lip. Great and often immediate relief is obtained by pushing up with the finger this anterior lip, and holding it firmly, and even croAvding it up farther during a pain. It then slips up sooner or later above the head, and the distress of the patient is relieved and the labor progresses finely to its completion. It will sometimes be difficult to distinguish betAveen the elongated or swollen lip and a fold of the vagina. In some cases we may find both. The uterine lip will be found hard and unyielding, Avhile the vaginal fold is soft and pliable. In these cases the fold of the Aragina must be pushed up first, and kept up as Avell as possible out of the way. Then the uterine lip can be made to folloAV more readily. Sometimes considerable time Avill be expended in making these manipulations. Induration and hypertrophy of both lips are found in some cases, when the distress of the patient during labor Avill furnish the symp- toms necessary for the indication of the remedy which will effect the desired dilatation. Incisions may have to be resorted to. Complete obliteration of the cervix uteri, it is admitted by all medical Avriters at the present day, does sometimes occur. Of course no os, in this case, can be found by exploring in any direction far back toward the promontory of the sacrum and in other directions; but much care is necessary here, for sometimes it is found at an incredibly distant point toward the promontory of the sacrum. When not the faintest line of demarcation of an os can be discovered, one must be made at the lowest or most pendant point of the uterus. Hernia of the womb, it is admitted, sometimes takes place by the inguinal or crural rings becoming so much dilated as to allow the escape of the uterus. Pregnancy may continue to the full term, when a reasonable time should be allowed for spontaneous delivery, but it is most likely that a Caesarean section will be found necessary. DYSTOCIA. 239 A prolapsed womb may become pregnant, or the womb may pro- lapse suddenly after conception, and the full term be accomplished; a slow and difficult labor Avill result, but it may take place fairly, and the uterus return to its place. Rupture of the Uterus and Vagina. Rupture of the uterus is one of the most serious complications or accidents which can possibly occur during the puerperal state. It may occur at any time during labor, but is much more frequent in the latter stage than in the former. Primiparae are much less liable to the accident than multiparae. It may occur in the body or in the neck : when it occurs in the neck, it almost always involves a rupture of the vagina also. The entire thickness of the uterine parietes may be ruptured, which is the most common form; or the peritoneum may not be involved; or again, the peritoneum may alone be torn. The cause of so unfortunate an accident may be referred to many circumstances: great thinness, a softening or a diseased condition of the walls, mechanical injuries, the administration of ergot, or too violent contractions may all be enumerated among the circumstances, especially too A'iolent contractions with an undilated os. When this accident occurs, a sharp, tearing pain is felt, and that so suddenly and severely as to cause the patient to scream out with great force. Sometimes the patient will complain of something having given Avay, followed by a cessation of uterine action. Cold and clammy sweats break out, the pulse is very small and quick, the presenting part of the child recedes beyond the reach of the hand, and if it escapes into the abdominal cavity, it can be felt through the ab- dominal walls. Collapse sets in, and there may be convulsions; vomiting follows; breathing becomes quick and labored, the pulse more accelerated; and unless reaction sets in, death shortly occurs from collapse. Hemorrhage to a greater or less extent always occurs. " Of all these symptoms, the peculiar sharp and sudden pain, the cessation of all uterine action, the recession of the child, and the being able to feel it easily by the abdominal wall, the hemorrhage and the collapse,—these together make up a total which are almost certainly indicative of ruptured uterus. Of course there is not only hemor- rhage per vaginam, but a good deal of blood may also escape into the peritoneal cavity—so much, indeed, that this alone causes death in some cases."—Meadows. When this accident occurs at an early stage of gestation, before the 240 DYSTOCIA. uterus contains much to be discharged through the rent, the product of conception may dam up the passage and cause the contents of the uterus to be retained for some days; so that when a reaction ensues after the first shock, a calm precedes a more violent set of symptoms after the final escape of the product of conception into the cavity of the abdomen. In the later months of conception the diagnosis is easier to be made, as described above. Should the patient survive the immediate consequences of a lacerated uterus, after some hours reaction sets in, and the symptoms of col- lapse are succeeded by those of inflammation of the peritoneum and womb, which is usually very severe, and consequently presents symp- toms of peculiar aggravation. If this should abate Avithout destroy- ing life, it may be folloAved by the formation of abscess or by cellu- litis, etc., Avhich will probably carry the patient off. There are cases on record, hoAvever, in which recovery has taken place even Avhen the foetus has not been delivered, but has become encysted in the abdom- inal cavity. Terrible as this accident is, therefore, it is evident that nature unaided has been able in some cases to overcome the tendency to death, and much more may be done by proper manual and instru- mental interference and by Avell-directed after-treatment. The first step to be thought of in cases of this kind is, the delivery of the child where that is at all practicable, for it is to be remem- bered that it is alive and may be born alive. If the os be either dila- ted or readily dilatable, the forceps should be promptly resorted to if the head can be reached. But if the child has passed upward, so that the head cannot be reached, or if the condition of the os contra- indicates the use of the forceps, turning should be resorted to and the child delivered with promptness. It is humane to the mother to de- liver the child as soon as possible, for her best chance of recovery rests on that. Care must be taken, in effecting delivery either by the forceps or by version, that no part of the intestines be drawn through the rent in the uterus, or that it be not alloAved to remain thus constricted after extraction has been accomplished. If nei- ther of the above methods is applicable, then the Cesarean section should be resorted to. This operation has been successfully per- formed and the mother has recovered even under such unfavorable circumstances. During the condition of collapse, the use of stimulants is perfectly admissible and perhaps necessary. The after-effects will be all the more successfully combated by a strict adherence to homoeopathic DYSTOCIA. 241 medication. (See the remedies under Puerperal Fever, Metritis, etc.) Rupture of the vagina may likewise take place independent of any laceration of the uterus. A similar condition prevails in all respects as in rupture of the uterus, except that the pain is not so severe and other symptoms may not be so intense. The treatment to be pursued is similar to that recommended in case of rupture of the uterus. Rupture of the Bladder. This can only occur from injudicious management, culpable neglect or ignorance. The laceration may take place either upon the perito- neal or the vaginal side of the viscus. In the former case, urine is extravasated into the peritoneal cavity, and violent inflammation is induced which may destroy life. In the latter case, while the imme- diate effects are not so serious, yet the consequence, in the shape of a vesico-vaginal fistula, is very severe and distressing. The evidences of rupture of the bladder will be similar in many respects to those of rupture of the uterus or vagina, but there will be little or no hemorrhage per vaginam; uterine contractions will be continued, the presenting part of the child and the uterine os will be found in their proper places, and the evidence of the child having escaped into the abdominal cavity will be wanting. This possibility of rupture of the bladder may be averted if the accoucheur sees to it that during a protracted labor the bladder is properly evacuated. Should the natural efforts of the woman fail of accomplishing this, the catheter should be used. If the accident does happen, however, from any cause whatever, delivery should be effected by the forceps or by turning, unless it be apparent that the child will soon be born without mechanical assistance. If urine is poured into the peritoneal cavity, the resulting inflammation should be treated according to the general principles of homoeopathic practice, and may thereby be successfully combated. Should vesico-vaginal fistula result, on the contrary, the niceties of the surgeon's art will be re- quired to relieve the suffering woman from her horrible situation. Laceration of the Perineum. Laceration of the perineum is more liable to occur in primiparae than in women who have already borne children. The extent of the injury varies a great deal. It may be a mere nick in the anterior thin border of the perineum, may extend from the fourchette to the sphincter ani, or may involve the sphincter and in some cases the entire 16 242 dystocia. recto-vaginal septum. Again, the anterior part of the perineum may remain intact, and perforation of the perineum take place, the child being actually driven through the perineum from mal-direction of the uterine expulsive force, from disease of the perineal tissues or from deformity of the pelvic outlet. Sometimes the perineum is preternaturally broad, and in such cases the head pressing downward forcibly distends it in every direction, and becomes, as it Avere, invested by a perineal cap. Laceration or per- foration Avill be pretty sure to take place unless the head be lifted out of the investing perineum by means of the vectis or blade of the for- ceps and supported thereby, care being taken that no pressure is made on the perineum by the instrument, the hand of the operator serving as a fulcrum for the lever. Laceration of the perineum may be caused by too speedy delivery, by rigidity of the perineum itself, by narrow- ing of the pubic arch, or by the use of instruments to effect delivery. It may also be occasioned by degeneration of the tissues of the peri- neum, or by the woman straightening herself out at the last moment when the head is emerging from the vulva. The treatment of ordinary cases of lacerated perineum, Avhen the sphincter ani is not involved, is very simple. Indeed, the natural restoration of the parts after labor will reduoe what at first appeared to be a formidable laceration to a very insignificant one. Rest upon the back for a number of days, and keeping the limbs in constant apposition, combined with perfect cleanliness, will suffice to restore these simple cases. It may be necessary to draw off the urine with a catheter, but as the bowels are not generally moved until the ninth day, fecal matter is not likely to disturb the healing of the Avound. The more serious cases require surgical interference. The torn surfaces are to be coaptated and held in place by sutures—quilled, interrupted or twisted sutures, as may be selected—and perfect rest enjoined. The operation should be performed immediately after labor, for obvious reasons. No serious case of laceration of the perineum should be neglected by the accoucheur, as prolapsus or procidentia uteri, or non-retention of the fecal matter, may give rise to serious trouble in after life, unless the structures are restored to their normal condition. Labor Complicated by Previously Existing Disease. There are certain diseases which may complicate labor that require special and particular attention. Of this kind are haemoptysis and hcematemesis. In these cases the remedies must be resorted to which DYSTOCIA. 243 are usually employed in treating such diseases. As a general rule, hemorrhages will be controlled and labor will terminate in a regular' natural Avay. But if Ave are not thus fortunate, the labor must be terminated as soon as possible by artificial means. In asthmas, pal- pitation and diseases of the heart, we should be governed in our action by the principle stated aboA-e. In aneurism, where there is a great danger of rupture at any pain, immediate resort should be had to artificial means of delivery. When hernia exists it should be reduced as soon as possible, and when it is utterly impossible to reduce it, the best practice is to resort to artificial means of delivery, in order that the hernial protrusion may not be strangulated longer than necessary. When the hernia is liable to return after reduction, it may be kept back by constant pressure. Syncope is curable by using the proper medicines. (See Therapeutics of Labor.) When there are great exhaustion and debility, and they cannot be relieved by the proper medicines, resort to arti- ficial means for delivery. Labor Complicated by Convulsions, Hemorrhage and Placenta Prcevia. These terrible complications of parturition are fully treated of in the latter or therapeutical portion of this volume, under the proper headings. Dystocia from Abnormal Conditions of the Fostus. We noAV commence the study of those obstacles to its ready expul- sion which depend on the foetus and its appendages, the passage being in a normal condition and the expulsive force sufficient. Hydrocephalus.—Some disease of the fcetus may develop a true hydrocephalic condition, in which the head becomes so large as to make it impossible for it to pass through the cavity. This state may be knoAvn from the cranial bones being separated far from each other, and each seems to swim, as it were, in water Avhen pressing upon them; there is also a Avide suture between the bones of the cranium. The trecdment in such cases depends on circumstances. Degen- eration of the foetal head may have occurred to the extent that it re- sembles a membranous bag, and under such condition it may be ex- pelled without operative interference. Such cases are of course rare. Again, the scalp may be ruptured and the fluid contents of the cranium expelled. But should it become evident that labor cannot be com- pleted without assistance, the head should be punctured and its con- tents discharged. For this purpose an ordinary trocar and canula 244 DYSTOCIA. or Braun's long obstetrical trephine may be used. The operation should not be delayed too long, as there is danger of rupture of the uterus occurring, or the pressure of the head upon the soft parts of the mother may give rise to very serious inflammation and sloughing. In some cases the breech or inferior extremities are born first, and a hydrocephalic head is found to be impacted either within the pelvis or above the brim. It would naturally be more difficult to correctly make out the condition of the foetal head under such circumstances than when the vertex presents, the neck and shoulders preventing to some extent a free examination. But by patiently forcing the finger upward to the head the condition may be made out. Here the trocar may be pushed into the base of the head with similar results. The instrument of Braun will perhaps be safer and more efficient. Hydrothorax may exist. This disease may be diagnosed after the expulsion of the head or breech by the arrest of progress, by the in- tercostal spaces being extended, and by the fluctuation of water between the ribs. Ascites may occur and arrest the further progress of the child. When this is the case fluctuation and enormous distension solve the mystery. In the last two or in similar cases the trocar is the only remedy. A small trocar should be used in these cases, as the abnor- mal conditions are not necessarily fatal to the child. An emphysematous condition may occur when the foetus has been long dead and has become so distended with gas as to hinder its ex- pulsion. The trocar is to be used also in this case. Upon using this instrument large quantities of offensive air escape. Tumors of the fcetus may also cause a delay until the tumor is removed if solid, or punctured if containing fluid. We must be on our guard against accidents, and be duly prepared for every exigency which may arise. Anchylosis of the foetal articulations has been known to exist, causing great delay. On the application of the forceps and making forcible traction the child Avill be delivered. Excess of volume on the part of the child may be a cause of delay; the volume may be so much in excess, indeed, as to constitute the child a monster. The application of the forceps or blunt-hook is the remedy in cases of this kind,—that is if the vital forces are inadequate to effect delivery. Multiple and adherent foetuses and other monstrosities constitute a A'ery formidable cause of dystocia. We can often ascertain before the time of delivery the fact of the presence of two or more foetuses in utero, DYSTOCIA. 245 but Ave cannot ascertain whether they are separate and independent until the hour of delivery has actually come. If tAvo bags of water are found to be present, it is necessary to rupture the membrane twice. The same must be done if we have evidence of there being two distinct gushes of liquor amnii. We may then be assured that two pouches have ruptured, and it is made certain that there are no adherent foetuses present; for adherent children are always enclosed in a single set of membranes, and perfect twins are seldom enclosed in a single amnion. If, moreover, the head and feet appear at the superior strait, and par- ticularly if Ave can draAv upon the feet without causing the head to ascend, Ave may be sure that there is no adhesion. If three or four feet appear at the vulva at the same time, and on pulling at one another moves simultaneously, but the others remain at rest, we may be sure of the foetuses being detached from each other. If all move simultaneously, we can only ascertain this fact to a certainty by carry- ing the hand up into the uterus. In all cases, Avhether there is an adhesion or not, sufficient time should be alloAved for nature to operate unaided, but efficient aid should be rendered the moment that there is reason to believe it to be called for. Whether the union takes place at the head or the breech, the expulsion takes place, the one after the other, without difficulty. But if the union be at the occiput and the full term has expired, craniotomy Avill probably have to be resorted to. Where there arc two heads to one trunk, one head will engage after the other, and the body will descend subsequently. Where each head has its body, and the union takes place at any point of the trunk, one head may be born first; the feet belonging to this head may be brought down ; next the feet of the other child may be brought down, and lastly the head of this same child. When there is but one head to two bodies, the head may be born first, and the two bodies simultaneously with each other. If the breech of one body comes first, the hand may be introduced and the feet of the other child brought down. But it is impossible to lay down positive rules for all the anomalies which may arise. In special cases the accoucheur, in deciding on his course, must be led by general principles. Multiple and independent foetuses, twins, triplets, etc., are often de- livered one after the other, promptly and with but little delay, but usually these cases are more tedious. The child first presenting can- not be acted on as efficiently as if there were but one, for the uterine contraction must force one by acting upon the other. 246 DYSTOCIA. Moreover, the over-distension of the uterine walls serves to weaken the contractile powers for the first child. When the first child presents by the breech, there is likely to be more difficulty in the birth of its head on account of the remaining child's hindering the direct applica- tion of the uterine contractions upon it. Hence Ave must not overlook the importance of introducing a finger into its mouth in order to flex the chin upon the chest, and make sufficient and prompt traction for a safe delivery. Soon after the birth of the first child, in the course of twenty minutes, the contractions return, feebly at first, but soon more efficaciously, and the next child and the next are promptly expelled. The accoucheur, as soon as one child is born, should always place his hand on the abdomen of the mother, to ascertain Avhether others are present there, and so on successively until all the births are effected. If another remains, the abdomen will seem to be but a little smaller for the expulsion of one or two: the presence of more Avill be unmis- takable to both sight and touch. Sometimes, after one child has been born, a rest of some hours seems necessary before the exhausted fibres are sufficiently recovered to reneAv their contractions. Sometimes even days elapse before labor is renewed. The accoucheur should not inter- fere in such cases unless it be absolutely necessary to do so. Nature is generally competent unaided. All troublesome symptoms, such as flooding, fainting, etc., may be relieved by the proper homoeopathic remedies, according to the principles already mentioned. If the pains are delayed very long, they may be reproduced if necessary by re- sorting to the remedies referred to under the head of Therapeutics of Labor. Sometimes it may be necessary to rupture the membranes for the passage of the second child, in order to excite contractions, and sometimes to tickle the os with the finger in order to excite a reaction. Sometimes both heads incline to present at the same time, in which case one must be pushed aside to alloAV the other to descend. The same course must be adopted in case the breech presents. If either child presents by the shoulder, and version is determined upon, great care must be exercised to seize the feet of the child to be turned; this is an easy matter by constantly keeping the hand on the child Avhose shoulder presents. When tAvo feet appear at the vulva, and it should seem advisable to interpose assistance, hut one foot should be draAvn upon, and that very gently at first, in order to ascertain Avhether the other moves simultaneously as belonging to the same body; and if this is found not to be the case, every effort should be made to return that Avhich DYSTOCIA. 247 does not. A good and perhaps the only Avay to accomplish this is to suspend the patient by the feet, at the same time holding on to a leg of one of the children; the others would then return into the uterus, to be extracted after the expulsion of the first. No attempt should be made to deliver the placenta of the first child before the second is expelled, as hemorrhage would certainly result; and care should be taken that no traction is made upon the cord for the same reason. Prolapsus of the cord is a serious complication for the child, Avhilst it brings no harm to the mother, the life of the child being alone en- dangered : Fig. 61 exemplifies a case of this kind. The first evidence Fig. 61. THE RIGHT POSTERIOR OCCIPITO-ILIAC POSITION COMPLICATED BY A FALLING OP THE CORD. which the accoucheur has of this accident is actual presence of tlie cord with the presenting part of the child. The fold of the cord hanging may be of different lengths, simply hanging below the superior strait or it may be six inches long or more. If the child is living, the cord Avill be felt to pulsate one hundred and twenty to one hundred and forty beats a minute, and it will be felt to be firm and like a living tissue. But if dead there will be no pulsation, and the cord will feel shriveled, soft and lifeless. The treatment of this complication needs to be very prompt, lest the presenting part descend and cause strangulation and consequent death of the child. The only plan of safety possible is to take a piece of wet sponge, about twice the size of a hen's egg, and cut entirely through its centre a hole large enough to receive the fold of cord. Then pass a string through the loop of cord, and next pass the same string through the sponge. Noav by holding on to the string and slipping the sponge upAvard the fold of cord is drawn into the sponge. 248 DYSTOCIA. Slip the sponge Avell up, so as to secure a full introduction of this fold into the sponge. Then with the fingers crowd the sponge and all well above the superior strait. The sponge will dilate and retain all above the presenting part safely. It may be well to be always prepared with a small piece of sponge ready for the occasion. If the presenting part of the child has become so firmly engaged in the superior strait as to render the return of the cord impracticable, the labor should be termi- nated either with the forceps or the blunt-hook. Should the shoulder present, and podalic version become necessary, the cord should be carried up Avith the hand used for this purpose. When the breech presents, it may become necessary to hold the sponge at the superior strait until the part becomes so engaged as to retain the sponge without further effort. A little thought and reasoning will enable the accoucheur to Fig. 62. THE LEFT OCCIPITO-ILIAC POSITION STRONGLY INCLINED ON ITS POSTERIOR PARIE- TAL REGION. quickly adapt himself to any variation which may occur. He should always endeavor to adapt himself quickly to circumstances as they arise. Shortness of the cord may occur as a complication, and delay the labor very much. It has been known to be not more than four or five inches in length. The strongest symptoms of this state of things are found in the continued retraction of the child, time after time, after the cessation of each pain, without any perceptible ad- vancement. If this condition of the patient continues too long, so as to endanger the welfare of the mother or child, the aid of instruments must be invoked. When the presenting part has advanced so far as to expose the cord, it should be severed at once, about an inch and a half from DYSTOCIA. 249 the child's body. It may be tied, or held tightly betAveen the fingers of an assistant, until a complete delivery takes place. There is danger of a rupture of the cord or of a separation of the placenta, exposing the child and mother to a severe loss of blood before the child is sufficiently far expelled to expose the cord; in this event the treat- ment is still the same; apply the instrument necessary for hastening the expulsion of the child. Inclined position of the foetus constitutes another cause on the part of the child of its tardy birth. Fig. 62 illustrates a case of this kind. In making an examination per vaginam, one ear, the side of the head and the neck are felt. In all similar cases it is only necessary to turn the patient so that she shall lie on the side opposite to the place where we feel the neck of the child. The body falls down on the same side, and soon rectifies the inclination. Inclined breech positions can be managed on the same principle, the mother being ahvays turned, in such inclinations upon the same side as the anus points to. Fig. 63. THE LEFT POSTERIOR MENTO-ILIAC POSITION COMPLICATED BY A DESCENT OF THE LEFT FOOT. Inclined facial positions should always be managed in the same Avay as any facial presentation; they should be converted at once and Avithout delay into vertex presentations, as will hereafter be described. Inclined positions of the trunk must also be interfered Avith at once and conATerted into vertex presentations or delivered by the feet as directed a little farther on. Complicated presentations, something similar to Fig. 63, must be managed by the application of general principles. The child is forced quite closely down into the superior strait. 250 OBSTETRIC OPERATIONS. Now, it is evident the trunk cannot go back and the head be brought down, because one foot has advanced too far. If the feet Avere far- ther up, the forceps might perhaps be applied, and the head brought down, and the cord Avould be less liable to become compressed. All things being considered, then, it is very evident that the best course to be pursued is to use a linen handkerchief as a fillet on the foot most advanced. An assistant should make powerful but steady and care- ful traction upon it, whilst the accoucheur steadies the uterus with both hands placed upon the abdomen. The labor will then terminate in the most favorable manner. The exercise of sound judgment is called for in all these unusual conditions. CHAPTER XV. OBSTETRIC OPERATIONS. Turning. VERSION, or turning, is that manual operation by Avhich we change one presentation for another more favorable to delivery. It is, when carefully performed, capable of effecting a great saving of life in difficult labors. There are two kinds of version: the podalic, Avhich consists in introducing the hand into the uterus, seizing one or both feet and delivering by the inferior extremities; and the cephalic, which consists in changing the head in such a man- ner as to bring a more favorable part of it to present, and thus facili- tate delivery. It is proper to be remarked here that when the history of a given case of parturition indicates a probable malposition in a future preg- nancy, the Avoman should be subjected to careful medical treatment, with a view to curing that abnormal condition of the system which led to the previous difficulty. If a malposition be detected near the close of gestation by means of auscultation or palpation, it is claimed that pulsatilla will so affect the uterus or the foetus, or both, as to bring about a change to the normal situation of the fcetus in utero. Con- siderable evidence has been given as to the truth of this assumption— to the extent, indeed, that a mere negative theoretical opinion does not suffice to disprove it. It is, at all events, worthy of careful trial. OBSTETRIC OPERATIONS. 251 Podalic Version.—When it is deemed necessary to change the presentation of the child by bringing down the feet, there are certain rules Avhich under all circumstances must be observed : 1. The patient should by all means be apprised of the nature of her case, and as simply and kindly as possible be made acquainted with the nature of the operation to be performed. When she is once made to understand that the proposed operation is for her safety and that of her child, she will the more cheerfully submit; her free con- sent must in the first place be obtained. 2. Her position must be upon the back, Avith the breech near the edge of the bed, her feet also near the edge of the bed, the thighs flexed at right angles with her body; the head and shoulders must be elevated to a reasonable height. 3. The accoucheur should slip off his coat as gently as possible, in such a manner as not to make a great flourish and thereby alarm his patient. The hand and wrist to be used in the operation should be rubbed with lard until perfectly smooth, that hand always to be em- ployed whose palmar surface corresponds with the face of the child. For obvious reasons care should be taken not to lubricate the palmar surface. 4. The os uteri must be sufficiently dilated or dilatable to admit of the free introduction of the hand and the passage of the child. If there is the least rigidity of the fibres, we must defer the operation a little longer, otherwise we incur the risk of rupturing the uterus or of badly injuring the patient in other respects. 5. The introduction of the hand can be easily effected by placing first the fingers and then the thumb within the vulva, at the same time bringing them all together into the form of an elongated cone. Now press carefully, slowly and steadily from before backward and ' from beloAV upward, and the hand will enter the vagina and soon come in contact with the child. Great care must be exercised in pass- ing the vuhTa and entering the vagina, especially in prirniparae, as this is sometimes the most painful part of the Avhole operation. The fingers should be straightened as the hand passes the os externum, to prevent the knuckles giving unnecessary pain, and this may have to be observed likewise in passing the vulva. The palmar surface must be spread out and kept upon the anterior surface of the child until we come in contact with one foot. If there is difficulty in finding the foot, carry the hand upward to the thigh, and then the hand can follow the thigh and leg along to the foot. Having ascertained that it is really the foot, make a firm grasp about the ankle close down 252 obstetric operations. to the foot. If action is taken before the rupture of the membraues, the hand should be insinuated gently between the membranes and the uterus, and passed upward until the foot can be felt. The mem- branes should then be ruptured by scratching with the nail, and the foot seized. By this means Ave gain the advantage of having the fcetus floating in liquor amnii, for that fluid cannot escape in any quantity Avhen ruptured in this Avay. Care should be taken that the membranes are not ruptured prematurely. All this stage can be accomplished from time to time during the intervals of the pains. During each pain the hand should remain perfectly quiescent and Fig. 64. Fig. 65. Fig. 64. In this the head has been pushed up into the left iliac fossa, and one hand takes hold of the foot while the other supports the organ externally. Fig. 65. The same position, in which the version is commenced by drawing down , the foot. spread out flat upon some part of the child, any part being prefer- able to the abdomen. The surest Avay to suceeed in finding a foot, especially Avhen the liquor amnii has been discharged, is for the hand to tra\Terse the body, thigh and leg. Never feel for the foot until the body, thigh and leg lead on to it. The free hand must be placed upon the abdomen in order to steady the uterus, or this office may be performed by an assistant. Having secured a foot, then, during the absence of a pain, the hand should be gently and carefully withdraAvn. If we have been careful to carry the hand upon the anterior surface of the child and secured a foot there, we shall succeed in turning the child by doubling it more and more upon its anterior surface. By doubling obstetric operations. 253 the child upon its anterior plane we run no risk of breaking its back or neck, as in doubling it backward. Moreover, by bringing down only one foot and allowing the other to remain in its usual position, we leave the breech to occupy a bulk nearly as large as the head, so that as it passes through the organs more dilatation is effected, which the head requires in order to pass freely, and Avith less compression upon the cord, and of course Avith less danger of strangulation. Fig. 66. ^ig. 67t Fig. 66. The version is here completed, and the occiput, which was placed in the left iliac fossa aWhe commencement of the operation, will now come down behind the right acetabulum. Fig. 67 shows the mode of management of the cord. Further, as one leg is left distended upon the abdomen of the child, it serves to protect the cord during the passage of the body. This is a self-evident fact. After the turning of the child is fairly accomplished, the labor may be effected by the natural process alone, or Ave may continue to act as occasion requires. Wait, by all means, if it will seem to answer to do so, but if not make traction upon the leg, but act only in concert with the pains. " The pains sometimes do not return for a whole hour, but then so poAverfully and quickly that the child is born in full vigor and activity."—Wigand. Do not draAv down the other leg; wait until it is fairly expelled, foot and all, for it may be the saving of the child's life to do so, the cord being in this manner protected. Now 254 obstetric operations. the chief danger arises from the strangulation of the cord by its being compressed between the head and the bony walls of the pelvis. 80 long as Ave can feel the pulsation of the cord all is well. Should the pulsation cease, a slight effort may be made to draw it doAvn a little. If this can be done, pulsation will often become re-established, and, all things being equal, Ave can still wait. If it cannot be draAvn down and pulsation ceases, Ave must hasten delivery as much possible by making careful traction upon the body of the child. As soon as pos- sible Ave must hook doAvn the arms by placing the index finger in the bend of the elboAv, and then as soon as possible hook the same finger into the mouth of the child and flex the head as strongly forward as possible; hold it thus Avhile with the other hand placed upon the shoul- ders make steady and strong traction, and the patient will soon be delivered. Manage all breech presentations in this way when inter- ference appears necessary in order to save the child or mother; other- Avise trust to nature. It sometimes happens that the arms slip up by the sides of the head, when it Avill be necessary to disengage them before the head can engage. This can be done by slipping two fingers up from the shoul- der along the humerus, and allowing these fingers to lie along on its Avhole length; Ave can pass them forward and downward on the child's face, and in this manner run no risk of fracturing its arm. The pos- terior arm should be disengaged first, and the sub-pubic afterward. In all cases of difficulty in the introduction of the hand to perform this operation from rigidity of the uterine neck, the difficulty can be overcome by the administration of the proper remedies for rigid os. It should be further observed that complications from^hemorrhages, etc. can all be controlled by suitable medication, and in this way time can be obtained for dilatation and other necessary advantages without resorting to brute force or allopathic measures. Let it not be forgotten that version must never be attempted until the os uteri is fully dilated or freely dilatable. It can then be safely performed, both to mother and child, Avhether the membranes are ruptured or not; but the fittest moment for the operation is Avhen the os uteri is fully dilated and the membranes are still unruptured. The operation becomes the more difficult the longer the time that has elapsed after the membranes have been ruptured and the less the quantity of liquor amnii contained within the uterus, for then the uterus more closely envelops the child and the hand is passed Avith greater difficulty. Some obstetric Avriters—Dr. Robert Barnes more especially—insist that the knee rather than the foot should be seized and brought obstetric operations. 255 down. On this point Dr. Barnes says: "There ought to be some good reason for going past the knees to the feet, which are farther off and more difficult to get at. Now, I know of no reasons but bad ones Fig. 68. Fig. 69. Fig. 68. Delivery of the posterior arm first. Fig. 69. The mode of flexing the head by drawing down the chin and pushing up the occiput. (This mode is several times mentioned or referred to in the text.) for taking this additional trouble. You can turn the child much more easily and completely by seizing one knee." (Barnes' Obstetric Opera- tions.) While it is true that the knee is reached sooner than the foot, and Avhile there are cases in which the seizure of the knee would not only be more easily accomplished, but would be equally satisfactory with a seizure of a foot, still, in a majority of cases where turning is required, grasping one foot and bringing it down is, in my opinion, the safest and most satisfactory procedure. " Combined internal and external version may be practiced in cases Avhere the os only admits the forefinger, provided the membranes be entire or the uterus be not too rigid. It depends for its efficacy upon the mobility of the child in utero by mere external palpation, and has the advantage of being simpler, less dangerous and difficult, and of being applicable in cases where ordinary version could not be per- formed."—Rigby. The simplicity and efficacy of this combined procedure in arm, shoulder, neck or transverse positions, when detected at an early stage of labor, will be apparent. The operation consists in introducing one or two fingers of the left hand within the os uteri, in order to reach a 256 OBSTETRIC OPERATIONS. finger's length within the cervix. The position of the child having been made out, and it having been ascertained to Avhich side of the os uteri the head lies, the right hand is placed on the abdomen of the patient over the fundus, and an effort should be made to make out the position of the child's breech by palpation. With the hand on the abdomen, gentle but firm pressure is to be made against the breech to push it over toAvard the right side, folloAving it by a gentle gliding movement of the hand over the abdomen as it recedes; while at the same time the hand within the vagina pushes up the head in the oppo- site direction, so as to gradually raise it above the brim. Thus, it will be perceived, by pushing the different extremities of the child in opposite directions by the two hands employed, the child Avill gradually be turned around within the uterus, until finally the knee or the foot is opposite the os and may be brought doAvn. As the head passes from reach under pressure of the fingers Avithin the uterus, and the shoulder, body and breech successively come Avithin reach, they are to be "moved on" in the same manner, until the knee or foot is felt. This method might be resorted to in securing a cephalic rather than a podalic presentation where the neck or the trunk presents under favorable circumstances. Dr. Braxton Hicks, Avho has Avritten more fully on the subject than any other author, says: " We should first of all endeavor to induce cephalic presentation, and then, should there be any difficulty in accomplishing it, to change our plans to podalic." And he thus describes the modus operandi of inducing cephalic pres- entation : " Introduce the left hand into the A7agina as in podalic version; place the right hand on the outside of the abdomen, in order to make out the position of the fcetus and the direction of the head and feet. Should the shoulder, for instance, present, then push it with one or two fingers on the top in the direction of the feet. At the same time pressure by the outer hand should be exerted on the cephalic end of the child." In regard to the question as to what limb of the child should be seized in effecting podalic version, Sir James Simpson has laid it doAvn as a rule that the limb should be chosen which is on the opposite side to that of the presenting part. By so selecting, the action upon the pre- senting part is more decided, and it readily recedes as the limb upon which traction is made is drawn down. On the other hand, if that foot be chosen Avhich belongs to the same side as the presenting part, there is danger that the limb may be draAvn doAvn without causing a corresponding retrograde movement of the presenting part, and thus OBSTETRIC OPERATIONS. 257 complicate the presentation still more. This is a good rule, and its force is more apparent in shoulder and arm presentations. It is possible that an arm may be seized and brought down, to the great confusion of the accoucheur, who supposes he has an inferior extremity Avithin his grasp. In other words, a hand may be mis- taken for a foot or an elbow for a knee. To distinguish between a hand and foot we have the following points: The fingers are longer and of more uniform length than the toes. The thumb is much more apart from the fingers than is the great toe from its fellows, and the thumb is more movable laterally than the great toe. The fingers can be folded upon the palmar surface of the hand, whereas the toes merely admit of being curled upon themselves, as it were, and not flexed upon the plantar surface of the foot. The hand comes off from the arm in a line with it, whereas the foot comes off from the leg at a right angle. To distinguish between an elbow and a knee Ave have the following points: The knee is larger, rounder and appa- rently more of a square than the elbow, while the elbow, on the con- trary, is sharper and smaller than the knee. Again, in the knee we find the movable patella, which can readily be distinguished from the olecranon process of the elbow. " We distinguish a knee from an elbow by there being two round prominences (condyles), with a de- pression between them; the elbow presents also two similar promi- nences, but there is a sharp projection (olecranon) betAveen them."— Rigby. The outer and inner hamstring, with the popliteal space between, is also a good point in making out a knee. Dr. Rigby lays down the follovving excellent advice: " When the arm presents, Ave should pass our hand, if possible, along its inner sur- face, as this Avill guide us to the breast and abdomen of the child. If the hand protrudes, the palm is almost certainly turned in the same direction as the abdomen of the child. "If you can just reach the extremity of the foot, hold it still dur- ing a pain; you will find that you can get further hold of it when the pain has ceased." Cephalic version is seldom practiced, although it may be very useful in some malpositions of the head. It consists in substituting a more favorable presentation of the head for one not so favorable. The different steps of this operation must necessarily vary Avith every case in which it is resorted to. In all cases the patient should lie on her back Avith her limbs drawn up, in order that as much muscular relaxation as possible may be gained. Manipulation with the fingers within the os may be aided by the hand applied to the abdomen, and 258 OBSTETRIC OPERATIONS. used after the method described in the combined method of effecting podalic version. General Directions to be Observed in all Cases where the Head, Face, Breech or Trunk presents. When the head presents do not change it for the feet. If hemor- rhage occurs and there be placenta prsevia, manage as directed for that condition. If there is not placenta prsevia, control the hemor- rhage by medicines. (See Uterine Hemorrhage.) Remove all other difficulties by medicine if possible. If not, apply the forceps or resort to craniotomy, as the case may seem to demand. It is a very unsafe plan to exchange the head for the feet if it can possibly be avoided. It is much safer in all respects for the child, as Avell as for the mother, to deliver by the aid of the forceps. In case of malformation of the pelvis, the advice of Simpson to turn and bring doAvn the loAver side of the fcetal cephalic wedge, upon the ground that the head can thereby be more readily delivered, should be taken Avith a good deal of caution, and his proposition should be regarded as problematical. As a principle, then, worthy of all confi- dence, never exchange the head for the feet. If the face presents, and we are called before it has become fairly engaged in the cavity of the pelvis, if it be in the right mento-iliac position, Ave must introduce the left hand, when the face will rest in the palm, and by proper manipulation with the fingers the face can be rotated upward so as to flex the chin upon the sternum, and thus bring the vertex into the superior strait, when the labor can be abandoned to nature. If the position be one of the left mento-iliac, the right hand is to be used and the same result brought about. If the face has become too much engaged to admit of a reason- able doubt as to final success, resign the case to nature, at the same time Avarding off hindrances and complications, as in vertex pre- sentations. In these facial presentations we must wait Avith great patience, sup- porting in the mean Avhile the vital energies for expulsion Avith such remedies as each individual case may seem to require. We must Avait until rotation is effected, bringing the chin under the arch of the pubes. When the chin is even found exactly posterior, by waiting and pre- scribing such medicines as may be indicated the chin will rotate to the front and spontaneous expulsion take place. Ramsbotham says of all face presentations that there is little doubt that originally they OBSTETRIC OPERATIONS. 259 were presentations of the head which have been changed by the action of the uterus. It does sometimes occur, however, that when the chin is posterior, instead of being transverse or anterior, it seems as descent takes place to lodge in the great sciatic foramen, and be retained there until the presentation is converted into one of the vertex; this should be re- garded as a very happy event. When it becomes necessary to offer instrumental aid to facial presentations, the forceps must be applied in such a manner that the chin may be in harmony with its concavity. This would favor the rotation Avhich brings the chin under the pubic arch. After the chin has engaged under the pubic arch very great assistance is often afforded by applying the forceps in such a manner as to gently aid the process of flexing. It will be recollected that at this stage the occiput is lying back in the cavity of the sacrum, and the expulsive forces are so applied as to render the flexion of the head very tedious, so that the life of the child may often be saved by producing flexion of the head by artificial means. Fig. 70. THE MODE OF USING THE BLUNT-HOOK IN BREECH PRESENTATIONS. When the breech presents it may be allowed to descend, turning being rarely admissible in these cases. If artificial means are thought necessary, the blunt-hook may be used. It can be applied by putting one finger on the presenting part as a guide to the point of the hook, 260 OBSTETRIC OPERATIONS. the handle being held in a perpendicular posture. Noav, whilst this point is kept in contact Avith the breech, the handle should be de- pressed until the hook is slipped over the thigh and into the groin. Before traction is made one finger must be slipped up between the thighs of the child and placed upon the point of the hook, where it must be kept during each traction, for fear of accidents. The hook must be kept closely applied to the groin, for fear of fracture to the femur if it slips down upon the thigh. HoAvever, later experience proves most conclusively that it is much safer and better practice to apply well-curved forceps such as Bethell's, instead of the blunt-hook; well-curved forceps apply to the breech very nicely, and Avill not slip off. When the trunk presents we always knoAv at once that the inter- vention of art is inevitable, and we must at once determine where or in Avhat position is the anterior surface of the child, so that Ave may be able to choose Avhich hand is to be used, ahvays remembering to use that hand whose palmar surface corresponds to the face of the child. In these cases we should generally resort to podalic version by introducing the hand into the uterus, seizing a foot and bringing it down. Version by the combined method may, howeArer, in some cases, be effective. If the child's arm be found hanging from the vagina, Ave must attempt to turn the child at once by introducing the proper hand. Seizing a foot very gently, withdraw the hand as before directed. No attention need be paid to the arm hanging in the vagina. If the arm is not hanging externally, the shoulder being felt in the superior strait merely, introduce the proper hand and make an effort to push up the child, so as to allow the head to fall into the superior strait in place of the shoulder. We may be aided in this operation by gravity. If the head is found to occupy the right iliac fossa, after crowding up the child as much as possible alloAV the patient to lie over upon her left side, whilst the accoucheur is still holding up the child, and the head will be aided in its descent to its proper place. The hand may then be partially withdraAvn, and at the same time aid in placing the head in the proper position. If Ave succeed, the case can then be abandoned to nature, aided, when requisite, by the forceps. If we fail, the hand should not be withdrawn, but should pass on upward, and, seizing a foot, bring down the breech. All Ave have to think of in any position is to diagnose the child's relative position, select the hand accordingly, and proceed as above directed. In those very difficult cases Avhere the body is so crowded into the superior strait as to make it almost impossible to introduce the hand, OBSTETRIC OPERATIONS. 261 and quite impossible to hold on to the foot, Avhen once secured, to produce version, Ave must hold the foot, form a slip-noose with a strong handkerchief around the arm holding the foot, and then slip the noose up little by little Avith the other hand, on to the ankle, Fig. 71. Fig. 72. Fig. 71. Introduction of the hand in the second position of the right shoulder. Fig. 72. Mode of seizing the foot in the same position. taking care to secure the noose properly and firmly, when powerful traction can be made and version produced. All these manipulations should be slowly and very carefully performed. The Forceps. We noAv come to treat of the forceps. Of all the artificial means resorted to for the relief of women in childbed, the use of forceps is the most effective and results in the greatest saving of life to both mothers and children. Although the instrument has undergone a great variety of modifications since its invention by Chamberlen, its general principles remain unchanged. Its power is exerted in three different ways—as an extractor, compressor and lever. Forceps are commonly described as being of two kinds, Long and Short Forceps, though the difference in length of the two varieties lies more in the handles than elseAvhere. They consist of two branches or blades, each of which is divided into three portions—viz., the handle, which alloAvs of their easy introduction and the tractive efforts of the accoucheur, and Avhich is A^ariously constructed and shaped; the cephalic portion, Avhich is intended to grasp the fcetal head, and which is curved in tAvo directions—one to accommodate the blade to the cephalic globe, and the other to accommodate the blade to the curve 262 OBSTETRIC OPERATIONS. of the pelvic axis; and an intermediate portion or shank which joins the other two portions, and which usually furnishes the "lock" by Avhich the two blades are held in apposition Avhen adjusted. Straight forceps are such as have only the cephalic curve. These are preferred by some practitioners, but we are at a loss to understand how they can be preferred in a high position of the head. The short forceps are used to deliver the head only when it is low down in the pelvis—the long forceps Avhen it is situated high up. Many obstetricians, however, use only the long forceps, as the instru- ment is adapted to all cases where the use of forceps is indicated, how- ever low or high the head may be. " The long forceps possess a more scientific adaptation to the pelvis throughout the whole canal than the short forceps; and if the long forceps is found in practice capable of taking the head through the pelvis from brim to outlet, it folloAvs that, since the whole contains the parts, the long forceps is qualified to take up the head at any point below the brim." Fig. 73. Fig. 75. The short forceps in most common use, and undoubtedly the best instrument of its kind, is Davis's (Fig. 73). Of long forceps, Hodge's (Fig. 74), or Hodge's as modified by Wallace (Fig. 75), can be very highly commended. Bethel's forceps, likewise a modification of Hodge's instrument, I have long used with great satisfaction. The "St. Louis forceps" (Fig. 76), the invention of Professor T. G. Corn- stock of St. Louis, appears to be constructed upon sound principles, and has been highly spoken of by those who have used the instru- ment. Each blade is numbered—the left or male blade, Avhich is to OBSTETRIC OPERATIONS. 263 be introduced first, is marked plainly No. 1, and the right or female blade, which is to be introduced last, is marked No. 2. Thev may be applied in all cases Avhere the long forceps are required, and conse- quently where the short forceps are required also. This instrument _____ Fig. 76. Fig. 77. is very nicely made by Mr. J. J. Teufel of Philadelphia. Elliot's forceps (Fig. 77), the invention of Professor Elliot of NeAv York, by means of an adjuster in the handle gives the advantage, if it be an advantage, of lessening the amount of compression exerted by the instrument upon the foetal head. When the forceps are required to be used the woman should be apprised of the fact, though in as gentle a manner as possible. The accoucheur might speak of having artificial hands in his posses- sion which would enable him to reach the child's head and hasten its deliverance, thereby relieving her more speedily of her sufferings. as well as rendering the saving of her child's life more certain. At all events, her full and free consent to their use should be obtained. Application of the forceps having been decided upon, and the con- sent of the patient having been gained, she should be placed in the following position: She should lie upon her back, with her hips Avell down to the edge of the bed (if the child's head is in the superior strait, the mother's breech should be brought down quite to the edge of the bed, so that the handles of the forceps when locked may hang over the side of the bed); the thighs and legs should be flexed, separated and supported on two chairs or by two assistants; one hand of each assistant should be placed upon a knee while the other holds a foot. The accoucheur takes his place between the separated limbs of the patient, and stands, kneels or sits as he may prefer. Care should be taken that the position of the patient is made as comfortable to her as 264 OBSTETRIC OPERATIONS. circumstances will permit. The forceps may be applied while the woman is lying upon her left side in the usual position of parturition, but the dorsal position is for all reasons by far the best. When the forceps are applied to the head at the outlet, it may not be necessary to subject the patient to the inconvenience of being placed on her back and moved to the edge of the bed, but it will be found in a o-reat majority of cases, even of this character, that an adherence to the above directions in regard to position will be most conducive to the proper use of the instrument. Before applying the forceps each blade should be dipped in hot Avater, that it may be warmed to blood heat, and the external or convex surface should be anointed with lard. The operation of using the instrument may be divided into four stages—viz., introduction of the blades; locking; traction and lever- age; removal of the blades. They are applicable in the following cases: 1. When the os uteri is either dilated or is soft and yielding, and there is a proper degree of moisture of the parts, but the action of the uterus appears to have subsided or ceased altogether, and the patient is becoming exhausted. In such cases, after a reasonable use of homoeopathic remedies without avail, the child should be delivered either altogether or partially by the forceps. It may not be necessary to continue the tractive force so as to complete the labor, for Nature sometimes seems to rouse from her sluggishness under a moderate de- gree of traction by the instrument, and is able to complete the act of parturition without further assistance. 2. In some cases of facial presentation, where the diameters of the head are opposed to those of the pelvis—the long diameter of the head lying in the short diameter of the pelvis, for instance—and a reasonable waiting on the efforts of Nature or other measures have failed to bring about a favorable change. 3. Where there exists disproportion between the cephalic globe and the maternal pelvis, yet not to a degree requiring crani- otomy or other more serious operative interference. In these cases the compressive power of the blades reduces the size of the head, while tractive efforts draw it through the pelvic cavity. 4. Where the hand, foot or cord presents with the head, the forceps may be needed to bring doAvn the head and effect delivery. 5. When certain emer- gencies which complicate the labor occur, such as convulsions, rup- ture of the uterus, etc., and it is necessary to effect a speedy delivery to save the life either of mother or child. 6. When the after-coming head in breech presentations is compressing the cord, and the head cannot be delivered by manual aid alone. Here the forceps must be OBSTETRIC OPERATIONS. 265 promptly applied and delivery quickly effected, or the life of the child will be sacrificed. The use of the forceps is contra-indicated when the os is undilated and the soft parts are rigid and unyielding, and again Avhen the dis- proportion betAveen the foetal head and the pelvis is so great as to give no reasonable hope of effecting delivery, either from the amount of compression the instrument is capable of exerting or the amount of traction that may be applied. In serious malformations of the pelvis, or where bony tumors obstruct the pelvic passage-Avay, its use is out of the question. The mode of application of the forceps varies slightly in different cases, although the general principles regulating the introduction and adjust- ment of the blades are the same in all cases, whether long or short for- ceps be used. The position of the patient has already been described. Now, having placed her in this position, and the forceps having been warmed and greased as directed, the accoucheur takes his position, and, having ascertained the position of the fcetal head and its relation to the surrounding parts of the mother, proceeds to. introduce the male blade first—that is to say, that blade the convexity of the cephalic curve of Avhich will adapt itself to the concavity of the left iliac fossa of the mother. This he does in the following manner: The blade is to be held in the left hand and in a perpendicular position; tAvo fingers of# the right hand should then be inserted into the vagina and passed up for a short distance Avithin the cervix uteri, between the uterus and the fcetal head; then the point of the blade should be laid against the inside of the fingers thus introduced and slipped along them until the blade reaches the foetal head. Noav the blade is to be introduced still farther, and in such a manner that its concavity will be adapted to the convexity of the foetal head, and this will be executed by laying the blade flatAvise upon the head and gradually lowering the handle, Avhile at the same time the blade is gently pushed onward, or rather alloAved to glide omvard, until the convexity of the head is Avell grasped by the fenestrated portion of the blade. This done, the handle should be pushed back still nearer to the perineum, in order to get it out of the way of the second blade. The second or female blade is to be held in the right hand and in a perpendicular position, while two fingers of the left hand are insinuated betAveen the cervix uteri and the fcetal head. The blade is then to be slipped along the inner surface of these fingers until the head is reached, Avhen its further introduction is accomplished in the same manner as before described. Both blades having been thus introduced, they are to be locked by 266 OBSTETRIC OPERATIONS. lightly seizing a handle in each hand and gently bringing the blades into apposition, being careful at the same time to guard against en- tangling the hair or any of the soft parts of the mother Avith the lock. It may be regarded as an axiom that if the blades do not readily lock one or both have been improperly introduced. In such a case one or both should be Avithdrawn and reintroduced, for no force should be exerted in locking. It is absolutely necessary in introducing the blades to proceed with the utmost gentleness. Force is altogether uncalled for, and great in- jury may be done by a disregard of this admonition. It may generally be taken for granted that when the blades are introduced easily they are introduced properly. "The rule, then, is this: hold the blade lightly; let it feel its way, as it Avere; let it insinuate itself into position. It will be sure to slide into the space where there is most room." Unless the necessities of the case compel us to resort to the most prompt measures to effect delivery, the blades should be introduced only during the absence of pains, and extractive force should be ex- erted only during the presence of and with the pains. The general direction is given to apply the forceps to the sides of the child's head, over the ears. This is not necessary, nor is it ahvays practicable. On this point Dr. Ramsbotham says: "In employing the short forceps I lay it doAvn as a rule that the blades should be passed over the ears; the head is more under command when em- braced laterally, and there is less danger of injuring the soft parts during extraction. But I confess that I have for many years been accustomed, however low the head may be, to introduce the blades Avithin each ilium, because they usually pags up more easily in that direction." It Avill be seen from this that this distinguished accoucheur regarded more the parts of the mother than the position of the fcetal head. The above description of the manner of introducing the for- ceps applies more particularly to the short instrument, but the mode of introducing the long forceps does not differ from it in any great degree. In using the short forceps the position of the foetal head is to be taken into account, and in some degree regulates the position of the blades, but in the introduction of the long forceps the pelvis only is to be considered. " The position of the head may be practically disregarded. The pelvic curve of the blades indicates that these must be adapted to the curve of the sacrum in order to reach the brim. They must therefore be passed as nearly as may be in the transverse diameter of the pelvis. One blade Avill be in each ilium, and the OBSTETRIC OPERATIONS. 267 head, Avhatever its position in relation to the pelvic diameter, will be grasped between them. The universal force of this rule much sim- plifies and facilitates the use of the instrument. Not only does it apply to the position of the head in relation to the pelvic diameters, but also to all stages of progress of the head, from that where it lies above the brim down to its arrest at the outlet."—Dr. Robert Barnes. In introducing the long forceps when the head is in the superior strait, the position of the patient is the same as already described, except that the breech must be brought to the edge of the bed, so that when the forceps are applied and locked their handles may hang over the side of the bed, for here the traction at first is dowmvard and somewhat backward. The blades are to be introduced in the same manner as described for the introduction of the blades of the short forceps. As a blade penetrates farther and farther within the pelvic cavity to grasp the head, the handle sweeps from before backward through a curve extending from an imaginary line prolonged upward from the anterior surface of the symphysis pubis to an imaginary line representing the prolongation of the axis of the superior strait or of the coccyx; and conversely, as the head is extracted the handles again sweep through this same curve from behind forAvard, while the head itself is traversing the " curve of Carus." If the os uteri should lie unusually high up, extra care will be necessary to insinuate the points of the blades within the cervix. If they should slip off into the cul-de-sac between the vagina and cervix, very serious injury might be done by pushing them through the vaginal wall into the cavity of the peritoneum. When the blades of the long forceps have been introduced, an easy locking indicates not only that they have been properly adjusted, but that the case is one suitable for their use; for their not locking without a resort to force shows either that they have not been properly applied, or that there is pelvic deformity to that extent that the blades cannot lie opposite to each other in the same diameter of the pelvis. Being firmly locked, pressure should be made upon the handles, and if this occasions no pain to the patient, we may feel assured that no part of the soft parts is included between the blades. Traction should then be made Avith a vieAV to accomplishing delivery. The direction of the handles Avill to a great extent indicate the direction in which the tractive force is to be applied. When the head is in the superior strait and the instruments are locked, the handles will always be at the extreme posterior commissure of the vulva, which shows (the 268 OBSTETRIC OPERATIONS. woman lying on her back) that the tractive force is to be made down- ward and backward, just as the handles point. As the head descends into the cavity more and more, the handles will elevate themselves more and more, till at the instant of the disengagement of the head from the A^ulva the handles will point almost or quite directly up- Avard. While operating, then, it is wise, after any tractive effort, to let go the grasp, that the handles may point in Avhat direction the next effort should be made. But the accoucheur should always bear in mind the curved axis of the pelvic canal through which the head has to be brought to be delivered. Traction should be made with every pain, and only then. The tractive efforts should imitate the uterine contractions as nearly as possible, resting Avhen the uterus rests, and drawing as carefully and gently as possible Avhen the uterus exerts its expulsive force, yet with sufficient force to be effectual. And we should, at the same time, relax the grasp upon the handles between the expulsive pains, to relieve the foetal head from the con- sequences of continuous compression. "Continuous compression is opposed to the course of Nature, which intermits the expulsive act, giving periods of rest, during which it is presumed that the brain may better adapt itself and its circulation be maintained. Hence the laAv that we ought in "forceps labors to imitate this intermitting action by interposing intervals of rest, endeavoring so to time our efforts as to be simultaneous with and in aid of the natural expulsive efforts." Great care should be used not to wound the soft parts by SAvaying the instrument sideAvays or upward and dowmvard, as all these move- ments are unnecessary. As the perineum becomes distended Ave should proceed very sloAvly and cautiously, giving the parts time to dilate, so as not to endanger a rupture or laceration of the perineum. The use of anaesthetics in these operations is particularly objection- able, since their use tends to increase the danger; for Avhen pain i? produced by pressure Avith the forceps we know all is not right, and hasten to correct the error; but where the patient is rendered uncon- scious by the use of anaesthetics, this valuable indication is lost. The direction to keep the blades of the forceps in introducing them closely applied to the child's head is of considerable importance. It sometimes happens that the cord lies close down to the occiput, and it is possible for it to fall between the point of a blade and the f etal head, and it would in that case naturally be compressed and the child s life endangered when the two blades were locked. If upon making traction the child should be felt to jerk about or struggle (as the squirming of a fish is felt by the angler), this untoward circum- OBSTETRIC OPERATIONS. 269 stance may be suspected to have occurred, and the blades should be instantaneously loosened and AvithdraAvn, to be reapplied. It is sometimes necessary to exert very poAverful tractive force to effect the delivery of the head. Should the accoucheur have satisfied him- self that the case is one adapted to the use of forceps, and that the instrument has been properly applied and locked, this may be resorted to without serious detriment to mother or child, provided traction is made steadily in the right direction, and only at the right time; that is, during the expulsive uterine efforts, even though these may be feeble. The vis a fronte exerted by the forceps supplements the defi- cient vis a tergo exerted by the uterus. Fortunately, cases requiring a great expenditure of muscular effort are of infrequent occurrence. The forceps may be applied to deliver the after-coming head—in breech presentations, for instance—where the hands alone and flexing the head by pressure with the finger in the child's mouth are not sufficient to secure expulsion. Should the cord be compressed by the retained head, very prompt action within a feAv minutes will be re- quisite to save the child's life. The best method of using the forceps in these cases is as folloAvs : The body of the child should be draAvn well forward toward the symphysis pubis, and held there by an assist- ant; then pass the left hand into the vagina and insinuate two fingers betAveen the cervix uteri and the child's head on the left side of the pelvis; slip the forceps blade up the palmar surface of these two fingers to its proper place on the head, then introduce the right hand into the right side of the pelvis, slip up two fingers as before, and let the blade for that side glide into its place, guided by these two fingers; then lock the blades. Then exert tractive force first in the direction of the axis of the superior strait, gradually changing the direction of the handles from behind forward as the head comes down, and finally, as the occiput appears. under the pubic arch, carry the handles well forward, so as to take off the strain from the perineum as the face and forehead SAveep over it. The late Dr. Casanova was in the habit of using, in cases where other practitioners would resort to ordinary metallic forceps, an instru- ment which he termed a " Tocological Flexible Forceps" of his own invention. Dr. Tuthill Massy of England published an article on the use of this instrument and of Casanova's " Flexible Cephalo-ex- trador? in the "British Journal of Homoeopathy," vol. xxix., p. 327, with two plates exhibiting the instruments and their application. 270 OBSTETRIC OPERATIONS. The plates are here reproduced, together with their description and that of the use of the instruments as given by Dr. Casanova: Fig. 78. No. 1. " Fig. 1.—Eepresents the head seized with the double forceps, and the manner in which it is extricated from the pelvic strait. " No. 1. A single forceps seizing the head round the middle and inferior part of the chin. " No. 2. A single forceps seizing the head round the occiput. " No. 3. A frontal safety check-band, to prevent the forceps from receding and choking the infant. " Each of these forceps is composed of a piece of whalebone about three feet long, three-tenths of an inch in breadth, and one-tenth of an inch in thickness; of two silver rings at their extremities, well fastened, and the whole well polished. OBSTETRIC OPERATIONS. 271 "The frontal safety check-band ought to be placed at about four inches from the centre of the forceps No. 1 on each side, and it must be well secured. A piece of silk or any other smooth cloth will answer. Its length is from seven to eight inches. Fig. 79. C FIG. 2 " Fig. 2.—Represents the cephalo-extractor seizing the head of the infant after its death and separation from the body. "This instrument is made of two pieces of whalebone of the same dimensions in every respect, as those of the forceps, without rings in their extremities. These two pieces are fixed by their centre with a silver pin riveted on both sides, flat and 19 272 OBSTETRIC OPERATIONS. smooth to allow the pieces to move or open and close as the blades of a pair of scissors. (iSee Fig. 2.) When closed and held by the two extremities, they represent one of the forceps. When opened, and holding the four extremities in one hand (see a), thev represent Fig. 2. " Fig 3 "Represents the head seized in a different manner; as the diameter ia generally found to be less from A to B than from C to D, 1 have found it much easier to seize and extract it in that way (when such a difference is clearly mani- fested) than otherwise. , , . . " Fig 4. Represents a plain silver plate of an oval shape, Avith three holes in it* centre to allow the four extremities of the cephalo-extractor to pass when it \m seized' the head. The lateral extremities pass through holes Nos. 1, 1, one by each and the anterior and the posterior both pass through the hole No. 2. (See Fio- 2 a) This plate renders the instrument open and immovable, and it serves to "press'the head as much as may be required to extract it, without injury to the mother. Dr. Casanova was led to the use of the flexible forceps for effecting delivery, through the success he met with in a difficult case where metallic'forceps could not be had, and where he used successfully a pair of loops or fillets made of rattan shaved down smooth and thin, and applied under the chin and occiput respectively. He thus de- scribes their mode of use, for which we are likewise indebted to the article by Dr. Massy : "Flexible forceps should be applied as folloAvs: The patient lying on her left side over the edge of the bed or on her back, as circum- stances may require, you should bend one of the branches of the instrument and hold the two extremities together Avith your right hand; the bent part, being pressed and guided by the left, will be introduced over the face of the child or over the occiput, according to its position, that you may reach the inferior part of the chin or that of the occiput. The head being thus seized, you will be able to extricate it by pulling toAvard you in the most favorable direction. Should one branch be not sufficient, introduce the other on the oppo- site side of the former; and Avhen you are assured that both branches are properly placed, you can move them in any direction you please, and perform the necessary rotations to extract it Avith safety. (See Fig. 1.) The simplicity of this instrument and its flexibility render its application much more easy and more safe than the old iron for- ceps. There is no force required to accomplish this operation, nor is any compression exerted on the child's head laterally. If you be patient and Avateh a favorable opportunity when pain is present, you will succeed in bringing forth the infant without any injury to it or to the mother. " For more than twenty years I have been in the habit of using OBSTETRIC OPERATIONS. 273 this kind of forceps exclusively, and the experience of that time has taught me to appreciate its utility from the successful results I have obtained Avith it." Doubtless skill acquired in the use of the above-described instru- ment enabled the eminent Casanova to do Avith it what other men Avould do Avith metallic forceps. But it is to be remembered that the only force capable of being exerted in any marked degree by the flexible forceps is that of extraction; while compression and lever- age, Avhich enter so largely into the valuable forces capable of being brought into use through the metallic forceps, are almost entirely want- ing to a flexible instrument. Nevertheless, it is apparent that there are many cases in Avhich such forceps as Casanova used could be made available in very many cases of immovable head in the inferior strait or at the \mlva, with less of suffering to the mother and less detri- ment to the infant than sometimes results from the employment of the ordinary instruments. They are referred to here as worthy of trial, and especially so as they are so highly praised by their in- ventor, a man Avho deservedly stood high in the esteem of all practitioners of the homoeopathic school of medicine. The Vectis. The vectis is an instrument which might be used to advantage much more frequently than it is. It resembles someAvhat a blade of the forceps, and may be used as a lever, or even, to a moderate de- gree, as a tractor. The ordinary instrument is about twelve inches in length, one-half of Avhich are taken up in the handle. It may be readily applied over the occiput, face or sides of the head, and by making a fulcrum of one hand considerable leverage can be made with the other hand, and at the same time a moderate degree of trac- tion may be exerted. In some cases of facial presentation, Avhere the head is impacted, it might be made very useful, and again, in brow presentations, by bringing down the vertex by means of the vectis, a facial presentation Avill be prevented. It should be Avarmed'and greased before being applied, and is to be introduced much in the same manner as a blade of the forceps. If it is intended to pass the instrument within the cervix uteri, the same precautions should be observed to ensure its going in the right direction as Avere laid doAvn for introducing the forceps blade—viz., two fingers should be insinu- ated betAveen the cervix and the foetal head, and the blade of the vectis should slide along their palmar surface until Avell within the cervix. After its introduction, and before any power of any kind is 18 274 OBSTETRIC OPERATIONS. exerted, the free hand should be placed at the vulva in such a manner as to afford a fulcrum for the instrument. In no case should the maternal parts be used as a fulcrum for the play of the instrument. Craniotomy. The operation of craniotomy is dictated by that natural law of humanity which commands us to save the life of the mother if pos- sible, even if it involve the sacrifice of the child. It consists in making an opening into the cavity of the fcetal cranium, discharging its contents, and thereby securing a diminishing of the bulk of the head, either by the compression exerted upon it by the soft parts of the mother under the force of uterine contraction, or by additional instrumental resources, thereby rendering possible its expulsion or extraction. It is indicated in cases where the child cannot be de- livered with safety to the mother either by the forceps or by version, and yet there is reasonable ground for believing that it might be if the bulk of the head were reduced. If no such hope can be enter- tained, the Caesarian operation alone remains to be resorted to. Obstetricians have variously stated the minimum pelvic measure- ments for the performance of craniotomy. It may be stated, however, that if the antero-posterior diameter at the brim or the transverse at the outlet measures less than two inches, delivery by craniotomy could not be accomplished. But there are cases requiring crani- otomy in Avhich there is no abnormality of the pelvis or soft parts of the mother. Here the difficulty is due to the enlarged condition of the fcetal head, as by hydrocephalus. If the head in such a case is not sufficiently moulded by the maternal parts, or cannot be suf- ficiently compressed by the obstetric forceps, craniotomy must be resorted to. It is impossible to lay doAvn any fixed rule in regard to the time at which the operation should be performed. If, however, its necessity is apparent from the first, the sooner it is resorted to after the os uteri is sufficiently dilated the better it will be for the patient. The os uteri should be dilated at least sufficiently to admit the instrument used in effecting perforation. If it be dilated more than this it is an advantage. A variety of instruments have'been invented for effecting perfora- tion of the cranium. Of these probably the best in skillful hands is the modified " Smellie's Scissors" (Fig. 80). Braun's Perforator (Fig. 81) is likewise a valuable instrument, and may be used with great advantage, particularly Avhen cran'otomy is required to deliver OBSTETRIC operations. 275 the after-coming head. The proper method of using the last-named instrument is suggested by the instrument itself. Fig. 80.. If craniotomy is to be performed, perforation is the first step, and Smellie's scissors being selected, the operation should be conducted in the following manner : The bladder and rectum ha\Ting been emp- tied, as before other obstetric operations, the patient should be placed in the same position as Avhen forceps are applied. Two fingers of the left hand are then to be passed up to the head, keeping the 'cervix uteri upon their dorsal aspect. The instrument should then be intro- duced very carefully along the palmar surface of the fingers, Avhich should serve not only as a guide, but as a guard to protect the parts of the mother from injury. In this way it is to be passed up to the head, great care being taken that its point does not touch anything until it strikes the foetal head. The most depending part of the head is usually selected as the site of the operation. This reached, the instrument by a combined boring and pushing movement is made to pierce the cranium; if a bone is to be perforated, extraordinary care will be requisite to prevent the point of the blades slipping off and doing serious injury to the mother. The instrument is then to be pushed into the head, up to its shoulder, which is about an inch back of the point of the cutting blades. While this is being done an assistant should support the uterus externally, making firm doAvn- ward pressure, to force the head -of the child doAvnward, and keep it fixed, and thus prevent its rolling about or retreating from the pres- sure of the instrument. The blades are noAv to be opened, when their outer cutting edges will enlarge the aperture, and if they are 276 obstetric operations. then closed, turned at right angles to their first position, and again opened, a crucial incision will be made Avhich Avill not readily close, and which will be sufficiently large to discharge the con- Fig. 82. MODE OP INTRODUCING AND USING SMELLIE'S SCISSORS. tents of the cranium, as well as break up the cranial arch. The brain should then be broken up by the perforator, which not only facilitates its extrusion, but at once destroys the suffering of the child. The instrument should then be carefully Avithdrawn, guarded as before. The second step of the operation consists in extraction of the child. Uterine action alone may now be sufficient to accom- plish this. At all events, should there be no reason for effecting immediate delivery, it will be well to wait for the "pains" and see what they can do. One authority says: "After perforation wait an hour or two for the pains;" and indeed this may be done if no unfa- vorable signs be present to indicate a more expeditious delivery. Should nature not be able to accomplish the expulsion of the child, instrumental aid must be sought. The craniotomy forceps, the crani- ocl'ast or the crotchet are instruments devised for this purpose. By their aid the accoucheur effects compression and traction. The great- est care is to be exercised in their use to guard against injury of the maternal parts, either by the instruments themselves or by pieces of the cranial bones that may be broken off and brought away. The most generally useful of all these instruments is the craniotomy obstetric operations. 277 forceps; of which those invented by Professor Meigs (Figs. 83 and 84) fulfill all that will be required of such instruments. By the craniotomy forceps the perforated head may be seized and extracted or, where that cannot be accomplished, portions of the cranial bones may be removed and extraction accomplished afterward. If the vault of the cranium be removed, so that its base and the face are Fig. 83. Fig. 85. alone left behind, the head thus reduced can be seized by the forceps and drawn through a comparatively small opening. But if this re- moval of the cranial bones should not be necessary, traction may be made by introducing one blade within the cranium while the other passes on the outer side and a hold is thereby taken. Simpson's cranioclast (Fig. 85) is justly regarded as a most excellent craniotomy forceps. It has separate blades, which are to be intro- duced much in the same manner as the obstetric forceps, and locked after their introduction. Professor Elliot of New York considers it the best craniotomy forceps. With this instrument, one blade being passed into the cavity of the cranium and the other on its outside, the bones of the cranium, particularly the occipital bone, may be broken up, and the size of the head thereby considerably reduced. Traction may then be made by means of the instrument. The crotchet is a dangerous instrument, even in skillful hands. The principle of its application is, to pass it into the perforated cranium and by means of its hooked process to obtain a purchase 278 obstetric operations. upon the head. The hook takes hold of some part of the cranium, or it may be passed through the foramen magnum. The danger to the mother is very great from the liability of this instrument to slip and produce laceration.. To guard against this accident, a finger should be passed up on the outside of the cranium, to serAre as a guard and support to the sharp point of the crotchet, which is fixed into the bone inside the cranium. The instrument is noAv constructed Avith a second blade, which passes up on the outside of the fcetal head, and takes the place of the finger in acting as a guard. If a firm hold can be taken on any part of the cranium, very powerful traction can be exerted through the crotchet; but, unfortunately, however firm the hold may seem to be, it is possible for the parts to give way, and the greatest care therefore should be exercised in its use. Cephalotripsy is an operation to effect delivery by means of crush- ing or breaking up the foetal head and reducing its diameters very considerably by means of an instrument through which great crushing power can be exerted. This instrument is termed the cephalotribe. It has two blades Avhich have some resemblance to the blades of the ordinary forceps, Avhile there is a screAV-poAver in the handles by which the crushing process is regulated. The blades are introduced in the same manner and Avith the AAroman in the same position as Avhen the obstetric forceps are used, and when locked the crushing process should be commenced. Before the cephalotribe is used, per- foration of the skull and evacuation of its contents should be effected, to ensure a more successful compression. This operation, hoAveArer, can only be regarded as a substitute for the ordinary method of crani- otomy, to be resorted to in extreme oases. Where there is very great pelvic deformity, after perforation and evacuation have been accomplished, it is recommended, in some cases where efforts at extraction haAre failed, to wait for some time until incipient decomposition has rendered the parts more yielding and capable of collapsing. Embryulcia. This formidable obstetric operation consists in perforating and eviscerating the thorax or abdomen of the child, or both. It may be demanded in cases of extreme pelvic deformity, Avhere, the head having been perforated and delivered, the delivery of the trunk in its natural condition is impossible; or it may be called for when the thorax or abdomen is greatly enlarged by dropsical effusions. Smellie's scissors is the best instrument to employ for this purpose. OBSTETRIC OPERATIONS. 279 The instrument should be pushed into the thorax through one of the intercostal spaces, and if necessary one or more of the ribs should be divided; or it should be pushed into the abdomen Avhere that is re- quired ; in both instances the instrument should be used with great care and the mother carefully guarded against possible injury. It has been stated that "this operation is required sometimes in cases of arm presentation, where the membranes have ruptured, the liquor amnii escaped, and Avhere the uterus is so firmly contracted on the child, Avhich is thus jambed doAvn into the pelvis, that turning has become impossible." I am by no means willing to coincide with this opinion, for I do not believe that turning is impossible in any of these cases under the manipulation of that most important obstetric instrument, an educated hand. Decapitation. I am not able to conceive of any case in which a resort to this operation Avould be an absolute necessity. If any such case should arise, a pair of strong, sharp-pointed scissors would be the best instru- ment for the purpose. With these the neck should be penetrated, the spinal column and cord should then be severed, and the soft parts subsequently divided. The head can be removed aftenvard by the forceps or other means. The Cesarean Section. This operation consists essentially in delivering a child through an opening made by dividing the abdominal parietes and the uterus of the mother. Its intent is to sa\'e the life of one or both Avhen delivery per vias naturales is regarded as impossible. Concerning this opera- tion, Dr. Robert Barnes writes as follows: " The Caesarean section occupies a doubtful place between conservative and sacrificial mid- wifery. It is conservative in its design, in its ambition; it is too often sacrificial in fact. It is resorted to with a feeling akin to de- spair for the fate of the mother, which is scarcely tempered by the hope of rescuing the child. It is looked upon by the great majority of obstetricians as the last desperate resource, as the most forcible example of that kind of surgery which John Hunter regarded as the reproach of surgeons, being a confession that their art Avas baffled. On the other hand it is regarded by some enthusiastic practitioners, dazzled perhaps by its false brilliancy, as an operation deserving to be raised into competition with turning, craniotomy or cephalotripsy." It is impossible to lay down such rules as Avill serve as infallible 280 OBSTETRIC OPERATIONS. guides to the obstetrician in making up an opinion for or against the operation, but Ave may state broadly our conviction that it should be regarded as a dernier ressort. "The Csesarean section is the last refuge of stern necessity." While, hoAvever, statistics of the operation shoAV quite a large rate of loss, both of mothers and children—about two-thirds of the former and one-half of the latter—it is to be borne in mind that the recent great advances made in operations upon the abdomen give a much better chance for recovery of the mother and of a safe extraction of a living child than formerly. The Csesarean section may be regarded as indicated Avhere there is pelvic deformity to the extent that the channel through which the child must pass does not exceed tAvo inches in diameter. Again, it may be called for in some cases of ruptured uterus, where the child is known to be alive, Avhere the mother's life is threatened in cases of extra-uterine pregnancy, or Avhere the mother has died suddenly un- delivered. In the last-named case the operation has to be resorted to promptly, and very expeditiously performed, probably not more than eight or ten minutes after the mother's death, in order to secure the extraction of a living child. It is questionable whether the Csesarean section should ever be performed when the child is knoAvn to be dead. The operation should be performed in the following manner: The rectum and bladder having been evacuated, the woman should lie upon her back, Avith head and shoulders slightly elevated and the pelvis supported and likewise slightly raised. An assistant should give firm and equable support to the sides of the abdomen, to prevent extrusion of the boAvels through the incision. An incision should then be made in the linea alba, extending from the umbilicus to within a short distance of the symphysis pubis—about eight inches. The linea alba is selected as the proper place for the incision, because there will necessarily be less hemorrhage, and because also the uterus will be found lying immediately beneath, uncovered by intestines. After this first incision—Avhich should not extend into the abdominal cavity—has been made, an opening into the abdomen should be secured, through which the finger or a grooved director should be introduced, and the abdominal incision then completed by cutting from Avithin outAvard, to avoid inflicting injury to the intestines or cutting unnecessarily the uterus. This incision completed, the uterus is seen. Before making the uterine incision, the location of the pla- centa should be made out, that it may be avoided. This may be done, according to Dr. Pfeiffer, by placing the hand flat upon the uterus, Avhen a peculiar thrill or vibration communicated to the hand OBSTETRIC OPERATIONS. 281 will mark the position of the placenta, and, in connection with this, the slight bulging of the part, "as if a segment of a smaller globe were seated on a large spheroid," will likewise serve to indicate the place of attachment of the placenta. The uterine incision should then be made, four or five inches in length, on a line with the cut through the abdominal parietes. Neither the fundus nor the cervix of the uterus should be involved in the incision, Avhich should be limited to the body of the organ, as by dividing either of these por- tions the subsequent contraction of the viscus would be interfered with. Then " an assistant hooks the forefinger of each hand in the upper and Wer angle of the uterine wound, and, lifting them up, fixes them in contact Avith the corresponding angles of the abdominal wound. This shuts out the intestine effectually, and tends to prevent the blood from running into the abdominal cavity." The membranes should then be ruptured and the child carefully extracted, by seizing- it, if possible, by the feet. Should the head of the child be caught and firmly held by the lips of the wound, it will be better to enlarge the incision rather than attempt to extract the head by force. The placenta and membranes should then be removed, together Avith all coagula, and the operator should ascertain that the os is free to admit of the passage of the lochial discharge. Dr. Barnes directs that a probang be passed through the os uteri and Angina to ensure this. Should the uterus now contract, the incision will be reduced to a small slit, and the hemorrhage from its divided vessels or from the mouths of the uterine sinuses made patulous by the detachment of the placenta will soon cease. If it should not thus spontaneously con- tract, direct pressure should be made upon it Avith the hand, or ice may be applied directly to it, and a piece be left in the uterine cavity. Should these measures fail to induce contraction, galvanism must be resorted to, and a proper apparatus should be at hand in case it should be needed. In regard to securing the uterine wound, authorities appear to be divided as to Avhether sutures should be used or not. If the con- traction of the uterus be firm, they will probably not be required; but on the other hand, in fatal cases autopsy has revealed the uterine wound in a gaping condition where sutures had not been used. Barnes states the case as follows : " If the patient is operated upon at a selected time, if the danger of ATomiting is lessened by not taking chloroform, and if the uterus contracts well after the operation, the sutures may be dispensed with; but under the opposite circumstances it would be better to stitch the uterus." If sutures are used, either 282 OBSTETRIC OPERATIONS. the uninterrupted silk suture or interrupted sutures of silver Avire may be employed; or any other that may be thought most suitable. Before closing the abdominal Avound, blood or other foreign mate- rial that has found its way into the abdominal cavity should be re- moved. The lips of the Avound should be brought together and held together by means of silver-wire sutures, introduced pretty closely together, and passing through the divided peritoneum as Avell as through the abdominal wall, so that there may be two peritoneal surfaces opposed to each other on the inside of the Avound. Adhesive inflammation is soon set up, and union is speedily effected. Broad bands of adhesive plaster should be applied across the abdomen as a means of support, and over these a soft compress should be laid. .\ broad flannel body-bandage should then encircle the abdomen to secure uniform support. The compress and the bandage should be saturated in the region of the wound with a solution of equal parts of calendula and water. The dangers arising from this operation are: immediate shock, hemorrhage, peritonitis and septicsemic puerperal fever. Should any of these arise, they should be treated strictly in accordance with homoeopathic principles; an adherence to Avhich Avill greatly lessen their dangers. The patient should be kept very quiet after the ope- ration, and for some hours should be allowed to take little or nothing into the stomach save cold water, which may be freely allowed. To excite vomiting is to add an additional and unnecessary risk. The danger arising from vomiting contra-indicates the use of chloroform; ether Avill be preferable. Local anaesthesia by means of rhigolene or ether spray has been recommended, and is free from the danger of exciting vomiting. Where this operation is performed under the most favorable circumstances there is a Arery great probability that the lives of both mother and child Avill be saved; but Avhere ex- haustion from protracted labor or other unfavorable conditions exist, the probabilities run strongly in the opposite direction. The Sigaultean Operation, or Symphyseotomy. This operation has been performed with the same object in view as in the Caesarean section—viz., the extraction of a living child which could not be born by the natural passages. It consists in cutting through the fibro-cartilage which constitutes the symphysis pubis, so as to separate the pubic bones, and by that means to increase the diameters of the pelvis sufficiently to allow of the passage of the fcetal head through the pelvic canal and A7agina. As it has been obstetric operations. 283 abundantly proven that the pubic bones, when their symphysis is thus divided, admit of but slight separation, and that this separation adds but very little to the diameters of the pelvis, the operation has fallen into discredit, and is seldom or never resorted to. Induction of Premature Labor. The induction of premature labor is admissible under certain cir- cumstances. By premature labor Ave mean that only which may take place after the viability of the child is established beyond a doubt. This period first occurs immediately after the close of the seventh month. In all cases where the excavation of the pelvis is so obstructed by any cause, either by pelvic deformity or by tumors of any kind that cannot be reduced or pushed above the superior strait, which will prevent the passage of the child at full term, premature labor may be effected; provided always that such a course will give a reasonable assurance of saving the life of the child, and at the same time of pre- venting greater sufferings and danger to the mother. Should the history of the patient prove that she cannot give birth to a child at term, and should the smallest diameter be about two inches and a half, premature labor should be resorted to immediately after the completion of the seventh month. If we could be assured that the smallest diameter is three inches, we may delay the operation till about the eighth month; if three and a half inches, two Aveeks before full term Avould suffice. Under judicious homoeopathic treatment no diseased condition of the patient would ever render necessary a premature delivery. Neither would it ever proA^e admissible to induce premature labor because the previous history goes to show that the child perishes at the eighth or eighth and a half month ; for all such cases are perfectly curable by medicines. Various methods of inducing premature labor have been resorted to. The author regards the following as the safest and best: The patient to be operated upon may assume the same position as in labor. The bed should be protected with oil-cloth or india-rubber cloth, arranged so as to guide a stream of Avater from the vulva into a pail or tub placed near the bed. Another pail must be provided, contain- ing tepid Avater: Avith a common syringe the Avarm Avater should be thrown directly upon the os uteri. This operation irritates and softens the neck of the ut""i s, so that contractions set in in the course of an hour or two, and thus labor is provoked and takes place in the most 284 obstetric operations. natural manner possible, except when it occurs in Nature's OAvn way at full term. The operation will fail unless the stream is so directed that it shall fall directly upon the neck of the uterus. It should be repeated in the course of two hours, unless the first experiment is successful. The common pump-syringe is the best for this purpose. The quantity of Avater used at each operation should be about ten quarts. Another method, and one very highly commended by Dr. Barnes, is to pass an elastic bougie or catheter six or seven inches into the uterus, avoiding the placenta and taking care not to rupture the membranes. The remainder of the bougie should be coiled up within the vagina, and this will serve to keep the instrument in situ. Sooner or later uterine action Avill set in. The os may then be dilated by means of Barnes's dilators, the membranes ruptured, and the rest left to nature if it is found that expulsive pains come on sufficiently. If not, the forceps or turning may be resorted to. Premature labor should never be induced without grave considera- tion of the case, and professional advice should be sought by the accoucheur in all such cases, as Avell for the advice as for a division of the very great responsibility. Of the production of abortion we have this to say : Can it be right under any circumstances Avhatever? Is it right to commit willful murder under any circumstances Avhatever ? If not, then it is never right to procluce abortion under any circumstances whatever, for is not abortion murder ? We have abundance of proof that under homoeopathic treatment no state or condition of health demands the production of abortion— that is, premature delivery before the product of conception is viable— for the subject of such a malady as might be thought to necessitate it under allopathic resources may be cured by homoeopathic medication, not only of the ills immediately occasioned by pregnancy, but of all ailments reducing the standard of general health. Abortion, there- fore, under such circumstances Avould be a terrible mistake; and not only does it destroy the life of the embryo, but it lowers the standard of health and endangers the life of the mother. Cases in which the least diameter of the pelvic excavation is below two and a half inches had better be alloAved to go to term, and then submitted to operative interference. If the Csesarean operation should then be performed and under favorable circumstances, the lives of both mother and child may be saved; the chances in favor of which are undoubtedly in- creased by the after-treatment being conducted in accordance with homoeopathic principles. disorders incidental to pregnancy. 285 CHAPTER XVI. DISORDERS INCIDENTAL TO PREGNANCY. IN a state of perfect health all the functions of the body are so har- moniously carried on—each receiving its proper portion of the vital force in due season—that no one preponderates over another. But where, as in cases of excessive intellectual development in chil- dren, any one structure obtains more than its just share, the others must suffer in equal ratio. Gestation is indeed a normal condition, but the remarkable development of vital action in the uterus renders it an exceedingly difficult task for nature perfectly to adjust the bal- ance. But while in general a similar increase of vital action seems to pervade the entire system, the health remaining perfect, there are numerous and sometimes most distressing exceptional cases. The greater number of these appear in connection with the nervous sys- tem, and at first take the form of sympathetic irritation. There are other disorders in the pregnant state Avhich arise from mechanical pressure, and even displacement of the abdominal organs, by the gravid uterus. And there is still another class of disorders, severe functional derangements, and even deeper-seated derangements of the elementary constituents of the blood, which seem to be the re- sult of some of those before mentioned. All these sympathetic irritations, structural difficulties and derange- ments of the constitution of the blood, acquire a still greater import- ance from the fact that they become the occasion for the development of every constitutional weakness and hereditary taint. The way is long and tedious; what AAronder then that the heavily-laden system of the pregnant woman sometimes stumbles? Hoav much greater the wonder if the nine months of gestation, even before being concluded by perhaps twice as many hours of almost convulsive effort, should not expose and aggravate every inherent debility and fully develop every latent miasm! There is yet another class of difficulties, which, if they do not actually make their first appearance during gestation, then at least for the first time become seriously troublesome; this class includes disorders con- nected Avith the uterus itself and with its appendages. Some of these are structural diseases of the vagina, os or cervix uteri, unnoticed be- fore, now rapidly deAreloped. And even if there Avere no morbid conditions, the suspension of the regular catamenia! flow could not but 286 DISORDERS INCIDENTAL TO PREGNANCY. exert an important disturbing influence upon the more delicate female constitution. But from Avhatever cause they arise, and to whatever class they may be referred, all the disorders of pregnancy require the most patient and careful attention on the part of the homoeopathic physician. The season of gestation is the time given him for sowing the good seed from Avhich his patient may reap a rich harvest of improved health during all her subsequent life. The fact just mentioned, that the almost herculean labors of nature tend to develop and ultimate all the hitherto latent, hereditary predispositions to disease, renders this period of gestation at once of the greatest value to the true physician and of the most serious importance to the patient. For even as an hereditary tendency to phthisis pulmonalis may be most readily and radically cured Avhen its temporary development in a bad cold, or even in a severe attack of pneumonia, renders its characteristics more apparent, so the exaggerated manifestation of her constitutional disorders which in one form or another so afflicts the pregnant woman, may be made the opportunity for radically purging them from her own system, and at the same time of purifying the constitutions of all her children. As already intimated, the tremendous strain upon the constitution during pregnancy finds its crisis in the agonizing labors of par- turition. These are rendered all the more terrible, are sometimes folloAved by the most disastrous consequences, and even rendered immediately fatal, by the culmination of the disorders developed during gestation. Thus, the same sedulous attention on the part of the true physician which will relieve her from present sufferings during the long months of pregnancy, will also render her confine- ment much more safe and easy, and entirely prevent those conse- quences Avhich so often fill her subsequent life with wretchedness. And the invaluable means and methods committed to the homoeopathic physician Avill often enable him not only to ameliorate the unfortu- nate condition of his suffering and despondent patient, but in many instances to secure for her the preservation of the fruit of her womb. In the homoeopathic jurisprudence, morning sickness and all other forms of gastric derangement must be entirely stricken from the list of justifiable causes for inducing premature delivery. The most distressing of these cases are relieved and the offspring preserved, where under allopathic regime the health of the mother was often rendered permanently wretched, and the child inevitably sacrificed at an earlier or later stage of pregnancy. And in many instances in which the mother had suffered for many DISORDERS INCIDENTAL TO PREGNANCY. 287 months from the disorders of pregnancy incidental to her constitu- tion, and had in consequence greatly deteriorated in her own vital nutrition, the child, if not actually destroyed, became of necessity greatly enfeebled. Such results are too common in allopathic prac- tice to attract much attention, and such offspring go far to savcII the bills of mortality to the frightful extent of one-triird of all who are born dying within the first three years. Contrast with this the fine healthy child born after the mother has been relieved of her dis- tressing disorders of pregnancy, and in a great measure at the same time cleansed of her constitutional impurities by homoeopathic medi- cation, and you have a picture of Avhat has been done in thousands of cases, and of what it is now the duty of the homoeopathic'physician at least to attempt to do in every case of the kind. He is the true physician who seeks not only to relieve the present suffering, but at the same time to remoA-e its cause in the constitution itself, and thus prevent the return of the evil. He is truly a benefactor of his kind who, not content Avith curing the generations with whose successive portions he mingles, thus seeks to improve his present opportunities in the light of an adA^anced and beneficent science, in such a manner that the race may be rendered more healthy in all the years to come. Our object in these remarks is simply to call attention to the pro- found importance of most carefully treating the disorders incident to pregnancy; even in cases Avhere their severity does not entail suffering, they may thus be seen to afford most precious opportunities for permanently improving the health of the mother, and of render- ing her confinement comparatively comfortable and perfectly safe, and of ensuring the preservation and health of the offspring; and finally, of securing the comfort of both mother and child during the season of lactation. We Avould state that, for reasons rendered obvious by the preceding remarks, the most valuable and efficient remedies for the disorders incident to pregnancy will be found among the anti- psorics; and that in some cases the higher these are given the more good they will do. Such is my own experience in very many cases. The disorders Avhich appear during gestation vary in almost every possible respect in different women; each individual, however, usu- ally suffering in the same manner whenever enceinte, and with the same comparative severity, unless relieved by appropriate homoeo- pathic medication. In some women these disorders appear Avith but slight intensity, and soon pass aAvay; while others declare they never 238 DISORDERS INCIDENTAL TO PREGNANCY. have such good health as they enjoy Avhen pregnant. Others, again, dread this condition as bringing Avith it for them a long train of vari- ous and distressing sufferings, by which their health is deteriorated, their strength exhausted, and their prospects in confinement rendered gloomy in the extreme. In some instances these disorders appear very soon after conception, and in different forms continue during the entire period of utero-gestation; in others they are relieved by the third, fourth or fifth month; while in other cases the difficulties make their appearance only during the later months, and continue to in- crease in severity till confinement. An I Avhile the disorders of pregnancy principally affect individual cases in one or more of their various forms, the entire range of these forms, as collected from the records of many cases, is found to cover every function and particular organized system in the female economy. The principal of these disorders may be classed under the following heads: Disorders of the digestive system and of the secretions and excretions; of circulation and respiration; of the uterus and Us appendages; of locomotion and innervation; and of the affections, emotions and feelings. Hygiene of Pregnancy. A few Avords on this subject, which is quite as important as the medical treatment of the disorders of pregnancy, inasmuch as it is intended to prevent such disorders from occurring. In order that this period may be gone through with in a thoroughly physiological manner, all unphysiological and unphilosophical habits must be laid aside and all pernicious practices abandoned. The pregnant Avoman should strive to cultivate for herself the utmost cheerfulness and tranquillity of mind ; she should strive to be at peace Avith all the Avorld and at peace with herself, for her mental and moral state Avill surely be engrafted upon her offspring, the education of the future being commencing while yet in utero. And in this effort she should be seconded by her husband, whose responsibility is very great at this period—whose conduct toward the wife of his bosom at this period, acting upon her mental organization, will be transmitted to their joint offspring, for weal or for avoc Medical men cannot be too particular in urging this point on all suitable occasions, as it falls to their lot not alone to cure diseases, both mental and physical, when they exist, but as Avell to prevent their occurrence when it is at all possible to do so. A pregnant woman, during the whole course of her pregnancy, will DISORDERS INCIDENTAL TO PREGNANCY. 289 require more sleep than at other periods, and an ample allowance of "tired Nature's sweet restorer" should always be indulged in. And yet, at the same time, habits of slothful ness are to be deplored and decried. " Early to bed and early to rise" applies Avith additional force at this juncture, and nine, or at the latest ten, o'clock at night should ahvays find her in bed, and six, or at the latest seven, o'clock in the morning should find her up. Habits of regularity in all things should be cultivated—regularity as to hours for sleeping and waking —regularity as to meals, exercise, stool, etc. As much exercise in the fresh air as is possible should be taken. Walking is indispensable, and every day should find her taking a Avalk leisurely and with the mind at ease; and this rule should be observed even in cold and, (xeteris paribus, unpleasant Aveather, excepting Avhen the Avalking is dangerous from snoAv or ice. A walk is often an excellent remedy for the slothfulness and heaviness that sometimes steals over the preg- nant Avoman like an incubus—a much better remedy than taking a nap, or even than a prescription from the doctor. Useful employment, reading or useful and agreeable conversation should engage the Avaking hours not otherAvise employed. In fact, the physician should enjoin upon his pregnant patients the importance of cultivating a proper condition of mental vitality as well as physical. Hoav important is it that the expecting mother, as a neAv thread of life is being spun within her, should think and do that alone which is good and right, for of a certainty her offspring will have Avoven into the tissue of its existence the resultant of what she is and does during her preg- nancy. It is a fact worthy of notice that as pregnancy advances the fluids of the body are increased in quantity, and of course an increase of circulating capacity is demanded. This has, in connection Avith other points, a decided bearing on the question of dress during pregnancy. Unusual looseness about the Avaist is requisite, and as Avell about the neck, wrists and lower extremities; even an elastic garter spanning the leg may be injurious, jand everything that can retard or in any way interfere with free circulation should be, if possible, avoided. The proper warmth of the clothing should be studied Avith great care. It should be composed of such fabrics as combine lightness with warmth, so that proper heat of body may be maintained Avithout the discomfort of oppressive clothing. In the later months, particularly, the clothing should not be tightened about the Avaist at all. The dress should be allowed to fall loosely and gracefully from the neck and shoulders, shoAving but little waist; and this will be found not 19 290 DISORDERS INCIDENTAL TO PREGNANCY. only most becoming, but far better for the mother and the fruit of her womb. One fact in connection Avith this question of dress is here noteworthy—viz., that women in the later months of pregnancy often complain of, and really suffer from, coldness of the abdomen, the protruding abdomen causing the clothing to set off to the extent of almost completely exposing that part of the body to direct contact with the air. In view of this, the clothing should be so adjusted, or an extra garment worn, to obviate the difficulty. Physicians will greatly benefit their patients by giving strict directions in regard to all these matters, which are so apt to be regarded as minor and insig- nificant points. The diet during pregnancy should be generous in meats, vegetables and fruits, and at the same time simple. The less tea and coffee are indulged in the better for both mother and foetus, as these have a tend- ency to produce nervousness and even convulsions. Sugar, salt and spices should be taken in moderation. Stimulants of all kinds should be most strictly and religiously avoided. Very many of the discomforts arising at this period may be promptly relieved or removed by a strict conformation to the laAvs of a rational mode of life. If, however, they should persist, and help seems neces- sary to adjust and properly balance the deranged vital forces, help is to be sought Avithin the pale of homoeopathic medication, and the law of the similars—here, as elsewhere, applicable—should be brought to exercise its wondrous health-giving powers. Thus pregnancy judici- ously managed prepares the way for the act of parturition, and, it may be remarked, just as pregnancy has been free or freed from sufferings and from complications, will, cceteris paribus, the act of parturition and its post partem consequences be likewise free from dangers and disorders.* Disorders of the Digestive System. The disorders of the digestive function and apparatus may be enumerated under the heads of variations of appetite and taste, gastric disturbances and intestinal affections. Under the first of these heads will be found anorexia, malacia or longing, and bulimy; under the second, nausea, vomiting and pyrosis; under the third, constipation, diarrhoea and fissure of the anus and rectum. I. Variations of Appetite and Taste. Anorexia, or Avant of appetite, and even disgust for food, very fre- * From a pamphlet by the author, entitled " Before, During and After Parturition." VARIATIONS OF APPETITE AND TASTE. 291 quently makes its appearance at the commencement of gestation ; less often it is seen only toAvard its close. In some cases there is a loath- ing for some particular kinds of food, especially meats; in other cases there seems to be simply a general loss of appetite. These symptoms are usually supposed to be the results of the sympathetic relations existing between the stomach and the uterus, but their deeper meaning, already referred to, will be particularly stated in connection with that of the other variations of appetite. Malacia or longing, another not uncommon affection of pregnant women, consists in a depra\Tation of taste, in which an almost univer- sal loathing is combined with an exclusive longing for some particular article of food. Where something injurious or not used for food is desired, the abnormity is termed pica. Chalk, charcoal, pepper, salt food, acids, alkalies, are sometimes very strongly and persistently craved and eaten. The desire for particular articles of food should be gratified to a reasonable extent. " The common tendency of the appetite in pregnancy is to prefer fresh vegetables, fruits and cooling drinks, and to avoid stimuli of all kinds. In this the taste of preg- nancy accords very Avell with all its requirements."—Smith. Bulimy, or inordinate and insatiable hunger, is another affection of pregnant Avomen; which here, as in other persons, generally indicates some disorder of nutrition or assimilation, although it may be due simply to sympathetic nerv^ous irritation. All these morbid condi- tions of the appetite are but indications of the various hitherto latent dyscrasia?, developed now by the pregnant state. And the careful ex- hibition of the appropriate remedies will not only relieve the suffer- ings of the patient, but will also greatly improve her general health, as already stated. We give the various remedies which have been found useful in these complaints. These should be compared Avith those more fully stated under Gastric Derangements, and carefully studied in the Materia Medica, in order to determine Avhich is the appropriate remedy in each individual case. Note.—In arranging these remedies for study* they have been classified and arranged in groups. Those in group 1 are most strongly indicated for the particular symptom or condition under which they are found. Those in group 2 come next in importance, and those in group 3 occupy the loAvest scale of relative importance. But while these indications of the relative prominence of particular symptoms in the confirmed pathogeneses of particular remedies are of great value, they will be found infallible only when they lead to the 292 DISORDERS INCIDENTAL TO PREGNANCY. determination of a medicine in accordance with the totality of the symptoms. And yet the totality of the symptoms will often be indexed by the characteristic symptom on the side of the patient and by the corre- sponding'key-note on the side of the remedy. Finally, and as elseAvhere observed in the present Avork, the charac- teristic symptom of a particular case may not be the most prominent or even the most distressing symptom: especially is this seen to be the case Avhere it consists in the time of aggra\7ation or other similar circumstance: nor yet will the key-note often be the most violent and painful of the pathogenetic results of the drug. The deepest streams are the most still and silent, and the true vital currents of the human frame are far more subtle, profound and spirituelle than the noisy rivers that rush through the arteries and the veins. Table of Remedies for Variations of Appetite and Taste. Anorexia—Want of Appetite.—1. Chin., Cycl., Nux v., Rhus tox., Sep., Sil. 2. Ant. cr., Am., Ars., Bar. c, Bell., Bry., Calc. c, Canth., Cic, Con., Ignat., Lye, Merc, sol., Natr. m., Op., Plat., Puis., Ruta., Sabad., Sulph., Thuj. Bulimy—Inordinate Appetite.—1, Calc. c, Chin., Cina, Jod., Lye, Nux v., Puis., Sil., Verat. a. 2. Ang., Aur., Bell., Bry., Coca, Kali c, Hell., Natr. m., Oleand., Nux m., Petrol., Phos., Puis., Rhus tox., Sabad,, Stann.,, Staph. Hunger without Appetite.—1, Natr.. m., Op., Rhus tox. 2. Agar., Ars., Bar., Bry., Chin., Dulc., Hell., Magn. m., Sil., Sulph. ac. Thirst—Too great.—1. Aeon., Ars., Bry., Calc. c, Cham., Chin., Merc, sol., Sulph. 2. Amm. mur., Ant. cr., Arm, Bell., Colch., Cupr. m., Hep., Hyos., Natr. m., Nitr. ac, Nux v., Rhus tox., Sec. corn., Sil., Stram., Veratr. a. ------ Want of—1. Apis, Hell., Merc, sol., Nux m., Puis. 2. Agn., Ars., Asaf., Camph., Con., CycL, Euphorb., Mang., Oleand., Sabad., Samb., Sep., Spig., Staph. ------ with aversion to drink.—1. Bell., Canth., Hyos., Nux v., Stram. 2. Agn., Lach., Natr. m., Rhus tox., Samb. Aversion to Acid Things.—1. Bell., Ferr., Sabad., Sulph. 2. Coca, Nux v., Ignat. ------Beer.—Coca, Nux v., Stann., Sulph. ------Brandy.—Ignat., Merc. sol. ------Bread.—1. Natr. m. 2. Con., Lye, Nux v., Puis., Sep., Sulph. variations of appetite and taste. 293 Aversion to—Broth.—Am., Ars., Graph. ----- Coffee.—I. Nux v. 2. Bry., Calc. a, Cham., Coff., Phos. -----Fat Food, Butter, etc.—1. Petr., Puis. 2. Ang., Bry., Carb. an., Carb. veg., Cycl., Natr. m., Sulph. -----Fish.—Graph., Zinc. -----Meats of all kinds.—1. Mur. ac, Petr., Sil., Sulph. 2. Calc. c, Carb. veg., Graph., Lye, Plat., Rhus tox., Sabad., Sep., Zinc. -----Meal and Flour {dishes made of).—Phos. -----Milk.—JEthayea, Bry., Calc. a, Guaj., Puis., Sep., Sil.,Sulph. -----Salt.—Carb. veg., Selen. -----Solid Food.—Ang., Bapt., Ferr., Staph. -----Sweets or Sweet Things.—1. Caust., Sulph. 2. Ars., Merc. sol., Phos., Zinc. ----- Vegetables.—Hell., Magn. m. ----- Water.—1. Bell., Calad., Nux v., Stram. 2. Bry., Natr. m., Caust., Canth. ----- Wine.—l. Merc, sol., SabacL 2. Ignat., Lach., Rhus., Sulph. Longing for Acids.—1. Veratr. a. 2. Ant. cr., Amm., Ars., Bry., Cham., Hep., Lach., Phos., Squill., Stram., Sulph. -----Bcer.—l. Bry., Merc. soL, Natr. a, Nux v., Petr., Puis., Sabad., Stront. 2. Caust, Coca, Lach., Op., Phos. ac, Spig., Sulph. -----Bitter Things.—Dig., Natr. m. -----Bread.—1. Ars., Plumb. 2. Natr. m., Stront., Aur. -----Brandy.—1. Op. 2. Ars., Hep., Nux. v., Selen., Sep., Sulph. -----Coal, Slate-pencils, Chalk, etc.—Cicuta, Nitr. ac, Nux v. -----Cakes.—Plumb. ----- Cheese.—Ignat. -----Coffee.—1. Ang. 2. Aur., Bry., Chin., Con., Selen. ■-----Fat Food.—Nux v., Nitr. ac. ■-----Fruit.—1. Verat. a. 2. Ignat., Sulph. ac. ----- Juicy Things.—Phos. ac. -----Liquid Food (soups, etc.).—1. Staph., Sulph. 2. Ang., Ferr. ----- Meat.—Magn. a, Merc, sol., Sulph. -----Meal and Flour (dishes made of).—Sabad. -----3Iilk.—l. Aur., Chel., Merc, sol., Sabad., Sil. 2. Ars., Bry., Calc. a, Phos. aa, Staph., Stront. -----Raw Potatoes and Flour.—Calc. c. -----Refreshing Tilings.—Caust., Phos., Phos. ac, Puis., Valer. ■---Salt Things.—Calc. a, Caust., Con., Nitr. ac, Veratr. a. -----Smoked Things.—Caust. 294 disorders incidental to pregnancy. Longing for—Saur Kraut.—Carb. an. -----Sweet Things.—1. Amm. a, Chin., Kali, a, Lya, Natr. a, Rhus., Sabad. 2. Ipec, Magn. m., Rheum., Sulph. ----- Vegetables.—Alum.,Magn. c. ----- Warm Food.—Ferr., Lye. ----- Wine.—1. Cic, Hep., Sep., Sulph. 2. Bry., Lach., Spig., Staph. Taste. Taste, Bitter.—1. Bry., Cham., Merc, sol., Nux v., Puis., Sep., Veratr. a. 2. Aeon., Am., Ars., Calc. a, Chin., Con., Dros., Ignat., Lye, Magn. m., Natr. a, Natr. m., Sabad., Stann., Sulph. ------Diminished or Lost.—1. Puis., Sil. 2. Calc. a, Sec. corn., Sulph. ------Metallic.—1. Cupr., Rhus tox. 2. Agnus, Nux v., Ran. bulb., Zinc. ------Putrid or Offensive.—1. Am., Merc, sol., Puis. 2. Ars., Bell., Bry., Calc. c, Carb. veg., Cham., Con., Jod., Merc, sol., Nux v., Rhus tox., Sep., Stann., Sulph., Valer., Zinc. ------Saltish.—Merc, sol., Phos., Puis., Sep. 2. Ars., Carb. veg., Chin., Jod., Lya, Natr. c, Rhus tox., Sulph., Tart, em., Veratr. a. ------Sour.—1. Bell., Calc. a, Chin., Nux v., Phos., Puis., Sulph., Tarax. 2. Cham., Ignat., Kali, c, Lya, Merc, sol., Natr. m., Petrol., Stann. ------Sweetish.—1. Phos., Plumb., Puis., Sabad., Squill. 2. Aeon., Alum., Dig., Stann., Zinc. II. Gastric Derangements. Nausea and Vomiting—Morning Sickness.—In many women nausea and vomiting set in at an early period of pregnancy, and are simply the result of a peculiar reflex irritation of the stomach : in these cases this affection usually continues but a short time. Those forms of nausea and vomiting which principally appear in the later months result, not from sympathetic irritation or reflex action, but from the direct irritation of the stomach, and perhaps also of the diaphragm, by the upward displacement. Next to the cessation of the catamenia, and especially in conjunction Avith it, morning sickness becomes one of the earliest as well as one of the most reliable original signs of pregnancy; while for all those who have eA7er before experienced it there is little room for mistake in regard to its nature; for in each individual in whom it occurs it has a uniform type and well-remem- bered character. The nausea may occur at an early period in the morning with un- GASTRIC DERANGEMENTS. 295 varying regularity, or in the evening, or at any period of the day, or even of the night. For each individual it maintains also its uniformity as to the date of its first appearance: in some it begins very soon after conception, in others it appears toward the third or fourth month, and in others again it comes on only toward the close of gestation: in these latter cases it may have appeared also for a short time soon after conception. In the duration of this affection there is also the same general variety and individual uniformity. Thus in some Avomen it lasts but a few Aveeks, from six to eight at most; in others it continues for four or five months; while in some few most distress- ingly severe cases this difficulty assumes the form of a formidable disease, and persists through the entire period of utero-gestation, un- less relieved by art. And this unfortunate condition has sometimes been still more fully developed and aggravated by sea-sickness, so that even life itself has been lost Avhere the voyage was tedious, homoeopathic treatment not being accessible. The nausea and vomiting of pregnancy, as already stated, are most apt to occur on first rising in the morning ; sometimes these symptoms disappear in a few minutes, sometimes they last through the greater portion of the day. In some the vomiting is very easy; in others it is attended with very severe retching, and even Avith other painful symp- toms. Those Avho vomit upon Avaking or rising in the morning usually throw up some viscid, glairy matters, which are generally colored with a little bile, especially if the retching has been very severe. Others vomit only after eating, occasionally after only one of the daily meals, but sometimes after all of them. Again, in some un- fortunate cases the vomitings continue even in the intervals of the re- pasts, everything taken into the stomach, whether liquid or solid, being immediately rejected. There are cases, finally, in which the mere thought of food, or the sight or the smell of it, is sufficient to induce the vomiting.—Cazeaux. In some cases nearly all the food ingested seems to have been thrown up, even for months in succession, and yet a good delivery succeeds at full term; the repeated and severe vomitings seemino- to exert comparatively little influence upon the general health. In like manner, pregnant Avomen may rise from the breakfast-table, vomit and return to their food as if nothing had happened. Such characteristics, so different from vomiting arising from any other cause, almost con- clusively indicate the presence of pregnancy. Important complica- tions, however, arise in the greater number of more severe cases, and the health of both mother and child is often greatly injured through 296 DISORDERS INCIDENTAL TO PREGNANCY. the marasmus and cachectic conditions Avhich ensue. Among the most serious of the symptoms which appear in connection with severe emesis is to be reckoned the sense of tenderness at the epigastrium. This may be attended by considerable pain, which is increased bv pressure. This epigastric soreness and tenderness, whether observed in the earlier or in the later stages of pregnancy, is due to the pro- found irritation of the ganglia or plexuses of the sympathetic nervous system which are located in this vicinity. And in this centre of organic life, in the very constitution itself, are planted the psoric ele- ments Avhose active development in pregnancy occasions these suffer- ings and innumerable others, Avhose duration and severity but too well indicate the gravity of the sources from which they are derived. The stomach itself is in no such direct sympathetic relation Avith the uterus, but the latter organ is in profound sympathy with the organic nervous system which is centred near the stomach, and which entirely controls the compound functions of digestion and nutrition. Hence the ma- rasmus and cachexia which succeed severe cases of morning sickness in the old practice; hence, too, the brilliant successes which in the new school follow the exhibition of arsenicum and other powerful and particularly indicated antipsorics. Hence, too, while under the allopathic regime these cases became worse and worse with each suc- ceeding pregnancy, under homoeopathic treatment they become better and better, until the Avoman finds she can pass through the formerly so much dreaded period of gestation Avith little or no suffering, and terminate her labor in a delivery as easy as it formerly was difficult and painful. Some of the remoter consequences of the nausea and vomiting, or rather of that morbid condition of the constitution itself which pro- duces these symptoms—such as chlorosis, anaemia and albuminuria— will be more fully described in a subsequent section. In the same connection it will be shown hoAV the disturbance of digestion, nutri- tion and assimilation is followed by important changes in the consti- tution and character of the blood and of some of the most important secretions; and hoAV dropsies and other forms of structural disease necessarily supervene. The diet and regimen of the pregnant Avoman should be carefully attended to: such articles as best agree should be advised in each individual case, and equal care taken to avoid every unwholesome or irritating influence. It has sometimes been found that the exces- sive irritability of the stomach in pregnancy is due to the presence of fumes from some neighboring manufactory, Avhich, although in- GASTRIC DERANGEMENTS. 297 sufficient to induce any unpleasant symptoms in the ordinary condition of. the woman, very powerfully affect her Avhen enceinte. Homoeo- pathic remedies may antidote the effects of these noxious vapors if they are not too poAverful, but in the greater number of such cases a temporary removal from the neighborhood may be necessary. The folloAving medicines Avill be found to cover the principal forms of gastric derangements of pregnancy; and the indications given should be confirmed by finding in the Materia Medica a full corre- spondence with the totality of the symptoms and accompanying con- ditions. Aconite. Nausea and perhaps vomiting, with thirst; fear of being in crowds or of being in busy places; fear of death, or fear that something untoAvard will happen. Everything tastes bitter except water. Pain in the stomach after every meal, headache, burning sensation extending from the stomach all the Avay to the mouth, and along the dorsum of the tongue. Decided tingling in the tongue or fauces, or in other parts. Especially adapted to young, full-blooded and active Avomen. Acetic acid. Sour eructations, sour vomiting, with profuse water- brash and salivation, day and night. Agaricus. Gastric derangements, with itching, burning and redness of various parts of the body, as if frost-bitten—of the ears, nose, cheeks, fingers or toes. Much hunger, but no appetite. Constipa- tion; the first part of the stool is very hard, the latter part liquid. Alumina. Gastric derangements Avith inactive state of the rectum, so that even a soft stool has to be urged with much force to cause it to pass off; at the same time a condition often prevails in the oesopha- gus, somewhere in its course, it may be in the chest, as though it were constricted, even small portions of food are swallowed with difficulty. She has to strain at stool in order to urinate. Tingling itching on the tongue; she must scratch it. Potatoes particularly disagree Avith her. Loss of taste; heartburn; eructations. The peculiar alumina constipation may characterise the whole case. Angustura. Nausea Avhen walking, as if she Avould faint; she has to sit doAvn. Stitches in the tip of the tongue, painfully aggravated on moving; it. Antimonium c. Nausea and vomiting, or only nausea, Avith Avhite- coated tongue. Watery stools, with occcasional hard lumps. Fright- ful vomiting, Avith convulsions. Belching, Avith taste of what has been eaten. Thirst at night. Painful sense of fullness of the stomach, Avhich is sore on pressure. 298 DISORDERS INCIDENTAL TO PREGNANCY. Apis mel. Irritable heartburn, extending up into the throat. Sen- sitiveness of the pit of the stomach to pressure, and burning therein. Dyspnoea, with feeling that each breath drawn Avill be the last. Very scanty secretion of urine. Constipation or diarrhoea. Absence of thirst or great thirst. Argentnm n. The head sympathizes with the gastric disturbance, and there are pain, vertigo, etc. Time seems to pass very slowly. The stomach seems as if it would burst from flatulence accumulated therein, accompanied Avith great desire to belch, which is accomplished Avith difficulty and the flatus is emitted Avith great violence. Belching after every meal. The bowels are usually regular. Arnica. The derangement is the result of concussion. The motion of the fcetus gives rise to pain. Bruised and sore feeling throughout the stomach and abdomen. Belching, as of rotten eggs. Frequent eructations. Vomiting of blood. At night the head is very hot, Avhile the trunk and extremities are cool. Arsenicum. Very great debility and exhaustion; the least effort causes exhaustion. Very pale, white look. Bitterness in the mouth, particularly after eating or drinking; sensation as of a stone in the stomach. Cold water seems to lie in the stomach as if it did not as- similate, therefore she cannot drink it, although she desires it. Nightly vomiting. Vomiting of fluids as soon as she takes them. Lienteria; exhausting diarrhoea. Feels cold, and wants to be in a warm room, or to be covered up warmly. Very uneasy and restless. Fluids do not agree with the stomach, and cause nausea. Vomiting of blackish or greenish matter. Belladonna. Face flushed or very pale, eyes red ; throbbing of the carotids; dread of light and of noise. A putrid taste arises from the fauces, also while eating and drinking, although the food tastes nat- ural. Nausea in the throat. Vomiting of bile. The symptoms become AArorse in the afternoon and evening. Sour vomiting. Thick coating on the tongue. Borax. Dread of a doAvnAvard motion. Everything tastes bitter, even the saliva. Distension of the stomach after every meal. Vom- iting of food and mucus. Symptoms are worse in very warm Aveather. Bryonia. Nausea on waking in the morning. Her nausea is usually relieved by keeping quiet. Dry, parched lips, dry mouth and tongue. Splitting headache. Vomiting of food immediately after eating. She desires to keep still. The gastric derangement is ameliorated by keep- ing quiet. Stool of hard dry feces as if burnt. Worse on sitting up, even sitting up in bed, after being angry, in warm air, from Avarm GASTRIC DERANGEMENTS. 299 weather or from warm food. Better in cool weather or from taking cool food. Calc. carb. She cannot sleep after three in the morning. Heartburn and food eructations. Vertigo on running up stairs or ascending. Leucophlegmatic temperament. Soreness of the tongue, either on the tip, sides or dorsum, so that she can scarcely talk or eat. She can- not bear tight clothing around the hypochondria. Stitches in the liver during or after stooping, or at other times. Sensation as if the feet were cold and damp. Vomiting of sour matter. Feels better from warmth, and cannot bear cold air. Cantharis. Gastric difficulties, accompanied Avith very frequent mic- turition, Avith cutting and burning pains, only a feAv drops being emitted at a time, and sometimes Avith blood. Sensation of fullness, extending into the chest and abdomen, after taking coffee. Burning in the region of the pylorus. Vomiting with violent retching and severe colic. Carbo veget. She has to eructate frequently, which affords only tern- ■ porary relief of her many sufferings. Sensation as if the oesophagus were contracted or entirely closed. Even the most innocent kind of nourishment disagrees Avith her. Sensation as if the stomach and ab- domen would burst when eating or drinking. Varices of the rectum, vagina, vulva or lower extremities. Itching of the genitals, perineum and anus. Causticum. Phlegm in the throat, AAmich she is unable to hawk up, and Avhich sickens her. She sits doAvn to the table with some appe- tite, but can eat scarcely a morsel. Constant sensation as of lime being burned in the stomach, Avith rising of air. Stitches in the liver for hours in the afternoon. Haemorrhoids, Avhich cause great suffer- ing on Avalking. Her upper eyelids are nearly paralyzed, she can hardly keep them open. Fatty taste. Constipation. Stools tough and shining, or hard and in pieces at first and aftenvard soft. Chamomilla. The existing pain is increased by eructations. Nausea as if she would faint. Great irascibility of temper—she «an hardly return a civil ansAver. Burning across the stomach into each hypo- chondria. The epigastrium is painfully bloated in the morning, with a sensation as if its contents were passing into the chest. The belch- nig of Avind is painful. She cannot compose herself to sleep; she imagines she hears the voices of absent persons. Cnelidonium. There is a constant pain under the lower inner angle of the right shoulder-blade; this pain may extend into the chest or stomach, or even cause severe gastralgia, nausea and vomiting. Her 300 DISORDERS INCIDENTAL TO PREGNANCY. nausea causes great heat of the body. Great desire for milk, the drinking of which ameliorates all her symptoms. China. The abdomen feels full and tight as if stuffed—eructations afford no relief. There may be diarrhoea and dejection of much flatus, but no relief is obtained. In connection Avith the tightness about the abdomen, she often feels as if her garters Avere too tight, and loosens them, and as if her Avaist were too tight; she must loosen that, etc. Bitter taste in the back part of the throat, bitter taste of everything. She craves dainties, but hardly knows Avhat. Flat or sour taste. Cina. Grinding of the teeth, tumbling and tossing during sleep. Diarrhoea always after drinking (compare Arsenic). Inclination to vomit, Avith a Aveak, hollow, empty feeling in the head. Constant pressure in the stomach at night, causing restlessness. Itching of the nose, occasioning boring or rubbing of it. Always hungry. Cross or peevish. Cocculus. Burning in the oesophagus extending into the fauces, with •a taste of sulphur in the mouth. She is scarcely able to raise herself in the morning from nausea and inclination to vomit, it makes her so faint. Metallic taste in the mouth. Sensation in the abdomen as if sharp stones rubbed together on every movement, and the lower ex- tremities seem almost paralyzed. Yellow-coated tongue, with aver- sion to food. Fetid eructations. Worse from riding in a carriage or from sailing. Painful sensation of fullness in the stomach. Frontal headache. Nausea which is felt in the head. Conium. Vertigo, particularly on turning over in bed. The urine intermits at every emission. Stinging in the neck of the uterus; scirrhus of any part. Terrible nausea and vomiting during pregnancy in Avomen having scirrhosities. Where the history of the case of nausea and vomiting reveals the fact of SAvelling and soreness of the breasts with each menstrual period, and the patient ahvays feels worse after going to bed, so much so that she is obliged to sit up or to Avalk about to get relief. Bitter taste. Eructations with heartburn. Crocus. Sensation of fermentation in the stomach, or of motion up- Avard and downward, hither and thither. Feeling of nausea in the chest and throat as if she would vomit. Very Ariolent heartburn. Cuprum met. Violent vomiting of frothy mucus. Sometimes green. When drinking the fluid descends Avith a gurgling noise. Sensation in the stomach as if she had something bitter in it. The violent nausea and vomiting are relieved by drinking cold Avater. Intense coppery taste. Profuse salivation. Cyclamen. After eating the least quantity, disgust and nausea in the GASTRIC DERANGEMENTS. 301 mouth and throat. Much dimness of vision, with fiery specks and sparks before the eyes. Intermittent thirst. Violent hiccouo-h. Fatty taste; fat food disagrees. Digitalis. Nausea as if she would die. Very sIoav pulse. Light- colored stools. Intermittent pulse. Very persistent nausea and vom- iting—nausea even after vomiting. Burning in the stomach extend- ing up the oesophagus. Want of appetite, Avith clean tongue and empty stomach. Very much nausea in the morning. Drosera. Nausea after eating fat. The nausea is worse after mid- night till morning. The mouth seems in a bitter state when eating. Nausea with inclination to vomit. Vomiting of slimy matter. Dulcamara. The sufferings are made worse by every cold change in the weather. Empty eructations, with throbbing as from disgust. Frequent eructations while eating. Sensation of retraction in the pit of the stomach, Avith burning. Ferrum. Vomiting of food, with a fiery red face. Renewed vomit- ing after eating. Vomiting at midnight. Everything she vomits tastes sour and acrid. Vomiting of blood. Graphites. Itching blotches here and there over the body. Vesicular eruptions, from which oozes a glutinous watery fluid. Sore varices. Constipation or diarrhoea. Feces very large and difficult of passage' Nausea with vertigo, so that she is afraid to walk. Rancid heart- burn, particularly after eating. Taste in the mouth as of rotten eggs every morning, which nauseates her. Gossypium. Great distress, weakness and prostration. Has been useful in very bad cases. Helleborus. Urine scanty, dark and depositing a coffee-ground sedi- ment. Nausea, yet hungry; still the food is repulsive although the taste is natural. Intensely painful burning in the stomach, extending into the oesophagus. Hepar. Itching rash in the bend of the arms and under the knees in the popliteal space. Frequent and momentary attacks of nausea. Vomiting every morning. Inclination to vomit, Avith flow of saliva from the mouth. Constant sensation of water rising in the oesophagus, as if she had eaten sour things. _ Ignatia. Great sense of emptiness at the pit of the stomach, with sighing and great depression of spirits. Full of suppressed grief as it were. Sensation as if she had been fasting a long time, with flat taste and languor in the limbs. Hiccough. Flat, sour or bitter taste. Ipecac. One continual sense of nausea all the time—not a moment's relief. Vomiting of large quantities of mucus. Diarrhoea and colic. 302 DISORDERS INCIDENTAL TO PREGNANCY. Disgust for food, empty retching; vomiting of food, slime or blood; sour vomiting. Cutting pains about the umbilicus. Jodium. Continual empty eructations from morning till evening, as if every particle of nourishment were turned into gas. Nausea and vomiting of saltish-tasting substances. A continual taste of salt in the mouth. Offensive taste. Symptoms relieved for a short time by eating. Kali bich. Discharge from the stomach, throat or mouth, or from any of the mucous membranes, of a tough, stringy mucus, inclining to stick to the parts and draAving out in long strings. Kali carb. Very sleepy during a meal, Avith strong desire to sleep. Nausea as if she would faint, relieved by lying doAvn. Vomiting, with a swoonlike failing of strength; with much colicky pain in the ab- domen of a stitching character. Disgust for food. "Sickness of pregnancy Avithout vomiting, coming on only during a walk, with a feeling as if she could lie down anywhere and die." Laurocerasus. Attacks of suffocation, with palpitation and a sort of gasping for breath—a feeling as if she were not going to breathe again—she must sometimes lie down to find relief. Eructations tast- ing of bitter almonds or prussic acid. Violent pain in the stomach, with loss of speech. Disgust for food. Lycopodium. Much rumbling and working in the abdomen; gurg- ling in the left hypochondrium. Sensation of satiety, on account of Avhich she cannot eat. Red sand in the urine. Great pain before urinating and relief as soon as the urine begins to flow. Immedi- ately after a meal sensation as of fasting, but no hunger. Much heat in the face after eating, particularly in the left cheek. Heartburn from the stomach, the acidity rising into the throat. After eating pain in the region of the liver and palpitation of the heart. Vomit- ing of sour matter or of bile. Aversion to bread. Bitter, fatty or sour taste. Magnesia carb. Much sour taste and sour vomiting. All her symp- toms are aggravated every third week. Much roughness or stinging or burning in the throat, with desire to vomit. Much loathing Avith- out desire to vomit. Magnesia mur. Constipation of large, difficult stools, which crumble as they leave the verge of the anus. A continual rising of white froth into the mouth. Eructations tasting like onions. Fainting nausea, succeeded by coldness and weakness in the stomach and gulping up of water. Loss of taste or bitter taste. Mercurius. Much salivation, ulcerated gums, sore and elongated GASTRIC DERANGEMENTS. 303 teeth. Mucous stools, followed by tenesmus. Rancid heartburn after a simple supper. Heartburn all night. Ptyalism with nausea, Avak- ing her from sleep, particularly after twelve at night. The pit of the stomach is very tender to the touch. Taste bitter, offensive, saltish or sour. Eructations and heartburn, vomiting of bile or of food. Moschus. Violent eructations tasting like musk, sometimes of garlic. The sight of food makes her sick. Eructations with hot saliva in the mouth. Heartburn with palpitation. Natrum mur. Waterbrash like limpid mucus, profuse and constant. She always awakens in the morning Avith headache. She craves salt. Has a strong aversion to bread. Clawing in the pit of the stomach. Feeling of great hunger, as if the stomach were empty, but no appe- tite. She ahvays has heartburn after eating. Very much nausea, particularly in women using much salt food. Dreams at night of robbers being in the house; she must have the house searched in order to be satisfied. Loss of taste or flat, bitter or sour taste. Much belch- ing. Heartburn and palpitation of the heart. Vomiting of food. Nitric acid. Much nausea and gastric trouble, relieved by moving about or riding in a carriage. Constant nausea with heat in the stomach, extending to the throat. Fat food causes nausea and acidity. Exceedingly strong and offensive urine, smelling like that of horses. Nux mosch. Mouth, tongue and throat very dry, so that they " stick to one another," particularly at night. Sensation of fullness of the stomach, with tightness of breathing; very useful for this symptom in the last months of pregnancy. Disposition to faint. Great sleepi- ness. Nux vom. Thinks she woulcj feel better if she could vomit. Nausea and vomiting every morning, with constipation; large, difficult feces. Putrid taste Ioav down in the pharynx when hawking up mucus. Food and drink have a fetid smell to her. She cannot bear the odor of tobacco. Stools very small and frequent, with frequent and pain- ful urging. Not much appetite; restless sleep, particularly after three A. m., Avith nausea and vomiting in the morning and great depression of spirits. She cannot enjoy reading or conversation. She is irrit- able and wishes to be alone. Canine hunger; aversion to water and bread. Longing for beer, brandy, etc. Bitter or sour taste. Belch- ing, eructations, hiccoughing, heartburn. Vomiting of food, of bile, of black or sour matter. Opium. Constipation. Stool consists of round, hard, black balls. Longing for brandy. Petroleum. In women affected with diarrhoea only in the daytime; 304 DISORDERS INCIDENTAL TO PREGNANCY. nausea when riding, she cannot ride in a carriage. Flat or sour taste. Vomiting of bile. Aversion to fat food and to meat. Particularly applicable in all gastric troubles of pregnant Avornen. Phosphorus. Constipation with narrow, long, hard, dry feces, which are difficult to evacuate. Very weak feeling in the abdomen. Heat up the back. Profuse watery diarrhoea, pouring away as if from a hydrant. Sour eructations and sour vomiting. Very sleepy all the time. Saltish, sour or SAveetish taste. Vomiting of blood, of food or of sour matter. Phosphoric acid. Sensation as if the stomach were being balanced up and down. Bread tastes bitter. Nausea, as if in the palate or throat. She frequently rises at night to pass large quantities of color- less urine. Much debility. Pulsatilla. Pulsations in the pit of the stomach. Vomiting of mucus. Bad taste in the mouth every morning on aAvaking; she has to wash it out soon, it is so bad she cannot bear it. Nothing tastes good to her. Absence of thirst; she does not relish as much water as usual. Nightly diarrhoea, stools very changeable. Loss of taste, or bitter, fatty, saltish, sour or sweetish taste. Eructations. Nausea. Rhus tox. Putrid taste after the first mouthful. Pain between her shoulders on swallowing food. Very restless at night, particularly the latter part of the night; she must turn frequently in order to find an easy position. No appetite, or hunger without appetite. Un- natural or metallic taste. Eructations and nausea, with inclination to vomit. Sabadilla. No relish for food till she takes the first morsel, when she makes a good meal. A kind of. heartburn, the heat commen- cing in the abdomen and extending upward to the mouth. Much nausea and vomiting with heat in the abdomen. Vomiting of ascarides. Horrid burning in her stomach, as if it would burn up through into her throat. Aversion to meat. Sweetish taste. Salivation. Selenium. Violent beating of the pulse in the whole body after eating, particularly in the abdomen. Sepia. Vomiting of milky water or milky mucus. Sense of emptiness at the pit of the stomach; the thought of food sickens her; a sense of weight in the anus. Eructations tasting like spoiled eggs. Taste as of manure. Aversion to meat. In the morning, nausea as if all the viscera were turning inside out. Inclination to vomit in the morning when rinsing her mouth. She cannot take her accus- tomed ride in the morning on account of nausea. Want of appetite. GASTRIC DERANGEMENTS. 305 Taste bitter or saltish. Eructations. Disgust for all kinds of food. Vomiting of food and bile. Constipation. Silicia. Hungry, but she cannot get down food, it is so nauseous. Prolonged after-taste of food. Nausea, with violent palpitation of the heart. Nausea after every exercise that raises the temperature of the body. Constipation, as if from inactivity of the rectum, the stool receding after partial protrusion. Taste of blood in the morning. Aversion to meat. Loss of taste. Nausea and vomiting. Staphysagria. Sensation as if the stomach were hanging doAvn relaxed. Shortly after a full and substantial meal she feels very hungry. Extreme hunger even when the stomach is full of food. Flat taste. Constant accumulation of water in the mouth. Very sensitive to all moral or physical influences. Stramonium. Troublesome thirst, even with very much saliva Every kind of food tastes like straw; in fact, she has no taste! Nausea, with flow of very saltish-tasting saliva. Sulphur. Profuse salivation, the taste of which causes nausea and spells of vomiting. All the trouble seems to be caused by the nauseous salivation. Flashes of heat; heat on the top of the head; cold feet; short sleep at night—she Avakes very frequently. Profuse waterbrash. Aversion to meat and craving for brandy. Bitter, saltish or sour taste. Belching; eructations; sour vomiting. Sulphuric acid. Coldness and relaxed feeling in the stomach; loss of appetite and great debility. Belching; eructations; vomiting Tremulousness; the Aveaker she feels the greater the sensation of tremulousness. Is impelled to do things hurriedly. Tartar em. Vomiting of large quantities of mucus. Belching; disgust for food; nausea; salivation. Valerian. Heartburn, with gulping up of rancid fluid, which, how- ever, does not rise into the mouth. Nausea, as if a thread were hang- ing in the throat, exciting attempts to vomit. She feels nauseated, faint, Avith white lips and body icy cold. Fatty and offensive taste J heartburn; risings into the throat; nausea in the throat. Veratrum. Much thirst for cold drinks. Craves fruits and juicy articles of food. Wants everything cold. Violent retching. Canine hunger Craving for acids and salt food. Taste bitter or saltish. Eructations; heartburn; nausea; inclination to vomit. Violent retching and vomiting; vomiting of bile. Cold sweat on the fore- head, with all the sufferings. Zinc. Taste of blood in the mouth and sweetish risings from the stomach. Terrible heartburn after taking sweetish things. Great 306 DISORDERS INCIDENTAL TO PREGNANCY. greediness when eating; she cannot eat fast enough, from canine hunger. Much nausea and vomiting. Fidgety feet. Aversion to meat. Metallic taste. Pyrosis—Acidity—Heartburn.—These distressing forms of gastric disturbance sometimes make their appearance soon after con- ception, Avhile in other cases they may not appear until after the fourth month. Some women are remarkably subject to these symp- toms Avhen enceinte; in others they are manifested with less violence; in others not at all. There may be merely a burning sensation- heartburn in the throat—which indicates sympathetic irritation; or the severer forms of pyrosis, with acidity, which arise from more fully-developed gastroses. As in the nausea and vomiting of preg- nancy, so in pyrosis, heartburn and acidity, every degree of intensity and variety of manifestation and complication may be seen in different individual cases. Sometimes these disturbances are found accom- panied Avith and greatly aggravating the nausea and vomiting; at other times they seem to appear instead of the vomiting. As in ordinary cases of dyspepsia, these sufferings are worse after taking particular articles of food or drink, such as meats, fat meats or gravies, milk, fruit. In the more severe cases nearly everything that is ingested becomes but an added fuel to the burning of the pyrosis and acidity. Still, a careful avoidance of all those articles Avhich, wrhether solid or liquid, are found most to disagree, and a careful administration of the truly-indicated homoeopathic remedy, Avill, as in cases of nausea and vomiting, go very far to remove the most distressing symptoms, and eventually to secure a great improve- ment in the general health. For these difficulties, when not merely the aggravations by pregnancy of already existing forms of chronic gastritis, are but the developments of constitutional dyscrasia? hitherto latent, as explained in the case of morning sickness. And while the classes of hereditary dyserasise are but few, still, modified as they are in their actual developments by individual peculiarities, they require a great variety of remedies for their proper treatment. Not indeed many remedies for each individual case—for the more skillful the physician the fewer Avill be the remedies which he will be obliged to administer in any given case, and the greater the number of cases which he will cure with a single remedy, sometimes even with a single dose—but a variety of remedies will be necessary to correspond to the variety of disorders which result in different persons, even from the same cause. gastric derangements. 307 The doctrine of individual specifics is based upon the most pro- found analysis of the human system and of the laAV of cure, and is confirmed by the radical and constitutional improvement—an im- provement which is found to be the more radical and permanent the higher the potencies of the remedies Avhich are administered. The doctrine of individual specifics is therefore truly scientific, since it harmonizes the results of practical experience with well-established principles, and even Avith those profounder explorations of our being in Avhich matter is seen to fade into spirit, and physiology to be re- placed by psychology. The doctrine of general specifics leads to just the reverse of all this, as well in principle as in the ratio and extent of actual success. For our allopathic and eclectic brethren, and even those of the so-called physiological school among the homoeopaths, are so manifestly blind that they totally ignore in therapeutics that predominance of mind over matter which they do not hesitate to admit in all other branches of scientific inquiry. They prove them- selves materialists and chemists—anything but true physiologists; while as to psychology, or the doctrine of the connection of the body with the soul, and of the influence of the latter over the former, they seem to regard it as entirely beneath their attention. Hence, what do we see in the practice of all these classes alike but temporary expe- dients—Avhich often result in manifest disaster, and which always oc- casion more injury than they are capable of discerning—instead of radical cures ? We see chemical antidotes which, if they sweeten the streams, do it at the expense of the fountains ; and mechanical ap- pliances which not only fail to assist Nature, but in many cases effect- ually prevent her from helping herself. Those who thus pride themselves in indulging in allopathic and eclectic modes of thought are greatly to be pitied; they know not what they do. All the advancing progress of modern scientific thought is against them, and the more enlightened of those Avhom they profess to admire despise them as foolish rejecters of the higher light held up before them. Table of Remedies for Gastric Disturbances. {Compare with the General Indications given on pages 292-294, as well as with the Materia Medica.) Belchings or Eructations. Am., Bell., Bry., Coca, Con., Merc, sol., Natr. m., Nux v., Phos. Puis., Rhus tox., Sarsap., Sep., Sulph. ac, Sulph., Verat. a., Tart. em. 308 disorders incidental to pregnancy. Hiccoughing. 1. Amm. mur., Cycl., Hyos., Ignat., Nux v. 2. Agar., Bell., Bry., Puis., Ran. bulb., Veratr. a. Pyrosis—Heartburn. 1. Calc. a, Con., Caust., Croc, Nux v. 2. Amm. a, Caps., Carb. a., Carb. v., Chin., Jod., Lya, Merc, sol., Natr. m., Phos., Puis., Sep., Valer., Veratr. a. Risings into the Throat. 1. Asaf., Merc, sol., Lach., Plat. 2. Con., Phos., Spig., Valer., Veratr. a. Disgust for Food. 1. Ipec, Kali a, Sep. 2. Ant. cr., Bell., Bry., Puis., Sil., Tart. em. Nausea ("Sick at the Stomach"). 1. Ars., Caust., Cham., Hell., Ipec, Natr. m., Nux v., Puis., Rhus., Sil., Sulph., Sulph. ac, Tart, em., Valer., Veratr. a. 2. Aeon., Angust., Ant. cr., Argent, nit., Asar., Bell., Bry., Caps., Cham., Cyclam., Calc. a, Carb. v., Chin., Con., Cupr. m., Graph., Kali a, Lya, Merc, sol., Mosch., Natr. m., Nitr. ac, Phos., Squill., Sep., Stann., Sulph., Sulph. ac, Valer., Tart. em. ------felt in the Throat.—1. Cycl., Phos. ac, Stann. 2. Cupr. m., Puis., Staph., Valer. ------felt in the Chest.—Aeon., Croc, Merc, sol., Rhus tox. ------felt in the Abdomen.—Bry., Puis. Empty Retching, Gagging. 1. Bell., Ipec, Veratr. a. 2. Arm, Asar., Bry., Chin., Nux v., Puis., Sulph. Vomiting. Vomiting of Bile, Bitter Vomiting.—1. Ars., Bry., Cham., Ipec., Merc, sol., Nux vom., Puis., Sep., Veratr. a. 2. Aeon., Bell., Chin., Con., Cupr., Dulc, Ignat., Lya, Petrol., Plumb., Sec. corn., Stann., Sulph. ------of Black Matter.—1. Ars., Nux v., Chin. 2. Petr., Phos., Plumb., Veratr. a. ------of Blood.—1. Am., Ferr., Ipec, Phos. 2. Aeon., Canth., Chin., Nux v., Plumb., Puis., Sep., Sulph. intestinal affections. 309 Vomiting of what has been Drunk.—1. Ars., Phos., Veratr. a. 2. Bry., Cham., Dulc, Ipec, Nux v., Sil., Tart. em. ------of what has been Eaten.—1. Ars., Bry., Ferr. Nux v. Squill. 2. Amm. a, Ant. cr., Calc. a, Cina, Cupr., Dros., Hyos., Ignat., Ipec, Lya, Natr. m., Phos., Plumb., Puis., Sep., Stann., Sulph., Veratr. a. ------of Fetid Matters.—1. Sep. 2. Ars., Coca, Cupr. m., Ipec, Nux v., Op., Stann., Sulph. ------of Slimy Matter.—1. Dros., Puis., Tart. em. 2. Ars., Bell., Cham., Chin., Con., Dig., Hyos., Ignat., Ipec, Merc, sol., Nux v., Sec. corn., Sulph., Veratr. a. ------of Sour Matter.—1. Calc. c, Chin., Lya, Nux v., Phos., Sulph. 2. Ars., Bell., Cham., Ipec, Puis., Veratr. a. ------of Watery Matter.—1. Bry., Caust., Veratr. a. 2. Arm, Bell., Cann., Chin., Con., Cupr., Ipec, Nux v., Stann., Sulph., Sulph. ac. ------of Worms.—1. Aeon., Cina, Ferr., Sabad., Sec. corn. 2. Hyos., Sil., Spig., Veratr. a. III. Intestinal Affections. Constipation.—This is so frequent an attendant of pregnancy that by some it has been deemed almost its natural consequence. But it is much more apt to occur, and is at the same time much more trouble- some and inveterate, in pregnant women who from habits of life and constitutional peculiarities are predisposed or subject to it in their ordinary condition. The mechanical pressure exerted upon the rectum, by which its calibre is diminished and its action paralyzed, and the habits of inac- tivity in which many pregnant women indulge, especially in cities, combine to produce costiveness. And as a final result of the consti- pation, haemorrhoids, either blind or bleeding, appear in many cases. And the very great amount of vital force consumed in the womb may also tend to draw away from the intestinal canal some of the energy that might have sustained its regular and daily evacuations. The indications for hygienic treatment will be suggested by the more apparent causes of the difficulty. Not only will the constipa- tion .itself be avoided in many cases by suitable and active exercise in the open air, but many of the attendant complications and conse- quences, such as headache and rush of blood to the head, may in the same Avay be escaped. The remedies will be indicated by the nature of the discharges and by the accompanying symptoms and totality of 310 DISORDERS INCIDENTAL TO PREGNANCY. the patient's condition. The constipation being but one of the forms of development of the constitutional dyscrasia in many instances— Avhether the most prominent symptom or not—requires a careful, radical treatment, by which not only Avill the present difficulty be re- lieved, but the general health improved, so that this trouble Avill not appear in succeeding pregnancies. The folloAving remedies, as well as those detailed under gastric disturbances, should be carefully studied and compared with the totality of the patient's symptoms: Aconite. Where there is much thirst, a general dryness of the skin, a constant restlessness, and where the same fears appear that are men- tioned in this remedy under gastric disorders. Alumina. Constipation from inactivity of the boAvels; much effort must be employed for the expulsion even of a soft stool, so great is the apparent inaction of the rectum. Agaricus m. Loud rolling and rumbling in the bowels. The stool is very hard and knotty at first, then it becomes soft, and finally diar- rhoeic, especially if there are red, itching and burning frost-bite look- ing places on the feet, hands or face. Anacardium. Frequent and ineffectual urging, the rectum feeling as if stopped up Avith a plug; if the stool does not pass soon, she feels colicky pains in the abdomen. Inactivity of the bowels. Antimonium c. Sensation as if a copious stool Avere going to pass when only flatus comes forth, but finally a very hard stool is evacu- ated. Incarcerated flatus. Apis. Stools seldom and very difficult, with stinging pains and sen' sation in the abdomen, as if of something tight, Avhich Avould break if too much effort Avere used. Heartburn. Scanty urine. Arnica. In cases where an obstinate constipation has remained ever since some severe concussion. Inactivity of the boAvels. Flatulency; colic ; loud rolling and rumbling in abdomen; foul-smelling flatus; stool seems to be unsatisfactory and insufficient. Belladonna. Flatulency. Obstruction of the bowels. Much tend- ency of blood to the head; flushed face; red eyes; throbbing of the carotids; heat in the head ; intolerance of noise and of light. With belladonna, high, I have succeeded in cases like this, when the most violent doses of the allopathic school had utterly failed. Bryonia. The stool is mostly dark, dry and hard as if burned, and is evacuated with much difficulty. The lips are parched and cracked; much thirst. Stinking flatulency ; rumbling and rolling in the abdo- men. Obstruction of the bowels from hardened stool. Stool too large to be evacuated without pain. CONSTIPATION. 311 Calc C. Indicated in leucophlegmatic temperaments. Stools very large, hard; sometimes in part undigested. She does not sleep after three A. m. Stinking flatulency. Constipation from indurated stool, Avhich is too white. Sour-smelling stool. Carbo V. Tough, scanty, not properly cohering stool; it seems to break off, and in consequence to become interrupted and rendered more difficult of expulsion. Stinking stool. Flatulency, Avith colic and rumbling of gas in the boAvels. Incarcerated flatus, smelling very badly Avhen emitted. Patient attributes all her troubles to " the wind." Obstruction from inactivity of the boAvels. Causticum. Constipation, in which the effort to effect a passage causes heat, redness and perspiration on the face. Flatulency, loud rolling and rumbling in the bowels. Obstipation of hardened feces. Stool knotty like sheep-dung, too small in size. Stool shining like grease. Chelidonium. In cases accompanied by pain under the inner and lower angle of the right shoulder-blade. Stool like sheep's dung. China. Hard, intermitting stool, with sensation of tightness and fullness in the abdomen; also with burning and heat in the head. Flatulence with colic; loud rolling and rumbling; black stools; ob- struction from inactivity of the bowels. Cocculus. Hard stool every other day, expelled with great difficulty. The loAver extremities are nearly paralyzed. Incarcerated flatus; ob- struction of the boAvels. Conium. Frequent and ineffectual urging, or a small quantity is evacuated each time; much vertigo, particularly on turning in bed. The urine intermits in its Aoav at each emission. Flatulency; colic from incarcerated flatus. Graphites. Large, hard, knotty stool, the knots being united by mucous threads, and much mucus after the stool. Itching blotches about the body, Avhich emit a glutinous fluid. Sometimes the stools are only the size of lumbricoides. Incarcerated flatus; colic; obsti- pation from hardened stool or from inactivity of the bowels. Stool knotty and too large. Hepar. Constipation resembling that of alumina: hepar may be given in preference where the skin-symptoms or others seem to indi- cate it more particularly; for instance, if eruptions appear on the bend of the elbow and on the popliteal space. Ignatia. Difficult stool, causing prolapse of the rectum. Empty feeling at the pit of the stomach; sighing and full of grief. Flatu- 312 DISORDERS INCIDENTAL TO PREGNANCY. lency, incarcerated, rumbling and rolling about. Constipation from inactivity of the bowels. Jodium. Constipation Avith ineffectual urging, but the stool passes with great facility soon after drinking some cold milk. Kali c. Unsuccessful desire for stool, with a sensation as if the rec- tum Avere too Aveak to expel it. She feels very strangely and badly an hour before stool. Itching pains in and about the anus and rec- tum during and after stool. Flatulency. Obstipation from hardness of stool or from torpor of the boAvels. Laurocerasus. Frequent attacks of suffocation about the heart, so that she must gasp for breath. Simple obstruction of the bowels. Ledum. Great Avant of vital heat; she can hardly keep warm even with much Avrapping; in constipation, AArhere this state of the system prevails, this remedy will be found useful. Lycopodium. She says her abdomen is like a yeast-pot, so great a fermentation goes on there. Borborygmus and gurgling, especially in the left hypochondrium. Much red sand in the urine. Distressing pain in the back before urinating. Incarcerated flatulence; sharp, shooting pains from right to left across the abdomen. Constant feeling of satiety; but a small quantity of food seems to fill to repletion. Magnesia mur. Large stool, passed with difficulty, and crumbling as it passes the verge of the anus. Obstipation, of hardened feces. Knotty, crumbling, insufficient and unsatisfactory stool. Mercurius. Constant and ineffectual desire for stool. Scorbutic con- dition of the gums. Salivation, sore throat, soreness of the gums and other mercurius symptoms. Constipation from hardness of the stool, blood Avith the stool. Natr. m. Hard, difficult stool, and inactivity of the rectum. Bad headaches always on waking in the morning. Craves salt. Aversion to bread. Very vivid and fearful dreams. Sore places in the mouth, which are very painful, sensitive even to liquids. Constipation from inactivity of the bowels. Rumbling and incarceration of flatus. Nitric acid. Hard, difficult, scanty stool. Urine exceedingly offen- sive, like horses' urine. She sleeps badly in the latter part of the night. Great feeling of Aveakness after a stool. Much flatus, incar- cerated, stinking Avhen emitted. Bloody stool. Nux mosch. Great dryness in the mouth and tongue, Avhich sticks to the palate. SIoav and difficult stools. Colicky pains from incar- cerated flatus. Constipation from inactivity of the bowels. For Avomen disposed to faint or Avho " bolt" their food. CONSTIPATION. 313 Nux vom. In women of sedentary habits, accustomed to the use of much coffee, wine and rich and high-seasoned food generally. Stools large and difficult, or small, frequent and painful. Flatulence, colicky pains, incarcerated flatus, or loud rumbling and rolling in the bowels. Constipation from torpor of the bowels, or in persons Avho have been in the habit of using cathartic pills or other purgatives. Knotty or bloody stools. Insufficient stool. Rush of blood to the head during stool. Oleander. First diarrhoea, then hard, difficult stool. Opium. Stools ahvays in round, black, hard balls; in such cases opium in the higher preparations never fails. Constipation occurring either from accumulation of hard, dry feces or from torpor of the bowels. Phosph. Stools narrow, dry, long, and difficult to expel—very like a dog's stool. Blood with the stool. Rumbling in the abdomen. Constipation from hardened feces. Phosph. acid. She is obliged to rise frequently at night to pass off large quantities of colorless urine. The stools are hard and in pieces. Flatulency. Phytolacca dec. Constipation habitual; the patient says the boAvels will not move without the aid of purgative medicines. Feeling of fullness in the abdomen before stool, which remains after stool as if all had not passed. Constipation from torpor of the rectum. Per- sons Avho are subject to rheumatic pains on change of weather, espe- cially in the hips and thighs. Platina. The stools adhere to the parts like soft clay, and pass off with difficulty on that account. Obstinate incarceration of flatus. Plumbum. Constipation, with violent colic. The stools are usually composed of little balls, compacted together like sheep's dung. Sen- sation as if of a string drawing the abdomen in toAvard the back. Flatulency, colic, commotion in the abdomen. Pulsatilla. Obstinate constipation in mild, gentle, tearful women, with very nauseous, bad taste in the mouth in the morning—so very bad that she must wash her mouth immediately on waking. Gastric disturbance; cannot bear the smell of food. Hard, bloody stools. In- carceration of flatus, emissions of foetid flatus, borborygmus. Ratanhia. Most obstinate and long-continued constipation, with urging feelings in the small of the back, as if a stool would come doAvn. Rhododendron. She is rheumatic, and all her pains reappear at the approach and during the continuance of rough, stormy and Avindy 314 DISORDERS INCIDENTAL TO PREGNANCY. weather. The stool is not so hard, but it is very tardy, requiring a good deal of urging. Flatulent and colicky patients. Rhus tox. She is rheumatic, has restless nights on account of not being able to lie long in one position, although she feels quite com- fortable for a short time after every change. She has almost constant tenesmus, Avith nausea and tearing in the intestines. Ruta. Difficult expulsion of stool, Avith a large protrusion of the .rectum; in fact, the rectum is very liable to protrude before the stool immediately on attempting to go to stool. Constipation from either inactivity of the bowels or from impaction of feces. Sabadilla. Very difficult stools, Avith much burning in the abdomen, and a sensation as of something alive in the abdomen. Colic, with violent urging to stool and borborygmus. Sabina. Hard, difficult, painful stools, Avith pain extending from the back directly to the pubes. Sarsaparilla. Obstinate constipation, Avith violent urging to uri- nate. Great desire, with contraction of the intestines and excessive pressure from above doAvnward, as if the bowels would be pressed out, when a small stool is passed, and then the same phenomena recur again. Sepia. Sensation of a weight or of a heavy lump in the anus; this is a very characteristic indication. The stool is very difficult, covered Avith mucus, and sometimes impossible to pass even Avith terrible, in- voluntary strainings. Flatulency, with loud rolling and rumbling in the abdomen. Obstipation from hardened stool. Knotty and insuf- ficient stool. Sepia200 was stated many years ago to be specific in the constipation of pregnant women. Silicia. Very much urging, the stool often receding after having been partially expelled. The stool is composed of hard lumps. In- carcerated and offensive flatus. Stannum. It exhausts her to talk much or to read aloud. It is more difficult and tiresome for her to descend than to ascend, to sit down than to rise up. Although the stool has been fully accomplished, she does not feel relieved. Staphysagria. The more trouble she has with her gums and teeth the more constipated she becomes. Colic from incarcerated flatus in the boAvels, offensive flatus. Constipation from inactivity of the boAvels or from impaction. Sulphur. The first effort to stool is often very painful, compelling her to desist. Flushes of heat, heat on the top of the head, coldness of the feet, faintness from eleven to twelve at noon, she can scarcely DIARRHCEA. 315 wait for her dinner. Bloody, knotty, hardened, insufficient stool. Loud rolling and rumbling in the abdomen, with emission of offen- sive flatus. Sulph. acid. Hard stool, consisting of small black lumps mixed with blood, accompanied by such violent prickings in the anus that she has to rise up on account of the pain. Sensation of tremor all over the body, without trembling. Thuya. Very violent pain in the rectum during stool, so violent that she can hardly pass the stool, Avith sensation as if she could not live any longer. Veratrum a. Flatulency, colic and borborygmus. Costiveness, owing to the hardness and size of the feces, as Avell as to the inactivity of the rectum. Cold swreat on the forehead during the movement of the boAvels, with exhaustion and faintness aftenArard. Verbascura. Stool like sheep's dung, scanty, very hard, and expelled with great effort. Zinc. This remedy is particularly indicated where there is remark- able dryness of the stools, Avhich are insufficient and difficult of expul- sion, and when the bowels, particularly the rectum, seem to be so very inactive, as if all peristaltic and expulsive poAver was lost. Diarrhcea may be developed during pregnancy, like constipation or haemorrhoids, from some constitutional dyscrasia, which is called into action by the profoundly vital function of gestation. Or it may be developed in consequence of some imprudence of diet or by taking cold. The condition of the bowels in which diarrhoea makes its appear- ance is more like actual disease than where constipation is present. The diarrhoea may alternate with constipation, and this is quite a common complication. Or it may be of that character Avhich natu- rally accompanies acidity of the stomach and great weakness of the digestion. Sometimes it assumes the form of lienteria or discharge of undigested food. In other cases the liver seems involved, and the stools have a bilious appearance ; such attacks of diarrhoea may occur in consequence of violent emotions of the mind, to which pregnant women are peculiarly liable. The discharge may be easy and pain- less, or accompanied by severe suffering, soreness, cutting pains and even tenesmus, as if of actual dysentery. This latter form, approach- ing inflammation of the bowels, is apt to come on after exposure to the night air, especially if the woman be not clad with sufficient warmth. 316 DISORDERS INCIDENTAL TO PREGNANCY. It is not necessary to detail all the symptoms of the various forms of diarrhoea which may appear in pregnant Avomen; the most im- portant of them may be found among the indications and character- istics of the various medicines. There are three directions which should be insisted upon in pre- scribing for cases of diarrhoea in pregnancy : First, the patient should carefully abstain from every unsuitable article of food; those which are found by experience to be indigestible or to occasion distress, Avhether immediately followed by aggravation of the diarrhoea or not, should be particularly interdicted. Second, the patient should take care that her Avhole body is amply protected from the cold and clamp, but especially her feet and abdomen. The former should be Avarm and dry as a matter of course ; the latter will often—from becoming so prominent—require extra covering, as of flannel. Third, perfect quiet is absolutely essential in cases of diarrhoea in pregnancy. This condition should indeed be ahvays enjoined in the treatment of diarrhoea, whether it extend to dysentery or inflammation of the bowels or not. But in the case of pregnant women it is if possible still more indispensable. Rest, repose, especially in a horizontal position, Avill enable the patient to recover her health and strength, under the influence of the homoeopathic remedy, in a very short time, when if she continued moving about those cases of diarrhoea which at first were mild and painless might become inveterate and greatly aggravated in character. Again, it is to be borne in mind that a diarrhoea long continued may bring about abortion or premature labor, and hence the importance of early and judicious treatment and of the due observance of dietetics and rest. Sometimes the diarrhoea, not very severe and apparently of no great consequence, which makes its appearance in pregnancy, is but the insidious forerunner of phthisis pulmonalis, othenvise held in abey- ance by the influence which the state of pregnancy exerts upon the entire economy of the female system. "We give the chief indications for the remedies which are oftenest called for in the diarrhoea of pregnancy. The remedy should always be made to correspond to the totality of the symptoms; and if the simile is not found in one of those here given, a more extended search must be instituted in the Materia Medica. Compare the indications here given with those laid down for the same remedies in gastric derangements and constipation. By such comparison a remedy may be chosen with great accuracy. DIARRHCEA. 317 Agaricus m. The diarrhoeic stools are accompanied with abundance of flatulency, with painful drawing in of the abdomen. The itching, burning and red places upon the skin fade away as the diarrhoea improves. Aloes. Sensation of weight or heaviness in the rectum, and frequent passage of accumulations of mucus of large or smaller size, sometimes with very distressing tenesmus. Morning diarrhoea, Avhich necessitates expedition in attending to the call, not so much on account of the urgency, as because of a feeling as if the stool could not be retained, but must drop involuntarily. Rumbling and rolling in the bowels previous to stool. Alumina. Diarrhoea with tenesmus; stools bloody and scanty. She has to strain at stool in order to pass water; she cannot pass her urine without straining at stool. Ammon. mur. Diarrhoea, with soreness of the anus, several pustules are discovered near it. Angustura. Diarrhoea, with shivering over the face and goose-flesh. Antimonium C. Diarrhoea at night and early in the morning, with white tongue. Watery diarrhoea, containing hard lumps. Acrid diarrhoea. Arnica. Involuntary stools, with sore and bruised feeling all through the body. Mucous, offensive or purulent stools. Argentum nit. Very offensive eA^acuations, with very profuse emis- sion of flatus, sometimes with noise. Stools watery or of green mucus. Often there is much colicky pain. The diarrhoea occurs more frequently at night. Arsenicum. Exhausting diarrhoea, the stools containing undigested food. The patient is very weak, the least motion occasioning a sense of great fatigue. The diarrhoea is reneAved after eating and drink- ing. Very offensive diarrhoea. Sharp, cutting or burning pains with the diarrhoea. Painless diarrhoea. Stools acrid, bloody or involuntary. The pain is greatest during the stool, and is relieved after stool. Asafoetida. Watery, liquid stools of the most disgusting smell imaginable. (Also the same in infants and children.) Colic with the diarrhoea. Aurum. Nightly diarrhoea, with much burning in the rectum. Of- fensive, painful diarrhoea. Belladonna. Involuntary diarrhoea. The diarrhoeic stool is followed by frequent urging, no more stool being passed. Flushed face; red eyes; throbbing carotids, etc. 318 DISORDERS INCIDENTAL TO PREGNANCY. Borax. Frequent, soft, light yellow, slimy stools, Avith faintness and weakness. Bryonia. Burning diarrhoea. The diarrhoea is worse or aggravated by Avarm Aveather. Lips dry and parched; thirst; nausea after eating; nausea on sitting up in bed. The patient Avishes to remain very quiet, as every motion aggravates her symptoms. Calc c. Much crawling and itching, as from ascarides, in the anus. Leucophlegmatic temperament. Does not sleep after three in the morning. Cantharis. A constant desire to urinate, with cutting, burning pain. Dysenteric diarrhoea. Stools Avhich resemble scrapings of the intes- tines or Avater in Avhich meat has been washed. Capsicum. Much burning and smarting in the anus, as if from cay- enne pepper. Pain in the back continuing after the stool. Carbo V. Much flatulency, with belching, which affords only tem- porary relief. Causticum. Haemorrhoids or fissures, rendering walking almost intolerable. Much suffering after each evacuation. Cham. Hot diarrhoeic stool, smelling like rotten eggs. The stools excoriate the parts. Painless, green, Avatery diarrhoea, a mixture of feces and mucus. Nightly diarrhoea with colic, causing her to bend double. In all chamomilkt cases the moral symptoms are about the same—i. e. quarrelsome, obstreperous. Chelidonium. Diarrhoea, with pain under the inner and lower angle of the right shoulder-blade. China. Diarrhoea of yellow, watery stools, undigested, and with much flatulence. Sensation of distension in the abdomen, which is not relieved by eructations or dejections. Painless diarrhoea. Lien- teria. Very offensive black or yelloAvish-brown stools. Prostration after each evacuation. Cocculus. Diarrhoea, Avith a sensation in the abdomen as of sharp stones rubbing together. Vomiting of bilious matter. Numb sen- sation in loAver limbs, as if paralyzed. Colocynth. Diarrhoea, with colic drawing one double, and which is very distressing, causing restlessness, Avrithing and twisting about; pain is relieved someAvhat by bending nearly double, and by making hard pressure upon the abdomen. The abdomen and thighs must often be approximated as much as possible during the stool. Aggravation after eating or drinking. Conium. Heat and burning in the rectum during the stool, and tremulous Aveakness afterward. Frequent stitches in the anus between DIARRHOEA. 319 the stools. Painful diarrhoea. The urine intermits during its flow. Vertigo, particularly on turning in bed. Crocus. Long, dull stitches near the anus from time to time, con- tinuous, and painfully affecting the whole nervous system. The stool contains dark stringy blood. Cuprum met. Violent diarrhoea, with cramps in the stomach and chest, the cramps extending upward. Much flatus escapes with the stool. Digitalis. Violent diarrhoea, the stools being ash-colored or very light. Very sIoav pulse. Accompanying the diarrhoea is violent beat- ing of the heart—not rapid, but too violent. Nausea. Despondency. Vomiting of food. A very depressing sensation of sinking at the stomach. Drosera. Loose stool almost continually, but rather worse after midnight. Bloody, mucous or offensive stools. Dulcamara. Stools yellowish, greenish, whitish, mucous or bloody; often attended Avith prostration or Avith colicky pains around the um- bilicus. Worse after every cold change of the weather or after taking cold. Euphorbium. Stools like glue prepared for use, painful and flatulent. Ferrum. Frequent diarrhoeic stools, corroding the anus, the face being fiery red. Lienteria. Painless diarrhoea. Vomiting of food soon after eating. Debility and emaciation. Gelseminum. Diarrhoea occasioned by fright. Disposition to go to stool Avhenever anything startles her. Graphites. Diarrhoea, with varices, and a smarting, sore feeling after the stool when wiping. Stool brown, very fetid, often undi- gested. In the morning taste in the mouth as of spoiled eggs. Ab- domen distended, often with a sensation of fullness and hardness. Much flatulency. Helleborus. In cases of diarrhoea in which the urine is found to be scanty and to contain a deposit like coffee-grounds. Stools of Avhite mucus, often tenacious or jelly-like. Hepar. Diarrhoea, with tenesmus, and an itching rash in the bends of the elboAvs. Stools of a lightish color, often undigested and of a sour smell. Sour regurgitations of food. Empty sinking feeling in the stomach, relieved by eating. The diarrhoea is Avorse during the day, after eating, or after drinking cold water. Hyoscyamus. Diarrhoea, with involuntary jerks of the muscles im- mediately before, during or immediately after the stool. Involuntary stools.' Yellow, watery, painless diarrhoea. 320 DISORDERS INCIDENTAL TO PREGNANCY. Ignatia. Empty, Aveak feeling at the pit of the stomach, Avith dispo- sition to take a long breath frequently, a sort of sighing inspiration. Ipecac. Diarrhoea, with one continual sense of nausea—not a mo- ment's respite. Fermented stools, looking like yeast. Sometimes the diarrhoea is accompanied Avith vomiting of mucus or of grass-green substance. Iris versicolor. Gastric disturbance and headache. Severe burning at the anus during and after liquid stools. Burning extending from the mouth to the stomach. Diarrhoea worse at night. Emissions of very fetid flatulence, accompanied with slight discharge of liquid fecal matter. Jodium. Diarrhoea of watery, foaming, Avhitish mucus, Avith pinching around the navel and pressive pain in the vertex. Kali c. Diarrhoea, with sharp, shooting and stitching pains all over the abdomen. Stools of a light gray color. Persistent stitching pain in the region of the liver. Suitable to cachectic persons Avith sacu- lated SAvellings over the eyes. Lachesis. Diarrhoea ahvays worse after sleeping, and Avith frothy urine. Laurocerasus. Diarrhoea, with peculiar suffocating spells about the heart. She is often obliged to lie down on account of this peculiar sense of suffocation. Green, liquid stools. When drinking the fluid rolls down the oesophagus Avith a peculiar rumbling noise. Ledum. Diarrhoea, Avith a sensation of great coldness; she has great want of vital warmth, and can hardly keep warm. Between the anus and coccyx a red humid spot, smarting, sore and itching. Leptandria. Black, fluid stools; great urging, with difficulty of re- taining the stool. Cutting about the umbilicus after stool. Stools like tar in color and consistency, very fetid, and worse in the after- noon and evening. Lycopodium. Diarrhoea, Avith a constant sensation as of fermentation in the abdomen like yeast working. Sensation of fullness up to the throat after eating even a small quantity. Rumbling of flatus re- sembling a loud croaking. Magnes. c. A green, watery diarrhoea occurs regularly every three Aveeks. The stools appear sometimes like the green scum coA^ering a frog-pond. Sometimes white masses, like pieces of tallow, are found floating in the green stools. Sharp pain in the abdomen before stool. Mercurius. Morning diarrhoea, composed mostly of slime and fecal matter, with tenesmus before and during the stool. Diarrhoea pre- ceded by a faint sickish pain in the abdomen, entirely relieved by DIARRHOEA. 321 stool. The stools are often mixed with slime and blood, and are at- tended with tenesmus. YelloAV stools of the color of sulphur. Saliva- tion, sore, ulcerated gums, loose and sore teeth, aching of the jaw-bones, etc. Frequent urging to stool, a small quantity only being passed at a time, often of green or bloody mucus. Mouth and tongue moist, and plenty of saliva, yet great thirst for cold water. Disposition to remain at stool, as if she " could not get done." Mezereum. Diarrhoea, with prolapse of the rectum; the anus becomes constricted about the prolapsed rectum, which is very painful to the touch. Muriatic acid. Diarrhoea, with intolerable itching of the anus, which is sometimes so sore that it can scarcely be touched. Dark purple- colored varices, excessively painful to the touch. Very weak and languid. Great tenderness of the anus after stool—so great that the slightest touch or pressure is very painful. Natr. mur. Diarrhoea, like Avater. Disgust for bread. Severe head- ache on waking in the morning. Very vivid dreams; they seem like a living reality. Nux mosch. Chronic diarrhoea during pregnancy, with unusual slug- gish flow of ideas, so much so that it takes her a long time to answer any simple question. Diarrhoea, with fainting. Nux vom. The stools are very frequent, but small in quantity, with sore pain in the anus. She often feels as if something yet remained to pass, although a fair quantity may have been evacuated. Stools usually dark. Alternation of constipation and diarrhoea. Irritable, morose and sullen; apt to be quarrelsome if disturbed. Sleeplessness, particularly toward morning. Want of appetite. Opium. Black, Avatery diarrhoea, sometimes frothy. Diarrhoea in consequence of a fright. Drowsiness, but refreshing sleep cannot be obtained. Petroleum. Diarrhoea only in the day-time. Phosph. Watery diarrhoea, pouring aAvay as from a hydrant, with great sense of weakness in the abdomen, and general debility. Stools of green mucus or of whitish fluid; little grains like boiled kernels of rice are seen with the stools. Sharp shooting pains in the abdomen. Phosph. acid. White, gray diarrhoea; copious, yellow, watery diar- rhoea, with rumbling in the abdomen. Diarrhoea painless, but not exhausting. Mental state characterized by decided indifference to ex- ternal influences or surroundings. Podophyllum. Morning diarrhoea, or diarrhoea occurring in the 21 322 DISORDERS INCIDENTAL TO PREGNANCY. latter part of the night; profuse, frequent, gushing, and painless or not very painful. Pulsatilla. Watery diarrhoea, only or usually at night—sometimes unconsciously evacuated. She has no thirst; a bad taste in the mouth, nothing tastes good. Blue eyes, tearful disposition. Stools very changeable in appearance, so that no two are alike. Rheum. Sour diarrhoea, Avith cutting and colicky pains about the navel. The emanations from the body are all sour-smelling. Re- pugnance to food as soon as a small quantity has been eaten. Rhus. Diarrhoea, with drawing and tearing down the legs with every eA^acuation. Stools reddish, bloody. Restlessness, frequent change of position, wdth temporary relief. Sabina. Diarrhoea, with pain extending from the back to the pubes. Secale c. Painful diarrhoea, Avith great prostration. Putrid, fetid, and colliquative diarrhoea. The patient does not wish to be covered up Avarm or to be near the heat, but prefers to be in the air or Avishes to be fanned. Involuntary diarrhoea. Sepia. Sense of weight in the anus, and an empty, sore feeling at the pit of the stomach; much burning at the anus and rectum. The diarrhoea soon becomes exhausting. Jerking pains from the anus upAvard through the rectum. Stramonium. Diarrhoea, the stools having a cadaverous smell; great thirst; food tastes like straw. The mental symptoms are Avorse in darkness and solitude. Great loquacity. Sulphur. Diarrhoea in the morning, driving her out of bed; has to hurry, and barely escapes soiling her clothing. Very hungry about eleven o'clock in the morning; she cannot wait for her dinner, she is so faint and hungry. Very sleepy during the day-time; aAvakens often during the night; gets Avide awake, as though she had not slept at all. Sulphuric acid. Diarrhoea, with great debility; sensation of general trembling without any actual trembling. Cannot do anything delib- erately, hurries as if impelled to do e\rerything hastily. Tabacum. Diarrhoea, the stools consisting of yelloAvish or greenish slime; sudden attacks of extreme faintness, often with cold perspira- tion. Beclouded condition of the mind, she cannot read or study satisfactorily. Feeling of oppression around the cardiac region. Tartar em. Colliquative diarrhoea, Avith meteorism. Nausea, with faintness; warm perspiration on the forehead and head from efforts to vomit and vomiting. Veratrum alb. Very exhausting diarrhoea, she feels very weak after REMEDIES FOR INTESTINAL AFFECTIONS. 323 every movement of the bowels, Avith cold sweat on the forehead, and sometimes cold general perspiration. Table of Remedies for Intestinal Affections. Incarcerated Flatulency. 1. Carbo veg., Cham., Coca, Graph., Ignat., Kali c, Lya, Nitr. ac, Nux v., Plumb., Puis., Staph., Tart. em. 2. Ant. cr., Arn., Asar., Canth., Chin., Coloc, Con., Natr. a, Natr. m., Nux m., Phos., Phos. ac, Plat., Rheum., Squill., Veratr. a. BORBORYGMUS. 1. Caust., Chin., Hell., Lye, Nux v., Phos., Phos. ac, Puis., Sulph. 2. Aloes, Agar., Arn., Bry., Canth., Carb. veg., Cham., Ignat., Natr. m., Plumb., Sassap., Squill., Sep., Spig., Staph., Tart. em., Veratr. a. Flatulent Colic. 1. Carb. veg., Chin., Lya, Nux v., Puis., Rhod., Staph., Veratr. a. 2. Anac, Arn., Asaf., Aur., Cham., Con., Graph., Hyos., Ignat., Nux m., Phos., Plumb., Rheum., Squill., Tart. em. Constipation (Simple). 1. Bry., Calc. a, Coca, Lya, Nux v., Op., Phytol., Plumb., Sil., Graph., Sulph. ■ 2. Alum., Bell., Canth., Carb. veg., Con., Creos., Dulc., Graph., Kali a, Laur., Meny., Merc, sol., Nitr. ac, Phos., Plat,, Sabad., Sep., Stann., Sulph., Sulph. ac, Veratr. a., Verbas. -----from Inactivity of the Bowels.—1. Alum., Hep., Kali a, Natr. m., Nux v. 2. Anac, Am., Camph., Carb. veg., Chin., Coca, Staph., Ignat., Natr. c, Nux m., Op., Phytol., Petr., Puis., Ruta, Staph., Sulph., Thuj., Veratr. a., Zinc. •-----from Induration of the Stools.—1. Bry., Magn. m., Op., Plumb., Verb. 2. Amm. a, Aur., Carb. an., Caust., Chel., Graph., Kali a, Magn. a, Merc, sol., Nux v., Petrol., Ruta, Sep., Sil., Sulph., Sulph. ac, Thuj. Diarrhoea (Simple). 1. Ant. cr., Cham., Chin., Merc, sol., Phos., Phos. ac, Puis., Rhus tox., Sulph., Veratr. a. 2. Aeon., Amm. mur., Ars., Asaf., Bor., Bry., Calad., Calc. a, Carb. v., Dig., Hyos., Lach., Natr. m., Nitr. ac, Petr., Rheum, Sep., Sil. -----Painful.—1. Rheum, Rhus tox. 2. Ars., Bry., Caps., Cham., Dulc., Merc, sol., Nux v., Petrol., Puis., Sec. corn., Sulph., Veratr. a. 324 DISORDERS INCIDENTAL TO PREGNANCY. Diarrhoea, Painless.—1. Chin., Ferr., Hyos., Lya, Phos., Phos. ac., Podoph., Stram. 2. Ars., Bell., Cham., Chel., Op., Plat., Sulph. Stools. ------Knotty, like Sheep's Dung.—I. Magn. m., Merc, sol, Op., Plumb., Sulph., Verb. 2. Amm. a, Carb. an., Caust., Chel., Graph., Nux v., Sep., Sulph. ac, Thuj. ------Acrid.—I. Ars., Chin., Ignat., Merc, sol., Puis., Sulph. 2. Ant. cr., Cham., Dulc, Ferr., Graph., Kali a, Lach., Nux v., Phos., Staph., Veratr. a. ------Bilious.—1. Cham., Puis. 2. Ars., Dulc, Ipec, Leptand., Merc, sol., Podoph., Veratr. a. —----Black-colored.—1. Ars., Bry., Chin., Leptand., Sulph. ac. -,---^.Bloody—1. Canth., Merc, sol., Ipec, Nux v., Puis., Sep., Sulph. 2. Apis., Arn., Ars., Asar., Bry., Calc. a, Caps., Carb. veg., Chin., Dros., Ferr., Led., Lya, Merc, sol., Merc, corr., Nitr. ac, Phos., Rhus tox., Sabin., Sassap., Sil. ------Frothy.—1. Chin., Coloc, Magn. m., Merc, sol., Rhus tox. ------ Green.—1. Cham., Phos., Puis., Rheum, Sulph. 2. Dulc, Merc, sol., Phos. ac, Stann., Veratr. a. ------ Whitish.—1. Dig. 2. Calc. a, Lach., Spong., Sulph. ------Involuntary.—1. Phos., Phos. ac, Veratr. a. 2. Ars., Bell., Mur. ac, Natr. m., Sulph. ------Mucous.—1. Asar., Bor., Caps., Cham., Nux v., Phos., Puis., Sulph. 2. Arn., Ars., Carb. veg., Graph., Hell, Ipec, Kali c, Magn. in., Merc, sol., Petrol., Rheum., Rhus tox., Ruta, Sep., Spig. ------Purulent.—1. Merc, sol., Sil. 2. Arn., Canth., Lye, Puis., Sulph. ------of a Sour-Smell—1. Calc. a, Cham., Graph., Hep., Merc. sol., Natr. a, Rheum., Sulph. ------Stinking^ or of a Putrid Smell.—1. Ars., Asaf., Carb. veg., Puis., Sil., Sulph. 2. Arn., Aur., Bry., Calc. a, Cham., Chin., Dulc, Graph., Nitr. ac, Nux v., Oleand., Plumb., Squill., Staph., Stram. ------too Large.—1. Bry., Kali c. 2. Graph., Ignat., Veratr. a. ------too Small.—1. Caust,, Merc, sol., Pbos., Sep., Sulph. -——^ Undigested.—1. Ars., Chin., Ferr., Oleand. 2. Ant. cr., Bry., Meny., Phos., Phos. ac, Sulph. ac. ----.— Insufficient.—1. Am., Cham., Magn. m., Natr. a, Nux v., Sulph. 2. Alum., Coleh., Hyos., Sabad., Sep., Staph. ------Tenacious.—1. Merc, sol., Plat. 2. Asar., Caust., Plumb., Sassap. FISSURE OF THE ANUS. 325 Stools, with Ascarides.—1. Calc. a, Chin., Cina, Ferr., Ignat., Sulph. 2. Asar., Merc, sol., Nux v., Phos., Plat., Squill., Sil., Spig., Spong. ------with Lumbrici.—1. Cina, Sabad., Sil., Spig., Sulph. 2. Aeon., Anac, Calc. a, Cham., Cic, Graph., Natr. m., Ruta, Sec. corn. ------with Taenia.—1. Calc. c, Graph., Plat, Puis., Sabad., Sil., Sulph. 2. Carb. A-eg., Chin., Kali a, Nux v., Petr., Phos., Sep. Fissure of the Anus. This very painful and distressing disorder occurs more frequently in women than in men, and is often an accompaniment of pregnancy. In milder cases the fissure is limited to the mucous membrane, but in the severer forms it involves also the sub-mucous tissues. The fissure is usually about a quarter of an inch in breadth and from a quarter of an inch to an inch in length, situated immediately Avithin the anus, Avith its inferior extremity corresponding to the margin of the sphincter ani. In recent cases the edges of the fissure are soft and pliant, but in cases of long standing they are indurated and promi- nent. Fissure of the anus should be distinguished from haemorrhoids, though they often coexist in the same individual. Haemorrhoids are almost ahvays attended Avith constipation, Avhich acts as a provoking cause, but fissure of the anus is as often accompanied by looseness of the boAvels as other\Aase. The fissures are always very painful during and after an evacuation—sometimes even before. They are accom- panied by a constriction of the sphincter ani in many cases, which renders the evacuation of the boAA'el still more difficult and painful, and in some instances almost impossible. The pain is increased by forced expirations, as in coughing, sneezing, and by urinating ; every effort to discharge flatus or feces is attended Avith excruciating torment, which continues for one or more hours, attended Avith Aaolent spasm- odic action of the sphincter ani: so violent is the agony that most persons thus afflicted put off the calls of nature and retain the recum- bent position. This diseased condition results from some constitutional dyscrasia. Its cure should not be attempted by surgical means. Its homoeo- pathic treatment results in a cure; Avhile its surgical treatment is merely temporizing, and may be folloAved by disastrous consequences; just as the cure of anal fistula by operative procedure is sometimes lolloAved by pulmonary disease. What have been termed rhagades or cracks of the anus appear to be a milder form of fissure of the anus. 326 DISORDERS INCIDENTAL TO PREGNANCY. iEsculus hip. This remedy has been successfully employed in some cases. The boAvels are costive, although they are moved daily. Face pale and haggard, as though from great suffering. Lameness of the back and hip, so that walking is not only painful, but Avellnigh im- possible. Itching, stinging, burning and feeling of fullness at the anus. Haemorrhoids. Arsenicum. On going to stool painful constriction immediately above the anus, AAdiich extends toAvards the sacrum. After stool the anus burns like fire, causing intense agony, restlessness and exhaustion. Heat and pain in the rectum, with a kind of tenesmus, as in dysentery, Avith continual pressure. Causticum. There is great difficulty in walking, for the pain in the anus aud rectum becomes intolerable. Much pain in the perin- eum. Large, painful pustule near the anus, discharging pus, blood and serum. BoAvels are usually very costive. Gratiola. After stool, painful pressure in the abdomen Avhen walk- ing, relieved by sitting doAvn. Sticking pain about the umbilicus. Tearing in the rectum or prickling in the anus. Painful cramps in the os coccygis. Ignatia. Painless contraction of the anus for many days. Soon after stool, pain in the anus, shooting far up into the rectum, or con- striction and smarting like touching a wound. Very easy prolapsus of the rectum. Pain in the anus returning at the same hour each day; Avorse walking and still worse standing, but relieved on sitting doAvn. Lachesis. On going to stool the anus feels as if closed. Internal, cramp-like pain in the anus before and after passage. Prolapsus of the rectum, which is thick and tumefied, and Avhen it returns it con- tracts spasmodically. Mezereum. Painful constriction, tearing and drawing at the anus, in the perineum, and from thence through the urethra. After stool the anus contracts upon the prolapsed rectum, Avhich remains stran- gulated, causing, when touched, a pain like a Avound.' Natrum mur. On going to stool the rectum seems contracted, then is voided, after great effort, only a small quantity of hard feces, with tearing, bleeding and smarting at the anus, and finally some soft mat- ter. Ripping-up sensation in the anus after stool. Much sticking and sharp pains in the anus and rectum between the stools, and at night in bed. Nitric acid. This remedy is used more frequently than any other. The symptoms Avhich indicate it are: On going to stool, pain in the FISSURE OF THE ANUS. 327 rectum as if something Avere torn away, or twitchings in the rectum and spasmodic contraction of the anus many hours aftenvard. Smarting more in the rectum than in the anus immediately after stool, and continuing tAvo or three hours. Sometimes prolapsus of the rectum or discharge of much blood accompanies some of the above symptoms. Nux vom. Painful stools, either much too large and difficult or too small and insufficient, with a sensation as if something remained in the rectum still to be discharged, but with an entire inability to void it. Phosphorus. The pains for phosphorus are mostly lancinating, in the anus and up the rectum—sometimes attended Avith smarting. After stool, strong desire to urinate. Acute smarting pains after a soft stool, extending into the abdomen. Plumbum. A sensation as if a rough body were traversing the rectum during stool. Sensation as if the anus were draAvn strongly upAvard. Much trouble with the urine in not being able to pass it —apparently from want of sensation to do so; the will to do so can- not effect it, as if from paralysis. Sepia. Constrictive pain in the rectum, extending to the perineum and into the vagina. Pain in the rectum on going to stool,and Avhich persists for a long time after sitting down, and finally an imperfect stool is voided Avith sore, smarting pain. There is a sense of Aveight in the anus, like a constant drag. Silicia. Painful effort to stool for some time, and finally the stool recedes into the rectum; such efforts are repeated several times before a passage is effected, with sore, sticking, shooting pains. Sulphur. Tenesmus for an hour after having been to stool. On attempting to sit down for stool the pain in the anus prevents her from doing so. After stool a pulsating pain continues in the rectum the whole day. Lancinating pains from the anus upAvard after stool, so violent as to cause syncope. At night there is much difficulty in lying in bed from lancinations and uneasiness in the rectum, tenes- mus, etc. Thuja oc. During an attempt at stool the pain in the anus and rec- tum is so great that she has to desist. Violent contraction in the anus and rectum, folloAved by tearing as if in the bowels. Burning pricking in the anus between stools. Violent burning in the anus while Avalking. The remedies laid down under the head of haemorrhoids, varicose veins, constipation and diarrhoea, with their indications, should like- wise be consulted. 328 DISORDERS INCIDENTAL TO PREGNANCY. Disordered Secretions and Excretions. Ptyalism. The profuse flow of saliva Avhich sometimes occurs in the earlier months of pregnancy usually lasts but two or three months, although cases are recorded in Avhich it continued during the whole period of gestation. Where this discharge is excessive it must necessarily prove very exhausting. Its source must be found in some peculiar constitutional dyscrasia, which ultimates itself in this direction under the stimulus of pregnancy. Hence the homoeopathic remedies are found to relieAre the difficulty, and at the same time benefit the whole system of the patient, This is just the reverse of the experience derived from the allopathic use of astringent gargles. Tavo cases are referred to by Cazeaux, in one of Avhich the sudden suppression of the ptyalism was folloAved by apoplexy, in the other symptoms of suffocation appeared. This eminent authority is unwilling to admit that these results were the actual consequences of such suppression, but the intelligent homceopathist would expect nothing less. The salivation, if unattended by other symptoms, may require mercurius, but in most cases there are other gastric disturbances, all of which must be duly considered. For remedies, therefore, con- sult those mentioned in the preceding sections. Spitting of blood sometimes exists in connection with pregnancy, but in ordinary cases need give rise to no alarm. It is usually due to the general congestion consequent on the condition of pregnancy, and con- sists of a mere exudation from the mucous membrane of the air-pas- sages or fauces. Such remedies as Aeon., Bell., Creos., Hamara., Ipec, Lachesis. Elaps., Mur. ac, may be indicated. Urinary Difficulties and Derangements. As gestation advances, the increasing size of the uterus causes it to press more and more upon the bladder. Thus the capacity of the latter organ is diminished by the lateral pressure, Avhich necessitates a much more frequent discharge of urine. The same frequent mictu- rition results also from the direct irritation of the neck of the bladder. Thus there may be hourly calls to pass water, Avhich are sometimes but partially relieved by the Aoav of a few drops only at a time, or the irritation may amount to dysury, an actual strangury, or even to a complete retention of urine. These difficulties may arise in the earlier stages of pregnancy, espe- cially Avhere the unusual size of the pelvic cavity allo\ys the fcetus to URINARY DIFFICULTIES AND DERANGEMENTS. 329 remain too long Avithin it, or they may appear in consequence of some displacements, such as prolapsus, anteversion or retroversion of the uterus. Where some displacement appears to be the cause—which may sometimes be knoAvn by the suddenness of the onset of the diffi- culty, especially if it follows some accident or over-exertion—the case should receive the treatment recommended in a succeeding chapter for uterine displacements. If it prove to be retroversion, the use of the elevator may be necessary to replace the organ. The other varieties of displacement scarcely ever require manual assistance, since perfect rest in the horizontal position and the exhibition of the homceopathi- cally indicated remedy Avill, in most cases, readily relieve the uterine and the urinary difficulty at the same time. The catheter may some- times be required, in order at once to relieve the patient of the great distress under which she may be laboring from enormous accumula- tion of uriue. Incontinence of urine sometimes appears, especially in the later stages of pregnancy. When it appears in the early months it may re- sult in part from the pressure of the Avomb upon the neck of the blad- der before it rises out of the pelvic cavity, causing a loss of tone of the part. This difficulty will often yield to the indicated remedy, but if not, Avhere it comes on in the early stage of pregnancy, it may be ex- pected to disappear upon the emergence of the uterus from the cavity of the pelvis. For the medical treatment of these difficulties the following reme- dies should be carefully studied according to the indications here given, and compared in the Materia Medica with reference to any concomitant and constitutional symptoms which may also be present in the case. It is to be noted, likewise, that these remedies should be consulted, and may be required for urinary difficulties occurring not only during pregnancy, but before, during, and after parturition as well. Aconite. Retention of urine, with stitches in the region of the kid- neys. Difficult and scanty emission, with pinching around the um- bilicus. Bright-red, hot urine. Enuresis, accompanied with profuse perspiration. Desire to urinate, accompanied Avith great distress, fear and anxiety. Worse from exposure to cold dry air. Apis. Burning smarting pain before and after urination. Stitching pain in the urethra during micturition; must urinate often. Arnica. After passing a little urine she Avishes to pass more, but is unable to do so at that time. Brown urine with brick-red sediment. 330 DISORDERS INCIDENTAL TO PREGNANCY. Sense of fullness of the bladder, Avith inability to urinate. A bruised and sore feeling exists if haemorrhoids complicate the case. Arsenicum. Considerable burning is experienced at the commence- ment of the flow, Avhich ceases upon the full establishment of the stream; restlessness, cold sweat. Sometimes the urine Avill not flow at all, and, although the bladder be full, there is yet no desire to uri- nate, as though there Avas paralysis of the viscus. Discharge of mucus and blood Avith the urine. Belladonna. Great difficulty in passing a small quantity of urine; it floAvs in a very feeble stream or in drops. The urine is often of a golden-yellow color. Constant involuntary dribbling of urine. Enu- resis with profuse perspiration. The region over the bladder is very sensitive to pressure, the slightest jar causing pain. Blood-red urine. Urine, at first clear, becomes turbid on standing. Retention of urine. Camphor. Retention of urine, with constant pressure on the bladder and desire to urinate. Burning in the urethra during emission of urine. This remedy will prove very useful if the urinary difficulty is the result of the injudicious use of cantharides, balsam copaiba, tur- pentine, etc. Cannabis. Burning during and after emission, particularly after cantharis has failed to relieve. Cantharis. Very frequent urination, even sixty times an hour, with violent cutting pain, so severe as to make her scream. The urine is often bloody. Strangury, with frequent urging. The urine does not flow in a stream, but dribbles away or passes drop by drop, Avith cut- ting and burning. Cutting and burning pains in and through the bladder. Tenesmus of the bladder, Avhich is agonizing in severity. Capsicum. Burning smarting after micturition, as from the applica- tion of cayenne pepper. Causticum. Frequent desire to urinate, a small portion passing in- voluntarily. Involuntary passing of urine at night. Also Avhere there are signs of paralysis of the bladder from prolonged retention of urine and over-distension. Coccus cacti. The urine does not form the usual jet, but runs down over the surrounding parts. Does not cut or burn. Colocynthis. Tough mucous sediment in the urine which can be drawn out into strings. Conium. The urine flows and stops, and flows and stops again, and so on. There are cutting pains during the Aoav, and burning or smarting afterward. Strangury, with vertigo, particularly on lying doAvn. URINARY DIFFICULTIES AND DERANGEMENTS. 331 Dulcamara. The urine on standing and becoming cooled, has an oily consistence, Avith a jelly-like sediment, intermixed Avith specks of blood. The urinary difficulty is increased at every cool change of the weather. Graphites. Urinary troubles, Avith burning in the urethra between the acts of micturition. Very frequent nightly micturition. Pain in the sacrum when urinating. Cutting and doAvnward pressure in both kidneys before urinating. Helleborus nig. In bad cases where the irritation at the neck of the bladder threatens to run into inflammation. Almost constant desire to urinate, very little being passed, of a dark color and depositing a coffee-ground-like sediment; the bladder at length becomes paralyzed and greatly distended. On straining to pass a small quantity of urine some drops of blood come away. Nausea and distended abdomen sometimes attend. Hepar. Intense soreness in the urethra during the emission of urine. Very slow but painless emission of urine, apparently from feeble con- traction of the bladder. Greasy and opalescent pellicle on the urine. Blood-red urine. Painful micturition. Lachesis. Stitches in the kidneys, extending doAvnward and appar- ently through the ureters. Frequent emission of a foamy urine, some- times dark and scanty, sometimes profuse. Dull pain in the bladder, occasionally with a sensation as though a ball were rolling about in there. Laurocerasus. Acrid urine, corroding the labia. Urinary difficulties, with palpitation of the heart and gasping for breath, coming on by spells. Very slow flow of urine; sometimes the bladder seems to be completely paralyzed, so that not a drop can be voided. Thick, red- dish or mahogany-colored sediment, Avith Avhite jelly-like flocks float- ing through it, Pain in the region of the stomach when urinating. Lycopodium. Much pain in the back previous to the emission of urine, so that she even screams out. Itching in the urethra during and after micturition. Violent jerking, sharp-shooting, tearing or cutting pains in the urethra not long after urinating. Red crystals are deposited in the urine, the urine itself being clear. Foaming urine. Stitches in the bladder, neck of the bladder and anus at the same time. The Aoav is delayed, Avith pain in the back, which, however, is relieved as soon as the flow begins. Urine turbid, milky, deposit- ing a thick sediment of a nauseating odor. Merc. sol. Constant desire to urinate, the desire not lessened by urinating. Pieces of filaments, flocks and hard pieces of mucus re- sembling pieces of flesh are passed in the urine. Burning and scald- 332 DISORDERS INCIDENTAL TO PREGNANCY. ing sensation of the urine from raw surfaces and otherwise. Very great tenderness over the bladder. Sour-smelling urine. Prolapsus of the vagina or swelling of the external genitals accompanies the urinary difficulty. Nitric acid. Painless retention of urine. Desire to urinate, with cutting in the abdomen. Urine Avith an intolerable odor. Very thin stream, as if from contraction of the urethra. Stitching pain in the abdomen when urinating. Burning in the urethra, and desire to urinate with the hope of relieving the burning, Avhich, however, is in- creased by the act. Nux vomica. She wishes to urinate very frequently, only a little at a time being passed, Avith a sore burning pain, usually accompanied with constipation. Strangury. Bloody urine. Spasmodic retention of urine, only a few drops passing at a time, Avith scalding sensation; reddish brick-dust sediment. Phosphoric acid. Frequent calls to urinate at night, a large quantity of colorless urine being passed each time. Creeping in the urethra between the acts of micturition. White, jelly-like flocculi in the urine. Pulsatilla. Retention of urine, with redness, heat and soreness of the vesical region externally. Continued pressure on the bladder, Avithout desire to urinate. Desire to urinate, with drawing in the abdomen. Involuntary emission of urine when sitting or Avalking. After uri- nating, spasmodic pain in the neck of the bladder, extending to the pelvis and thighs. Frequent and almost ineffectual urging to urinate, Avith cutting pains. Great urgency of the call, it seems impossible to delay. The urinary difficulties are increased by taking cold, and at such times the urine may deposit a tough, slimy sediment. Rhus tox. Involuntary urination, particularly Avhen at rest. Dysu- ria, Avith discharge of drops of bloody urine. SnoAV-\\diite sediment in the urine. Retention of urine, with great restlessness and uneasi- ness, no position being comfortable except for a few moments. Belch- ing of Avind while urinating. Ruta. At every step after micturition she feels as if the bladder were full and moved up and doAvn. She feels as if she could not retain the urine, so urgent is the desire, although she can pass but a very small quantity. Involuntary emission of urine whether at rest or in motion. Sepia. The urine deposits a sandy, sometimes pinkish sediment, which becomes firmly attached to the vessel and is with difficulty re- moved. Frequent urging at night, the urine voided often having a ALBUMINURIA. 333 putrid odor in the morning. Sensation as though urine were passing through the urethra, Avhich is not a fact. Burning and smarting in the urethra. Violent itching about the vulva accompanies the urinary difficulties. Stramonium. The urine dribbles aAvay very sloAvly and feebly. Re- tention of urine, or it flows feebly or in drops, though painlessly, as though there existed a spasmodic stricture of the urethra. Sulphur. Very frequent desire to urinate day and night, in fact al- most constant urging; the pain caused by the act of micturition scarcely ceases until the patient is again obliged to urinate, Avhich gives rise to a renewal of the pain. Very urgent call to urinate; she is unable to wait even for a moment. Fetid urine, Avith a greasy pellicle on its surface. The urine is emitted Avith great force. The urine occasions an acrid or corrosive sensation when voided, as though it were strong lye. Albuminuria. Albuminuria, or the presence of albumen in the urine, constitutes one of the most interesting of the pathological changes induced by pregnancy. Healthy urine contains no albumen, and the urine of healthy women in the pregnant state is equally destitute of this element. This change in the urine is not ahvays constant or equal in amount: in proportion as women are constitutionally healthy, they will be found free from albuminuria in pregnancy. And in proportion as their systems are affected by some dyscrasia, the derangement of the vital fluid will be greater; for it must be borne in mind that albumen must be diminished in the blood in the same ratio that it is increased in the urine. Cases of albuminuria might be cited illus- trating all the different degrees, from the slightest and scarcely per- ceptible trace of albumen which appears in the urine for a brief period only of pregnancy, up to those forms of anasarca which involve the entire system, and in which the urinary secretion, almost totally suppressed, is so loaded with albumen as to become entirely solid on boiling.* Albuminuria may be either temporary or permanent. In the former case it may arise from a great variety of morbid influences and in connection Avith various forms of disease. And it may be occasioned by pregnancy, which, although not itself a morbid con- dition, seems to develop in some form or other any latent dyscrasia which may have been lurking in the system, just as scarlatina de- * Am. Horn. Review, vol. v., p. 492. 331 DISORDERS INCIDENTAL TO PREGNANCY. Arelops any scrofulous taint Avhich may belong to the constitution of children whom it attacks. And, in fact, scarlatina does actually develop an albuminuria in post-scarlatinal dropsy, which must be deemed a purely psoric affection, since it appears only in a particular variety of constitution, although the presence of the albumen is par- tially accounted for by the temporary failure of the functional action of the skin during desquamation. Permanent albuminuria is principally found in connection with chronic disease of the kidneys, whether in the pregnant or in the un- impregnated condition. In that form of hypertrophied degeneration in which the kidneys become white and enlarged, the urine is greatly diminished in quantity and contains a large amount of albumen. This nephritic affection never proves fatal without the previous occurrence of dropsy, which is one of its most usual and prominent symptoms. Such cases belong to strongly-marked psoric diatheses, of which in- stances have been observed in three successive generations in which the albuminuria, morbid affection of the kidney, almost total suppres- sion of the secretion of the urine and general dropsy were the un- avoidable attendants of every pregnancy. This intimate connection of albuminuria Avith psora is Avell illustrated in the report, by an allo- pathic physician, of the treatment with arsenic of this disease compli- cated with psoriasis and lichen.* The arsenic chanced to be the true homoeopathic similimum to the entire case, and, although given in allopathic doses, both albuminuria and skin disease were thoroughly cured. The prompt disappearance of the albuminuria at the termination of pregnancy in many cases, gives rise to the belief that some local in- fluence, such as pressure of the gravid uterus upon the emulgent veins, may be an important cause of this condition. But, as already stated in the case of varices and haemorrhoids, such results can occur from local pressure only in persons constitutionally predisposed to this af- fection. Thus, in the milder cases particularly, we see all the abnor- mal symptoms removed by the recuperative energy of nature alone on the discontinuance of the provoking cause. Thus, too, even during the continuance of pregnancy, the homceopathically indicated remedies are so far capable of antidoting the constitutional dyscrasia that the albuminuria in many instances may be made to disappear entirely in spite of the persistence of the provoking cause. And these remedies may even then have been selected under the prevailing influence of other (sensational) symptoms—remedies perhaps in which we have * Brailhwaite's Retrospect, July, 1862, p. 95. ALBUMINURIA. 335 hitherto discovered neither pathogenetic nor clinical evidences of their adaptation to albuminuria. The important relation which albuminuria bears to puerperal in- sanity and convulsions ought not to be overlooked in this connection. " Albuminuria precedes arid attends the first access of puerperal in- sanity in a large proportion of cases, but not perhaps so frequently nor so constantly as it precedes and attends upon attacks of puerperal convulsions. The coagulability of the urine generally disappears within a short time after an attack of puerperal insanity commences. When the insanity recurs in the form of successive attacks or explo- sions, each attack is connected with a neAv attack or advent of albumi- nuria." The albuminuria mostly appears in the later months of pregnancy, and its presence, especially if accompanied by anasarcous conditions, will serve to place the physician on his guard agajnst puerperal con- vulsions. And while on the one side the albuminuria seems to pre- dispose to severe nervous affections, on the other excessive nervous excitement appears to cause albuminuria. Where from collateral symptoms there is reason to suspect the presence of albumen in the urine of a pregnant Avoman, the urine should be subjected to the usual qualitative tests, that its presence or absence may be ascertained with certainty, and the presence of albu- men having been discovered, its quantity should likewise be made out. At the same time in treating the case the attention of the practitioner should not be diverted from the general symptoms by the presence of the albumen, but, as in all other cases, the subjective symptoms should have equal weight with the objective symptoms, and the remedy chosen should be as nearly in accord with the totality of the case as possible. These cases are amenable to treatment, and it is feared that failures to cure sometimes result from the entire at^ntion, in choosing the remedy, being directed to the albuminuria. Uraemia, or retention of the urea in the blood, Avhich usually forms a part of the albuminuria, is probably the direct cause of the convul- sions and other nervous affections that sometimes result. And it is remarked that these difficulties are more apt to occur in primiparse than in multipara. This affection has been mentioned as a powerful and frequent cause of abortion, of premature labor and of the death of the foetus. This, however, is more apparently than really correct; for the presence of albumen in the urine forms but a single one of the symptoms of a general dyscrasia Avhich pervades the entire system, the radical cure 336 DISORDERS INCIDENTAL TO PREGNANCY. of Avhich forms one of the most gratifying results of homoeopathic practice. The ansemia, oedema, ascites and anasarca which appear in connec- tion Avith albuminuria will be subsequently considered. The follow- ing medicines, together with those mentioned under the head of urinary difficulties and of dropsy, should be considered, as Avell as the general table of remedies appended to this section, and, above all, the Materia Medica should be carefully studied. Allium cepa., Amm. carb., Apis., Ars., Aurum mur., Bell., Bry., Cinnabaris, Cobalt, Colch., Cupr. m., Dig., Dulc, Eupat. purp., Glo- noine, Lachesis, Natr. mur., Ononis sp., Phos., Phos. ac, Squill, Terebinth. Remedies for Urinary Difficulties and Derangements. Urine acrid.—1. Hepar., Merc. sol. 2. Cann., Caust., Clem., Par., Rhus tox., Thuja. ------smelling like ammonia.—1. Asaf. 2. Mosch., Nit. ac., Phos. ------hot or scalding.—1. Ars., Canth., Hepar. 2. Aeon., Caps., Cham., Colch., Dig., Merc, sol., Phos. ac, Squill. ------bloody.—1. Canth., Puis. 2. Ars., Calc. a, Caps., Ipec, Lya, Merc, sol., Mezer., Nux v., Phos., Sec. corn., Sep., Sulph., Zinc. ------with greasy or variegated pellicle on its surface.—1. Paris. 2. Calc. a, Hepar., Jod., Lya, Petrol., Phos., Puis. ------dark.—1. Aeon., Bell., Bry., Colch., Merc, sol., Sep., Tart. em., Veratr. a. 2. Ant. cr., Arn., Calc. a, Canth., Carb. veg., Dig., Hell., Hepar., Ipec, Puis., Selen., Staph., Sulph. ------flaky.—1. Canth., Mezer. 2. Cham., Cann., Sassap., Zinc. ------frothy.—1. Lach., Lye. ------greenish.—1. Camph. 2. Rheum., Veratr. a. ------milk-colored.—1. Aur. mur., Cina, Phos. ac. ------mucous.—1. Natr. mur., Puis. 2. Ant. crud., Canth., Coloc, Dulc, Merc, sol., Valer. ------pale.—1. Con., Nitr. ac, Phos. ac. 2. Agar., Alum., Ang., Arn., Bell., Colch., Coloc, Ignat., Puis., Rhus tox., Sassap., Squill., Sec. corn., Stram., Stront. ------purulent.—1. Canth., Clem. 2. Lye, Puis., Sabin., Sil., Sep. ------stinking.—1. Dulc. 2. Ars., Carb. veg., Natr. mur., Nitr. ac, Phos. ac, Puis., Sep., Viol. tr. ------with urinous odor in excess.—1. Benz. ac. remedies for urinary derangements. 337 Urine turbid or cloudy when voided.—1. Cina, Con., Merc. sol. Sabad. 2. Ambr., Cann., Chin., Dulc, Ignat., Phos., Puis., Rhus tox., Sep. -----becomes turbid or cloudy on standing.—1. Bry., Cham., Phos. ac. 2. Caust., Merc, sol., Seneg., Valer. -----sticky or viscous.—1. Coloc. 2. Creos., Cupr. met., Phos. ac. Sediment, reddish.—1. Canth., Natr. mur., Puis., Sep., Valer. 2. Aeon., Ambr., Ant. crud., Arn., Chin., Lye, Nitr. ac. -----whitish.—1. Phos., Rhus tox. 2. Coloc, Con., Hepar., Nitr. ac, Oleand., Petrol., Phos. ac, Sep., Spig., Sulph., Valer. -----yellow.—1. Cham., Phos., Sil., Spong., Sulph. ac, Zinc. -----bloody.—1. Canth., Phos. ac, Puis., Sep. 2. Aeon., Dulc, Lye, Phos., Sulph., Zinc. -----clay-like.—1. Sassap., Sep., Sulph., Zinc. -----cloudy.—1. Bry., Nitr. Phos. ac, Seneg., Thuj. -----flaky.—1. Canth., Mezer., Zinc. -----like flour.—1. Calc. c, Graph., Natr. mur. -----like pus.—1. Canth., Cham., Lye, Puis. 2. Calc. a, Con., Kali c, Sep., Sil. -----mucous.—1. Dulc, Natr. m., Puis., Valer. 2. Ant. crud., Aur., Bry., Caust., Coloc, Con., Merc, sol., Natr. a, Phos. ac, Sassap., Seneg., Sulph., Sulph. ac. -----sandy, gravelly.—1. Ant. crud., Calc. a, Lya, Phos., Ruta., Sassap., Sil., Zinc. 2. Ambr., Arn., Chin., Meny., Natr. m., Nitr. ac, Nux m., Nux v., Puis., Thuj. Desire to Urinate, ineffectual.—1. Canth., Dig., Sassap. 2. Arn., Camph., Caust., Coloc, Hyos., Kali a, Nux v., Phos., Phos. ac., Plumb., Puis., Stram., Sulph. Discharge, too copious.—1. Arg. nit., Mur. ac, Rhus tox., Squill., Verb. 2. Agnus., Bar. a, Bism., Canth., Guaj., Ignat., Merc, sol., Nitr., Phos. ac, Seneg., Tarax., Viol. tr. -----scanty.—1. Canth., Colch., Dig., Graph., Hell., Op., Ruta., Staph. 2. Aeon., Arn., Bell., Bry., Caust., Chin., Dulc, Hep., Hyos., Kali c, Laur., Nitr. ac, Nux v., Phos., Plumb., Puis., Sulph., Veratr. a. ■----- too frequent—1. Agar., Bar., Canth., Caust., Merc, sol., Nitr. ac, Rhus tox., Squill., Staph. 2. Bry., Creos., Ignat., Kali a, Lach., Mur. ac, Natr. c, Phos. ac, Selen., Spig., Thuj. -seldom.—1. Canth. 2. Aeon., Arn., Ars., Aur., Camph., Hepar., Hyos., Laur., Nux v., Op., Plumb., Puis., Ruta., Stram. 22 338 disorders incidental to pregnancy. Discharge by drops, dribbling.—1. Canth., Sulph. 2. Am., Camph., Clem., Dulc, Petrol., Staph., Stram., Thuj. ------involuntary.—1. Caust., Puis., Rhus tox. 2. Bell., Creos., Dulc, Lye, Merc, sol., Natr. m., Petrol., Ruta., Sep., Sil., Spig., Sulph. ------involuntary at night, " wetting the bed."—1. Ars., Bell., Bry., Caust., Cham., Merc, sol., Op., Puis., Rhus tox., Sep., Sil., Stram., Staph. 2. Aeon., Arn., Bar. a, Calc. a, Chin., Cina, Creos., Dulc, Hep., Hyos., Ignat., Kali c, Lye, Natr. m., Nux v., Petrol, Phos., Phos. ac, Rheum., Ruta., Spig., Zinc. ------ interrupted.—1. Clem., Con. 2. Agar., Caust., Dulc, Sulph., Zinc. Retention.—1. Aeon., Arn., Ars., Canth., Hepar., Hyos., Laur., Lye, Plumb., Puis., Ruta., Stram. 2. Aur., Bell., Caps., Caust., Chin., Cic, Coloc, Con., Cupr. m., Dig., Graph., Nux v., Op., Sec. corn., Sulph., Veratr. a. Complaints before urinating.—1. Bor., Coloc, Lye, Nux v., Puis. 2. Arn., Bry., Dig., Phos, ac, Rhus tox., Sulph., Tart. em. ------when beginning to urinate.—1. Canth., Clem., Merc. sol. ------while urinating.—1. Cann., Canth., Hepar., Lye, Merc. sol., Phos. ac, Puis., Thuj. 2. Aeon., Clem., Colch., Con., Ipec, Nitr. ac, Nux v., Phos., Sassap., Sep., Sulph., Veratr. a. ------on cessation of flow.—Bry., Canth., Sassap., Sulph. ------after urinating.—1. Canth., Coloc, Hepar., Merc, sol., Natr. m., Sassap., Thuj. 2. Anac, Arn., Bell., Calc. c, Cann., Caps., Chin., Con., Dig. Natr. a, Nux v., Par., Puis., Ruta., Staph., Sulph., Zinc. Remedies acting especially on the Bladder.—1. Canth., Hyos., Lye, Nux v., Puis., Ruta. 2. Aeon., Ant. crud., Am., Bell., Calad., Caps., Dulc, Mur. ac, Petrol., Sassap., Squill., Sep., Staph. Remedies acting especially on the Urethra.—1. Cann., Canth., Caps., Clem., Merc, sol., Phos., Thuj. 2. Aeon., Bry., Calc. c, Caust., Chin., Colch., Con., Mezer., Natr. m., Nitr. ac, Nux v., Phos. ac, Puis., Sabin., Sep., Sulph., Zinc. Disorders of Respiration. cough and dyspnoea. These are the principal forms of disorders of the respiratory organs which occur in connection with pregnancy. There may also be oppres- DISORDERS of respiration. 339 sion of the chest, palpitation of the heart, and other similar symptoms; but these belong rather to disordered circulation than to disordered respiration. Yet so intimate is the connection between these two vital functions that it Avould be difficult in any given case to de- termine whether the disturbance of the respiration affected the cir- culation, or whether the disturbance of the circulation affected the respiration. For our purpose it is sufficient to remember that both these functions are under the immediate and absolute control of the nervous system of organic life, which, as has already been explained, is most intimately connected with the uterus and sustains all the development of utero-gestation. From reflex, sympathetic irritation of the pneumogastric, either in connection with gastric disturbances or in lieu of them, the cough of pregnancy may arise in the earlier months, or it may be the direct result of irritation of the diaphragm from the upward displace- ment in the later months. In either case tlie cough is short, frequent, irritating, and it may be perfectly dry or attended with some expecto- ration. Influenza may also set in as a complication, in which case prompt attention should be rendered and a cure effected at once, since otherwise abortion itself may result. A certain spasmodic form of cough sometimes makes its appearance, resembling hooping-cough, and arising from an apparently similar irritation of the pulmonary nerves. Such cough as may be connected with a tuberculous condition of the lungs, as in cases of incipient phthisis, is more apt to disappear under the influence of pregnancy. Should the pulmonary difficulties be so far developed that a purely phthisical cough maintains itself during the period of gestation, the state of the patient will require the most serious attention, since the phthisical symptoms usually appear with far greater intensity after delivery. Another most important indication of this condition in pregnancy is to be found in the chills, which haA^e been known to occur every day, and which in the entire absence of cough or expec- toration Avere belieA^ed to he due to some miasmatic influence. Such a patient was readily delivered of an apparently healthy and full-sized child, but was herself found upon examination to be in the last stage of consumption, never being able to leave her bed or scarcely to speak. She lived but a few weeks after her confinement. Dyspnoea in its various forms, panting respiration, shortness of breath, oppression of the chest, is a not unfrequent accompaniment of pregnancy. The symptoms of this class, as well as those con- nected with cough, are more apt to appear in persons whose chests 3 40 disorders incidental to pregnancy. are naturally weak, Avho are constitutionally predisposed to phthisis pulmonalis, or Avho have a similar predisposition to hydrothorax. A very sad case of a fatal complication of all these difficulties recently came under observation. A young woman, aged about thirty, of scrofulous constitution, rather short in stature, inclined to hydrothorax, Avho probably had some small accumulation of water about the heart for a considerable time, was married in the fall, and found herself enceinte in the winter; she consulted her physician, at a dis- tance, for a severe cough with great shortness of breath. She reported herself very much relieved by the remedies advised, but soon after taking, as was stated, " a cold on her lungs," she died in a feAv days, suffocated by the copious pulmonary effusion. Plethora has also been mentioned as one of the causes of dyspnoea in pregnancy, for which of course venesection is the allopathic remedy. But a more sound physiological view, which denies that there is ever too much pure blood, leads also in this instance to a more accurate pathology, which attributes the dyspnoea to irregularity or obstruction of the circulation—to congestion perhaps in the more aggravated cases—but never to plethora. The local congestions which arise in such cases from the obstruction of the general circulation, or even from constitutional predisposition to pulmonary apoplexy, are connected with palpitation of the heart and rush of blood to the face and head. These local difficulties, Avhether dependent upon constitutional dyscrasia or not, are insepa- rably connected with the other forms of disorder Avhich occur in the pregnant condition ; since every part of the system sympathizes with the Avhole and the Avhole Avith every part, the remedy which will cure any one must also be the one which more or less accurately corre- sponds to them all. Hence, too, the radical cure of such cases is seen to be a work of time; the disturbance of the harmony of the system by pregnancy becomes gradually relieved, as the circulation and play of the vital forces are equalized by eliminating from the interior of the organization those subtle hereditary miasms which poison the springs of life in their original fountains. For the treatment of the cough, dyspnoea, and other disturb- ances of the respiratory system in gestation, we recommend there- fore no particular medicines, but advise the thorough study of those already detailed under the various forms of gastric disturbance, and more particularly a reference to the most copious and reliable works on Materia Medica that can be procured. The leading symp- toms of the case may be found in connection with the pulmonary derangements of circulation. 341 difficulties, Avith the gastric derangements, or with some abnormal condition of the secretions or excretions; and the remedy at first in- dicated by the principal symptoms, if it do not in time remove the entire train of morbid conditions, will remove some of them; at which time a new prescription may require to be made for the case as it then presents itself. But it will sometimes be found that the remedy which is indicated at the first, being homoeopathic to the particular form of constitutional dyscrasia in the patient, and given at intervals and in higher potencies, will eventually remove all the various forms of trouble and restore the patient to complete health.* Derangements of Circulation and of the Circulatory Apparatus. plethora, hydremia, anaemia, etc. Plethora, in pregnancy, means principally that increased activity of the circulation which corresponds to the increased activity of the nervous system. The volume of the blood may be increased, and this increase may sometimes be obtained at the expense of the quality of the blood itself. Thus, as the bulk of the circulating fluid is aug- mented, it becomes more thin and watery. And this condition is ex- pressed by the term hydrozmia or Avatery blood. Plethora alone is insufficient to account for the vertigo, giddiness, flushes of the face, dimness of vision, ringing in the ears, flashes of heat all over the body and attacks of fainting which often annoy pregnant women. Some of these conditions it should, however, be remembered, may arise from the opposite or anajmic condition of the blood. Even in plethora, while some few of the symptoms may be due to the pressure of the apparently augmented quantity of the blood, the greater part must doubtless arise from the influence of the vitiated character of the blood itself rendered more serous, since it is evi- dent how similar symptoms, as of debility, may appear to spring from too much and also from too little blood. The same thing is seen in cases of severe haemorrhage, where the other fluids in the body are rapidly called upon to replace the quantity Avhich is requisite for the flow of the current. The intimate connection of this hydremic con- dition of the blood, which often appears in the latter part of the period of gestation, with the various forms of dropsical accumulation, will be obvious. It is sufficient to remark here that the common source of all these morbid conditions of the blood, and of the subsequent effu- Consult also Dr. Carroll Dunham's Bonninghausen on Hooping-Cough, and Dr. B. Simmons' Cough Repertory. 342 DISORDERS INCIDENTAL TO PREGNANCY. sions and cedematous infiltrations is to be found in the psoric dyscra- sia developed and aggravated by the constitutional excitement of pregnancy. Anaemia constitutes a still greater degree of depravation of the blood under the prolonged influence of many of the other morbid con- ditions of pregnancy. The failure of nutrition from the severe nausea and vomiting which sometimes persist even through the Avhole course of pregnancy, and from other gastric disturbances and intestinal diffi- culties, in addition to some original morbid tendency in the system itself, sometimes reduces the pregnant woman to a very feeble, almost cachectic condition. This condition is still further aggravated by the constantly-increasing demand made upon it for the support of the growing fcetus. And the exhaustion in such cases may prove fatal, either before or after delivery, unless the very root of the difficulty is reached and removed by the appropriate remedy. Among the more active consequences of such impoverished condi- tion of the blood in pregnancy-—as in chlorosis—should be noticed certain local congestions. These are developed in different parts of the body, according to the direction of the constitutional Aveakness; thus in some persons we see epistaxis, in others haemoptysis, in others still hsematemesis, and in others, finally, certain forms of uterine hsemorrhage, to be afterward described more particularly in connection with the other principal causes of abortion. For each of these forms of local congestion the appropriate remedy must be selected in accord- ance Avith all the conditions present. Uremia, or the retention of the urea in the blood, has been men- tioned in connection with albuminuria, with which it is usually a com- plementary symptom. All these forms of dilution, depravation or poisoning of the blood may be cured by the exhibition of the reme- dies indicated by all the attendant circumstances, symptoms and con- ditions ; not by any means failing to consider the mental and moral states and symptoms, Avhich latter may constitute the most important indications to guide us in the selection of the curative remedy even for such pathological changes. The same deep-seated constitutional influence that disturbs the harmony of the circulation and the propor- tions of the constituents of the blood, most powerfully and much more palpably affects the intellectual faculties, the sensibilities, and even the affections. 03DEMA. 343 (Edema—A nasarca—Ascites. These various forms of dropsical affections may occur during preg- nancy, either resulting entirely from the condition of pregnancy itself, or complicated and in great part caused by serious diseases of the heart, kidneys or liver. Some women when pregnant are invariably more or less dropsical, while others, on the contrary, do not show even the slightest evidence of simple oedema. And again, a dropsical condition of considerable magnitude may give rise to no inconveni- ence during pregnancy save that of causing clumsiness, and disappear promptly after parturition, AArhile in another case it may be very fruitful of suffering and of peril, not only to health, but even to life. What at the first is merely an cedematous enlargement of the feet and ankles may be developed as gestation advances into a general dropsy, the primary infiltration into the cellular tissue being finally accompanied by extensive effusion into the great serous cavities. (Edema of the Lower Extremities is a very common attend- ant of pregnancy, often occasions no great inconvenience, and is usually confined to the seventh, eighth and ninth months. It is sup- posed to arise in most instances from mechanical pressure alone, and to be entirely independent of constitutional disease. This may be true in those cases where it is not accompanied by other dropsical af- fections. Standing and Avalking serve to aggravate this condition; it becomes Avorse towards evening, gradually increases as pregnancy advances, and is often combined Avith a varicose state of the veins. In some instances the oedema becomes A^ery great, the integuments of the lower limbs become enormously distended, and a certain angry redness appears, as if erysipelas would set in. In such cases there is reason to suspect the presence of some more deeply-seated cause than mechanical pressure upon the veins, or even upon the lumbo-sacral nerves, nor will the dropsical infiltration be restricted to the inferior extremities. (Edema of the vulva will nearly always be present Avhen that of the lower limbs is so largely developed; and this will often cause much suffering in the latter months of gestation, and even render the patient unable to lie on either side. Cases are on record in which the oedema of the external genitals was so enormous that the patients were obliged to lie on their backs Avith their loAver limbs widely separated. In the worst forms of this affection the tumefaction may occasion considerable difficulty in the dilatation of the perineum and passage of the child's head. Acupuncture has sometimes been re- 344 disorders incidental to pregnancy. sorted to in advance of parturition, with considerable relief of the pain arising from the excessive distension of the delicate and sensitive tissues. Anasarca represents the extension of the oedema from its original local seat in the lower extremities over the entire surface of the body. Both oedema or partial dropsy of the cellular or areolar tissue, and anasarca or general dropsy of the same tissue, belong to the class of infiltration, as contradistinguished from ascites and hydrothorax, Avhich are effusions respectively into the abdominal and thoracic cavities. The more the oedema comes to resemble anasarca, the more we realize the existence of general constitutional causes of the affection, and are thus led to look for the means of curing it in corresponding constitutional remedies. The attendant symptoms in each case will aid us in the selection of the remedy, since we must prescribe for the patient, not for a particular pathological condition alone, however distressing it may be, or however thoroughly we may understand it. Much experience proves the truth of this. Ascites, or dropsical effusion into the cavity of the abdomen, may make its appearance in the first half of pregnancy, although it is more usually developed about the fifth or sixth month, and then con- tinues during the remainder of the period of gestation. This affection is attended with more or less oedema of the inferior extremities, of the labise, and infiltration of the abdominal Avails. The accumulation of fluid in the abdomen may be slow and gradual, or it may be very rapidly effused, especially after a certain degree of general oedematous infiltration has been reached. In pregnant Avomen this disorder cannot fail to cause much greater inconvenience, and even positive suffering, than in other persons, since it will cause greater obstruction of the movements of the thorax. So great is the dyspnoea in the advanced stages of pregnancy from this cause that the respiration becomes as difficult and distressing, and the erect posi- tion is almost as necessary, as in ordinary cases of hydrothorax. There are frequent attacks of faintness and a constant sense of suffo- cation from the insufficient aeration of the blood. And these suffer- ings are often aggravated by difficulty of sleeping, headache, thirst and disgust for food. The presence of Avater in the abdomen may be determined by per- cussion, the fluctuation being usually more perceptible in the left ascites. 345 hypochondrium just below the false ribs. The existence of any large accumulation of water in the cavity of the abdomen will usually prevent conception, by impeding the action of the fimbriated ex- tremities of the Fallopian tubes; and the same cause tends to prevent the full and healthy development of the foetus, although women with dropsy are said to have had often very lively and healthy children. Ascites should be treated by homoeopathic physicians with medicines alone if possible, since tapping, either in the earlier or in the later months of pregnancy, is very apt to be folloAved by the expulsion of the fcetus. The severity of' the dropsy itself, and the consequent danger of its interfering with gestation, may be measured by the earlier or later period in which it makes its appearance. When the effusion is evident in the first half of the pregnancy, if its increase cannot be arrested or the disease removed by the use of the appro- priate remedies, it may even be necessary to resort to paracentesis. The causes of ascites, and in fact of all forms of dropsical dis- order, except perhaps the most trifling, Avhich may be considered to result from pressure and general AA^eakness, must be found in the constitutional dyscrasise that haAre already been referred to in con- nection with disorders of the blood and its excretions. The mor- bidly serous condition of the blood forms but a single link in the chain that terminates in cellular infiltration and dropsical effusion. Still farther back Ave may trace the fault of nutrition, by which the blood is impoverished, rendered watery and the receptacle of urajmic poisons. It is important to be familiar with these pathological changes so far as they can be detected, and some of their objective manifestations may afford valuable aid in selecting the appropriate remedy. Espe- cially, if not only, is this true where the pathogenesis of the remedy has furnished us with similar pathological symptoms. But that physician will be most successful in his prescriptions who carefully avoids encumbering his mind with theoretical generalizations, most patiently studies his Materia Medica, and never allows himself to rest satisfied till he has found the remedy which constitutes the most com- plete simile to the mental, moral, sensational and physical symptoms of the case. For the remedies which may be indicated in the various forms of dropsical affections liable to appear in pregnancy, consult those de- tailed in the article on Dropsy of the Uterus. Dropsy of the Amnion and Hydrorrhcea are treated of under the bead of Disorders of the Uterus and its Appendages. 346 disorders incidental to pregnancy. haemorrhoids, or plles. Hemorrhoids may make their appearance in the earlier or in the later months of pregnancy. In the first instance they may result in part from pressure exerted directly upon the internal iliacs by the expanding uterus before it has emerged from the pelvis. In the latter case the gravid uterus exerts pressure upon the common iliacs. Still this affection of the hsemorrhoidal veins is by no means entirely caused by such mechanical pressure, otherwise it would be much more com- mon than it iioav is, if not indeed universal. In women predisposed to constipation, or in whom some dyscrasia develops itself in such obstruction of the boAvels, haemorrhoids are an almost necessary consequence of this condition in pregnancy; and the inactive habits that aggravate the constipation at the same time augment the hsemorrhoidal enlargements. But whether due to the inactive state of the circulation, which is a necessary attendant of in- active habits, to mechanical pressure, to constipation, to dyscrasia, or, as is generally the case in greater or less degree, to all these influences combined, the piles constitute a very painful condition in pregnancy. They may be blind, that is, never bleed, and inAvard, never protrud- ing, and still occasion much suffering. They may protrude with each evacuation, sometimes become strangulated and difficult of re- placement, and by their exhausting haemorrhages may greatly weaken the strength. The constipation greatly aggravates the hsemorrhoidal condition, and at the same time the pain accompanying an evacuation is so great that the woman dreads going to stool, and hence by delay- ing causes increased atony of the boAvels and aggravates the constipa- tion. This circumstance should be borne in mind by the practitioner, and should lead him to urge upon his patient the necessity of not neglecting the alvine evacuations, and at the same time lead him to suggest a suitable diet, such as would have a tendency to produce rather a relaxed condition of the bowels. Most of these cases are en- tirely amenable to treatment, and even the worst may be so modified that the suffering may be almost entirely removed. Under allopathic treatment the constipation is attacked by purga- tives, which are incapable of removing either the cause or the conse- quences ; Avhile the indicated homoeopathic remedy exerts a beneficial influence equally upon the obstruction of the bowels and upon the en- largement of the hsemorrhoidal veins. The following medicines should be studied, and that one selected which best corresponds to all the con- ditions and symptoms of the patient, Avho should carefully abstain from coffee, wines and liquors, and from food too much concentrated, and •- HEMORRHOIDS, OR PILES. 347 take as much daily exercise as her circumstances and situation will allow with comfort to herself. The medicines mentioned under Con- stipation may likeAvise be consulted Avith advantage. Aconite. Shooting and constant pressure at the anus, pain in the back and sacrum as if bruised, feeling of fullness of the abdomen, colicky pains, great uneasiness; the piles occasion great annoyance. ^Isculus hipp. Sensation in the loAver portion of the back, across the sacro-iliac symphyses, as of great Aveakness; she "gives out" there Avhen walking. Bleeding piles, or purple-colored piles which do not bleed; constipation, great pressure in the rectum. Aloes. The varices protrude and resemble clusters of grapes, fre- quently feel hot and sore. When urinating, sensation as though something had passed or Avould pass from the bowels. Feelino- of heaviness or weight Avithin the pelvis. Large masses of mucus are sometimes discharged per anum. Alumina. Evacuations look like laurel-berries, and are passed with much difficulty and with cutting pains. Occasional discharge of blood from the rectum, followed by sore pains. The urine cannot sometimes be passed except when straining at stool. Ammon. carb. The varices protrude during stool, and even between the e\'acuations, and feel raAv as if excoriated. Burning and itching in the anus. Discharge of blood during and after stool. Ammon. mur. Continual sore smarting in the haemorrhoids. Sore pustules on the verge of the anus. Pain in the perineum, especially when Avalking. Particularly useful if hsemorrhoids occur after the suppression of a leucorrhoeal discharge. Antimonium C. Diarrhoea and constipation alternate, the evacuations while diarrhoea exists consisting of a Avatery fluid with hard lumps. General gastric disturbance Avith the hsemorrhoids. Excretion of large quantities of mucus, Avith burning, tingling and itching so great that she can scarcely keep still. Apis. Constipation. Scanty urine. Much stinging pain in the anus and rectum ; the stinging is followed by severe burning sen- sation. Arsenicum. Burning, like fire, and shooting pains in the varices; heat, agitation, and sometimes a feeling of great Aveakness and rest- lessness. Fissures in the anus, which burn and render urination diffi- cult, Pain or a painful stiffness in the back, making stooping diffi- cult. Belladonna. Bleeding piles, accompanied Avith a sensation as if the 348 DISORDERS INCIDENTAL TO PREGNANCY. back Avere breaking or Avould break. The varices sometimes become strangulated from spasmodic constriction of the sphincter ani, at Avhich time they are excessively sore and sensitive. Dysuria and congestion of blood in the head are frequent accompaniments of the hsemorrhoidal condition AAdien this remedy is indicated. Calcarea c. The piles often bleed profusely, to the extent of blanch- ing the patient. The pain occasioned by the piles is aggravated by walking. Very great pain in the anus after stool. Sleeplessness in the early part of the night. Acrid and offensive sweat from the feet, Avhich makes them raw and sore. Feet are cold, as if from damp stockings. When not pregnant the patient menstruates too frequently and too profusely. She is very sensitive to cold air. Capsicum. Burning and smarting in the varices, as though pepper Avere sprinkled on them. Bleeding piles, the Aoav of blood causing a burning pain in the anus. Carbo veg. The hsemorrhoidal tumors are large and blue, with shoot- ing pains in the loins, stiffness in the back, burning and rheumatic pains in the limbs. Burning feces. Frequent congestion to the head; epistaxis; flatulence. There may also be much burning mucus from the rectum. Discharge of an acrid, offensive humor from the anus, particularly at night. Much itching about the anus and perineum. Cascarilla. The bowels are evacuated with difficulty, and the feces are covered with much mucus, or the feces are mixed with quantities of mucus. Frequent and profuse bleeding from the anus during or after stool. Causticum. Large and painful hsemorrhoids, which burn Avhen touched and seem to hinder the passage of the feces; the suffering is much increased by walking. Sometimes in connection with the hsemorrhoids we find a large and painful ulcer near the anus, con- stantly discharging blood and pus. Chamomilla. In painful, bleeding, burning hsemorrhoids; but the mental symptoms will particularly indicate this remedy. She is rest- less, can hardly control herself; gives short answers; she can hardly endure her slight sufferings. Irritable and spiteful. China. Hsemorrhoids, with burning, itching, tingling or creeping, extending into the urethra. They sometimes bleed profusely. The patient is very sensitive and debilitated, and the piles and her general symptoms are worse every other day. Collinsonia. A jagging sensation is felt in the lower part of the rectum and anus, as though sticks or gravel had lodged there. The symptoms get worse in the evening, and continue so till late at night. HEMORRHOIDS, OR PILES. 349 Blind or bleeding piles. Constipation or diarrhoea. Weight or pres- sure in the rectum, with intense irritation or itching there. Colocynth. Pricking at the anus, Avith constant discharge of mucus. Darting in the rectum, alternating Avith stitches through the bladder. Blood flows continuously from the hsemorrhoids for a long time. Emission of large quantities of flatus per anum. Persons Avho are subject to violent attacks of cramp colic. Graphites. Easy prolapse of the rectum, as though the parts had lost their tonicity; it becomes prolapsed without even a desire for stool. SAvelling of the anus. The varices feel very sore after an evacuation. Painful burning fissures betAveen the varices. The patient menstru- ates scantily, and has itching blotches on the face and other parts of the body. Hamamelis. The varices bleed very profusely, with sensation of soreness, Aveight and burning in the rectum. The varices protrude, and the anus feels sore as if raw. The stools are covered with mucus; the back feels as if it would break; restlessness at night; dryness of the mouth. Ignatia. When the piles are attended with pains shooting deep into the rectum, seemingly up into the abdomen. Itching and tingling in the anus, and prolapsus recti during an evacuation. Sensation of excoriation and contraction in the rectum. The pain in the anus and rectum continues for hours after an evacuation. Kali carb. Stitching and cutting pain in the varices, which become greatly swollen and enlarged. The feces are large and hard, and the stools are followed by bleeding from the varices. Lachesis. The anus feels as if it Avere entirely closed by the varices, and as if nothing could pass; the bowels are very costive, apparently on this account. (Hsemorrhoids, which make their appearance at the climacteric, when the menstrual flow becomes scanty.) Lycopodium. Much rumbling in the abdomen; red sand or red sediment in the urine; itching eruption around the anus; great tendency to excoriations, which bleed easily. The varices protrude, and are particularly painful when sitting. Cutting in the rectum and bladder. Tearing in the rectum, so sharp that it arrests the breathing. Mercurius sol. Piles which bleed during stool and Avhile urinating. The bloody stool causes an acrid, painful sensation in the anus. Prolapsus of the rectum, the fallen gut having a dark and bloody appearance. Inflammation and suppuration of the hemorrhoidal tumors. 350 DISORDERS INCIDENTAL TO PREGNANCY. Muriatic acid. Exceeding tenderness of the parts; she cannot bear the least touch upon them, not even of the sheet. The piles bleed profusely; there is much itching of the parts, which is not relieved by scratching. Great debility. Prolapse of the rectum when uri- nating. Involuntary discharge of a small' quantity of feces while urinating, which seems unavoidable. Natrum mur. A moisture constantly oozes from the varices, which are very painful, stinging, smarting and throbbing. Herpetic erup- tions about the anus, with itching and burning. Stitches in the rectum from beloAV upward occasionally during the day. Hard, difficult and painful stool followed by a liquid stool, the pain lasting a long while afterward. Nitric acid. Old hsemorrhoidal tumors, secreting much slime and bleeding profusely at every fecal evacuation. Smarting in the rec- tum a long time after a stool; also sharp cutting pains Avhich last a long time. Nux vom. This remedy should be thought of for all persons of sedentary habits, and for those who use spirituous liquors or coffee in excess. It is especially indicated when there are shooting and shocks in the loins; contused pains which hinder from rising up; consti- pation, with frequent and ineffectual effort to evacuate, and sensation as if the anus were closed or contracted; no appetite; sleepless in the latter part of the night; headache; loss of energy. Sensation in the rectum after an evacuation, as though something remained which should be passed; or a frequent or even continual inclination to stool, Avith a sensation as though the rectum contained a small quantity of feces which must be passed, although nothing passes. Petroleum. Hsemorrhoids, Avith itching about the anus, which compels her to rub and scratch till the part becomes raw and sore. A moisture constantly oozes from the vulva, with violent itching. Phosphorus. The hsemorrhoids are accompanied with a sensation of weakness or sinking in the abdomen; they protrude very easily, coming down even during the emission of flatus. Relaxation of the sphincter ani; constant discharge of mucus from the varices. Podophyllum. Piles, with prolapsus ani; prolapsus uteri; consti- pation or morning diarrhoea; too frequent but natural passages. Pain in the lumbar and sacral regions, worse during a stool and still Avorse afterward. Constipation with headache. She is subject to " bilious attacks." Pulsatilla. Discharge of blood and mucus during stool; pallid coun- tenance and disposition to faint; dysuria; tearful disposition, mild and HEMORRHOIDS OR PILES. 351 gentle; bad taste in the mouth in the morning. She cannot bear to be in a close or warm room; generally feels worse in the evening, and is better from going into the fresh open air. Feels worse after partak- ing of rich or greasy food. Absence of thirst. Rhus tox. Protrusion of blind hsemorrhoids after every stool, Avhich feel sore. Drawing in the back from above downward, which sensa- tion seems to be due to the piles, and with a feeling as though every- thing would come through the rectum. Constant restlessness and fidgetiness. Sabina. The piles discharge bright red blood, and cause pain in the back from the sacrum to the pubes. Biting, sore pain in the varices, especially during the morning stool. Sepia. The patient is subject to a painful sensation of emptiness in the epigastric region; has delicate and sensitive skin. Protrusion of the varices and of the rectum, attended Avith difficult micturition. Heat, burning and SAvelling of the anus when the piles do not pro- trude, and defecation is then excessively painful, the stool being rather small, narrowed down by the diminished calibre of the anus. Sometimes the fecal mass is triangular in form and very painful. Constant oozing of moisture from the anus. Stitches and jerkings from the anus upward into the rectum and abdomen. The symptoms are usually aggravated by partaking of milk. Silicia. If the varices protrude ever so little they are apt to become strangulated and painful, and are returned with much difficulty. Difficult stool, the fecal mass receding into the rectum several times when on the point of being discharged. The hsemorrhoidal tumors inflame and suppurate easily. Sulphur. Much itching and soreness of the anus on account of the varices, Avhich bleed during stool. Prolapse of the rectum during a hard stool. The indications for this remedy are to be found rather in general characteristics than in local symptoms. Heat on the top of the head, general flushes of heat, weak, fainting feeling; very hungry and faint about eleven o'clock A. M.; awakens frequently at night, and feels very weak and faint in the morning; very cold feet, sometimes burning in the soles of the feet at night in bed. Inclina- tion to stoop forward when walking, or even when sitting. Desire to sleep late in the morning. Despondency and sluggishness of the mind; she finds it difficult to do anything. Thuja occ. The hsemorrhoidal tumors are excessively sensitive to even the slightest touch. Fig-warts around the anus or elsewhere are an accompaniment. 352 DISORDERS INCIDENTAL TO PREGNANCY. Varicose Veins. Varicose veins often appear during the latter months of utero-ges- tation, and are commonly supposed to be caused by the pressure of the gravid uterus upon the iliac vessels and inferior cava. But this local pressure can be but a single one of the exciting causes, since varices are seen in some who are not pregnant, and they do not make their appearance in the larger proportion of those who are. If the pressure Avere the main cause, all or nearly all pregnant women should have more or less of this varicose condition before they are confined, which is far from being the case. The constitutional condition of the system in general, and perhaps of the organs of venous circulation in particular, which gives rise to varices under the influence of exciting causes, is no doubt similar to that which produces hsemorrhoids. In each affection, constipation seems to exert no small provoking influence, although it may be that the same deep-seated disorder of the constitution may at the same time cause the varicose and the constipated condition. The varicose and the hsemorrhoidal enlargements are alike liable to rupture and to occasion serious hsemorrhage. And both these disorders are equally amenable to homoeopathic medication. The appropriate remedies, taken in season, will entirely cure the varicose condition, or, if re- sorted to only after the enlargement has already become very exten- sive in the latter months of utero-gestation, will at least prevent its further increase. And as on the one hand homoeopathic treatment perseA^eringly employed will entirely remove the constitutional pre- disposition to varix, so, on the other hand, the highest allopathic authority states that " this condition of the veins gradually increases in amount and severity with every succeeding gestation." * The various and severe pains, and all the attendant symptoms and conditions of varices below the knee, in the thighs, in the labia, vagina, and even in the os uteri itself, the appearance of the enlarged veins themselves, their color, inflammation or rupture, and the concomitant and constitutional symptoms and seasons and occasions of aggrava- tion, will enable the attentive physician to prescribe in such cases, with the certainty of greatly ameliorating the general health, and so of improving the prospect in parturition, as well as of removing the varicose diathesis itself. The vascular nature of much of the substance of the external geni- tals predisposes them to varices. They may occur in the veins of the vulva or in those of the vagina. * Churchill, Diseases of Women, chap. vi. varicose veins. 353 These enlargements of the veins are scarcely less common during pregnancy than are hsemorrhoids, but, except they appear in the vulva or vagina, are usually less painful. They should be treated upon general homoeopathic principles, all the attendant and constitutional symptoms being taken into account in prescribing. The following medicines are more particularly useful, and the indications given for their use under the head of Hsemorrhoids or Piles, together with those of the other medicines there given, may be consulted with advantage: Apis mel. Burning and stinging pains in the varicosed veins, either with or without constipation. Arnica. The varices are very sore, with a bruised feeling. Espe- cially useful for varicose veins of the vulva or vagina. Arsenicum. If they burn like fire. Carbo veg. Painful discharge or complete suppression of urine at- tends the varicosed condition of the vagina. The varices have a blue appearance. Causticum. If they become much more painful when the patient is walking. Ferrum met. In weakly persons, with fiery-red face. Fduoric acid. In obstinate cases and in those of long standing, espe- cially in women who have borne many children. Graphites. The varicosities itch very much, and have little pimples on the surface of the integument over them. Itching blotches on various parts of the body. Hamamelis. The varicose veins are hard, knotty, swollen and painful. Lycopodium. Varicose veins of the lower limbs, extending nearly to the feet; they seem very large, and hard under pressure of the finger. Red sandy sediment in the urine. Borborygmus and constipation. Nux vom. In women who habitually use wine and rich and highly- seasoned food, who keep late hours and suffer from habitual consti- pation. Pulsatilla. Especially suited to women of mild disposition, Avho are easily moved to tears. The pain from the varicosed veins and the general symptoms are aggravated toward evening. The varices pre- sent a blue appearance. Sulphur. This remedy will often be found useful when indicated by its well-marked and well-known characteristics. It will be especially useful to women who suffer from hsemorrhoids as well as varicose veins of the extremities or vulva. 23 354 disorders incidental to pregnancy. Zinc. Varicose veins which give rise to fidgetiness of the feet and limbs. External treatment for this affection, such as bandaging, is of far less value than internal medication. In extreme cases, however, Avhere there appears to be danger of rupture of the vessels, a roller or a laced stocking may be applied to support the veins until the remedies have time to act. In such cases, also, placing the limbs Avhen they are the seat of the affection upon a stool or chair relieves the over-distended vessels from the downward pressure of gravity. Perfect rest and quiet are indispensable in the treatment of these worst forms of varicose veins. CHAPTER XVII. DISORDERS INCIDENTAL TO PREGNANCY—CONTINUED. Affections of the Uterus and its Appendages. THE morbid affections to which the uterus is liable in the pregnant state may be arranged in three classes : I. those which are prin- cipally sensational, such as cramps, pains and excessive sensibility; II. displacements; III. abnormal secretions, such as leucorrhcea, dropsy of the amnion and hydrorrhcea. I. Pains ; Cramps ; Sensibility of the Uterus.—The uterus in pregnancy, even if it does not experience an enlargement of its nerves corresponding to that of the arteries and veins, still partakes in a remarkable manner of the increased sensibility of the nervous system in general. Hence all influences, from within or from Avithout, are very acutely felt—many of them very painfully—which in the unimpregnated condition would scarcely be noticed. In addition to this excessive sensibility, there are actual uterine pains, seated appar- ently in the walls of the uterus, which are doubtless the result of the contraction of the uterine muscles. These may appear at any time after the first three months of utero-gestation; they may return at intervals in paroxysms, and increase in severity as the pregnancy advances. These pains may even become so severe as to resemble uterine cramps. The excessive sensitiveness of the uterus renders the ordinary motions of the fcetus very painful to the mother, Avhile at the / AFFECTIONS OF THE UTERUS AND ITS APPENDAGES. 355 same time the morbid irritability of the mother's state in general ren- ders the movements of the fcetus much more active and violent. All these morbid conditions may be greatly ameliorated by the exhibition of appropriate homoeopathic remedies, thus rendering the patient more comfortable, and at the same time removing influences which mio-ht otherwise terminate in abortion. II. Displacements of the Uterus.—Conception may occur in women Avho are subject to prolapsus uteri in cases where the Avomb is temporarily replaced, or the already gravid uterus may become subject to either of the different forms of displacement under the influence of accidental causes connected with its OAvn weight or Avith the disproportionate size of the pelvis. In the former case the pro- lapsus, while it affords no bar to conception, greatly endangers the safety of the fcetus until after it is established above the superior strait. In the latter case the already gravid uterus may be projected so far over the pubes as to constitute anteversion, or turned back in such a manner as to undergo retroversion by its fundus being lodged beneath the promontory of the sacrum. Prolapsus uteri in pregnancy, as in the unimpregnated condition, may come on gradually or suddenly; it may also be a partial descent or a complete procidentia. This is especially apt to be the case when the pelvis is Unusually large. In all cases of prolapsus uteri in preg- nancy, whether the result of a previous habit or of more recent influences, it is simply necessary for the patient to remain quiet and take the remedy indicated, according to the conditions and symptoms of her case. The appropriate remedy, together with the increasing size of the ovum, Avill in a short time remove the prolapsus and render its return impossible. Anteversion chiefly occurs in the more advanced stages of pregnancy when the uterus has become very heavy, although some few instances are recorded in which this accident happened in the second and third months of pregnancy. In the slighter forms of this displacement the term obliquity is more applicable, Avhile in complete anteversion the fundus uteri may even be engaged below the symphysis pubis. Perfect quiet, a recumbent position, and the judicious exhibition of the remedy indicated by the symptoms of each case, will almost always suffice to effect a complete cure. In cases where the fundus is actually engaged beneath the symphysis, manual assistance will be needed in order to secure reposition, the patient lying on her back. Retroversion, in the pregnant as in the unimpregnated condition of the uterus, forms a very serious complication, whether it occur 356 DISORDERS INCIDENTAL TO PREGNANCY. suddenly or sloAvly. In many cases the symptoms will scarcely lead us to suspect the presence of this form of displacement until the fundus is actually engaged beneath the promontory of the sacrum. In this condition the use of the uterine elevator, described in another chapter, may be found necessary. Retroversion is most apt to occur in the third and fourth months, but it may occur in the fifth, or even as late as the seventh month, of gestation. It may take place very sloAvly, so as to become complete by the third month of pregnancy, aided very much by the gravity of the ovum when once it has be- come deflected from its proper position. This first beginning of the mischief may result from a too great and too long-continued distension of the urinary bladder. The complete or partial retention of the urine forms one of the most characteristic indications of the retroversion itself. In order to facilitate the restoration of the retroverted uterus it may be necessary to place the patient prone upon her face; thus, as soon as the fundus uteri is disengaged from beneath the promontory of the sacrum, its OAvn gravity will enable it to resume its proper place in the pelvis. It Avill be necessary to distinguish this form of displacement from extra-uterine pregnancy, since very disastrous con- sequences must otherAvise speedily result. And this will be best accomplished by a careful study of the conditions and symptoms of the case, and of the causes which have apparently produced the mis- chief, in addition to the most careful exploration per vaginam, and, if necessary, per anum. Retention of urine in the bladder, from want of opportunity to discharge it, as sometimes in traveling, violent strain- ing to lift a heavy Aveight, a fall backAvard, bloAvs or other accidental pressure upon the navel, may occasion the retroversion. A previous retroversion is no doubt the most frequent cause of the retroversion of the uterus in pregnancy. In such cases the trouble is at first entirely unsuspected, as in the first weeks of gestation the increased size of the uterus scarcely occasions any more inconvenience than before conception. But after a while the cervix uteri begins to press upon the bladder and hinder its evacuation. Then the sudden and severe symptoms, Avhich are really the consequences of the gradual enlargement of a previously retroverted uterus, are supposed to result from a sudden displacement. Careful attention to the calls of nature, as well in respect to the boAvels as to the bladder, Avill be important, in order to obviate any disposition to this displacement, particularly in persons Avho have suffered from it in former pregnancies. And where retroversion has either suddenly set in, as in consequence of AFFECTIONS OF THE UTERUS AND ITS APPENDAGES. 357 an accident, or gradually developed from partial displacement of this kind existing previously to conception, it may be necessary to evacuate the bladder and rectum before any progress can be made in restoration. Then, after the womb has been replaced, perfect rest in a recumbent posture, for a longer or shorter time, according to circumstances, will greatly aid the proper remedy to effect a complete cure. The various pessaries proposed and used in such cases we consider entirely unne- cessary, and in many cases positively injurious. With the aid of the appropriate remedies, and of such favorable circumstances and hygienic conditions as are indispensable under any plan of treatment, Nature may be enabled to hold the uterus up; which she can never learn to do as long as it is propped up and the muscular structures are thereby weakened. The medicines appropriate for these various forms of uterine dis- placements existing during pregnancy, as well as explicit directions for their treatment, will be found elsewhere, in the chapter on Dis- placements of the Uterus. III. Abnormal Secretions.—Leucorrhoea may exist during preg- nancy, especially in persons constitutionally predisposed to this affec- tion. The discharge is usually of a mild character, thick and white in its appearance, and sometimes profuse in quantity. The increased activity of the circulation of the uterus and its appendages, incident to pregnancy, extends to the muciparous glands of the vagina and cervix uteri, and an excess of the secretion which closes the cervix may occasion a constant discharge. In connection Avith the discharge may occur irritation, itching, heat and burning in the vulva and parts adjacent. Where the leucorrhoea is very profuse, symptoms of debility may follow. The treatment required for all these cases will be found under appropriate headings in another part of this work. Hydrorrhea is the name given to such discharges of water from the womb as occur in the course of gestation without rupture of the mem- branes. It is probable that this accumulation of fluid—false waters —takes place between the inner surface of the uterus and the mem- branes, the latter being stripped off as the fluid accumulates and forms tor itself a pouch. This pouch gradually increases in size in the direction of the os, and Avhen that outlet is reached the flow of false waters takes place. This phenomena may deceive the accoucheur, and [cad him to believe that the membranes are ruptured and that labor is about to set in, Avhereas careful examination will discover the mem- branes intact, and there may be no signs of labor present. 358 DISORDERS INCIDENTAL TO PREGNANCY. Iii the later months of pregnancy this affection is not uncommon, the uterus from time to time relieving itself of the undue accumula- tion Avithout special muscular effort, very much as the urinary blad- der does. An examination of the os uteri in such cases will satisfy the practitioner that the discharge does not come from within the true Avater-sac, and that therefore there is no cause for alarm as from a threatened miscarriage. The Aoav appears at irregular intervals, and without any especial provoking cause; neither does it occasion any re- markable symptoms. The concurrence of other dropsical conditions, such as oedema of the limbs, the fact that the discharge arises spontaneously, and the almost entire absence of pains or uterine contractions, will enable the physician to diagnose the hydrorrhcea with sufficient certainty. The false waters may make their exit without any noticeable provoking cause, and Avithout any more than the very slightest constitutional dis- turbance ; Avhile the membranes which enclose the true amniotic waters can only be broken by some great bodily exertion, some special acci- dent or posith^e effort, and their discharge of these Avaters cannot but be followed by strongly marked symptoms indicating the approach or actual existence of labor. Perfect quiet, freedom from excitement or anxiety, and the exhibition of the remedies indicated by all the at- tendant symptoms and conditions, will be all that is requisite to pre- vent serious mischief from this condition, and to remove as fur as possible its constitutional causes. Dropsy of the Amnion.—The determination of the existence of this disorder of pregnancy is not so easy as that of hydrorrhcea, since there may be an excessive amount of amniotic liquid without any very re- markable distension of the abdominal parietes, and since also the normal amount of the liquid itself is capable of very considerable variation. But generally speaking, dropsy of the amnion is an acute disease, and the rapidity of its development, together Avith the dis- tressing constitutional symptoms, affords our best means of diagnosis. This is the more especially the case since also ascites almost always complicates this affection. There does not seem to be any change in the specific gravity or con- stitution of the liquor amnii, only an excess of production. The nor- mal quantity may be estimated at three or four pounds, according to the state of pregnancy, but from forty to fifty pints haA^e been found present in dropsy of the amnion. Thus at the fifth or sixth month the uterus may be more distended than usually at full term. The uterus is rounded; fluctuation is more obscure; there is not much DROPSY OF THE AMNION. 359 thirst; the urine is natural except in cases complicated Avith general dropsy, and there is sometimes little or no cedematous enlargement of the inferior extremities. Among the most important diagnostic signs are to be found, therefore, the disproportionate size of the tumor to the period of pregnancy, the feebleness of the movements of the child, and the great size of the abdomen, evidently dropsical, which is less apt to be accompanied by oedema of the thighs and legs than in ascites. Dropsy of the amnion may occasion severe suffering to the mother, sensations of suffocation and hindrance of the circulation: these are probably due in part to the rapidity of the enlargement itself, and in part to the general constitution of the patient. But this difficulty very rarely becomes dangerous, since its very excess tends to self- relief by producing abortion. The most important results of this dropsical affection are found in the injury to the foetus, whose nutrition is enfeebled by such excessive secretion; in the total destruction of the fcetus, which is sometimes almost entirely dissolved in the amniotic fluid; and in the premature expulsion of the fcetus at a period when its insufficient age, its enfee- bled condition, or both together, render it incapable of viability. As has been already remarked, ascites usually accompanies and complicates dropsy of the amnion. But ascites may exist during pregnancy Avithout amniotic dropsy, and the reverse may likewise occur. It is therefore a matter of importance to be able to make a correct diagnosis. Cazeaux gives the following points for their differ- ential diagnosis: " In ascites complicating pregnancy the urine is small in quantity, whitish and turbid, the thirst great and constant, and the lower extremities and genital parts mostly much infiltrated. It is difficult, and sometimes even impossible, to distinguish the shape and fundus of the uterus, on account of the irregular form of the belly and the enormous distension of the hypochondriac regions. Percus- sion produces an undulation or sort of fluctuation, Avhich is much more perceptible at the upper than at the lower part of the abdomen. " In dropsy of the amnion the size of the belly approaches much more nearly that of a uterus at term, although the pregnancy may not have existed more than five or six months. The uterus is so rounded as to be almost spherical. Fluctuation is more obscure, thirst slight or absent, urine natural, and in some cases little or no infiltration of the loAver extremities. The umbilical tumor is rarely present, and when it exists has not the transparency observed in ascites." The treatment of dropsy of the amnion must be principally pro- phylactic, and based upon attendant symptoms and such constitu- 360 DISORDERS INCIDENTAL TO PREGNANCY. tional indications of predisposition to general or particular forms of dropsy as may be discovered, aided and confirmed by the sensational symptoms which may especially characterize the individual case. For Avhen dropsy of the amniotic cavity has become so extensively developed as to be clearly diagnosed, there will be small hope of eventually saving the product of conception. But even if perfect success may not be thus obtained in the first instance, there will still be reason to hope that in a subsequent pregnancy a constitutional treatment begun at an earlier period, and more intelligently directed by ampler knowledge of the case, its tendencies and its dangers, may enable the practitioner to obtain a decided improvement in the health of the mother, and at the same time secure the safety and the health- fulness of her child. Dropsy of the amnion is always the result of some constitutional dyscrasia, Avhich, under the stimulus of preg- nancy, develops itself usually in other directions and in other forms also. For the remedies for this affection consult therefore those men- tioned under other varieties of dropsy, and such as may be par- ticularly indicated by the sensational symptoms, such, for example, as the sense of suffocation. With regard to the propriety of inducing premature delivery in extreme cases of this kind, see the subsequent chapter on Abortion. Affections of the Appendages of the Uterus. Pruritus of the vulva forms one of the most distressing disorders to Avhich women are liable in pregnancy. This affection consists in an incessant and intolerable itching of the external genitals. The immediate cause may be found sometimes in an irritated, inflamed condition of the parts involved, or, as described by another, "it com- monly depends on follicular irritation of the vulva, Avhich, if un- checked, passes to aphthous ulceration." Sometimes there may be found no abnormal appearance of the vulva, except such as must arise from the violent rubbing and scratching to Avhich they have been sub- jected ; but on examination, congestion and even superficial granular ulceration of the cervix uteri may be detected. This affection is most apt to occur in young Avomen. Churchill relates a case the symptoms of Avhich are very strongly marked: Avhen about four months pregnant she Avas attacked by the most intense and incessant itching of the vulva; she had no rest, day or night; could scarcely ever sleep, but was obliged to walk up and down all night; she was kept in such an irritated condition by thin distress and loss of sleep that she became \rery cross and irritable. PAINS. 361 In this case no relief Avas obtained until after delivery, Avhen the pruritus disappeared of itself. In her next pregnancy this woman suffered in a similar manner, the pruritus returning at about the same period of gestation; but it Avas removed by local applications directed to the cervix, Avhich was found greatly congested, with superficial granulations around the edge of the os uteri. This affection is sometimes accompanied by sexual excitement, or it may have a periodic character, coming on or being aggravated at certain times of the day. The homoeopathic treatment of this disorder should always be constitutional rather than local; for, Avhether the pathological seat of irritation be found in the parts immediately affected or in the cervix uteri, the true cause of it must consist in the disturbance of the system Avhich is occasioned by pregnancy. For the remedies consult those mentioned in a future chapter under Pruritus. Pains. Pains, fixed or Avandering, irregular or constant, are often experi- enced by women during pregnancy, and are frequently so severely felt as to cause them to become the subject of complaint to their physicians. These pains are principally felt in the abdominal, lumbar and inguinal regions; they may be considered as myalgic, Avhether characterized by cramps or not, when they result from fatigue of the muscles; and they may be deemed purely neuralgic when they are caused by (reflex) irritation of the nervous centres. The pains which are experienced in the lumbar and inguinal re- gions, especially in the early stages of pregnancy, when they cannot be attributed to the size or weight of the gravid uterus, are usually the manifestations of some disordered condition of the uterus itself Pains felt in the loins in the advanced stages of gestation may be purely myalgic, or the result of strain of the muscles so constantly exerted to maintain the equilibrium by bearing the body backward. Pains felt in the breasts, and the excessive tenderness and sensibility of these organs, are due to sympathetic nervous irritation, and are therefore properly called neuralgic. Those Avhich are felt in the abdominal parietes usually appear in the more advanced stage of pregnancy, and may be attributed to over-distension of the muscles and tension upon the nerves. Certain pains in the interior of the thighs, numbness and cramps of one or both legs, have been supposed to result from pressure upon the sacral nerves. But even these may be caused by the severe dragging upon the various ligaments, and 362 disorders incidental to pregnancy. consequent irritation of the nervous centres in different parts of the abdomen and back. Where these pains are aggravated by exercise or movement, perfect quiet should be enjoined. But it is believed that with the help of the appropriate homoeopathic remedies these pains can be so far re- lieved as to admit of as much exercise as may be necessary for the general health of the mother, and consequently for the greater vigor of the child. There is no doubt that the greater susceptibility to these various pains witnessed in some individuals, like the predisposition to many other morbid affections in pregnancy, is in a great measure due to constitutional peculiarity, just as we see in certain constitutions a remarkable facility of straining and laming the muscles and tendons and of suffering dislocation of the joints from comparatively slight causes. At any rate, the following remedies, or others that may be especially indicated, are capable of affording very marked relief in these cases, whether the symptoms appear in the earlier part of gestation, and so threaten to result in abortion, or whether they occur principally in the latter part of pregnancy, and tend to increase the immovability and helplessness of the patient. The same may be said of those pains regarded as the results of a certain constitutional Aveak- ness of the muscular organs or of a corresponding irritability of the nervous system. Aconite. If the sufferings seem to be developed immediately after an exposure to cold air or to a draught. Sensation of soreness, with restlessness and uneasiness, although each movement causes pain. Fear of approaching evil. Distressed and unhappy. Thirst, with more or less feverishness. Argentum nit. Almost constant belching of wind after eating, which continues until the time for the next meal has nearly arrived. Pains in the back and lower extremities. Time seems to pass very slowly. Arnica. Very great soreness, as if from a bruise. The motions of the foetus cause a bruised and sore feeling in the abdomen, and the woman feels as if her child were lying crosswise, Avhich position hurts her constantly. Belladonna. If the pains appear suddenly, and after a time as sud- denly cease. The bed feels very hard to her. She cannot bear the slightest jar of bed or chair. The back feels as if it Avould break. Bryonia. The sufferings are rendered more severe by motion; even the slightest motion aggravates, taking a full inspiration, for instance; she desires therefore to keep quiet and to rest in a recumbent position. Stitching pains. PAINS. 363 Calcarea C. Cramps in the toes or soles of the feet. The feet feel cold and damp. Feels badly on ascending an eminence or going up stairs. Sensation of crackling or crepitation in the joints, as though they were dry. She is a long time in getting to sleep at night. Camphor. Cramps, Avith inability to remain covered. The surface becomes cold at night—as cold as marble—and yet covering is in- tolerable. Chamomilla. Abdominal pains, with frequent emission of pale, color- less urine in large quantities. Feels disagreeable and unhappy. Spite- ful irritability. Whatever pains she may have she feels very keenly, and regards them as unbearable. Sleeplessness. Chelidonium. A great deal of pain under the inner inferior angle of the right scapula, sometimes extending into the chest; this pain is frequently accompanied Avith gastric or hepatic disturbances. Cimicifuga. Cramps in the extremities, and even intermitting spasms. Especially suitable for Avomen who have a tendency to hysterical attacks. Cocculus. A paralyzed feeling in the limbs, which are very Aveak. Nausea, Avith vertigo and tendency to faint. Spasms, which occur frequently at midnight. Coffea. Often indicated when there is much excitement and sleep- lessness. The pains she experiences are continuous and very distress- ing, so that she feels as if she would " go distracted." Colocynth. Frequent attacks of colic, which draw the patient nearly double. The pains she has cause great restlessness, so that she Avrithes and twists herself in every direction, yet without obtaining relief. Cuprum. When there are cramps in the fingers and toes or in the pit of the stomach; violent cramps. Coppery taste. Restlessness. Gelseminum. Pains in the abdomen, which run directly upward or backAvard and upAvard, which are very severe and resemble the pains of commencing labor. Feeling as if the muscular power was weakened, which arises from a weakness of the will-poAver, which is unable to command muscular movements as in health. Ipecacuanha. Sharp, colicky, coiling pains around the umbilicus, with nausea; clutching and squeezing in the abdomen. Lycopodium. Cutting pains running from right to left across the abdomen. A great deal of commotion and borborygmus in the ab- domen. The foetus is unusually active. Red sand in the urine. Nux v. Sufferings from high living or from a sedentary life; con- stipation of large, difficult stools as an accompaniment. Aggravation in the morning at four o'clock; she is obliged to get out of bed at 364 DISORDERS INCIDENTAL TO PREGNANCY. that time, on account of a pain in the back, and she finds relief from rising and walking about. She cannot turn over in bed on account of the pain in the back. Plumbum. A sensation in the abdomen at night in bed, which causes the patient to stretch violently for hours together; sometimes she must stretch in every possible direction, or she feels that she must do so, and this inclination is almost uncontrollable. Feeling as if there Avas not room enough in the abdomen, or as if the abdomen and back were too close together. Sensation as if the abdominal walls were pulled inward. Pulsatilla. She cannot sit long at a time; she must walk about to relieve her pain. A close or warm room is very oppressive, and she feels as if she must be in the open air, which is extremely grateful to her. Rhus tox. Cramps in the legs, causing her to rise and walk. Cramps in the legs every night, causing her to jump out of bed. She is very restless at night, and can find ease but for a short time in any position. Secale c. Frequent and prolonged forcing pain in the abdomen, particularly in thin and ill-conditioned Avornen. Sepia. Frequent bearing-down pain in the back and abdomen. Sense of weight in the anus as an accompaniment. Painful sen- sation of emptiness in the pit of the stomach, which makes her feel miserable. Sulphur. Cramps in the loAver extremities, with hot flushes and weak, faint spells. Burning in the soles of the feet; she must put them outside the bed-covers or into a cool place. Feels hungry and faint at about eleven A. m. ; she cannot wait for her dinner. Cannot walk or sit erect. Always feels worse before a storm. Pains are mostly on the left side. Veratrum a. Cramps in the extremities, with cold perspiration. Very great feeling of distress in the pit of the stomach after eat- ing, lasting for an hour or two. She feels very weak, so much so that she is obliged to lie down. Violent retching, with cold sweat breaking out. Disorders of the Apparatus' of Locomotion. inflammation of the pelvic articulations. This not very common form of inflammation is sometimes seen during pregnancy, but less rarely after parturition. The affection ap- pears spontaneously, Avith severe, acute and sometimes lancinating RELAXATION OF THE ARTICULATIONS OF THE PELVIS. 365 pains in one or several of the pelvic articulations. These pains are necessarily aggravated by pressure, by standing and by attempts at walking, AAdiich the inflammation may render impossible. In some cases, probably those Avhich were strongly predisposed to suppuration, the inflammation has taken this course, the articular surfaces becom- ing denuded of cartilage. In two instances referred to by M. Cazeaux this affection terminated fatally. Perfect quiet must of course be observed in such inflammation of parts which are not only immediately engaged in locomotion, but which have to sustain also all the superincumbent Aveight of the body. The character of the pains themselves, together Avith their conditions of aggravation as to time and circumstances, will readily suggest to the homoeopathic practitioner the remedy applicable to each particu- lar case, by the timely exhibition of Avhich much suffering will be saved to the unfortunate patient. Relaxation of the Articulations of the Pelvis. In certain constitutions there appears during pregnancy a consider- able amount of relaxation of the ligaments which unite the bones of the pelvis, and a consequent mobility of the pelvic articulations. This change occurs in different degrees in different persons, being scarcely perceptible in some and rendering walking impossible in others. The precise cause of this affection it may not be easy to designate although those who suffer in this manner usually appear to possess what is termed a scrofulous constitution. And indeed this tempo- rary relaxation and displacement is in no small degree analogous to the chronic scrofulous disease which goes by the name of rachitis. The immediate cause of the relaxation is found to consist in a soften- ing of the ligaments by which the pelvic articulations are usually so firmly bound together. And in this respect this affection differs from the rachitic softening of the bones Avhich so often produces distortion during the period of childhood, and also from the corresponding soft- ening of the bones in adult years, malacosteon, which occasions so many varieties of pelvic deformity. A certain enlargement of the synovial bursa?, and corresponding hypersecretion of the synovial fluid, have been noticed in the more aggravated cases of pelvic re- laxation. This spontaneous relaxation and dislocation from the very first occasions such an amount of instability in standing and insecurity in attempting to Avalk as to indicate at once the nature of the difficulty. The pains which accompany the affection, being felt principally from 366 disorders incidental to pregnancy. motion or pressure, such as standing or Avalking, might be incapable of being distinguished from those of inflammation of the articulations, but for this remarkable sense of instability Avhich appears in the in- cipient stages, and Avhich is subsequently aggravated to exceeding difficulty of standing and impossibility of walking. In such cases the sensation experienced on attempting to stand is that Avhich so strongly characterizes belladonna, as if her whole body would sink down betAveen her thighs. This relaxation of the pelvic articulations may, when not too much developed, render delivery less easy and speedy by destroying the firmness and stability of the point dJappui which the abdominal mus- cles derive from the bones of the pelvis. But when farther advanced this relaxation, by enlarging the pelvic cavities, may facilitate the ex- pulsion of the child's head, thereby rendering spontaneous a delivery Avhich Avould otherwise have been very difficult on account of the dis- proportion between the size of the head and the dimensions of the pelvis. After delivery the relaxation has been known to continue for several months, or even for years or the whole lifetime. In all cases of relaxation of the pelvic articulations in pregnancy the most perfect quiet, and even absolute rest, should be enjoined, in order to prevent the increase of the difficulty which must result from moving about, and in order to obviate the danger of inflammation arising from undue irritation of tissues already morbidly affected. A careful study should be made of all the indications and symptoms, in order to reach the constitutional dyscrasia which lies at the bottom of the difficulty, and thus at the same time arrest the progress of the present mischief, prevent future trouble, and radically and perma- nently improve the patient's health. A disposition to fall sometimes greatly troubles the pregnant woman. That which arises from sudden attacks of syncope is not referred to here, but rather that Avant of firm balance in walking, that danger of stumbling and that general sense of instability Avhich often prove a constant source of annoyance. The equilibrium of the body in mo- tion in the natural state is only preserved by the incessant although entirely unconscious effort of the muscular apparatus, Avhich as in- stinctively regulates the movement and position of the body in accord- ance Avith the la\y of gravity as the muscles of the eye adapt the size of the pupil to the various degrees of light. In persons afflicted with hereditary muscular Aveakness, Avhich is but the particular manifestation of some general and constitutional dyscrasia, the constant task of main- taining the proper centre of gravity, aggravated by the aAvkward dispro- RELAXATION OF THE ARTICULATIONS OF THE PELVIS. 367 portion in size and large addition of weight in front which characterize the advanced stages of pregnancy, is entirely beyond their strength. Hence the severe myalgic and neuralgic pains already described as affecting the abdomen, breasts, back and lower limbs; hence, too the difficulty of Avalking, the unsteadiness of gait and the danger of fall- ing with which such persons are afflicted. A careful collection of all the symptoms of such cases, and an equally careful comparison of them with those belonging to the fol- lowing remedies, and to others Avhich may be indicated in the rarer forms of lesion of the locomotory apparatus in pregnancy, will enable the homoeopathic physician to prescribe for these various difficulties with confident hope of affording to these sufferers both present and permanent relief. Jlsculus h. Where the sacro-iliac symphysis is the point of the trouble. She cannot walk because that part of her back gives out, and it fatigues her so that she must sit down, and she feels better still when lying. Aloes. Where a sense of weight and pressure into the pelvis seems to cause the lameness. Arnica. Where a sensation of soreness as of a bruise prevails. She can hardly move about at all from the soreness in the symphysis pubis or in the sacro-iliac symphyses. Calc. carb. Will be indicated in leucophlegmatic constitutions; great fatigue on Avalking even but a short distance, from a general feeling of lameness in the pelvis. Cold, damp feet. Vertigo on ascending. Does not sleep after three A. m. She is clumsy. She stumbles and falls very easily. Calc. phosph. She is very much worse after taking a little cold. She is liable to rheumatic pains in all her joints after taking cold. ^ Gelseminum. This remedy will be found useful in cases where the difficulty of walking or the inability to stand appears to be due to an inability to control muscular movements. Kali carb. The back aches so badly while she is walking that she wishes to lie down at once, and says "she feels as if she could lie down in the street" at such times, to obtain immediate rest and relief. Manganum. The limbs are affected, and are very tender and sen- sitive to the touch. The point or part affected, and to which the lameness is ascribed, is sensitive on pressure. Pulsatilla. She cannot walk so well toward evening. She feels 368 DISORDERS INCIDENTAL TO PREGNANCY. worse Avhen warm in bed. She can hardly find an easy jiosition through the night, owing to the pain in the pelvic articulations. Rhus tox. A sense of stiffness in the pelvic articulations on first attempting to walk; better after getting Avarm in Avalking. At night she must change her position frequently, feeling quite easy for a Avhile after every change, but she must shortly change again. Silicia. In cases where ulcerations take place Avith fistulous open- ings, which are very tender to the touch. If pimples make their appearance around the ulcerations, hepar may be indicated. Sulphur. With her pelvic sufferings she has flushes of heat and weak, fainty spells. She is weak and faint from about eleven o'clock till noon. Coldness of the feet. Thuya. The sufferings are greater in the left sacro-iliac articulation, the pains running into the left groin. The pain from walking is so insupportable that she must lie down. Derangements and Affections of the Nervous System. The sympathetic nervous disorders Avhich affect young girls in dif- ficult menstruation are but the prototypes of those affections which occur during pregnancy in women of corresponding unhealthy consti- tutions. Hence, in addition to the more strongly-marked disorders of pregnancy just described, we find disturbances of the nerves of special and of general sense, abnormal conditions of the intellectual faculties, and various depravations of the moral and emotional sphere. The more important of these various disturbances will now be briefly considered. Loss of Hearing. Davis mentions having seen two cases of entire deafness which came on during gestation. In the one case the abolition of the sense of hearing came on suddenly during one of the earlier months, and very gradually returned after delivery; whilst in the other it came on by imperceptible degrees in the seventh and eighth months of gestation, and returned suddenly and with painful acuteness on the sixth day after delivery, when the lochia entirely ceased to flow. From Paul- lini the same author quotes the case of the wife of a citizen avIio was subject to be seized Avith an entire loss of hearing about four or five days before being taken with labor-pains, the deafness going off after delivery. Indeed, such cases are by no means uncommon, particu- larly where the deafness is not complete, but is merely an impairment of the sense of hearing in a greater or less degree. And there may be accompanying the deafness, or occurring with but little or no deaf- affections of the eyes. 369 ness whatever, various and most distressing noises in the ears, tinni- tus aurium, etc. Where these sounds are heard, however, the practi- tioner before prescribing any medicament should ascertain whether they are not due to impacted cerumen making pressure upon the membrana tympani. The following remedies should be consulted, as well as others not here enumerated: Capsicum. The petrous portion of the ear is much swollen, red and painful. Carbo. an. She is able to hear, although faintly, but cannot tell ac- curately from whence the sounds proceed. Causticum. Keverberation of all sounds, even of the patient's own voice, in the ears. Graphites. Great dryness in the ears. The deafness is better when riding in a carriage. Lachesis. The cerumen is too hard, too pale and insufficient. Mercurius. Sensation of coldness in the ears continually. Nitric acid. Much swelling of the internal ear; it is nearly closed, and sometimes there is much pain Avithin it. Phosphorus. Difficulty in distinguishing the human voice. Pulsatilla. Sensation as if the ears Avere stopped up. Silicia. Partial relief is obtained by blowing the nose. Sulphur. Aggravation for a while after eating or blowing the nose. Compare, also, Calcarea c, Petroleum, Hepar, Staphysagria, etc. Affections of the Eyes. The eyes sometimes become the seat of a still more painful affection in pregnancy. Dr. Bezard * relates the case of a lady who, in the fifth month of her ninth pregnancy, was suddenly and without any known cause seized with a deep-seated pain in her right eye. There was no external sign of disease, except that there was no secretion of tears; there was, however, a sensation of strong pulsation at the bot- tom of the orbit, accompanied by acute and frequently repeated lanci- nating pains, by appearances of rapidly-darting specks before the eyes and by errors of the vision. Pain of the forehead and at the root of the nose, together with a sense of weight and oppression about those parts, aggravated the patient's distress. In a short time the rays of hght ceased to irritate the retina, the eye became insensible to the con- tact of the finger, and the patient could intently stare at the sun with- * Journ. de Med., par Leroux, xxxiii., p. 72. 24 370 DISORDERS INCIDENTAL TO PREGNANCY. out producing any painful excitement. Inability to sleep accompanied this local affection for several weeks. The delivery Avas happily ac- complished, and in the course of some days subsequently the lady found that she could perceive light with the eye which she considered as lost to her, and after some days she could clearly distinguish objects Avith it. She gradually improved in this respect for eighteen months, when she became enceinte for the tenth time. At about the fifth month, at the same time as in the former pregnancy, she Avas seized with similar but much more intensely severe pains in the same eye. In this pregnancy the difficulty extended to the left eye also, Avhich after delivery in great measure recovered its functions, but the right eye remained permanently insensible to light. According to Beer,* amblyopia or amaurosis, accompanied with nausea or Avith vomiting which cannot be quieted, sometimes occurs early in pregnancy and ceases after parturition. He saAV a young JeAvess, Avho in her first three pregnancies, which followed in quick succession, began to grow blind in the early period, and became quite amaurotic in the third or fourth month. On the first two occasions she continued blind until after parturition, and the third time her sight never returned. Desmarres also mentions pregnancy among the indirect causes of amaurosis.f Exactly opposite to this is the case quoted by Cazeaux, of a young woman whose imperfect vision had compelled her to use spectacles from childhood, but whose sight had so much improved immediately after the beginning of her pregnancy that she had no longer need of magnifying-glasses. In affections of the eyes study the following remedies: Aurum. Objects appear as if divided horizontally. Belladonna. Dim appearance of objects; they appear inverted or double. Calc. c. All objects appear as if seen through a mist. Causticum. Sudden and frequent loss of sight, with sensation of a film before the eyes. The dimness of vision is greater after every headache. Paralysis of the upper eyelids, so that they hang down. China. She can only distinguish the outlines of distant objects. When reading, the letters appear pale and surrounded with a white border. She sees better after sleeping. Cicuta V. The letters seem to move about when she is reading. Cina. She can see more clearly for a while after rubbing the eyes. * Lawrence on the Eye, p. 612. f Maladies des Yeux, Paris, 1847, p. 715. HEADACHE AND NEURALGIA. 371 Hyoscyamus. Frequent spasms of the eyelids. Strabismus. All objects appear of a red color, or larger than they are. Natrum mur. Frequent spasmodic closing of the eyelids. Nux V. Heaviness and contraction of the lids. Phosphorus. All objects appear to be covered with a gray veil. Pulsatilla. Sensation as if the eyes were covered with a mist, or as if the dimness could be removed by rubbing something off from the eyes. Sulphur. Dimness of vision 'and the gas- or lamp-lights appear to be surrounded by a halo. Compare, also, Cyclamen e., Drosera, Glonoine, Mercurius, Ruta, Senega, Sepia, Veratrum, etc. Headache. This forms one of the most common and most painful affections of pregnancy. It may arise in part from sedentary habits, especially in the more advanced stages of pregnancy, and for similar reasons it may be both complicated with and aggravated by constipation. In persons who are usually subject to headache the condition of preg- nancy may serve to increase the difficulty. The cephalalgia of preg- nancy may attack those of an anaemic habit and nervous temperament, or it may appear in connection with a plethoric condition, indicated by flushing of the face and giddiness aggravated by stooping. Or, again, the headache may accompany nausea and other gastric disturb- ances, with paleness of the face and general debility. The treatment will usually be very simple, since the indications can hardly fail to be plain. When the disorder appears in connection with constipation, increasing in severity upon each occasion till the bowels are moved, and seems also to result in some measure from the sedentary mode of life to which so many women addict themselves even when not enceinte, exercise in the open air should be strongly advised, to be taken in the manner best suited to the circumstances of the patient. Neuralgia. Facial neuralgia in pregnancy differs but little from headache in its causes and requisite mode of treatment, except that while like headache it may arise in connection with constipation, it is otherAvise more apt to occur in persons of a pale, anaemic or nervous tempera- ment than in those of a ruddy, plethoric habit of body. According to Tyler Smith, "facial neuralgia from uterine irritation is a very common affection of pregnancy. It generally affects the dental nerves, 372 DISORDERS INCIDENTAL TO PREGNANCY. particularly those of the upper jaw. In many subjects acute caries of the teeth occurs; in some child-bearing Avomen a tooth or two is lost in each pregnancy." In neuralgia of the face in pregnant Avomen, without disease of the teeth, the same author says a generous diet is called for, and he ad\dses also wine and porter.* The latter articles we think can hardly ever be needed in this country, unless perhaps temporarily in cases of great privation from suitable nourishing food; in such instances a^little Avine may aid in restoring the system from its enfeebled condition, and thus enable it the more readily to avail itself of a wholesome and nutritious diet. Great care must be taken in cases of severe neuralgia in pregnancy—cases which may constitute a true spinal neuralgia—lest from loss of sleep, inability to assimilate suitable food and the depressing influence of long-continued suffering, the system may become so much reduced as to induce abortion, and even fatal marasmus. In selecting a remedy for the cure of the headaches and neuralgias of pregnancy the practitioner should bear in mind the importance of the concomitant symptoms, as well as of those especially of the disorder itself. The following medicines may be studied among others for these painful and distressing affections: Aconite. In headache or neuralgia, accompanied by vertigo on rising up in bed. Crampy sensation in the root of the nose. Sensation as if the whole brain would press out at the forehead. She fears to be in a place of excitement or confusion. Belladonna. Flushed face and injected eyeballs. Cannot bear noise or bright light. She seems to be in a stunned or stupid condition. Bryonia. A splitting headache; she wishes to keep very still. Dry- ness of the lips and mouth. Nausea on rising in bed. Calc. c. Headache, with an unusual accumulation of dandruff on the scalp. Headache is aggravated by ascending, as in going up stairs; the blood seems to be forced into the head, causing a burning sensation. Vertigo on ascending. Coccuius. Her head feels worse after eating or drinking. Head- ache, as if the eyes would be torn out, particularly on motion, with vertigo. Cimicifuga. Lancinating pain over either eye or in the eyeball, which is Avorse every other day. Heat, sense of fullness and throbbing in the head.^ The pain is relieved in the open air, and aggravated by the heat of the stove. Throbbing in the head when ascending. * Braithwaite's Retrospect, xxxiii., p. 252. HEADACHE AND NEURALGIA. 373 Coffea. Intense pain, the head feeling contracted or as if too small. Nervous excitement, with sleeplessness; or droAvsiness, yet with in- ability to go to sleep. Gelseminum. Sharp shooting pains through the face, eyes and head, which feel like rheumatic pains; the face is congested and of a dark or dusky hue. The headache commences in the neck quite suddenly, and spreads from thence over the head, or vice versa; dimness of vision; heaviness of the head; vertigo; stupor; dull expression of the countenance. Glonoine. Whirling in the head, with giddiness; sensation as of expansion of the brain, the head feeling as though it would burst. Confused feeling in the head; perceptible throbbing of the carotid and temporal arteries. The headache or the neuralgia has been brought on by exposure to the rays of the sun, or is aggravated by such exposure. Ignatia. Headache confined to one side of the head; clavus; un- bearable pain, as of something sharp being forced into the brain; weak feeling in the stomach; suitable for women of melancholy disposition who are given to sighing, or to hysterical women. Magnesia c. The pains are aggravated by talking or by mental ex- ertion. She feels sad and disconsolate. Nux V. This medicine is especially suitable for headaches or neu- ralgias of pregnant women who are addicted to high living, the use of wine and spirits or coffee, and to keeping late hours, or who lead a too sedentary life. Constipation of the boAvels or hemorrhoids habitual. The head feels as if it would split, and the scalp is sore to the touch; pressure with the hands on the head relieves the pain. Nausea; accumulation of gas in the stomach after a meal, and other symptoms of dyspepsia. Pulsatilla. Hemicrania, occurring in women of mild and gentle disposition, given to weeping. The suffering, whether from headache or neuralgia, is much worse in a Avarm or close room, and is relieved by going into the fresh, open air. Sepia. Headache, with aversion to all kinds of food, a feeling of emptiness or goneness in the pit of the stomach, which is very dis- tressing. Headache occurring every morning, with nausea, vertigo, epistaxis. In Avomen who have "moth-patches" on their foreheads, who are of sallow complexion, or who have a yellow streak across the Midge of the nose and under the eyes. Spigelia. Facial neuralgia, generally of the left side of the face, and vei7 severe type. The parts supplied by the fifth pair of nerves 374 DISORDERS INCIDENTAL TO PREGNANCY. are especially affected. The pain invol\res the eyeball and orbit, and sometimes the eye of the affected side is very much congested. The pains are lancinating or lacerating, and are someAvhat relieATed by firm pressure. Verbasc'im thapsus, on the contrary, is indicated when even the slightest pressure greatly aggravates the suffering. Sulphur. Heat on the vertex, habitually; frequent flushes of heat all over; cold feet; spells of faintness. Veratrum a. Headache causing delirium, dementia, and cold sweat on the forehead. Toothache. Toothache is a common and very distressing accompaniment of pregnancy, being in fact only a particular form of neuralgia. Leadam strongly advises against extracting the teeth in such cases, since abor- tion has been known to follow the operation. Tyler Smith states that they ought only to be extracted with caution under such circumstances. But those having in their hands the homoeopathic remedies, and blest with even a moderate amount of skill in administering them, will nevTer be tempted to resort to a practice at once barbarous and danger- ous. Still, it must be borne in mind that neither local applications nor remedies selected with reference to the teeth alone will suffice, in many cases, to remove an affection which is at once painful, sympa- thetic and constitutional—that is, connected with some individual idiosyncrasy. Here, as in all other cases of disease, the remedy should be selected in accordance with the totality of symptoms. One or the other of the following remedies Avill usually be found useful: Alumina. Drawing toothache, extending to other parts, as down the larynx, neck or shoulders, etc. Arsenicum. Periodical toothache, occurring most frequently at night, however; it is then unbearable and drives the patient almost to frenzy. She is unable to remain in bed, and must get up. Belladonna. Pains as if caused by ulceration, Avorse after lying down at night or when in the cold air. Pains mostly on the right side of the face, extending to the eye and its orbit. The pain causes moan- ing and Aveeping. Calcarea c. The pain is aggravated by the slightest change, as from a current of air, whether warm or cold, drinking anything warm or cold, noise, mental excitement, etc. Chamomilla. The pains are perfectly unbearable, and give rise to TOOTHACHE—chorea. 375 much irritability of temper and impatience; redness of one cheek Avhile the other is normal or pale; jerkings in the teeth. Gelseminum. General nervous excitement or weak and trembling. The pains come in paroxysms, are decidedly neuralgic, and dart through the jaAvs and face. Congestion of the head and face. Hyoscyamus. Violent tearing and pulsating pain, causing spasmodic jerks of the fingers, hands, arms, facial muscles. Spasms in the throat, etc. Magnesia C. Insupportable pain during repose; she must get up and walk about. Mercurius sol. The teeth feel sore to the touch—so much so that pressing them together, as in eating, increases the suffering. The teeth feel elongated and as if loose". Mezereum. Pains extending to the bones of the face and temples, particularly Avhen they run along the left malar bone to the temple. Nux m. Pains in the front teeth on inhaling cool air or taking warm drinks; feeling as if the teeth Avere grasped to be pulled out. Nux v. Toothache occurring in Avomen of irritable disposition, or who are high livers and are troubled with constipation or haemor- rhoids. Phosphorus. The pain is of a jerking or twitching character. The periosteum of the tooth is inflamed and tender of pressure. Pulsatilla. The pain is better Avhen taking cold food or drink or upon exposure to cold air, and is worse from Avarm food or drink and in a warm room. Rhus tox. Rheumatic toothache, or toothache occurring from get- ting wet. The pain is relieved by applying warmth to the face. Staphysagria. The teeth grow black, become carious and brittle. She is very sensitive to either mental or physical impressions. Chorea. Where this affection occurs in connection Avith pregnancy the spinal system of nerves is affected secondarily through the ganglionic. The symptoms of this disorder are too strongly marked and too Avell understood to need to be repeated here. The folloAving conclusions, arrived at by Dr. Lever twenty years ago, fully represent the present state of our knowledge in respect to most of the points mentioned. " In conclusion," says this Avriter, " I venture to submit the follow- >ng propositions: 1. That pregnancy is occasionally associated Avith cho- rea or convulsive movements; with paralysis of various parts of the body, of the extremities and of the nerves of special sense; and with 376 DISORDERS INCIDENTAL TO PREGNANCY. mania. 2. That the varying symptoms of such complications may be produced at any period of pregnancy, but when produced, although modified by treatment, are rarely removed during the existence of gravidity. 3. That the patients in whom these complications exist are Avomen of a highly nervous temperament, of great irritability, or Avhose constitutional poAvers have been reduced by some long-con- tinued but serious cause of exhaustion. Lastly: That although in most instances the symptoms will continue so long as pregnancy exists, yet in a majority of cases we are not justified, in inducing a prema- ture evacuation of the uterine contents." To these views of an old-school author let us add what our own school teaches in one most important respect. In those cases in which chorea or epilepsy appears for the first time during pregnancy, Ave must regard this latter state as having sufficed to develop a certain morbid element of the constitution which had hitherto remained latent; and Ave should seize upon the opportunity thus afforded to endeavor, by the exhibition of the appropriate remedies, to radically cure this morbid taint, and thus, at the same time, prevent the con- tinuance of the convulsive disorder after delivery, and provide against its return in a succeeding pregnancy. In those cases in Avhich wo- men become pregnant who have been subject to either of these ner- vous affections, the pregnancy may either render the convulsive attacks less frequent, cause them during the continuance of this state to cease entirely, or even render them of much more frequent occurrence than before. But Avhile it is believed that no instances are recorded of epileptic patients having been permanently benefited by pregnancy, M. Malgaigne * cites a singular case in Avhich the first attack of epilepsy Avas developed during pregnancy in an unfortunate young woman, who retained this fearful malady through all her sub- sequent life. Similar is the case quoted from a German author by Dr. Davis,f of a lady twenty-six years of age, of a bilious constitu- tion, and the mother of three children, who aa^s attacked Avith a periodical epilepsy whenever she conceived, and Avho sustained a paroxysm of this malady once a fortnight during the whole of her gestation. But as soon as she was delivered the disease left her. Its occurrence, therefore, was always a sign to her that she had become pregnant. Chorea, whether occurring during pregnancy or at any other period, is amenable to homoeopathic treatment. The subjoined reme- dies are presented as those most likely to be required, while the * Traite Theoretique et Pratique, etc., p. 368. f Obstetrics, ii., p. 900. CHOREA—HYSTERIA. 377 remedies and their indications given under the article on Chorea in the portion of this work devoted to the consideration of diseases of children may be studied with advantage : Belladonna. When the tongue is partially paralyzed. Difficulty of articulation. Right side more particularly affected. Red eyes. Much debility. Rather stupid. Calc. c. Chorea from a fright. In leucophlegmatic temperaments. Causticum. If the upper eyelids are particularly affected, so that they hang down—can't keep them up. She is worse in the open air and in the evening. Cocculus. She is always worse for a while after drinking, eating, sleeping or talking. Crocus. She is worse every evening, with alternations of excessive happy, affectionate tenderness and rage. Cuprum. When the spasms come on in paroxysms, grouped with other symptoms Avhich always appear grouped with these paroxysms. Or Avhen the paroxysm commences in one part—the finger or limb, for instance—and gradually extends till the whole frame is involved. Hyoscyamus. Twitching and jerking of all the muscles, including those of the eyes, eyelids and face. Ignatia. When there is much deep sighing and sobbing, or when the disorder is the result of a long-suppressed grief.. Nux v. Very fond of high living; troubled with constipation. Chorea is worse in the morning or in the early part of the day. Stramonium. Full of strange, inconsistent fancies. The attacks are brought on by fright or care, and are very violent, especially at night; excessive jactitation of the muscles. Study also Apis mel., Asafoetida, Arsenic, China, Cicuta, Cimicif., Coffea, Dulcamara, Opium, Pulsatilla, Sabina, Sepia, Silicia, Zinc, Vera- trum v. Hysteria. This affection is a frequent accompaniment of pregnancy. But in this place we need do little more than refer the reader to the very full discussion of the subject of hysteria in the succeeding portion of the work, similar indications being present and similar remedies called for in the pregnant as in the non-pregnant condition. Still, in cases of pregnant Avomen the remedies should be selected, if possible, with still greater care, since, for obvious reasons, much greater importance must be attached to the hysterical condition in the pregnant state. 378 disorders incidental to pregnancy. Dr. BurroAVs states that he has seen two cases in Avhich hysterical symptoms attended during pregnancy, and the patients in each case became insane almost immediately after delivery. Romberg instances among the debilitating influences which are the most fertile sources of hysteria, " repeated miscarriages and a rapid succession of preg- nancies and lactations." In most cases of women subject to hysteria, or any other form of general disorder of the nervous centres, the occurrence of pregnancy serves rather to aggravate than to ameliorate the pre-existing morbid condition. Disturbances of the Intellectual Faculties. Pregnancy is sometimes accompanied Avith a partial mental derangement, Avhich may become complete insanity. Esquirol men- tions the case of a young woman of a sensitive habit who had an attack of madness in two successive pregnancies, commencing imme- diately after conception and lasting fifteen days. Montgomery states that he knew a lady Avho was attacked with insanity in eight suc- cessive pregnancies; and another who was similarly affected three times soon after conception, and remained so until Avithin a short time after labor, when she became sane and continued so until the next pregnancy. It should be obsen7ed that insanity in pregnancy, Avhether arising in connection with the hysterical condition or not, has two distinct sources; in the one, the disturbance of the intellectual faculties appears to result rather from the physical condition, and to be dependent upon pregnancy physically considered; in the other, the mental powers manifestly gh7e way and the reason loses its balance under the depressing influence of the melancholy and settled gloom Avhich belong entirely to the moral sphere. And at the same time it should be remembered that a certain constitutional dyscrasia may be the real cause of the physical condition Avhich leads up to insanity on the one hand, and even of the profound moral and spiritual dejection which leads down to it on the other. There are, hoAvever, numerous unfortunate cases, especially of young AAromen who become pregnant while yet unmarried, in Avhom the agony of disappointed hopes, of affections misplaced and cruelly abused and betrayed, the present scorn of society, and the apprehension of a still increasing shame, suffice to hurl reason from its throne, to destroy the better judgment, and induce such madness as finds its necessary crisis in suicide. These are cases in which the grief of irreparable afflic- tion, the mental anguish and moral suffering, can scarcely fail to disorders op the affections, emotions and feelings. 379 derange the soundest mind in the soundest body, and destroy both together. But Avhile time alone can effectually mitigate the more poignant forms of affliction, the homoeopathic remedies are yet remarkably efficacious in " ministering to a mind diseased," whether the mental derangement result from physical dyscrasia, from moral suffering, or from both combined. The physician should most carefully explore all the symptoms, circumstances and conditions in respect to the physical system, to the sensorial, the intellectual, and the affectional faculties, in order to discover in the Materia Medica the exact simile of his patient's case. The serious responsibility which rests upon the physician to do all that human science can accomplish in such cases is not limited to the present condition or future well-being of the mother; regard must also be had to the unborn child, to preArent the predisposition to insanity from being perpetuated in the infant, and in a still greater degree developed in succeeding generations. To give indications for remedies for the various and varying dis- turbances of the intellectual faculties Avould be a task of great magni- tude, and, Ave might add, a work of supererogation, inasmuch as all the remedies comprising the Materia Medica would haA7e to be recorded. Reference may be made with advantage, hoAvever, to those especially recommended for Disorders of the Affections, Emotions and Feelings. In addition to the disturbances of the intellectual faculties already mentioned as incidental to the condition of pregnancy, there are fre- quently seen certain anomalous variations of the spirits, temper and affections, for which the physician will be called upon to prescribe, either in connection with physical symptoms or in their absence. The special adaptability of the homoeopathic Materia Medica to abnormal conditions of the sensational, intellectual, emotional and affectional faculties gives the homoeopathic physician an immense advantage in this class of cases. The settled gloom, the profound melancholy to which allusion has already been made as occasionally productive of insanity is some- times seen to appear Avithout any other assignable cause than the general one of pregnancy. When this depression of spirits assumes some particular phase—as, for example, that of a disposition to commit suicide—the appropriate remedy is at once suggested. The limits of the present Avork restrain us from doing more in this connection than merely to mention some of the most prominent forms of mental and 380 disorders incidental to pregnancy. moral derangement, and to indicate the principles upon Avhich thev should all be treated. For a fuller exposition of the various mental and moral diseases, and a more detailed statement of the numerous homoeopathic remedies applicable to them, the reader is referred to Dr. Franz Hartmann's very excellent work on Mental Diseases.* Remarkable changes of temper also appear, and in a still more nu- merous class of pregnant women. " FeAV Avomen are quite as self- possessed or in as even spirits during pregnancy as at other times; little things annoy them, trifles depress them. Sometimes the most sweet-tempered women become irritable, cross and quarrelsome. The husband of a patient of mine, Avhose wife was remarkably good-tem- pered and attached to him, told me that the earliest symptom of pregnancy in her case was a disposition to quarrel Avith him espe- cially. Dr. Montgomery mentions the case of a lady Avho, for the first two or three months of her pregnancy, was so irritable that, to use her OAvn words, ' she was a perfect nuisance in the house.' "— Churchill. Sometimes women whose ordinary dispositions have been soured by the trials of life, or who are characterized by a habit of fault- finding and complaining, experience a very happy change of temper on becoming pregnant. But more often those usually of a cheerful, lively disposition become sad, depressed and even morose, refuse all comfort or encouragement, and persist in the fixed belief of a fatal termination of their labor. Except in a very few and remarkable cases, such gloomy anticipations of impending evil are happily dis- appointed by a successful delivery, which is therefore succeeded by the restoration of the accustomed cheerfulness. And in those few instances in Avhich the foreboding of a fatal termination of the labor proved prophetic, it is believed that some deep-seated dyscrasia of the physical system gave rise to this instinctive fore-consciousness, such as is sometimes seen in a similar fulfillment of such predictions in cases of ordinary illness. The feelings and affections in many instances undergo a distressing transformation in pregnancy. It is related of one young woman that she was seized at about the fifth month Avith an unconquerable aver- sion to her apartment; so that, after much effort of reasoning and persuasion had been tried in vain, it became necessary to leave her in the country during the remainder of her pregnancy. Another * Special Therapeutics, according to Homoeopathic Principles, by Dr. Franz Hart- mann. Third volume, Mental Diseases. Edited by Dr. G. H. G. Jahr. Translated by J. M. Galloway, M. D. Manchester: Henry Turner, 1857. disorders of the affections, emotions and feelings. 381 case is recorded of a young lady, for the first time pregnant, Avhose former love for her husband was replaced by an almost invincible antipathy to him. Similar to this is the moral state of those Avho from imagining, in their hypersensitive, nervous condition, that they do not receive proper and necessary attention from their husbands and their friends, turn against them and conceive for them a strong dislike. In most cases all such morbid changes of the affectional sphere disappear Avith the termination of the pregnancy under the in- fluence of Avhich they Avere developed. But it becomes no less im- portant for the physician to do all in his power to relieve such moral disorders, not only on account of the present suffering and distress to all concerned, but also because in some instances, at least, these dis- orders may become permanent, and even ultimate themselves in dis- turbances of the intellectual faculties, in subsequent puerperal mania, and finally in some dangerous forms of physical disease. These dis- orders of the feelings, emotions and affections may be connected with an hereditary predisposition to insanity, or with some deeply-seated and even malignant dyscrasia, which, if not remedied at its incipient appearance, may develop the most serious mischief in the present and in future generations. Happily, these disorders are usually amenable to careful medical and hygienic management. In selectirfg a remedy for any of the above-described conditions, even the most trifling symp- toms, as Avell as those of apparently more grave import, should be taken into the account which makes up the totality of the individual case. And while individualizing is the touchstone of successful treat- ment in all cases, it is through it only that success can be attained in treating any of the varied affections of the mind. A few of the medicines most frequently called for in these cases are herewith sub- joined : Aconite. Fear and presentiment of approaching death; she fixes the time of her death. Aurum. She has no confidence in herself, and thinks others have none in her; this makes her unhappy. She looks on the dark side of everything; Aveeps and prays ; thinks she is not fit to live, and has a strong inclination to suicide—to jump out of the window or from a height. Sleepless at night. Anacardium. Estrangement from individuals and society, with fear of the future. Strange temper; she laughs at serious matters; is grave over laughable occurrences. Swears; thinks herself a demon. Loss of memory, dullness of the mind and inability to think. Dyspepsia. 382 disorders incidental to pregnancy. Arsenic. Periodical attacks of anguish, inquietude, tossing and in- ability to lie in bed; fear of death; excessive dread of death; she is sure she will die. Easily exhausted; looks pale and haggard. Puffed and waxy appearance of the face. Arnica. Thoughtless gayety; great frivolity and mischievousness. Belladonna. Great distress with inquietude. Frightful visions; she Avishes to hide herself. She has a Avild look, a stunned appearance. She wishes to strike, bite and quarrel. Difficult deglutition. Calc. C. Excessive mischievousness, with obstinacy. She thinks and talks about murder, incendiarism, rats and mice. She imagines people think she is insane. China. She thinks she is very unfortunate and constantly harassed by enemies. The symptoms appear to be paroxysmal and are worse every other day. Hyoscyamus. She fears she will be poisoned or betrayed or in- jured; she Avishes to run away. Ignatia. She wishes for solitude; sighs and sobs; she will not be comforted. She is full of grief. Lachesis. Excessive loquacity, with rapid change of subject, talks of one thing, then of another, etc. Jealous, proud, suspicious. Lycopodium. Very reproachful and overbearing. Restless at night, and complains of not sleeping well. Moschus. She complains much, but of nothing in particular. Natrum c. Estrangement from individuals and society, even from her husband and family. See also Anacardium, Conium and Natrum m, Nux v. Loss of mental power; can't read or calculate, because she loses the connection of ideas; she thinks she will lose her reason. Worse in the morning or early part of the day. Opium. Thinks she is not at her home; this is continually in her mind. Phosphorus. Great sadness with tears, alternating with gayety and laughter. Suitable especially for tall and slender Avomen; thin, hard and dry stools, which are evacuated with difficulty. Platina. Past events trouble her. Contempt for other persons. She thinks all persons are demons. Pulsatilla. Much Aveeping, even at answering a question. Most suitable for mild and gentle women, who are easily controlled. Sepia. She is very uneasy about the state of her health; constantly worrying, fretting and crying about her real or imagined illness. Silicia. She is occupied with pins—counts them, hunts for them, etc. She is always worse during the increase of the moon. DISORDERS OF THE AFFI CTIONS, EMOTIONS AND FEELINGS. 383 Staphysagria is very similar in some respects to Sepia. The pa- tient is very sensitive to either mental or physical impressions. Stramonium. She is worse in the dark or in solitude. Full of strange, ridiculous ideas. Talks or prays earnestly and constantly. Sulphur. She is very happy, and imagines she is in possession of beautiful things. Awakens at night singing, she is so happy; she dreams very happy dreams, etc. Veratrum. A desire to Avander about the house. Erroneous and haughty notions. Disposed to be very taciturn. Asafoetida, Gelseminum, Cimicifuga, Cocculus, Cypripedium, Moschus, Nux moschata, Phosphoric acid and Zincum may likewise be consulted. The patient should receive the best advice from her physician in regard to the necessity of self-exertion in assisting to overcome the tendency to a disordered mental state. She should be urged to bear up bravely, and to resist, to the full strength of her ability, those feelings which are unnatural and are harmful. And those who sur- round her should likeAvise be instructed, if necessary, to treat her with the utmost kindness and consideration. If these conditions are not fulfilled, it is possible for the homceopathically selected medicine to effect a cure; but there can be no doubt that its effects will be poAver- fully aided by a proper attention to mental discipline and hygiene on the part of the patient, and a proper degree of kindness, yet withal firmness, on the part of her friends. In concluding the general subject of disorders incident to preg- nancy, it may be proper to remark— I. "While pregnancy serves in many cases to develop in some form —physical, mental or emotional—whatever latent tendency to disease had existed in the system, it does not render the body more liable to be attacked by external diseases; and in some instances, as is often seen in the phthisis of those enceinte, it actually retards the develop- ment and prevents the fatal termination of pre-existing disorders until after delivery. II. The disorders of the mental and moral or emotional and affec- tional spheres Avhich so often accompany pregnancy will ahvays speedily disappear with the successful delivery of the child, unless based upon and representative of some profound constitutional dys- crasia. In this latter case such affections not only tend to perpetuate themselves after parturition, but to become developed in puerperal mama, and even ultimated in some malignant form of bodily disease. 384 THERAPEUTICS OF LABOR. CHAPTER XVIII. THERAPEUTICS OF LABOR. The Pains of Labor. PAINS ceasing.—1. Bell., Kali c, Op., Puis., Sec. corn. 2. Cham., Natr. m., Nux v., Ruta, Sep. 3. Arn., Bor., Camph., Carb. veg., Chin., Coca, Graph., Ignat., Lye, Magn. m., Nux v., Plat., Sulph., Thuy. ------ distressing.—1. Cham., Gelsem., Kali c., Sep. 2. Aur., Bell., Coffi, Con., Lye, Nux v., Sec. corn. ------spasmodic.—1. Cham., Gelsem., Hyos., Puis. 2. Bell., Coca, Cupr. m., Ipec, Nux v., Sep. ------too weak.—1. Bell., Cann., Cauloph., Cimicif., Gelsem., Kali c, Op., Puis., Sec. corn. 2. Cham., Natr. m., Nux v., Ruta, Sep. 3. Arn., Bor., Camph., Carbo veg., Chin., Cocc, Graph., Ignat., Lye, Magn. m., Nux m., Plat., Sulph., Thuy. ------too strong.—Bell., Cham., Coff., Con., Nux v., Puis., Sec. corn. Aconitum. Great distress, moaning and restlessness during every pain. She fears that she will not be delivered, that she will die, or that something will certainly go wrong. The vulva, vagina and os are dry, tender and undilatable. Arnica. With each pain there is great flushing of the face and heat of the head, Avhile the rest of the body may be cool. The pains are so violent as to drive her almost distracted, yet little good is accom- plished. Frequent desire to change position. She feels unaccount- ably sore and bruised in any position. The pains are very feeble, Avith a desire to change the position frequently. Aurum. The pains make her desperate, so that she would like to jump out of the window or dash herself doAvn; with congestion to the head and chest and palpitation of the heart. Belladonna. The pains come on suddenly, and disappear after a time as suddenly as they came. Spasmodic contractions of the os, which is hot, dry and tender. Very red face and injected eyeballs, with pain ; labor slow and tedious. Throbbing headache, Avith great sen- sibility to light and noise. The os uteri does not dilate readily in proportion to the pains. Borax. The pains are accompanied by violent and frequent eructa- THE PAINS OF LABOR. 385 tions. She fears a doAvmvard motion. She is very sensitive to the slightest noise, as the rumpling of paper, fall of the door-latch, etc. Chamomilla. Her pains are spasmodic and distressing. She can hardly bear them; she Avishes to get away from them. She is very fretful, peevish and cross; can't return a civil answer. Tearing pains down the legs. She is spiteful, or shrieks out sharply. Camphor. Her pains have ceased, and her skin is cold, dry and shrunken; she does not like to be covered, and is restless. Cam- phor200, or higher, will Avarm the patient, restore the pains, and, other things being equal, produce spontaneous delivery. Caulophyllum. Extraordinary rigidity of the os uteri. Spasmodic and severe pains, without progress being made. The pains become very weak and flagging from exhaustion, on account of the long con- tinuance of the labor. Thirst and feverishness. False pains. Causticum. She complains mostly in her back of a sore, distressing pain. ^ Her suffering is principally in the back. When the unnatural condition of the pains is attributable to debility from night-Avatching, grief, or other depressing influence. Carbo veg. The pains are too weak, or cease from great debility. Particularly indicated Avhere there is a varicose condition of the vulva, or when there has been a great loss of animal fluids, or the woman is laboring under the debilitating effects of previous or existing disease. China. Where much blood has been lost or there have been fainting fits, convulsions, etc. Cessation of pains from the loss of blood, a pro- tracted diarrhoea, etc.; her skin may even be cold and blue. She can't bear to be touched during the pains, not even on her hands. Cimicifuga. The Avoman complains that the pains do not seem to be located properly to effect expulsion, but they are of a tearing and distressing character. Suitable to women of a rheumatic tend- ency. The pains are very violent and spasmodic, and there is great nervous excitement. Cocculus. Her pains are of a spasmodic, irregular and paralytic character. She will have one hard one, and then, after a longer in- terval, several light ones, etc. Much headache. Numb or paralyzed feeling of the loAver limbs. Coffea. Labor-pains insupportable to her feelings; she feels them intensely, weeps and laments fearfully. Although the pains are severe they are not efficacious. Comum. If there are scirrhosities in either the breasts or uterus and abor does not progress normally—pains spasmodic; vertigo, particu- larly on turning in bed; rigidity of os uteri. 386 THERAPEUTICS OF LABOR. Cuprum. Violent spasmodic pains appearing at irregular intervals, often Avith violent cramps in the lower extremities, or the cramps may be confined to the fingers and toes. Great restlessness between the pains. Gelseminum. Cutting pains in the abdomen from before backward and upAvard, rendering the labor-pains useless; these come on with every pain. These pains are very distressing, and may be felt throughout the abdomen. Gossypium. In cases of lingering almost painless labors, Avhere the uterine contractions are entirely inefficient. The case presents nega- tive rather than positive symptoms. Graphites. In large and corpulent women of venous constitution, Avho are subject to tettery eruptions, which itch and emit a glutinous fluid. The pains are weak or have ceased entirely. Hyoscyamus. There is delirium, startings and jerks in various parts of the body, in the face, eyelids, and sometimes all over. Ignatia. Deep sighs and sadness; she must take a deep breath in order to breathe at all. The labor does not progress. Ipecacuanha. One constant sense of nausea, not a moment's relief. The pains are distressing by reason of a sharp cutting about the um- bilicus, which darts off toward the uterus; this distress hinders the proper action of the uterus. Kali C The pains begin in the back, and instead of coming round in front like a regular pain, pass off down the buttocks or the glutsei muscles; or they are sharp and cutting across the lumbar region, arresting contractions. She is sometimes greatly disturbed by sharp stitching pains. Lycopodium. During the paroxysms of her pain she is obliged to keep in constant motion, Avith weeping and lamenting; there may be even spasmodic contraction of the os, Avith the above symptoms. She finds relief by placing one foot against a support and pressing and relaxing alternately, so as to agitate her Avhole body. Magnesia m. The labor-pains are interrupted by hysterical spasms. (See Hysteria, same remedy.) Natrum c. Anguish, tremor and perspiration with every pain, during which she desires to be gently rubbed; this rubbing affords relief. Natrum m. Very, very sad and foreboding—so much so that labor goes on very slowly, from feeble pains. Nux m. She is very drowsy, sleepy and disposed to fainting spells, the pains being correspondingly slow and feeble, or quite suppressed. THE PAINS OF LABOR. 387 Nux v. Every pain causes an inclination to go to stool or to urinate. Every pain causes fainting, and thereby interrupts the progress of the labor. Retarded and painful labor in women accustomed to a seden- tary life, and to those accustomed to high living and an inactive, in- dolent life. Opium. The pains have been suppressed by fear or fright. She is in a soporous condition, with red face, injected eyes and stertorous breathing, and there is twitching and jerking of the muscles. Phosphorus. Tall and slender Avomen of phthisical diathesis, the pains being distressing and of but little use. Very weak and empty feeling in the abdomen, sometimes with cutting pains. Platina. The contractions are interrupted OAving to the very painful sensitiveness of the vagina and external genitals. Very painful though ineffectual, spasmodic labor-pains. Pulsatilla. Suitable to mild, tearful Avomen, who are in an appar- ently healthy condition, yet the uterus seems almost inactive. The pains excite palpitation, suffocating and fainting spells, unless the doors and windows are Avide open; she feels that she must have them open, as she wishes for cool, fresh air. Absence of thirst, Labor progresses very slowly. Ruta. General lameness and soreness all over, with weak, feeble contractions. Secale c. Particularly in weak, cachectic women, or in women de- bilitated from venous haemorrhages. In such cases it is particularly efficacious for weak, suppressed or distressing pains. By far the best is the m, or higher. Fainting fits in such cases, small or suppressed pulse. Sepia. Shuddering attends the pains, and she rather wants to be covered up more, because she can bear the pains easier. Indura- tions are felt upon the neck of the uterus. Shooting pains in the neck, extending upward. Spasmodic contractions of the os in these cases. Stannum. The pains seem to exhaust her very much, and make her speech difficult from weakness in the chest. She cannot answer ques- tions; she is all out of breath ; the labor does not progress. Sulphur. She has flushes of heat, frequent weak and fainty spells wants more air. Cold feet, heat on top of head. Thuya. In some cases of complication Avith syphilis, Avhich hin- ders the proper contractility, this remedy will do much good imme- diately. Veratrum. The pains are accompanied Avith cold sweat, particularly 388 THERAPEUTICS OF LABOR. on.the forehead, fainting on the least motion, the pains exhaust her much, and she feels completely done over after every pain. Rigidity of the Os Uteri. Where rigidity of the os uteri in labor depends on organic lesions of the cervical tissues the treatment to be resorted to is laid down on page 236. But Avhere, as is commonly the case, the rigidity or spas- modic contraction is due to mere functional disturbance, one of the following remedies Avill be found to be sufficient to produce a gradual relaxation and dilatation. Bigidity of the vaginal walls, dependent on a similar cause, may likewise be removed by the same remedies. Aconite. When there is great dryness of the vagina; much moan- ing, restlessness, feeling of discouragement; fears she will not do well; the parts feel contracted, rigid and undilatable. Aconite, in Avater, every half hour till better. Belladonna. There is heat of the parts,, with great tenderness; moan- ing; flushed face; injected sclerotica; throbbing of the carotids; all her motions are quick; pains come suddenly and disappear suddenly. Caulophyllum. The pain is spasmodic; it appears in various parts of the abdomen; patient seems much exhausted and the pains very inefficient. Chamomilla. Where there is great irritability of a spiteful nature; she seems scarcely able to bear the pains; she moans, laments, calls for assistance, sometimes screams outr and the pains appear as if too severe to be endured. Cimicifuga. The pains seem intensely severe, but spasmodic and in- effective. The patient is of a rheumatic diathesis and subject to rheu- matic pains. Gelseminum. The pain extends, in the abdomen, from before back- ward and upward; this pain is a false pain, and is so severe as to in- terrupt the true labor-pain. The Za&or-pain seems utterly inefficient. The pain is sometimes cramping in various parts of the abdomen. The os is rounded and hard, and feels as though it Avould not dilate. Lobelia inflata. When the respiratory organs sympathize in the trouble, as in violent dyspnoea, with every uterine contraction, Avhich seems to neutralize the pain. Any remedy in the Materia Medica may be useful in these cases, as the rigidity or contraction is but the result of some morbific influence working upon the system; therefore see remedies for difficult labor. HOUR-GLASS CONTRACTIONS. 389 Hour-Glass Contractions. (See page 202.) The medicines most suitable for this condition are: Belladonna Chamomilla, Kali carb., Platina, Secale cornutum and Sepia. Next best: Cocculus indicus, Conium, Cuprum ars., Hyoscyamus Nux vomica, Pulsatilla, Rhus tox, Sulphur. Belladonna. Almost constant moaning, which seems to afford relief; injected eyeballs; flushed face; can't bear light or noise; pulse full and bounding; very hot skin. Chamomilla. Distress Avhich it seems she can hardly endure; a spite- ful irritability; thirst; desires fresh air; restless; more or less dis- charge of dark blood from the vagina. Cocculus indicus. Terrible pain in the small of the back; lower limbs feel paralyzed; frequent vomiting. Conium. Great vertigo Avhen turning the head; very sensitive across the abdomen. Cuprum. Violent and distressing cramps in the uterine region; cramps in the extremities, hands and feet. Hyoscyamus. Delirium; jerking and twitching of muscles; bluish color of the face. Kali carb. Distressing pain in the back, running down into the glutsei muscles; stitching pain in the abdomen; abdomen bloated with wind; restlessness and thirst. Nux vomica. Sore aching pain in the region of the uterus; a very frequent inclination to stool; great mental depression and nervous irritability. Platina. Very great sensitiveness of the organs; severe cramping pains in the region of the uterus; constant oozing of dark, grumous blood from the vagina. Pulsatilla. In very mild, tearful women; desires fresh air; very rest- less ; absence of thirst. Rhus tox. Occasional paroxysms of pains extending doAvn the pos- terior surface of the limbs; restless, with relief after every change of position; must change frequently. Secale cornutum. A sensation of a constant tonic pressure in the uterine region; this causes great distress; wishes fresh air; don't like to be covered much. Sepia. Numerous little darting pains, shooting upAvard from the neck of the uterus; flushes of heat; cold feet. Sulphur. Frequent weak and fainty spells; Avishes to be fanned; flushes of heat and cold feet. 390 therapeutics of labor. In the preceding cases the remedy should be repeated every fifteen minutes or half an hour till improvement sets in. Fainting, Swooning, Syncope. These are synonymous terms, but perhaps syncope represents the complete stage of SAVOoning. In treating this abnormal manifestation much will depend upon the correct observation of the practitioner, and much care is needed that a proper prescription be made. If the patient is not already lying doAvn, she should be placed in that position, and an abundant quantity of fresh air should be allowed to enter the room. All applications are usually injurious, excepting perhaps a little cold water applied to the face by sprinkling or gentle bathing. The homoeopathic remedy is the safest dependence. The remedies herewith mentioned are suitable for attacks of syncope occurring before, during or after parturition: Aconite. When there is violent palpitation of the heart; congestion of blood to the head; buzzing in the ears; pale face on assuming an erect position from the recumbent; after a fright. Arnica. From injuries of any kind; from fatigue; from stitches about the heart; when the head is very hot and the body cool. Arsenicum. Result of debility or prostration, when the least effort causes fainting; thirst for frequent sips of cold water; wishes to be wrapped up warmly; pale bloating of the face. Carbo vegetabilis. Fainting from weakness caused by loss of animal fluids; after sleeping; after rising in the morning; much belching of wind or eructations. Chamomilla. Where there is great irritability of a spiteful kind; she is very sensitive to the pains, which cause fainting, with vertigo, dimness of vision, dullness of hearing and nausea; must have fresh air and fresh water. China. After loss of blood particularly or other animal fluids, with ringing in the ears, coldness of the skin, loss of pulse, and cold perspiration. Coffea. In highly sensitive persons after a fright, if aconite fails. Digitalis. Where the pulse is very slow and irregular; cold sweat; deathlike appearance of the countenance. Nux vomica. As the result of over-indulgence, as from over-eating, etc.; after vomiting; after every labor-pain; after stool; with con- gestion of the blood to head or chest, with trembling. weakness, debility, exhaustion. 391 Ignatia. When the fainting seems to result from grief; much trembling; sighing and sobbing. Sepia. Feet and hands cold as ice; flushes of heat; a distressed empty feeling in pit of stomach. Stramonium. Fainting spells occurring every day or several times a day; the person suddenly falls, with pale face and almost insensible breathing; sometimes face is bloated red; the fainting may continue a long time. Veratrum album. Fainting from the slightest exertion, turning in bed, straining at stool, retching as if to vomit, etc.; cold SAveat upon the forehead. Bryonia. When the fainting fits occur from the least motion, even Avhen no effort is required; sighing respiration; thirst for cold water. Camphor. Where there is a marble coldness of the surface of the whole body; very weak pulse. Cocculus indicus. Paralyzed feeling in all the limbs, with trembling; paralytic weakness, particularly in the lower extremities; spasmodic pains in the uterus, Avith nausea and vomiting. Lachesis. Fainting fits, Avith great and almost unconquerable sadness and gloom; dreads society and company; great and persistent consti- pation, Avith a sensation as though the anus Avere closed. In all these cases during the attack it is better to administer the remedies every five or ten minutes till consciousness is restored, and then wait for the next attack. Weakness, Debility, Exhaustion. Arsenicum. From any cause Avhen there is sense of great exhaustion after every effort, however small; chilly, wants to be Avrapped Avarmly; cold water disagrees; waxy paleness of skin; may be bloated; going up stairs is very exhausting; great restlessness, particularly after tAvelve o'clock at night. Calcarea carbonica. In leuco-phlegmatic temperaments; much per- spiration about head and upper part of body; every exertion is fatig- uing; ascending causes vertigo; cold, damp, clammy feet; the least cold air is almost unendurable. China. Particularly Avhen haemorrhages or loss of animal fluids are the cause; ringing in the ears like bells; vertigo; cold perspiration; feeble pulse; almost insensibility. Ferrum. Frequent attacks of tremor, alternating with a sensation of weaknesses if very weary; trembling of the whole body; feeling 392 THERAPEUTICS of labor. very weak; feels very Aveak even from talking; Avishes to lie do#n; face and lips very pale, or the cheeks may be fiery red. Iodine. Pulsation in all the arteries at every muscular effort; great prostration of strength, so that even talking causes perspiration; the sensibility of the nervous system is greatly increased. Kali carb. When one feels the pulsation of all the arteries even doAvn to the tips of the toes; feeling of emptiness in the Avhole body, as if the body Avere hollow; the whole body feels heavy and broken doAvn, so that it is only Avith the greatest effort that one can make any exertion. Lycopodium. When lying in bed she feels as if she would die from weakness; the loAver jaAv drops, not being able to keep the mouth shut; the breathing is slow and through the mouth; the eyes half open; Avhen walking she is obliged to let her hands hang down, and the bones of her lower extremities are painful; sudden weakness com- ing on even Avhen sitting; red sand in the urine; flatulency. Muriatic acid. Great debility, with hsemorrhoids so sensitive they can hardly be touched, and they often bleed; so weak cannot lie up on the pilloAV, but constantly slides doAvn into the bed. Nux vomica. Debility from abuse of coffee, wine, spirituous liquors or narcotic substances, from the abuse of highly seasoned food; night-Avatching; cannot walk on account of giving out of lower ex- tremities; knees knock together; wishes to lie doAvn all the time; cannot sleep Avell after three o'clock in the morning; great sensitive- ness to external impressions, noise, talking, strong scents and odors, or bright light; trifling ailments affect her almost beyond measure; blue margin around the eyes; nose looks sharper and more pointed than usual; the face shrunken. Rhus tox. Restlessness characterizes the use of this medicine; she is very restless, and is ahvays relieved for a short time by a change of position, Avhen she must move again; loss of appetite; cold Avater disagrees. Sepia. Sepia debility is usually characterized by a painful sensation of emptiness at the pit of the stomach; icy coldness of feet and hands; urine deposits a very hard, crusty sediment; flushes of heat; loss of appetite. Stannum. Characterized by great sense of weakness in the larynx and chest, thence all over the body, from talking or reading aloud. Sulphur. Weak, fainting spells coming frequently during the day; feels very faint and Aveak from eleven to tAvelve every morning; flushes of heat; cold feet; heat on top of the head. HAEMORRHAGE. 393 Veratrum. Excessive Aveakness; is obliged to move very slowly; so weak she can hardly raise her hand, and every motion seems to in- crease the debility; even a movement of the boAvels causes great de- bility ; very Aveak, almost imperceptible pulse; cold SAveat, particularly on the forehead; thirst for icy cold water. The above treatment, it need hardly be remarked, is suited not only to the Aveakness which sometimes manifests itself during the progress of labor, especially of tedious labor, but as well when occurring either during pregnancy or after parturition, or, in fact, at any other period of the woman's life. CHAPTER XIX. HEMORRHAGE. rjIHE haemorrhage that may occur in non-pregnant women will -L hereafter be considered under the head of Metrorrhagia, Avhile that which arises during the earlier months of pregnancy will be dis- cussed in connection with Abortion, in which it tends to result. Puerperal haemorrhage, our present theme, includes the flooding which occurs during the latter months of pregnancy, just previous to parturi- tion, during its progress or subsequent to the delivery of the child. No complication of labor is more justly dreaded by the practitioner, since there is none capable of proving more rapidly fatal unless promptly arrested. Nor indeed can this indispensable result be pro- duced unless the physician so completely retains his presence of mind in the most trying moments as to be able to ascertain the cause of the mischief, institute the requisite procedure where direct interference is needed, and select the proper medicaments Avhen operative interfer- ence is not called for. Fortunately, uterine haemorrhage is not a fre- quent complication of pregnancy and parturition. According to Churchill, out of 170,221 cases, haemorrhage occurred 1370 times, or nearly 1 in 124. The mortality of mothers and children is in frightful proportion, however, to the number of cases, for, according to the same author, out of 782 cases, 126 mothers died, or about 1 in 6; while of 944 cases, 288 children perished, or about 1 in 3. These results occurred in cases treated by practitioners who knew nothing of the efficacy of medicines applied homceopathically for controlling 394 HAEMORRHAGE. haemorrhage. The extent of the modifying effect homoeopathic treatment has upon the mortality of mothers and children in these cases is truly Avonderful and diminishes fatal cases almost to none at all. It may be laid doAvn as a general proposition that nearly all forms of hsemorrhage connected with child-bearing are due to a partial separation of the placenta, by which the utero-placental vessels are torn and their uterine orifices left patulous through the non-contraction of the uterine muscular fibres. (Post-partum haemorrhage, either before or after the expulsion of the placenta, may depend upon a variety of causes other than that just stated.) When hsemorrhage occurs before or during deli\rery it is due either to an accidental separation of the placenta, which may be properly im- planted at the fundus of the uterus, or to an unavoidable separation, in consequence of its being unnaturally located at the cervical extremity of the uterus and implanted more or less centrally over the os, so that the placenta beyond a certain point cannot grow nor the uterus ex- pand, nor can delivery be effected Avithout a more or less extensive separation of the placenta. From these circumstances haemorrhages occurring before or during labor ha\re been termed Accidental and Unavoidable. Accidental Haemorrhage. This form of hsemorrhage occurs when from any cause the placenta becomes partially detached from the uterine Avail; and generally the danger is proportionate to the extent of the detachment, though this is not always the case, for a fatal result may follow a slight separa- tion. The flow of blood may show itself externally if there be room for it to descend betAveen the uterus and the epichorion, and generally this is the case; or, on the other hand, it may be concealed, going on insidiously even to a fatal extent, and can only be known by its effects upon the system. The usual causes of this separation of the placenta are—shocks or bloAvs or violence of any kind, fatigue, over-exertion, straining from lifting or reaching, jolting in a carriage or on a rail- road, etc. It may likewise be produced by mental emotions, which, by exciting uterine action, may produce a separation of the placenta. In some constitutions, plethoric or susceptible, the slightest influences suffice to bring on the detachment and hsemorrhage, and in certain cases it seems to arise, as it were, spontaneously and without traceable cause during the course of labor. And again, there appears in some ACCIDENTAL HAEMORRHAGE. 395 cases to be an acquired tendency to accidental hsemorrhage, which the history of the case reveals to the practitioner. When the Aoav of blood is external the case is plain enough, and even Avhen the hsemorrhage is concealed its effects are so pronounced that a diagnosis is easily made. The most marked and characteristic symptoms are—acute pain, which occurs at the seat of injury, gener- ally the fundus; collapse ; great distension of the fundus of the uterus. In addition to these there may be rigors, tension and sensation of weight and fullness in the abdomen, and fainting. The pulse will be quick and feeble, and if the loss t of blood be considerable there will be pallor of countenance, great agitation, partial or total blindness, noises in the ears or complete deafness. In an article on " Concealed Accidental Haemorrhage " in the Amer- ican Journal of Obstetrics, August, 1869, Dr. William Goodell of Philadelphia gives the histories of one hundred and six cases. From this article Ave quote a portion of his summing up of the most marked indications of the occurrence of this unfortunate complication : " An analysis of the foregoing one hundred and six tabulated cases shows that by far the most frequent symptom is an alarming state of collapse, carrying dismay into the heart of the bystander. Every de- tailed example, without exception, presents most of its characteristics, such as coldness of the surface, excessive pallor, feebleness of the pulse, yaAvns, sighs, dyspnoea, restlessness and retching. "Pain holds the second rank in frequency. Out of these cases, sixty-four exhibit every grade of suffering, from the ' queerish feeling' to the 'greatest torture' and 'agonizing shrieks.' ... In the great majority the pain Avas referred to the site of the placenta, and Avas of a bursting character. . . . "The third most constant symptom is the absence or extreme feeble- ness of the pains of labor. Of the former, twenty-eight examples are tabulated, of the latter, fifty-six; but of these the majority presented no labor-pains until the membranes Avere ruptured, either naturally or artificially. In only twelve were the pains normal from the outset. "Next folloAvs a marked distension of the uterus, which produces those painful sensations of ' bursting,' that burden of every cry of the sufferer. Out of the one hundred and six examples, forty-tAvo presented this symptom, although not ahvays recognized during the life of the patient. . . . " V ery often, before the lapse of many hours, a show of blood, rang- ing from an ooze to a gush, will clear up all obscurity; but this trust- worthy symptom does not usually occur at the outset of the attack, 396 HAEMORRHAGE. but at a time Avhen it may be too late to interfere. A diagnosis should not, therefore, depend upon its presence, but simply be affirmed by it." The occurrence of such grave symptoms as these during the course of a labor should always excite strong suspicion of internal haemor- rhage ; and if there be a history of a fall, a bloAV, or any other me- chanical injury having been inflicted, the diagnosis is strongly con- firmed. Should accidental hsemorrhage occur during the progress of labor, and the pains are not arrested thereby, it will be noticed that during a pain the flow nearly or entirely ceases, in consequence of the closure of the mouths of the bleeding vessels by that natural hsemostatic uterine contraction. The opposite of this is the case in unavoidable hsemorrhage (placenta prsevia), where the floAV occurs during a pain and nearly or entirely ceases during the intervals. The diagnosis of accidental from unavoidable hemorrhage is essential to its proper treatment, and it may be determined by means of the following distinctions: I. Accidental hsemorrhage before labor or during its progress usually results from some definite and ascertainable cause, such as mechanical injury, while in placenta prsevia there is no such history, and the Aoav of blood commences, as it were, spontaneously, perhaps while the Avoman is at perfect rest or asleep in bed. II. In accidental hsemorrhage the discharge takes place freely in the intervals between the pains, and is arrested during the continuance of the pains ; Avhile in unavoidable hsemorrhage from placenta prse- via the conditions are exactly opposite, the flow occurring during the pain, Avhich expands the os uteri. III. In accidental hsemorrhage the os uteri is free, and closed by the membranes only, which may be tense or flaccid, and the presenting part of the fcetus may be made out by the finger; while in placenta prsevia the placenta, as a soft, spongy mass, may be detected Avithm the os, and in all probability the presenting part of the fcetus cannot be touched or made out. IV. In cases in Avhich accidental hsemorrhage occurs the lips of the os Avill not have more than their usual thickness; Avhile in placenta prsevia they will be thick, and active pulsation will be strongly marked. V. " In accidental hsemorrhage the blood, before being discharged, having to find its way some distance to the os, deposits its fibrin, so that coagulation does not occur in the vagina, which is free from clots; whereas the blood in placenta prsevia comes directly from the uterine ACCIDENTAL HAEMORRHAGE. 397 or placental vessels, or both, into the vagina, and is there discharged as blood, leaving coagulations behind in the vagina." * The treatment of cases of accidental hsemorrhage must be directed entirely by the circumstances of each case. If the woman has not advanced to full term and the hsemorrhage is slight, Avhich may be known by its effects upon the system, there is reason for believing that placental detachment has not taken place to any great extent. In such a case, by perfect rest in the recumbent posture, the allaying of all excitement or anxiety, cool drinks, and the administration of the appropriate and homoeopathic medicaments, the hsemorrhage may be arrested, and the Avoman delivered at term without any further untoward circumstances arising. At the close of this chapter the medicines appropriate in all cases of uterine haemorrhage are given, with their indications in detail; and to these remedies the reader is referred. The nicest discrimination is needed in effecting a proper selection of the remedy, and when the truly homoeopathic remedy has been selected in accordance with the totality of symptoms, subjective and objective, the practitioner will often be surprised by the happiest results in A^ery gloomy cases. The use of plugs of any kind, or the resort to other mechanical measures in such cases, will almost cer- tainly bring on labor. Even in the Avorst cases of accidental hsemorrhage a fair trial should be given to the homceopathically indicated medicament before proceeding to operate interference; this being Avarranted by the well-ascertained hsemostatic power of such specific medication, and by the success which has attended such efforts. In cases, hoAvever, where the flooding is very great, the danger is imminent, the woman is at her full term and the hamiorrhage is accom- panied with pains; or, again, in the above-described milder cases, where the measures recommended have failed, and labor has come on sponta- neously or in consequence of the irritation produced by plugging the vagina, the object of treatment must be to bring on labor, to induce uterine contractions, and to secure the expulsion of the child. These indications will be best fulfilled by rupturing the membranes, by which means the bulk of the uterus is diminished by the evacuation of the hquor amnii, its walls more effectually contract upon the placenta, at least temporarily arresting the Aoav from the uterine sinuses, and at the same time facilitating the expulsion of the foetus. This being done, a period of rest should be allowed to the patient, giving her time to rally, and at the same time giving opportunity to the natural * Dr. Calthrop, in Braithwaite's Retrospect. 398 HAEMORRHAGE. forces to complete the labor; and if dilatation of the os uteri pro- gresses and expulsive pains come on and increase, the case should be left Avithout further interference. Should the os be dilating naturally though slowly, and the flow be great, the vagina may be plugged if medicine fails to arrest the hsemorrhage Avhile the dilatation is com- pleted. Should the pains be feeble and the os not dilating, remedies suited to the existing condition in these respects must be selected- remedies Avhich will render available such desultory and inefficient pains as may be present. If, however, the case is such as to demand prompt delivery to secure safety for the mother, and the os fails to dilate, Barnes' dilators must be used for the purpose of effecting dilatation; and when that has been sufficiently accomplished labor may be completed by the long forceps, by podalic version or the bimanual mode of turning, according to circumstances. After the delivery of the fcetus, which is generally born dead in consequence of the collapse of the mother, the placenta usually comes aAvay as in ordinary cases; if it does not, the course of treatment to be pursued will be similar to that laid down for retained placenta under other circumstances. The after-treatment of the woman must be conducted with the utmost care, in order to secure a reaction of the vital forces. The remedy homoeopathic to her deplorable condition should be chosen, and such a remedy may be found in China or some other medicament mentioned hereafter. Unavoidable Haemorrhage—Placenta Previa. Placenta prsevia occurs when the ovule has descended after concep- tion, and has become fixed to some spot in the loAver part or cervical region of the uterus, so that the placenta becomes developed very near the internal os, overlaps a portion of it, or covers it completely, centre for centre. Such malposition of the placenta is by no means of fre- quent occurrence, happening about once out of every five hundred cases. In cases where the placenta is thus, misplaced, it is obvious that, as the uterus develops from above downward to the internal os, the dis- proportion betAveen the rapidly developing placenta and the slowly developing cervical region must become greater and greater, and about the sixth month it is very considerable: hence a rupture or de- tachment usually takes place at this period of pregnancy, and haemor- rhage—unavoidable hsemorrhage—occurs, more or less abundantly, and is repeated from time to time. UNAVOIDABLE HAEMORRHAGE—PLACENTA PRAEVIA. 399 In explanation of the phenomena Avhich occur in cases of pramal implantation of the placenta, Dr. Robert Barnes writes thus lucidly: " The inner surface of the uterus may be divided into three zones or regions by two latitudinal circles. The upper circle may be called the upper polar circle. Above this is the fundus of the uterus. This is the seat of fundal placenta, the most natural position. It is the zone or region of safe attachment. The lower circle is the lower polar circle. It divides the cervical zone or region from the merid- ional zone. The meridional space comprised between the two circles is the region of lateral placenta. This placenta is not liable to pre- vious detachments. Attachment here may, however, cause obliquity of the uterus, oblique position of the child, lingering labor, and dis- pose to retention of the placenta and post-partum hsemorrhage. " Below the lower circle is the cervical zone, the region of danger- ous placental attachment. All placenta fixed here, whether it consist in a flap encroaching downward from the meridional zone, or whether it be the entire placenta, is liable to previous detachment. The mouth of the womb must open to give passage to the child. This open- ing, which implies retraction or shortening of the cervical zone, is incompatible with the preservation of the adhesion of the placenta within its scope. In every other part of the womb there is an easy relation betAveen the contractile limits of the muscular structure and that of the cohering placenta. Within the cervical region this relation is lost. The diminution in surface of the uterine tissue is in excess. " The lower polar circle is, then, the physiological line of demarca- tion between prsevial and lateral placenta. It is the boundary-line below which you have spontaneous placental detachment and hsemor- rhage; above which, spontaneous placental detachment and hsemor- rhage cease." Haemorrhage seldom occurs until after the sixth month, and then comes on suddenly, Avithout admonition or apparent provoking cause. The flow may commence while the woman is sleeping, sitting at her sewing, at the piano, or elsewhere, and will as suddenly cease. The first hsemorrhage is not apt to be so profuse as subsequent attacks, and as a general rule the nearer the Avoman is to full term the greater will be the discharge. " The suddenness of the attack, the profuse- ness of the discharge, and its coming on without any evident cause, are peculiarly suspicious." In a longer or shorter period after the nrst attack the hsemorrhage is repeated, and is liable to become more and more profuse at every attack; for the disproportion between the 400 . HAEMORRHAGE. placenta and the de\relopment of the loAver segment of the uterus be- comes greater and greater as the time for delivery approaches. When these haemorrhages occur prior to the eighth month, and sub- side spontaneously Avithout bringing on labor or doing serious damage to the system of the mother, the best treatment is to keep the patient as quiet as possible and to prescribe such medicines as seem to be in- dicated by her symptoms. This course may be pursued from time to time till the arrest of the hsemorrhage or the prevention of labor seems no longer possible. Indeed, if from the first the hsemorrhage is great, and the mother is reduced to so miserable a condition that it would seem unadvisable and almost impossible for her to go to full term, labor may be induced as the best procedure. " It may be laid down as a rule of general application, and one which ought to be rigidly observed, that, no matter Avhat the period of gestation, any large loss of blood demands the termination of preg- nancy; for to leave a patient to be subjected to another attack, coming on, as it Avould do, without any warning, is in truth to place her life in imminent danger. The only justifiable ground for a temporizing policy is the concurrence of the folloAving conditions—that the dis- charge is slight, the period of pregnancy short of six months, the absence of pain, and an undilated os. If, on the contrary, the dis- charge is excessive, that alone justifies interference; and if at the same time there is pain, the result of uterine contraction, and the os is beginning to dilate, so much the better, as the chance of a speedy delivery is greater; but if the two latter conditions are not present, the chief object of our treatment will be to secure them."—Meadows. On making an examination per vaginam, the finger passed into the open os will detect the presence of a thick, soft, spongy mass, having the feel of a clot of blood, but with more firmness and consistence, quite unlike the smooth surface of the membranes, and blocking up the entrance to the uterus. It may be judged that the placenta in such a case is centrally implanted over the os uteri. If the placenta but partially cover the os uteri, then only one lip or side Avill be thickened ; and the condition will be shoAvn by the inability to carry the finger up within the uterus on that side, and by the ability to carry it up on the other side, and to feel there the smooth membranes or the presenting part of the child. If labor has set in, and there are pains, the haemorrhage will ahvays be Avorse during the pains, and will lessen or cease when they subside. The cause of this circumstance is as fol- lows : The object of the pain, or contraction of the uterus, is to dilate the os, so as to complete the first stage of labor; and of course the UNAVOIDABLE HAEMORRHAGE—PLACENTA PRAEVIA. 401 more the os dilates the more its adhesions with the placenta will be broken up; and as it cannot expel a bag of membrane full of water so the greater the pains the greater the hsemorrhage during their continuance. By far the best method of treating such cases—of lessening the haemorrhage and causing it to cease, of securing uterine contractions, and of bringing about dilatation of the os uteri—consists, in my opin- ion, in puncturing the membranes through the placenta and evacuating the liquor amnii. By this means the bulk of the uterus is lessened ; it contracts upon itself, and the haemorrhage is controlled. As the con- tractions take place, the os is dilated Avithout tearing up the adhesions of the placenta. And as dilatation is effected the placenta separates between its cotyledons, and the presenting portion of the child is per- mitted to pass through it. The placenta itself is finally delivered after the birth of the child, as in ordinary cases. The method of operating is as folloAA's: The finger must explore a sulcus between the cotyledons of the placenta, and with the same hand a female catheter, previously concealed in the palm, must be forced through the placenta and the membranes during a pain. The liquor amnii now passes off freely through the catheter; the bulk of the uterus begins at once to shrink and the hsemorrhage ceases. The finger may be used instead of a catheter, but much care is needed in this event, in order that the Avaters do not discharge themselves too rapidly, and thus produce atony from too sudden relief, for then the haemorrhage would not cease. The liquor amnii must drain off slowly; and as surely as it thus Aoavs, so surely will the hsemorrhage cease. After the waters have pretty much escaped, the finger may take the place of the catheter and aid in tearing the orifice larger, so that the presenting part can descend. Should the presenting part be the head, which is not always the case, its engagement in the os acts as a plug against any possible flow of blood, and gives further security if any is needed. If the shoulder is found presenting, or there be any other malpresentation, the case must then be treated in accordance with the directions laid down for such cases occurring under other circumstances. I have not heard of a single case of loss of the mother Avhere this method of procedure has been followed, and the child is almost in- variably saved. It must be remembered to evacuate the liquor amnii very slowly. Every accoucheur knows what bad effects follow the emptying of the uterus rapidly under such circumstances ; the atony thereby produced is more to be dreaded than the former state. When 26 402 HAEMORRHAGE. the placenta is only partially over the os, even if it be but the edg< of it, the same principle and practice hold good. Almost invariably after placenta prsevia has been thus treated the os uteri dilates in a natural manner, until it is sufficiently enlarged to admit of the passage of the child. Sli mid, however, a case occur in Avhich dilatation does not take place, Barnes' dilators may be used to effect dilatation, provided the homoeopathic remedy carefully chosen fails of its purpose. Some obstetricians have recommended, in cases of placenta praevia, that the hand be insinuated between the placenta and the uterus, the membranes reached and penetrated, and the child delivered by turn- ing. This is especially taught in cases where the placenta is placed centrally over the os. The suffering entailed upon the woman by this method, and the very great mortality of both mothers and children following its practice, sufficiently condemn it. Another plan of treatment has been recommended, especially by Sir James Simpson—namely, that of separating the placenta from the uterus entirely, and then trusting the case to nature. This procedure doubtless was suggested by the fact that in cases of placenta praevia, Avhere the placenta was spontaneously cast off and expelled previous to the expulsion of the child, the rate of mortality of mothers and children was less than under the ordinary methods resorted to by accoucheurs. In regard to this method Dr. Robert Barnes very justly remarks as follows: " But it is contended that clinical ob- servations prove that hsemorrhage has stopped on the total detach- ment of the placenta. These observations are partly true, partly fal- lacious. The true observations are those in Avhich the placenta has been spontaneously cast off and expelled before the birth of the child. These cases are not numerous. They do not justify the conclusion draAvn, that the artificial total detachment of the placenta will be equally followed by arrest of hsemorrhage. There is a fundamental physiological distinction between the two cases. When the placenta is cast off spontaneously, it is because the uterus contracts poAverfully. This contraction stops the bleeding. When the placenta is detached artificially, there may be, and probably is, defective uterine contrac- tion. The bleeding will be likely to continue. There is no inde- pendent virtue in the mere detachment of the placenta, as post-partum haemorrhage abundantly proves." Dr. Barnes offers a modification of Simpson's plan, which consists in separating from the uterus as much of the placenta as adheres within the orificial or cervical zone, and no more. He directs that one POST-PARTUM HAEMORRHAGE. 403 or two fingers be passed Avithin the os uteri and swept round in a cir- cle, so as to separate the placenta from the uterus as far as the finger can reach. " Commonly," he says, " some amount of retraction of the cervix takes place after this operation, and often the haemorrhage ceases. You have gained time. You have given the patient the precious op- portunity of rallying from the shock of previous loss, and of gather- iug up strength for further proceedings." Notwithstanding, however, the dictum of so eminent an authority, I am still fully persuaded that the puncture of the membranes and the gradual eA^acuation of the liquor amnii, as directed, is altogether the best method of treatment for cases of placenta prsevia. Post-Partum Haemorrhage. Haemorrhage following the delivery of the child may occur either before or after the delivery of the placenta. In the natural course of labor the child is delivered, while the placenta still retains more or less perfectly its connection with the uterus. In such cases little or no haemorrhage takes place up to this time. But with the first pains which occur after the expulsion of the child from the uterus the placenta begins to separate from its adhesion to the uterine parietes; and from this moment until the uterus has considerably contracted upon itself after the discharge of the placental mass there is some- times considerable loss of blood, sometimes almost none at all. Where all goes well, and the placenta is delivered, as it usually is, within fifteen or twenty minutes after the birth of the child, the hsemorrhage that does take place proves beneficial rather than injurious to the mother, by relieving the engorgement of the uterus and enabling the system in general more readily to adapt itself to the new condition. But just in proportion as this haemorrhage becomes prolonged, it be- comes more and more dangerous, whether it arise from causes Avhich hinder the progress of the labor in the first instance, or prevent the subsequent contraction of the uterine parietes. Hence, in order to be able intelligently to employ the requisite means, it is absolutely essen- tial to learn what are the efficient causes of the flooding in each indi- vidual case. This knowledge is to be obtained from the history of the case, from the conditions and symptoms obviously present, and from digital examination. If the haemorrhage be due to retention of the placenta, and the re- tention of the placenta be due to a want of tonicity of the uterus, in consequence of which it fails to contract, to close the mouths of the ute- rine sinuses and to expel its contents, the remedy appropriate to the con- 404 HAEMORRHAGE. dition should be chosen and administered; and if the placenta is de- tached and lying Avithin the uterus, it should be removed, as directed on page 201 of this Avork. From the list of remedies mentioned at the conclusion of this chapter the appropriate medicament may be selected. If, hoAvever, the placenta is adherent, and does not come away after a reasonable lapse of time and the administration of such remedies as Pulsatilla, Caulophyllum or Secale, Avhich have a tend- ency to excite uterine contractions, or if hsemorrhage should occur in consequence of the adherence of more or less of the placental mass, the hand must be introduced Avithin the uterus, and the placenta must be carefully and guardedly peeled from its attachments, in the manner directed on page 202, care being taken that neither too much nor too little is done, that the uterus is not injured by the fingers of the ac- coucheur, and on the other hand that no portions of the placenta are left behind, to occasion subsequent hsemorrhage or oozing of blood, septicaemia or other troubles. When the attempt is made to detach an adherent placenta in this manner, while the right hand of the ac- coucheur is engaged Avithin the uterus the left hand should be placed over the fundus uteri, to steady that organ in its place; and as the right hand and the placenta are AvithdraAvn, firm compression should be made with the left, following down the retreating uterus, to secure its complete and tonic contraction. If this is skillfully done the haemorrhage will cease. " You may suspect morbid adhesion if there have been unusual difficulty in removing the placenta in previous labors ; if, during the third stage, the uterus contract at intervals firmly, each contraction being accompanied by blood, and yet, on folloAving up the cord, you feel the placenta still in utero; if, on pulling on the cord, two fingers being pressed into the placenta at the root, you feel the placenta and uterus descend in one mass, a sense of dragging pain being elicited; if, during a pain, the uterine tumor do not present a globular form, but be more prominent than usual at the place of placental attach- ment." The other form of post-partum hsemorrhage, occurring after the de- livery of the placenta, is frequently very alarming, and may even be followed by a fatal termination. It is due to atony and relaxation of the uterus, whereby the mouths of the utero-placental sinuses remain open and pour forth a flood of blood, Avhich continues until firm ute- rine contraction is secured. Sometimes this comes on immediately after the delivery of the placenta, and continues Avithout cessation until arrested by appropriate treatment. At other times it comes on POST-PARTUM HAEMORRHAGE. 405 more insidiously; the uterus contracts apparently well after the deliv- ery of the placenta, and is found as a hard ball above the pubes, when suddenly the attention of the accoucheur is attracted by the woman declaring that she is flooding, or he sees by her countenance that her life-blood is wasting. The hand placed on the abdomen discovers the uterus distended and relaxed, high up in the abdomen and tender of pressure; and an examination per vaginam discovers a more or less copious Aoav of liquid blood, and perhaps the vagina, and even the uterus, filled with clots. It is evident that prompt and efficient measures are necessary in a case like this, not only with the view of saving life, but with the view also of saving blood, for " a pint of blood saved, and a pint of blood lost to the patient, may make all the difference between a rapid and a tedious convalescence—may make all the difference between a successful and a fatal issue." The most prompt and most efficient measure in such cases, according to my experience and that of a very large number of able homoeopathic practitioners, is, to apply that remedy which is homoeopathic to the totality of the case. This can be done as quickly as can any other procedure, and will be found efficient even in those cases where the blood flows pleno rivo and threatens almost immediate dissolution. The remedies appropriate for such occasions will be found laid down, with their indications, at the end of this chapter; and let me here remark that every practi- tioner should be as familiar with these indications as with the alpha- bet, and being so he will stand prepared in such emergencies with an armamentarium equal to the vanquishing of the most dangerous and desperate cases. It has been recommended to give brandy in unsparing doses, but this I regard as unnecessary. The pillow should be removed from beneath the woman's head, and the foot of the bedstead may be elevated a few inches higher than the upper part. Vomiting is not an unfavor- able indication, as it may excite uterine contraction; but if it occurs the woman's head should not be raised, but merely turned to one side' *irm pressure or grasping with the hand upon the Avomb is com- mended as a method of inducing contraction, and no doubt it is a measure of very great efficacy; but since the haemorrhage can be arrested by the administration of homoeopathic medicines alone it may be regarded as unnecessary to thus compress the tender womb effects6 thereby giVG n'Se t0 Seri°US and GVen dangerous after~ The use of cold or hot Avater injections, pieces of ice within the 406 HAEMORRHAGE. vagina and uterus, pouring cold or hot Avater from a height upon the abdomen, colpeurysis, and other similar measures for arresting the haemorrhage, all of Avhich are recommended by old-school authorities, are doubtless of more or less efficiency; and the homoeopathic prac- titioner Avould be justified in their use if the similar remedies failed to produce a prompt and satisfactory arrest of the flooding; but these do not fail when intelligently selected and applied, and a resort to them is avoided and a reliance on them condemned, a priori, by those only who have more faith in the above-mentioned appliances, or rather whose faith in the law of cure becomes faint when they are in the presence of a bad case of post-partum haemorrhage. Remedies for Uterine Haemorrhage. The medicines here mentioned are those most commonly indicated in cases of uterine hsemorrhage, whether occurring before, during or after parturition, or during the non-pregnant period. Special indica- tions, however, are given for the remedies useful in cases of threatened Abortion under the article on that subject, as well as for cases of ex- cessive menstruation under the article on Menorrhagia. The practi- tioner will do well to refer to these indications in connection with those given below. It is recommended that the indications for the remedies appropriate to all these forms of flooding be very carefully studied, that they may be indelibly impressed upon the memory and ready for instant use at the bedside. 1. Bell., Calc. c, Cauloph., Chin., Ferr., Ipec, Nux v., Sabin. 2. Bry., Cham., Croc, Erig., Hamam., Hyos., Lye, Merc, sol, Nitr. ac, Phos., Puis., Sec corn., Sep., Stram., Sulph., Trill. 3. Aeon., Ant. cr., Amm. c, Apocyn. c, Ars., Canth., Carb. veg., Coff, Iod., Nux m., Plat., Sang., Sil., Sulph. ac Aconite. In active haemorrhage, with fear of death and much ex- citability. She cannot sit up even in her bed. She seems so giddy she falls over. Particularly suitable to women of full, plethoric habit. Antimonium crud. Uterine haemorrhage, with a distinct pressure in the womb as if something would come out. Somewhat rheumatic. White tongue. Nausea and vomiting. Apis. Profuse uterine haemorrhage, Avith heaviness in the abdomen; faintness. Great uneasiness and yaAvning. Red spots like bee-stings REMEDIES FOR UTERINE HAEMORRHAGE. 407 upon the skin, and sensation as if stung by bees in the abdomen and in different parts of the body. Apocynum cann. There is great irritability of the stomach and vomiting; the blood is expelled in large clots, sometimes, however, in a fluid state; the vital powers are much depressed, and there is a disposition to faint. Argentum nit. Uterine haemorrhage, Avith much trouble in the head. Confusion, dullness and much pain, greatly aggravated by the least movement. A short time seems very long to her, and everything done for her seems done so very slowly. She has, for instance, been flowing an hour, and to her it seems hours ; we Avork rapidly for her safety, and she thinks Ave are so very slow. Arnica m. In cases from a fall, a shock to the system or a concus- sion. Blood bright red or mixed Avith clots. Nausea in the pit of the stomach. Warmth about the head and the extremities cool. Arsenicum. Haemorrhage, with lancinating burning pains; in low states of the system, when aphthae appear. Belladonna. Profuse discharge of bright red, hot blood, Avith press- ing or forcing (outAvard) as if all would escape the vulva, or pain in the back as if it Avould break. The blood sometimes has a bad smell. Sometimes a Avascular excitement prevails; throbbing of the carotids; flushed face, red eyes and full, bounding pulse. This remedy is very frequently indicated in uterine haemorrhage, particularly in that occurring after labor. Bryonia. Haemorrhage of dark red blood, with pain in the small of the back, and headache as if it Avould split. Dry mouth and lips. Nausea and faintness on sitting up in bed, or even on raising the head from the pillow. Calcarea carb. The history of the case shows that she has ahvays menstruated too often, too much and too long. Leucophlegmatic constitution. Cold, damp feet. Swelling at the pit of the stomach, like a saucer bottom up. Vertigo on stooping; Avorse on rising again or going up stairs. Cantharis. Uterine haemorrhage, with great irritation in the neck of the bladder. Urinating often, smarting, cutting and burning in passing only a few drops. Carbo veg. Passive metrorrhagia, Avith much itching of the vulva and anus. Caulophyllum. Haemorrhage occurring after labor, especially hasty labor; the flow is very profuse, and is due to a want of tonicity of the womb, which is relaxed and contracts very feebly. 408 HAEMORRHAGE. Chamomilla. Metrorrhagia of dark, coagulated blood, with tearing pains in the legs and violent labor-pains in the uterus. Hsemorrhage of dark blood, Avith pressure toward the uterus and frequent discharge of colorless urine. Great irascibility. China. Haemorrhage from the abuse of Chamomilla. Haemorrhage from atony of the uterus. Discharge of clots of dark blood. Uterine spasms. Desire to urinate. Colic. Also after miscarriage or labor, or at any other time when there has been much loss of blood. Coldness and blueness of the skin. Twitching and jerking of single muscles. Heaviness of the head, ringing in the ears, loss of sight and fainting. In the most desperate cases of this type China will be found of very great service. Coffea. Haemorrhage, Avith excessive sensitiveness of the organs and voluptuous itching; she would like to scratch, but there is too great sensibility. Creasotum. Discharge of a large quantity of dark blood; then for a feAv days bloody ichor Avith pungent odor, corrosive itching and smarting of the parts; then the discharge recommences and the same phenomena occur again. Crocus. After miscarriage or labor, or from dancing or a long walk during the catamenia, with or without pain, there is a discharge of a dark, stringy blood; it comes away in dark or black strings. Often there is a sense of rolling and bounding in the abdomen; sometimes there is a similar feeling in the stomach. Crocus is very frequently called for in post-partum haemorrhage. Ferrum m. Hemorrhage, Avith fiery-red face, and hard, full pulse. After parturition or miscarriage a frequent discharge of partly fluid and partly black clotted blood, with violent labor-like pains, full, hard pulse and frequent short shudderings; headache and A'ortigo; constipation and hot urine. Hamamelis. In uterine haemorrhage occurring at any time, Avhere the flow is steady and sIoav, the blood is dark colored, and there are no uterine pains. Hyoscyamus. Haemorrhage after accouchement, miscarriage, or at any time when there are general spasms of the Avhole body, inter- rupted by jerks or by twitching of single limbs; the bright-red blood continuing to flow all the time. Ignatia. Haemorrhage after the abuse of Chamomilla. Heavy sigh- ing and sobbing, with empty feeling at the pit of the stomach. Great despondency. REMEDIES FOR UTERINE HAEMORRHAGE. 409 Iodium. Uterine hsemorrhage occurring at every stool, with cutting in the abdomen, pains in the loins and small of the back. Ipecacuanha. Constant Aoav of bright-red blood, Avith cutting about the umbilicus, constant nausea and vomiting. The Avoman feels cold and is very pale; complains of dizziness and headache. Very fre- quently used after parturition or miscarriage. Lachesis. Pain in the right ovarian region, increasing more and more until relieved by a discharge of blood. Lycopodium. Haemorrhage, with cutting pain across the abdomen from right to left. Great fermentation in the abdomen and discharge of much flatulence. Sensation as if " full up to the throat." Mercurius s. Metrorrhagia in aged females, scorbutic gums, saliva- tion. Mucous or muco-sanguinolent stools, with tenesmus. Nitric acid. After miscarriage or confinement, Avith violent pressure as if everything Avere coming out at the vulva; with pain in the small of the back, through the hips and down the thighs. Nux mosch. The blood is thick and dark, with intolerable dryness of the mouth and tongue; the tongue is so dry that it sticks to the palate. Fainting. Sleepiness. Nux vomica. Metrorrhagia as a precursor of the critical age; also after parturition, particularly if there be constipation of large, diffi- cult stools, or frequent call to stool, with small and painful stools, or without result. She leads a sedentary life, drinks much coffee, Avine or other liquors, and livTes on highly seasoned food. She is dyspeptic, and cannot sleep after three or four A. M. Dreams frightful dreams, and does not sleep Avell. Phosphorus. After difficult labor, betAveen the monthly periods, or during pregnancy. Particularly in tall and slim women. Weak and empty feeling across the abdomen. Constipation of narrow, dry, dif- ficult stools. Much belching of wind after eating. Feeling of intense heat running up the back. Platina. Metrorrhagia of dark, thick blood, Avith pain in the small of the back, which penetrates into both groins, Avith excessive sensi- tiveness of the genital organs. Metrorrhagia, Avith the sensation as if the body Avere growing larger in every direction. Haemorrhage during pregnancy. Pulsatilla. Metrorrhagia, profuse at times, at other times intermit- ting and mixed with clots—most profuse in persons given to reveries. Also at the critical age. In women of mild, tearful temperament. Rhus tox. Metrorrhagia, in pregnant women of a rheumatic diathe- sis, worse on change of weather. 410 HAEMORRHAGE. Sabina. Hsemorrhage at the menstrual periods, after miscarriage, after parturition. The blood is dark, having blackish clots mixed Avith thin, Avatery blood. The pain extends from the back through to the pubes. Atony of the uterus. Painless loss of dark-red blood immediately after delivery. Sabina is used in frequency next to Ipecac Secale corn. Passive haemorrhage of very fetid or dark blood. Sal- low face.' General debility, insensibility and feverish pulse. Passive hsemorrhage in feeble, cachectic women, particularly Avhen the weak- ness is not caused by previous loss of fluids. Hsemorrhage, with strong and spasmodic contraction of the uterus, eA7ery Aoav being preceded by such contraction or by strong bearing-down pains. Hsemorrhage from atony of the uterus, especially after protracted labor. The patient is prostrated, cold and Avith pinched face; although cold, she does not wish to be covered. Sepia. Chronic metrorrhagia, when it is excited from the least cause. She has yellow spots on the face, and a yelloAV saddle across the bridge of the nose. She has icy cold paroxysms, icy cold feet, and has flushes of heat. Painful sense of emptiness at the pit of the stomach. Urine fetid; it has a sediment as if clay were burned on the bottom of the vessel. Constipation. Stools mixed Avith mucus. Sense of Aveight in the anus. Silicia. Metrorrhagia, with terribly offensive sweating of the feet. Constipation, of difficult lumps, which the rectum has not action enough to expel, and Avhich sometimes recede after being partially expelled. Stramonium. Metrorrhagia, Avith excessive loquacity, singing, prayers and praise. Full of strange and absurd ideas. Sulphur. Chronic hsemorrhage. She seems to get almost well, when it occurs again and again, day after day, for weeks. She is weak; has Aveak and fainting spells, flushes of heat, heat on the top of the head, and cold feet. Sleep very light; often gets awake, wide aAvake. Feels very Aveak in the morning ; gets hungry spells, when she cannot wait for her food, especially for her dinner. Sulph. acid. Metrorrhagia, with tremulous sensation in the whole body, Avithout trembling. Trillium pend. Profuse flow of dark, thick and clotted blood, con- tinuing at intervals for several days. Suitable for women who in- variably flood after parturition. PUERPERAL CONVULSIONS. 411 CHAPTEE XX. PUERPERAL CONVULSIONS. rilHE convulsions which occur during the first eight months of J- pregnancy are usually hysterical, although in some persons orig- inally predisposed or actually subject to epileptic attacks, convul- sions would be liable to appear during pregnancy, even in its earlier stages, and they would of course partake of the same epileptic nature. But in general only those convulsions which arise during the last month, and especially during the last weeks of gestation, are allied to epilepsy; and they are properly termed puerperal, because of their precise similarity in character to those Avhich occur during labor and after parturition. Still, in common language all convulsions of preg- nant women may be termed puerperal, whether they appear in the earlier or in the later stage of gestation, during labor or subsequently. And in fact such convulsions may arise in all these A^arious conditions of the same individual. The hysterical form of convulsions appear- ing in persons of a nervous or hysterical constitution may be consid- ered rather as an aggravated kind of hysteria, and studied in the article on that disorder. In the present section Ave shall have refer- ence rather to the so-called epileptic form of convulsions, or the true puerperal eclampsia—to those which precede, accompany or succeed labor, and shall consider their causes, symptoms and treatment. Causes.—The causes of puerperal convulsions may be most conve- niently studied by first dividing them into tAvo general classes—the Centric, or those which arise from direct irritation of the great nervous centres; and Eccentric, or those Avhich arise from more external influ- ences affecting the extremities of the incident nerves and reflected back upon the centres. The Centric causes are either physical, acting as material irritants of the nervous centres, or psychical, consisting in mental emotions. The physical causes may be either intra-cranial, such as act primarily upon the brain and medulla oblongata, or they may be intra-vertebral, acting upon the membranes of the spinal cord and upon the substance of the spinal centre itself. the most prominent of the physical intra-cranial causes consists in that derangement of the sanguineous system incidental to many cases of pregnancy, and knoAvn by the old term of plethora. " Pregnancy is usually and very justly considered a state of plethora; and it may 412 PUERPERAL CONVULSIONS. be readily presumed that the balance of such plethora may determine toAvard the head, inasmuch as the great \Tessels of the abdomen must be supposed, during the latter Aveeks of gestation, to be liable to much impediment to their action from the pressure of the gravid uterus."— Davis. Any agent which, like a clot of blood,* serous effusion or full- ness of the cerebral circulation, causes undue or unusual pressure on any part of the brain, by causing also a counter-pressure on the me- dulla oblongata, may occasion convulsions. And the derhTation of the accustomed pressure on the brain and on the spinal cord must necessarily be attended with similar results. Thus, cases of con- vulsions arise either in plethoric conditions with red, bloated face and projecting eyes, or in anaemic conditions characterized by excessive pallor and debility. In cases of excessive and fatal uterine haemor- rhage, commlsions always appear before death from this very cause. The psychical class of causes of convulsions consists in sudden and vio- lent emotions of fear, of joy or of grief, or in deeper and more pro- tracted influences, such as the sense of shame inseparably connected in many instances with pregnancy in unmarried females. The intra-vertebral causes of puerperal convulsions have reference either to the quantity or to the quality of the blood. Too large a quantity relatively, exerting an undue pressure upon the spinal cord —either directly or by means of serous effusion—may give rise to puerperal convulsions; and a similar result, as already stated, will folloAV the opposite or anaemic condition. The abnormal character of the blood itself may cause convulsions. This may arise from defi- cient oxidation of this fluid, on account of the hindrance to respira- tion due to the encroachment of the abdomen upon the thorax; from that state of the blood which corresponds to albuminuria; from a true toxaemia or poisonous state of the blood, due to its double function of eliminating the debris of the fcetal as well as of the maternal system; and from the fever connected with the first secretion of milk. Gen- erally speaking, '•' the immediate causes of puerperal convulsions are often very obscure. They appear sometimes to depend upon a loaded state of the brain; at other times the brain appears to be influenced by some distant irritation, either in the uterus or digestive organs; and again in some cases puerperal convulsions are induced apparently by a peculiar irritability of the nervous system. It has been remarked that there has been a greater disposition to puerperal convulsions in those patients Avho have been in early life subject to convulsive attacks. particularly of an epileptic character, and also in those who have suf- * Romberg, Diseases of the Nervous System, ii., p. 188. PUERPERAL CONVULSIONS. 413 fered similarly in former labors, and have omitted those measures usually employed as precautions." " A remarkable relation appears to exist between albuminuria and dropsy and puerperal convulsions, but how far these two conditions are related as cause and effect it is difficult to determine. Some sup- pose that the condition of the urine is simply the result of reflex irri- tation starting from the uterus, and that the convulsions are brought about in the same Avay; others believe that the albuminuria is the result merely of pressure on the kidney, and that the convulsions have no relation to this condition of the urine; Avhile others, again, regard both conditions as due to ' a pathological state of the blood, to the occurrence of which pregnancy may some way dispose' It is very doubtful whether either of these opinions be true, Avhile it is certain that albuminuria often exists without convulsions: I have seen sev- eral cases of this kind myself. On the other hand, convulsions may occur without any preceding albuminuria. The same may also be said in regard to anasarca, which has no necessary connection either with convulsions or with albuminuria. In cases where albuminuria exists the urine is found also to contain less than its normal amount of urea, while the blood has it in excess; hence it has been surmised that the convulsions resulted from the influence of the uraemic poisoning in the central nervous system. The German observers, Fre- richs and Lehmann, on the other hand, believe that it is not the urea itself, but its decomposition in the blood, and the formation there of carbonate of ammonia, which can undoubtedly be detected in the breath and perspiration, that is the chief cause of the convulsion."— Meadows. The Eccentric causes of puerperal convulsions consist in irritation of the extremities of the incident nerves. The greatest and most frequent and important of all these are found in direct irritation of the uterus itself and of the uterine passages. This may be caused by the pressure of the head or of any other presenting part upon the incident spinal nerves of these organs. In some excessively nervous or epileptic conditions, the convulsions may be brought on by the changes of position of the foetus in the first stages of labor, by the irritation resulting from over-distension of the uterus by excessive quantity of liquor amnii, and by the presence of a dead fcetus within the womb. The introduction of the hand into the uterus for the sake of removing an adherent placenta has sometimes immediately throWn the woman into convulsions. The same result may also follow the irritation caused by indurated faeces, by purgative medi- 414 PUERPERAL CONVULSIONS. cines, by irritability of the bladder, the stomach, and even of the mammae. Symptoms.—The symptoms of puerperal convulsions may be divi- ded into premonitory and actual symptoms. And by a careful atten- tion to the former, when they occur some days or even weeks before labor, we may be able to avoid the frightful complication of convul- sions in child-bed. The premonitory or predisponent symptoms may sometimes consist in a sense of fullness in the head, even to vertigo; of intense pain in a part or in the Avhole of the head; confusion of the understanding; a sense of ringing and of other noises in the ears; temporary confu- sion or the loss of power of vision, and temporary abolition of the poAver of thought, and even of sensation. For such symptoms, which may appear at any time in the later stages of pregnancy, Dr. Davis recommends the abstraction of blood, but a no less decided and much more beneficial result may be secured by the exhibition of the appropriate homoeopathic remedy. For convulsions threatened dur- ing labor the same author gives the following predisponent symp- toms : an excited state of the circulation; a gradual accession of cephalic symptoms, such as those above enumerated, with rigors, nausea, and even vomiting; a great excitement of the heart and arteries; immense irritation and restlessness; a great development of heat, unaccompanied by adequate moisture on the surface of the body; unusual strength and fullness of the pulse; engorgement of the vascular structure of the face, producing much turgescence and flushing; an approach to or actual delirium; great fullness and wild- ness of the eyes, often accompanied by an expression of extreme dis- tress, or else of a state approaching to fatuity; perception of scintil- lations of light or the fancied presence of divers other bodies; and in many cases a sudden seizure with violent pains in the abdo- men, differing in character from those of labor. Severe pain in the stomach and an intense pain in the forehead have been mentioned as premonitory of the worst kind of cases of convulsions. A tumid state of the hands and face sometimes precedes an attack ; a dropsical swelling of the face alone, or face and upper extremities, is not un- commonly folloAA'ed by convulsions, and if the urine is at the same time albuminous this condition should excite strong apprehension of such a catastrophe. Sometimes, however, there are no precursory symptoms; and however similar such attacks may be to epilepsy, they differ from this disorder in seldom or never being preceded by the aura epileptica. PUERPERAL CONVULSIONS. 415 The actual symptoms of puerperal convulsions are indeed scarcely to be distinguished from those common to epilepsy itself. They are thus described by Churchill: " During the attack the face is swollen, of a dark red or violet color, and distorted by spasmodic contractions; the eyes are agitated, the tongue protruded, and the under jaw re- peatedly closed with force, so as to wound the tongue. A quantity of froth is ejected from the mouth, which is generally drawn more to one side of the face than to the other. The muscles of the body are thrown into violent and irregular action ; the limbs are jerked in all directions, and with such force that it is sometimes difficult to keep the patient in bed. The respiration is at first irregular, and being forced through the closed teeth and the foam at the mouth, has a peculiar hissing sound ; it subsequently becomes nearly suspended. The pulse is quick, and at the beginning full and hard, but afterward small and imperceptible. The body participates in the purple color of the face. The urine and faeces are often passed involuntarily. This terrible paroxysm, however, is not of very long duration. After a period varying from five minutes to half an hour, the convulsive movements become less violent, and gradually subside; the counte- nance is less distorted, and assumes a more natural and placid appear- ance ; the eyelids close, the respiration becomes more regular, though still sibilant, and the circulation is restored, the pulse becoming more perceptible, though still very weak; the patient rests quietly in bed, and the paroxysm has terminated for the time. " During the interval the patient's condition is very variable. She may partially recover consciousness, so as to recognize persons around her, and to be aware of something extraordinary having happened, without knoAving what, and without being able to express herself clearly. In other cases the return of intelligence (Avithout recollection) may be complete until the approach of the next fit, accompanied with great weakness, headache and confusion. In the more unfavorable cases the patients remain in a state of total insensibility, almost ap- proaching to coma or asphyxia, with sibilant or stertorous breathing, and Avithout muscular motion, or with a restless throwing about of the body and extremities. The calm is, however, of no very long dura- tion; it may be half an hour or two hours, but sooner or later the paroxysms return, to be succeeded by an interval, which in its turn gives place to a paroxysm." Under the head of eclampsia parturientium, puerperal convulsions are thus described by Romberg: * The convulsions coming under * Diseases of the Nervous System, ii., p. 187. 416 PUERPERAL CONVULSIONS. this denomination break out suddenly, and the patient is at once de- prived of consciousness. The face and neck SAvell and become red and livid. The carotid and temporal arteries pulsate violently, and the jugular veins SAvell; the eyelids are distended, the eyeballs are elevated, or stare rigidly, and their vessels are congested, or they roll about under the closed eyelids. The tongue projects and is bitten bv the grinding teeth, causing it to bleed, and bloody froth issues from the mouth. The facial muscles tAvitch, the limbs are curved or stretched, and again contract Avith lightning-like rapidity. The whole trunk is at one time rigid, immovable, drawn backward to one side; the next moment it is throAvn about by twitchings and convulsions so violent that the patient can scarcely be restrained. The muscles of respiration, and especially the diaphragm, are implicated; there is danger of suffocation. Vomiting supervenes, and urine and excre- ments escape involuntarily. The temperature is raised, the face drops Avith perspiration. The pulse is very frequent, full and strong, or weak and hard. The abdomen is tympanitic; the uterus is hard, and this hardness increases as often as convulsions are renewed. These attacks are more apt to occur in primiparae, although they are by no means confined to them. Some women even have the mis- fortune to be seized with them at each succeeding pregnancy; in such cases they are very apt to result in premature delivery. In different individuals these attacks terminate differently : some remain in a state of half stupor and great exhaustion for hours or days, and gradually recoATer; others become maniacal, and may even remain so for a long time, and eventually recover. In some cases the patient continues comatose, gradually passes into a state resembling apoplexy, and dies. In these ctses the danger is said to be greater during the last months of pregnancy than during and after parturition. When the convul- sions are originally associated with profound sopor and stertorous breathing, they are said to prove almost invariably fatal under the old-school treatment. Plethoric and robust women are in greater danger than weak and hysterical subjects. And Avhen the interva's are very short betAveen the paroxysms, or become imperceptible, death is at hand. Dr. Hodge * states that " after much anxious experience and reflec- tion it is evident to my mind that there is no essential pathological difference between the usual form of puerperal convulsions and those Avhich occur in the non-parturient state in hysterical Avomen. I have seen so many cases in the latter precisely similar, as regards their * Diseases Peculiar to Women, p. 128. PUERPERAL CONVULSIONS. 417 phenomena at the time and after the attack, to those of the former, and so many of the puerperal form resembling those of the hysteric as to the precursory, attendant and consecutive symptoms, that I must believe that pathologically they are virtually the same. The only real difference is the degree of congestion, this being comparatively trifling in the unimpregnated state, very great during gestation, and still more so during labor. The engorgement in this case arises from the almost universal plethoric state of pregnant women, which during labor is enhanced, particularly as regards the brain, by the " pains " and the bearing-doAvn efforts ; these include, of course, the holding of the breath, the temporary suspension of respiration, and the conse- quent passive congestion in the lungs, right side of the heart, the brain, etc Hence the danger#and fatality of puerperal convulsions. The original nervous irritation is aggravated by this congestion, so that effusion of serum or blood may ensue, and the patient become comatose and die." When this affection appears in the last months of pregnancy the infant almost always perishes, but it may be saved when the convul- sions appear during parturition; in these cases the fits will usually be found synchronous with the uterine contraction—that is, each pain is attended by a convulsion. But if there have been no pains before the fits come on, the os uteri most frequently begins to dilate in all cases of puerperal convulsions of this kind—that is, during parturi- tion : the condition of the os uteri, as dilated, dilating or as rigid, will afford important indications as to the course to be pursued and the remedies to be employed. In connection Avith these convulsions the uterine contractions are usually feeble and irregular ; sometimes they either pass into the spasms or alternate Avith them. In some in- % stances, according to Leadam, the opening of the os is the signal for the manifestation of convulsive action, each parturient effort being ac- companied by a convulsion; in others, every paroxysm seems to cause a firm, spasmodic contraction of the os, and so interferes Avith and delays the progress of the labor. The convulsions sometimes continue at intervals until the birth, which, therefore, is an event looked forward to Avith great anxiety; and it has happened that labor has proceeded, even to the expulsion of the child and secundines, Avithout the sur- rounding attendants being aware of it, in consequence of the convul- sions so obscuring the parturient efforts that there wras no outward manifestation of the labor, and also from the fact that uterine action is sometimes very powerful, and the labor is proportionately quick in some cases. This shows the duty of ascertaining without doubt the 27 418 PUERPERAL CONVULSIONS. actual condition of the uterus by a proper and timely examination. If delivery—whether it be at the full time or not—be inevitable, and if, in spite of the application of appropriate remedies, the convulsions continue or increase, then it Avill be a matter of serious consideration whether the birth of the child can be expedited by manual or instru- mental interference with safety to the mother. The sooner the child is born, the sooner may we reckon on the probable cessation of the convulsions and the safety of the mother, although they do not always terminate when that desirable object is accomplished. The proper course to be pursued under the different conditions of Convulsions in Parturition will now be indicated. First. Ascertain, by examination, if any loaded condition of the rectum or of the bladder offers any impediment to the progress of the labor or predisposes to the convulsions. Second. Remove any such obstructions by the use of the enema syringe or catheter. Third. Administer the similar remedy according to the indications given at the close of the chapter—either one of those mentioned or any other which may be more homoeopathic to the case. Fourth. Should the convulsions not be relieved, it will be necessary to induce artificial delivery as soon as the os uteri is found to be suf- ficiently dilated or dilatable. The course to be pursued in convulsions of pregnant women before the close of term at first corresponds to that necessary in severe cases of hysteria, of which, in fact, these convulsions are usually but an aggravated variety. The exceptional cases will consist principally of those who have either had epileptic attacks in early life, or whose parents had been troubled with this affection, or of those in whom the pregnancy itself has evidently developed the epileptic condition. In each of these cases the remedy homoeopathic to the existing condi- tion should be administered in as high a dose and at as long intervals as may coincide with the judgment of the physician. If the treatment fails,-the convulsions grow more frequent and severe, and evidently threaten to produce miscarriage, the case must be treated as one of abortion from this cause. The convulsions which make their appearance after parturition are generally believed to be far more dangerous than those which precede and accompany labor, since they are usually the result of profound exhaustion of the patient's system. This exhaustion may be princi- pally nervous, and analogous to the " shock " which constitutes the most fatal form of puerperal fever; or it may be vascular, resulting PUERPERAL CONVULSIONS. 419 from excessive haemorrhage during and immediately after the labor itself. The individuals most liable to the former class of exhaustion are those of a Aveak, nervous temperament, while the full-blooded and plethoric are most apt to suffer from severe losses of blood. In either case the condition is one of exceeding gravity; and unless the physician is sufficiently master of his business to enable him to give the right remedy without loss of time, he may have the mortification of seeing the convulsions become constantly more violent until the little remain- ing vitality is at last expended in futile efforts to maintain the respira- tion and circulation, and the patient is relieved by death. It should ahvays be remembered that there is still another influence to Avhich the puerperal woman is remarkably sensitive, and which may prove as efficient and as fatal a cause of convulsions after labor as either the nervous or the sanguineous exhaustion just mentioned, and which comes Avith tenfold force if brought to bear upon patients already so exhausted. And this is fright, fear, or a sudden emotion of grief, or even of joy. The least intimation to the mother during labor that there Avas something wrong has been knoAvn instantly to stop all pains, and necessitate the use of instruments, resulting in the final destruction of mother and child. Hoav much more, then, should we carefully avoid shocking the feelings and wounding the sensibili- ties of our patient in her enfeebled condition at the close of a labor, which may have been far more exhausting than is apparent, by rudely announcing the death or the deformity of her child! These trying circumstances, through which the young physician may at any time be called to pass, demand from him not only the most entire self-control and presence of mind under the most critical circumstances of labor, but also, and no less absolutely, the most careful and tender con- sideration for the personal feelings and moral state, as well as for the physical condition, of his patient afterward. In all these alarming conditions the homoeopathic remedies, properly selected and adminis- tered, will be found endowed Avith an efficacy vastly superior to the debilitating or stupefying means employed by old-school practitioners. And however discouraging the symptoms may be, especially to the young physician, let him be sure neither to "lose his head" nor to give up in despair; but let him patiently and perseveringly administer the proper remedies, and leave the event Avith Him Avho doeth all things Avell, remembering, at the same time, that very many cases are thus saved, even of those which he might deem not only desperate, but perfectly hopeless. Treatment.—The prodromic symptoms should be met by such 420 PUERPERAL CONVULSIONS. remedies as are appropriate, carefully selected from the Materia Medica. A nervous and excitable condition of the mind, persistent and con- gestive headache, insomnia, persistent pain in any part of the bodv, local anaesthesia, when occurring in pregnant women, should receive special attention. Where oedema exists the case should be carefully treated; the urine should be subjected to a careful examination for the presence of albnmen and the absence of urea. " Although there are exceptional cases in which dropsy occurring in pregnant Avomen is not folioAved by puerperal convulsions, yet the rule is quite the reverse. Hence you will be on your guard Avhenever it occurs, and more especially if the «oedema began in the face and upper extremities. For in most cases of dropsy, whether incident to gestation or not, if the infiltration begins in this manner, we take it as a hint of renal disease or embarrassment of some kind. So your patient may have had a latent form of Bright's disease, Avhich has been aggravated by her con- dition, or she may be suffering for the first time from an attack of acute desquamative nephritis, from congestion of the kidney or from uraemia, due to direct pressure of the gravid uterus upon one or both the ureters, the earliest token of which may be seen in the puffy and bloated face and eyelids. If you act upon this suggestion you may avert the threatened eclampsia—ahvays providing the degeneration of the kidneys has not gone too far already, and that the pressure upon the ureters does not cause a complete retention and reabsorption of the urine."—Ludlam. Let it be the first duty of the physician to make sure that no ligatures or other encumbrances obstruct the circulation or in any manner aggravate the existing difficulty; that there be pure and fresh, air; that the light be not too bright; and that all the at- tendant circumstances and conditions are rendered as favorable as possible for his patient. If the room is crowded, as is often the case, Avith friends, anxious, distracted and rushing about in confusion, lei him at once restore the room to order ; otherwise he may chance to find himself inextricably involved in the same hopeless confusion. Then, if not before, let him administer the remedy Avhich seems to him most homoeopathic to the symptoms and conditions of the case. Let him calmly and patiently wait for the action of the first dose, and before repeating it let him be fully satisfied not only that it is the right remedy, but that the beneficial action of this first dose is exhausted. If no improvement arise, and the appearance of neAv symptoms or the further development of the old ones should convince him that the right remedy had not been chosen at first, let him endeavor to select another in accordance with the present condition of the case. And PUERPERAL CONVULSIONS. 421 in all cases let him remember that the more violent the symptoms the less should he expect instantaneous relief—that the gradual sub- sidence of the nervous excitement and the corresponding gradual abatement of the spasmodic action are not only the best methods by which the patient may improve, but that they are also the only methods possible. In addition to the remedies already mentioned under Hys- teria, the folloAving may be studied with reference to the convulsions which precede or accompany labor, and to those which arise subse- quently : Aconite. In those cases where, in their incipiency, there is a hot, dry skin, thirst, restlessness, fear of death, more or less cerebral congestion,—in such cases a dose of Aconite once every half hour acts like a charm. In primiparae, where at the outset o£ labor there is evidently great fear and anxiety, restlessness, feverishness and thirst— symptoms that might be the precursors of puerperal eclampsia—a dose or two of Aconite very frequently has a very calming influence. Argentum nit. She has a presentiment of the approaching spasm. She is in constant motion from the time she comes out of one spasm till she goes into another. The spasms are violent, and are preceded by a sensation of expansion of the Avhole body, especially of the face and head. Sometimes the woman lies quietly for some time after a spasm has ceased, but becomes very restless before another begins. Arnica. When the pulse is full and strong, and during every pain the blood rushes violently to the face and head; symptoms of paral- ysis of the left side; loss of consciousness; involuntary discharge of stool and urine; while the head is very hot, the body is nevertheless cool or of a natural temperature. Belladonna. She has the appearance of being stunned; a semi-con- sciousness and loss of speech; convulsive movements in the limbs and muscles of the face; paralysis of the right side of the tongue; difficult deglutition; dilated pupils; red or livid countenance. She may have paleness and coldness of the face, Avith shivering; fixed or convulsive eyes; foam at the mouth ; involuntary escape of the faeces and urine. Renewal of the fits at every pain; more or less tossing between the spasms, or deep sleep, Avith grimaces, or starts and cries, with fearful visions; violent pulsation of the carotids; jerking and twitching of muscles between the spasms; sound sleep or uncon- sciousness after a paroxysm. Bryonia. Is often indicated after the spasms have been controlled, and there remain fullness of the pulse, abdominal tenderness and per- 422 PUERPERAL CONVULSIONS. spiration, dry, parched lips and thirst. The woman does not wish to move, and cannot bear to be moved. Cantharis. Dysuria belonging to Cantharis. The presence of bright objects, the sight, the drinking or the sound of water, and touching the larynx, seem to reproduce the spasms, Avhich are usually violent. Caulophyllum. This remedy Avill doubtless prove useful in some cases occurring during labor. Causticum. When the paroxysms are complicated Avith screams, gnashing of the teeth, and violent movements of the limbs, etc. Chamomilla. The spasms have been excited by a fit of anger, or she has one red cheek Avhile the other is pale. Starts and shocks during sleep. Great impatience and disposition to anger. Spiteful excitability. China. The loss of a large quantity of blood is the exciting cause of the eclampsia. Cicuta. Strange contortions of the upper part of the body and limbs during the paroxysms, with blue face, and frequent interruptions of breathing for a few moments. Cimicifuga. The spasms are preceded by great mental excitement and perturbation, Avith visions of objects which are not present, and are folloAved by languor or relaxation of the entire system. The paroxysms are very violent. Cocculus. Spasms following difficult labors, and those which are developed by changing the position of the patient. Coffea. To quiet the extreme excitability of the nervous system when spasms are apprehended, or if spasms have actually been de- veloped, attended with cold extremities and grinding of the teeth. Cuprum. Spasms complicated with violent vomiting. Opisthotonos with every paroxysm, Avith spreading out of the limbs and opening of the mouth. The spasms begin in the shape of cramps in the fin- gers and toes or in the whole of the extremities. Gelseminum. This remedy bids fair to become one of our most useful agents in this fearful disorder. It seems indicated by the pre- monitory symptoms, where the head feels very large, or in those cases in Avhich the spasms occur as the first symptom of the os uteri being unchanged or perhaps rigid. Distressing pains running from before backward in- the abdomen, but more especially Avhen the pains run upward. Helleborus. A shock passes through the brain, as if from a shock from electricity, folloAved by considerable movements in the body. Hydrophobin. The spasms are excited Ayhenever she attempts to PUERPERAL CONVULSIONS. 423 drink water, or if she hears it pouring from one vessel into another. This remedy may also be indicated by the sight or sound of water affecting the patient unpleasantly, even though she desires the water. Hyoscyamus. When there is a bluish color in the face, and twitch- ings and jactitation of every muscle in the body—those of the face, eyelids and all. Almost constant delirium. Ignatia. Deep sighing and sobbing, with a strange compressed feel- ing in the brain. The convulsions commence and terminate with groaning and stretching of the limbs. The paroxysms are accom- panied with vomiting. Fright, with grief, may have been the excit- ing cause. Ipecac. One constant sensation of nausea the whole time, with occa- sional convulsions. Such symptoms—convulsions characterized by continuous nausea—are always relieved by Ipecac, alone. Kali c. The spasm seems to be relieved or to pass off by frequent eructations. Lachesis. The convulsions are particularly violent in the lower limbs, Avith coldness of the feet, stretching backward of the body and crying out. Laurocerasus. She is conscious of a shock passing through her whole body before the spasm. Mercurius. Much salivation, a constant driveling from the mouth; convulsions, mostly in the extremities. Nux mosch. Particularly when there is a convulsive motion of the head from behind forward. Nux v. Great torpor of the intestinal canal; in persons who are of an irritable disposition, and in those who are accustomed to wines and high living generally, and who lead a sedentary life. Opium. Sopor, with stertorous respiration; the stertorous respira- tion continues constantly from one spasm till the next, and so on. In- coherent Avandering and convulsive rigidity of the body, with redness, swelling and heat of the face; hot perspiration and insensible pupils. Suppression of the pains of labor may have been the proximate cause. ■ Phosphorus. Previous to the convulsion a sensation of heat rushes up the back into the head. This was several times perceived as a forerunner of the first convulsion. Pulsatilla. The countenance is cold, clammy and pale. Loss of con- sciousness and of motion; stertorous breathing and full pulse. The labor-pains are deficient, irregular or sluggish—othenvise she is in good condition; mild and tearful; the patient demands fresh air. .424 POST-PARTUM DERANGEMENTS. Secale C. In scraAvny, illy-nourished women, with too feeble labor- pains. " Ergotismus convulsivus." Stramonium. This medicine is particularly indicated Avhere the patient shows such signs of fear as to cause her to look frightened and to shrink back from the first objects she sees after opening her eyes. If she has had no spasms, she soon Avill have after betraying such symptoms, unless Stramonium be immediately administered. The same frightened appearance occurs also after the convulsions commence. Sardonic grin. Stammering or loss of speech. Puffed and red face ; loss of consciousness and sensibility. Cries; frightful visions; laughter; singing; attempts to escape. The fits are renewed by the sight of brilliant objects, and sometimes by contact. Verat. viride. Great activity of the arterial system. Convulsions or mania, or Avhen the mania continues after the convulsions have ceased. Zinc. Particularly if eruptions have recently disappeared, even old eruptions. Zinc has been known to cure obstinate puerperal convul- sions after Phosphorus, being indicated, had failed. CHAPTER XXL POST-PARTUM DERANGEMENTS. Retained Placenta. (See page 201.) BELLADONNA. Redness of the face and injected sclerotica; great distress and moaning; great heat and dryness of the vagina; dry- ness and heat of surface; profuse flow of hot blood, which speedily coagulates; the slightest jar of the bed causes suffering. Cantharis. Swelling of the lips of the os; burning pain in the pel- vic portion of the abdomen and in the back; feverish ness; vomiting; great deal of anguish and distress, Avith predominantly burning pain. Cimicifuga. For women who are subject to rheumatic affections; there is a distressing, tearing pain in the uterine region; there appears to be no uterine action. Gelseminum. When, with the retained placenta, there are cutting pains in the loAver part of the abdomen, usually running upward, or sometimes upward and backward. RETENTION OF URINE AFTER PARTURITION. 425 Pulsatilla. This remedy is more frequently indicated and more gen- erally useful than all others. It is indicated equally for retained placenta from Avant of expulsive power of the uterus, and for the spas- modic retention. The symptoms presenting must decide for or against its use. The patient is of a mild and yielding disposition; inclined to Aveep because her labor is not completed; intermittent flow of blood; restlessness; she cannot bear the heat of the room, of which she com- plains, and demands that fresh air be admitted. Sabina. Pain, or an uneasy, bad feeling, extending from the sacrum to the pubes; a slight sensation as of motion in the abdomen ; intense after-pains, notwithstanding the retention, with discharge of fluid blood and clots, in about equal proportion, with every pain. Secale C Constant sensation as of bearing doAvn; it seems to her too constant and too strong to be effectual; passive haemorrhage; the parts feel to her as if relaxed, and there is an absence of uterine action; especially suitable for thin, scrawny women. Sepia. She complains of little sharp, shooting pains in the cervix uteri, sometimes with burning. Caulophyllum and Gossypium have been commended for retained placenta. Retention of Urine after Parturition. Arnica. Retention of urine, with urging to urinate, there being a sore, bruised feeling prevailing. Mechanical injury is the apparent cause of the difficulty. Arsenicum. There is no sensation as of desire to urinate; it is time the bladder should be evacuated, but there is a want of disposition to urinate, as Avell as a want of desire or urging to do so; in fact, there is, so far as the urinary organs are concerned, an entire want of sensation. Belladonna. The urine can be passed only in drops at every effort, without pain. Cantharis. Great desire to urinate, with cutting, burning pains in the bladder or in the urethra; complete strangury, or the urine may dribble or drop, with cutting, burning pain. Causticum. Retention of urine, with frequent and urgent desire to urinate, but occasionally a few drops or a small quantity passes aw^ay involuntarily; the desire may be frequent and urgent, but unsuccess- ful, as only a little flows involuntarily. Hyoscyamus. Retention of urine, with constant pressure in the blad- der; apparent paralysis of the bladder. Lycopodium. Retention of urine, with much violent pain in the back, 426 POST-PARTUM DERANGEMENTS. coming on in paroxysms, or the flow is suddenly interrupted, with in- creased pain in the back at every interruption. Nux vomica. Painful and ineffectual desire to urinate, the pain being burning and tearing; retention of urine, Avith frequent urging to stool. Pulsatilla. Retention of urine, with redness, heat and soreness of the external region of the bladder, which is painful to the touch; mild, tearful women. Stramonium. Retention of urine, Avith a sensation as if the urine could not be passed on account of the narroAvness of the urethra;'after straining a while a few drops are passed, no stream being formed in spite of all straining; retention Avithout any painful sensation. After-Pains. (See page 208.) Arnica should be administered immediately after delivery, un- less contraindicated; and this remedy is particularly called for by the bruised condition of the genital organs and the strain of the gen- eral muscular system. It aids in restoring the parts to their natural condition, thus preventing severe after-pains by removing the causes Avhich otherwise Avould have produced them. Belladonna is indicated Avhen the pains come on suddenly, and after a time disappear Avith corresponding suddenness; or if the pains be severely forcing, as if the contents of the pelvis would be forced through the vulva. A jar of the bed is very unpleasant. The lochial discharge seems to her to be hot. The head and eyes are congested. Bryonia. The after-pains are excited by the least motion, even by taking a deep inspiration; she wishes to lie perfectly quiescent. Head- ache as if the head would split. Thirst for large draughts of cold water; parched lips and dry mouth. Caulophyllum is particularly suitable after protracted and exhaust- ing labor. Pains which are apparently spasmodic across the lowei part of the abdomen or in other parts, sometimes extending into the groins. Chamomilla. The pains are very distressing, and she feels that she cannot bear them. She wishes to get away from herself. She is ir- ritable and ill-natured. The lochia is dark colored. Thirst. Desire for fresh air. Cimicifuga. The patient is very low-spirited, sleepless, restless and very sensitive to impressions; she feels her pains very acutely. AFTER-PAINS. 427 Coffea. She is sleepless ; the pains are very distressing, and she feels them acutely. Or, desire to go to sleep but unability to do so. Cuprum acet. Terrible cramping pains; pains which often produce cramps of the extremities, including the fingers and toes. Ferrum. Violent pains in the loins and abdomen, like those of labor, with discharge of partly fluid and partly clotted blood; full, hard pulse; frequent short shuddering, headache and vertigo. Espe- cially suitable for feeble women Avith fiery red face. Gelseminum. The pain is severe, and inclines to run upAA^ard or up- ward and backAvard. She seems to have lost the ability to regulate her muscular movements. Hyoscyamus. Much jerking and twitching of various parts of the body; she is delirious; the pains are spasmodic. Ignatia. Much sighing, sadness and despondency with the after- pains. Kali carb. The pains are stitching and shooting, or they are in the back, shooting doAvn into the gluteal region or hips. Nux v. Aching pains. Every pain causes a feeling of desire to go to stool, or there is a constant sensation as though there was something in the rectum which should be evacuated. A sore feeling in the region of the uterus, to the extent that she dreads being moved or disturbed in any way. Inclined to be irritable. She likes to have the room warm and to be Avell covered. Pulsatilla. For women of mild and tearful disposition; the pains become worse toward evening; thirstlessness ; bad taste in the mouth. She feels uncomfortable if the room be warm, and complains of its warmth; great desire for fresh air, and she feels better if the room be cool. Restless and changeable in her feelings—noAV better, now worse. Rhus tox. The pains are always worse at night, with great restless- ness; they last sometimes throughout the night, while there is not much pain during the day. Frequent desire to change her position, which change gives some relief for a short time. Likes a warm room and to be coA'ered warmly. Sabina. The pains run from the sacrum to the pubes. With every pain—the pains being generally severe—fluid and clotted blood is dis- charged. The pains sometimes extend from the back and sacrum to the uterus and down the thighs. Secale corn. This remedy is especially adapted to thin, scrawny women. The pain is prolonged, as though pressing and forcing the womb. Brown, thin lochia. Although she may feel cold, yet she does not wish to be covered. 428 POST-PARTUM DERANGEMENTS. Sepia. Constant sensation of Aveight in the anus; pain shooting up- ward in the vagina. Pain Avhich is felt mostly in the back; severe bearing down or forcing in the back, occurring in regular par- oxysms. Sulphur. Pains Avhich are located especially in the uterus. The lochial discharge seems to be scant. She complains of feeling badly in the abdomen. Bleeding hsemorrhoids, Avhich itch very much and are sore. Flushes of heat; weak and faint spells; feet either cold or burning hot, especially the soles. Sulphuric acid. Great sense of general Aveakness, or a sense of tremb- ling all over, Avithout actual trembling. (Consult also the medicines for disordered conditions of the lochial discharge.) Disordered Conditions of the Lochia. (See page 210.) Aconite. A suppression of the lochia, or too scanty discharge, occurs soon after confinement, with distress in the abdomen, chest and head, apparently from congestion of blood in these parts. Feverishness, Avith thirst; uneasiness : fearfulness; she feels that something unfortu- nate Avill occur. Sharp cutting pains in the abdomen, which is very tender of pressure. Offensive lochia, other symptoms agreeing. Baptisia. The lochial discharge is very acrid and very foetid, and there is great debility, with prostration. Belladonna. Offensive lochia, feeling hot to the parts. Flushed face and injected eyeballs; delirium and frightful visions. Pain in the region of the uterus, Avhich comes and goes suddenly. Drowsi- ness, or she is half asleep and half awake; does not sleep soundly, and is not refreshed by her sleep. She is very sensitive to even a slight jar of her bed; great tenderness of the abdomen. Bryonia. Suppression of the lochia, with sensation as if the head would burst. The least motion aggravates her suffering. Dryness of the lips and mouth. The lochia may be too profuse, with burn- ing pains in the region of the womb. Thirst, with desire for large draughts at a time. Calcarea carb. The lochial discharge lasts too long, in women who ordinarily menstruate too profusely, or the discharge has a milky appearance. Suitable especially to women of leucophlegmatic tem- perament. Caulophyllum. The lochia lasts too long and remains bloody too long; it seems to ooze passively from the relaxed uterine vessels, and there is great exhaustion. Chamomilla. Suppression of the lochia, followed by diarrhoea, colic, DISORDERED CONDITIONS OF THE LOCHIA. 429 toothache; irritable and impatient; thirst; redness of one cheek while the other is pale. Coffea. The discharge is too profuse, with an exalted nervous sensi- bility and great Avakefulness. Colocynth. Suppression of the lochia, with violent colic; suppression arising from anger; suppression with tympanitic abdomen and diar- rhoea. She feels Avorse after taking food or drink. Great restlessness. Carbo animalis. Lochia too long continued, thin, offensive, excoria- ting, Avith numbness of the limbs. Creasote. Very offensive lochial discharge, which produces excoria- tion. The lochia almost ceases to flow, when it freshens up and becomes more profuse and bloody, and again almost disappears, to freshen up .again. Crocus. The lochial discharge appears in dark strings. Sensation of motion in the abdomen, Avhich becomes much distended. Dulcamara. Lochia suppressed by cold or dampness, and the quantity of milk is greatly diminished. Erigeron. In cases Avhere the least motion excites afresh a return of bloody lochial discharge, which is relieved by rest. Hyoscyamus. Much delirium and jerking of the muscles; she says she is being drugged or poisoned. Very suspicious. Ignatia. Derangements from the abuse of Chamomile tea. In some cases Nux v. Or if produced by fright or grief, Avith sighing and sobbing. Merc. sol. The discharge is Avorse at night, Avith some inflammation and swelling of the genital organs. Swollen and sore groins. Nux v. The lochia are scanty and offensive in women accustomed to highly seasoned food, coffee and wine; or the patient has an irri- table rectum, calling her to stool frequently. Frequent calls to uri- nate, the urine producing a scalding sensation. Sensation of soreness in the uterine region; she does not Avish to be moved or disturbed in any Avay. Prefers to be warm. Opium. Suppression of lochia from fright, with sopor. Platina. A little discharge will remain, but it will be black and clotted. The genital organs will be very tender. On account of the excessive sensitiveness she cannot bear the napkins usually applied. The discharge becomes intermittent, occurring in gushes. Very change- able in her sensations. Cannot bear a Avarm room. Pulsatilla. In cases where the milk has suddenly disappeared from the breasts. The scanty lochial discharge remaining is milky; she is feverish, but has no thirst. 430 POST-PARTUM DERANGEMENTS. Rhus. The lochial discharge lasts too long, is thin and offensive. It has Avellnigh exhausted her; it is thin, ichorous and offensive or it occasionally becomes bloody. Shooting pains up the rectum. Rest- lessness at night. Must change often, with relief. Secale C. In thin, scrawny women; very offensive and thin lochia • the discharge may be scanty or profuse. It may be painless or accom- panied by prolonged bearing-down pains. Very dark discharge. Sepia. Where the foetid odor is the most characteristic symptom. Offenshre lochia, excoriating, with little sharp shooting pains in the region of the neck of the uterus. Distressing bearing down in the back. Silicia. Pure blood is caused to flow every time the infant nurses. The discharge is sometimes excoriating. After-pains in the hips. Stramonium. Her mind is full of strange and absurd, but strongly marked ideas. Lochia having a cadaverous odor. Sulphur. The discharge causes a sensation of weakness, and she has hot flushes; perspiration; heat in the soles of the feet, or her feet feel cold all the time. She has bleeding piles, which are sore and itch. See also remedies under Nymphomania, Metrorrhagia, Constipation, Diarrhoea and After-Pains. Pendulous Abdomen. Belladonna. When there is much sensitiveness to touch, to pressure or to jarring Avhile riding in a carriage or when walking. Under the influence of Belladonna the tenderness ceases, and the size of the ab- domen will be greatly reduced gradually. Crocus. There is a sense of motion, as of something alive bounding and leaping in the abdomen. Platina. Occasional sensations of cramp in the uterine region; ten- derness to touch; everything seems strange and horrible to her. Podophyllum. Much nervous irritability and sleeplessness. She feels as if weak and unable to move about. Stools too frequent, but natu- ral in appearance. Sepia. Sensation of painful emptiness in the pit of the stomach. Little darting, shooting pains in the region of the cervix uteri; con- stipation. Secale corn. In women of very lax muscular fibre, and who are of a thin, scrawny appearance. Study also Calc. carb., China, Colocynth, Kali carb., Nux vomica. PUERPERAL FEVER. 431 For Rhagades and Cracks on the Surface of the Abdo- men, study Hepar, Sepia, Silicia, Sulphur. For Ulceration of the Umbilicus, Arsenicum generally suf- fices. Study also Apis, Lachesis, Lycopodium, Sepia, Silicia, Sulphur. CHAPTER XXII. POST-PARTUM DERANGEMENTS.—CONTINUED. Puerperal Fever (Child-bed Fever). rpHE multiform disease which goes by the various names of Child- -1 bed Fever, Puerperal Fever and Puerperal Peritonitis has this double characteristic, that it attacks only pregnant and lying-in women, and involves in various degrees the genital organs and the viscera more immediately adjacent. Scarcely any disorder Avhich the physician is called upon to treat is more insidious or more dangerous • certainly there is none which runs a more rapid course or which may prove more suddenly fatal. And Avhen Ave reflect that this frightful malady is not necessarily confined to individual cases, that it may be- come epidemic, and even most virulently contagious, it will be evident that a thorough understanding of the disease, as essential to its suc- cessful treatment, will at once assume a tenfold importance. " The breaking out of an epidemic child-bed fever, or even the oc- currence of a single case, commonly excites a feeling of sharp interest and alarm as far as ever the rumor of it extends: the public curiosity becomes speedily aroused, and among many physicians whose opinions are taken, how wide is the diversity of their sentiments! If the pub- lic do become greatly alarmed on these occasions, it is because they know that any one of our women seized with child-bed fever is at once placed in a most perilous position; and we know it even better than they; and half our distress and anxiety arises from this, that we are ourselves uncertain what Ave have to do, what to contend with and by what principles to be guided." These very candid confessions of l)r. Meigs Avill at once serve to show the dangerous character of this disease, and the necessity which therefore exists for a thorough acquaint- ance with its essential nature and proper treatment. -No single form of disease, or class of diseases, has given rise to 432 POST-PARTUM DERANGEMENTS. greater differences of opinion among medical men as to its nature and causes, and in no others have serious physiological and pathological errors so manifestly led to erroneous and destructive methods of treat- ment. And although the homoeopathic physician, from general princi- ples avoiding some of those untimely interferences Avhich have been seen to lead immediately to child-bed fever, and from selecting his remedies under the direct guidance of the existing conditions, rather than under that of a supposititious and often mistaken diagnosis has in general far greater success than his allopathic neighbors, he Avill none the less require, for the sake of his students, if not for his own a clear exposition of the Natural History, Essential Nature, Causes Symptoms, Diagnosis, Course and Tendencies, and Treatment of this disease. I. Natural History.—Under this title we consider child-bed fever, or the disease commonly so termed, in a general manner only. This disease may be sporadic, appearing in one or more isolated cases, which are supposed to arise in consequence of influences inherent in the constitution of the individual, or from such as are additionally developed by the incidental circumstances of her confinement. In general, the cases of puerperal fever Avhich appear as sporadic are less difficult of cure than those met Avith in epidemics. In different countries and at different times child-bed fever has assumed an epidemic form, raging with great virulence and fatality, and attacking almost every puerperal woman, but neither including any very extended range of territory, nor lasting more than a few months on any one occasion. Watson * states that puerperal peri- tonitis "is observed to reign as an epidemic especially in lying-in hospitals, and that it occurs at irregular intervals, sometimes leaving them quite exempt from its ravages for years together." The mortal- ity of child-bed fever in private practice among old-school practitioners has always been very great, and in the lying-in institutions and hos- pitals this disease has sometimes proved so dreadfully fatal as to ren- der these public charities a curse rather than a blessing to the com- munities in Avhich they were situated. Of the one hundred and sixty cases of severe inflammation of the uterus and its appendages which occurred to Dr. Lee in London from March, 1827, to the end of April, 1835, and of which he gives a tabular view,f eighty-eight, or a little more than fifty per cent., recovered. In another author men- * Practice of Physic, p. 819. f Lectures on the Theory and Practice of Midwifery, by Robert Lee, M. D., F.B.S., p. 478. PUERPERAL FEVER. 433 tion is made of thirty-one cases being lost out of thirty-two, or 96^ per cent., while of twenty women in child-bed in Hotel Dieu Hospi- tal, Paris, in February, 1746, affected with puerperal fever, scarcely one recovered. The question as to the contagious or non-contagious nature of child- bed fever has given rise to the most violent disputes and to the most opposite conclusions among medical men. A frightful array of facts may be collected from the works of innumerable authors, which seem to prove in the most incontestable and overwhelming manner not only that this disease is contagious, but that in many remarkable instances it has been confined to the practice of a single physician, every woman whom he attended during a course of weeks or months being stricken down with this fell disorder.* Dr. Churchill writes as follows : "It seems impossible to doubt that contagious matter capable of exciting puerperal fever may possibly be conveyed by a third party unaffected by it; for example, in the cases on record following the services of med- ical men and nurses who were in attendance upon erysipelas immedi- ately before. The instances are too remarkable and too numerous to be regarded as coincidences, nor would even the prevalence of an epi- demic of puerperal fever at the same time invalidate our conclusions; it might certainly render the cause more influential." Dr. West of Philadelphia states that "seven females delivered by Dr. S. Jackson in rapid succession were all attacked with puerperal fever, and five of them died. These were the only cases that occurred in that dis- trict, for the women became alarmed and sent for other assistance." Dr. Ramsbotham has known the disease to spread through a particu- lar district, or to be confined to the practice of a particular person, almost every patient being attacked with it, whilst other practitioners had not a single case; and he considers the distemper as being capable of conveyance not only in common modes, but through the dress of the attendants on the patients. At a meeting of the College of Physicians in Philadelphia, Dr. Warrington stated that "after assisting at an autopsy of puerperal peritonitis he was called to deliver three women in rapid succession. All these women were attacked with different forms of what is com- monly called puerperal fever." " A young surgeon, shortly after ex- amining the body of a sporadic case that had died, delivered three women, who all died of puerperal fever." Mr. Davis states "that in 18WV1» Pwerperd Fever M a Private Pestilence, by O. W. Holmes, M. D., Boston, p 530 M6d' ^ Sur9'Jour-> vol-lu-> PP'95> 41°; Bamsbotham's Obstetrics, 28 434 POST-PARTUM DERANGEMENTS. the autumn of 1822 he met Avith twelve cases, while his medical friends in the neighborhood did not meet Avith any, or at least with very few. He could attribute this to no other cause than his having been present at the examination of two cases, and his having conveyed the infection to his patients, notwithstanding every precaution." Dr. Roberton of Manchester states that betAveen the 3d of December 1830, and January 4th, 1831, a midAvife attended thirty patients of a public charity, sixteen of Avhom had puerperal fever, and all died. Other midAvives of the same institution attended three hundred and eighty women during the same time, and none suffered from it.* Hitherto we have only adduced proof of the direct communicability of puerperal fever by physicians or nurses who ha\re been in attend- ance upon previous cases of the disease, or by physicians going to women in labor from autopsies of persons dead Avith the same com- plaint. But there are still other modes by which the poison Avhich is capable of exciting this disease in puerperal women has been conveyed —modes which are necessary to be known in order to a full under- standing of the natural history of the disease itself. A practitioner had been attending cases of typhus fever. Within the space of four days he delivered five women. All these women were attacked with puerperal fever, and all of them died. This was in a country prac- tice, and the cases were remote from each other. Different practices intersected the practice of this medical man at various points, but no other cases were known to have occurred in the neighborhood. Again, a patient suffering from typhus fever was admitted into a lying-in hospital, where she remained for a few hours only. In the beds on the right and left of this patient were two lying-in Avomen; both were attacked almost immediately with puerperal fever, and both died. A medical man was in constant attendance upon a patient suffering from gangrenous erysipelas, and between the 8th of January and the 22d of March he attended the labors of ten women; all had puerperal fever, and eight of the patients died. This was in a town of moder- ate size, and no other patients in the place were knoAvn to have had puerperal fever. " It has been made out very conclusively by Semel- weis and others that the miasms derived from the dissecting-room Avill excite puerperal disease. Exposure of the puerperal Avoman to the poison of scarlatina will give rise to puerperal disease in patients proof against the reception of scarlet fever itself. The mortality amongst child-bed women seized with smallpox is well known, and such persons die with the symptoms of puerperal disease in addition * Churchill's System of Midwifery, p. 549. PUERPERAL FEVER. 435 to the variola." * The mode in which these several similar or differ- ent poisons develop the disease called child-bed fever will * be ex- plained Avhen in a subsequent section we consider the essential nature of this disease. But since, as already stated, the opposite opinion, or that of the non-contagiousness of puerperal fever, is strongly maintained by many able physicians, it is but proper that we allow them also to speak. The most powerful and influential among these is Dr. C. D. Meigs, who writes as folloAvs. We quote: " I have practiced midAvifery for many long years; I have attended some thousands of Avomen in labor, and passed through repeated epidemics of child-bed fever, both in town and in hospital. After all this experience, however, I do not upon careful reflection and self-examination find the least reason to suppose I have ever conveyed the disease from place to place in any single instance. In the course of my professional life I have made many microscopic researches of child-bed fever, but did never suspend my ministry as accoucheur on that account. Still, I certainly was never the medium of its transmission." This statement is indeed remark- able, but it is difficult with any conceivable amount of negative testi- mony of this kind to disprove the positive affirmative evidence of many other equally intelligent and no less trustworthy observers. The following words of Spallanzani are very much to the point: "It is the custom of certain dabblers in philosophy to deny facts, however particularly described, and though related by persons of the highest authority, merely because their oavii endeavors (in the same direction) fail of success. But they do not reflect that this is acting in direct opposition to the principles of sound logic by which we are taught that a thousand negative facts cannot destroy a single positive fact." Thus the entire sum and substance of Dr. Meigs's testimony is perfectly expressed in the last phrase quoted from him: he certainly was not "a medium of transmission" of such poison; but this amounts to nothing in disproof of others being such mediums. The full elucidation of this most important practical subject re- quires an additional statement in this connection. The statements already given—mostly in the very words of the unfortunate actors in these domestic tragedies—which prove the direct communication of poison sufficient to cause child-bed fever, comprise but a very small portion of those recorded in medical works; these prove what may be termed common communicability, by means of Avhich the poison may be directly conveyed from a variety of sources and under a great * Tyler Smith's Lectures on Obstetrics, p. 630. 436 POST-PARTUM DERANGEMENTS. variety of circumstances. The testimony of Dr. Meigs (and that of others Similar, if any such there be) must be regarded as anomalous and as furnishing an example of most uncommon incommunicabilitu. But as nature is never one-sided, we shall find in the recorded evi- dence of medical men some corresponding anomalies on the opposite side—some still more remarkable instances of most uncommon com- municability ! Thus, Dr. Merriman* states that he Avas present at the examination of a case of puerperal fever at tAvo p. m. He took can not to touch the body. At nine o'clock the same evening he attended a woman in labor; she was so nearly delivered that he had scarcely anything to do. The next morning she had rigors, and died in forty- eight hours. Dr. Gooch relates the case of a general practitioner in large midwifery practice who lost so many patients from puerperal fever that he determined to delh7er no more for some time, but that his partner should attend in his place. This plan was pursued for one month, during which not a case occurred in their practice. The elder then, being sufficiently recovered, returned to his practice, but the first patient he attended was attacked by the disease and died. Very similar Avas the experience of the unfortunate Dr. Rutter, for- merly of Philadelphia, as related by Dr. Meigs, f This gentleman " seemed to be tracked by the cause of the disease, to judge from the numerous attacks of it in his lying-in patients. He Avas charged with being a carrier of contagion. Worn out Avith fatigue, and Avounded in spirit by his cares for the unfortunate victims of an epidemic dis- ease, Dr. Rutter left the city for the purpose of regaining some strength, and to escape from the repetition of such disheartening labors." He spent ten days rusticating at a distance of thirty-five miles from the city, and on his return he caused his head to be close shaved, took a warm bath, dressed throughout in clothes entirely new —leaving behind him even his pencil and his Avateh—and " went out to attend a lady in labor, who had a favorable parturition, yet was next day assailed by a horrible child-bed fever, of which she died!" " Dr. Rutter repeated this attempt at personal disinfection at a subse- quent period, Avhich was two years later, and met with the same ill success." Dr. Gordon of Aberdeen, Scotland, one of the earliest Avriters on child-bed fever, says : " I have abundant proofs that every person Avho had been with a patient in puerperal fever became charged with an atmosphere of infection, which was communicated to every preg- nant woman who happened to come within its sphere." And he ac- * Lancet, May 2,1840. f Child-bed Fever, p. 105. PUERPERAL FEVER. 437 knowledges that he was himself the means of carrying the infection to a great number of women. Reference has already been made to puerperal fever arising from the poison of erysipelas; a few facts will show the constant relation of these two forms of disease. The explanation of the cause of this relation will appear Avhen we come to consider the essential nature of puerperal fever itself, in the following section. Dr. Drake, in his analysis of the several accounts of epidemic erysipelas in the interior valley of North America, states that pregnant, and especially lying- in, females were peculiarly liable to the erysipelatous inflammation, and the most fatal cases were the puerperal. Dr, Corson, describing a severe epidemic of erysipelas which occurred in NorristoAvn, Pa., in the autumn of 1847, says: " Old and young, male and female, fell before it, and yet there seemed to be one class that it preferred. The mother, as she lay helpless and exhausted from the labor and agony of giving birth to her child, was marked as a victim. The deadly poison was infused into her veins, and in many instances a few hours sealed her doom." In the latter part of March, 1852, epidemic erysipelas made its appearance in Palmyra county, Pa.; " few lying- in women escaped its attack, and the ratio of mortality was quite large." Of a similar epidemic occurring in Montgomery county in the same year, Dr. Geiger states " that it spared neither age, sex, nor condition. It marked the parturient woman for its especial victim. Not a single woman living within the range of the disease Avho was delivered during its prevalence escaped an attack." * In the erysipe- las which prevailed as an epidemic in Dayton, Ohio, it was found that women advanced in pregnancy were especially prone to premature labor, and the period of accouchement was looked to by both patient and physician with the deepest anxiety and solicitude. But one par- turient woman within the range of Dr. Sutton's information escaped an attack of puerperal fever; and every one that Avas attacked died. Thus we have shown—1. That puerperal fever may be directly communicated from one to another, through the medium of a third person—especially the nurse or physician. 2. That it is very sure to be thus transmitted by persons who have recently been engaged in making autopsies of such as have died of puerperal fever and of peritoneal or erysipelatous inflammation. 3. That it may be caused by the effluvia from dissecting-rooms, from typhus fever, from gan- grenous and epidemic erysipelas and from scarlet fever. 4. That no amount of personal ablution, changing clothes, etc., will ahvays pre- * Trans. Penna. State Med. Soc, vols. ii. and iii. 438 POST-PARTUM DERANGEMENTS. vent such communication of poisonous influence, since even the blood of the person acting as a medium is affected, and by the breath a cer- tain infectious influence is given out, which acts upon the blood of the puerperal woman through her lungs, and thus carries to her system the germs of the disease. 5. From the various facts of the personal experience of different physicians it will be seen that some persons, like Dr. Meigs, seem to be incapable of thus absorbing and conveying this kind of infection, while others possess in a most remarkable de- gree this unfortunate faculty of retaining and imparting the poison for months, and even years. These facts might be deemed to have been introduced with needless prolixity, did they not suffice to exert a controlling influence over the conduct of the physician in such cases, and afford ground for the fol- lowing admirable advice by Dr. Copland: " A physician or surgeon engaged in obstetric practice, upon the occurrence of puerperal fever in any of his cases, should either explain the matter to her friends, and call in a physician not engaged in this practice, to whose care she ought to be committed; or he should relinquish the care of puerperal females during his attendance on cases of this form, or even of ery- sipelas ; or he should change all his clothes and wash his hands after seeing cases of either of these maladies before proceeding to a puer- peral female." (This latter precaution Avould prove almost always unaATailing, as shown by the cases above given: fumigating himself and his clothes with chlorine gas, and washing his hands, even beneath the finger-nails, with a solution of chloride of zinc or carbolized soap, Avould be more effectual.) " An obstetric practitioner should not make an autopsy of a case of puerperal fever, or of erysipelas, or of peritonitis, or of diffusive inflammation of the cellular tissue, of diseases occasioned by the ne- croscopic poison, nor even attend, dress or visit any such cases, with- out immediately afterward observing the precautions just stated, and allowing two or three days to elapse between such attendance and conducting engagements or visits to puerperal females." * In this last paragraph the prohibition should be deemed absolute, since, if they are violated, the subsequently advised precautions may prove most disastrously unavailing. Puerperal fever runs a very rapid course, sometimes terminating fatally in a few hours; in other instances, in which the uterus itself is less immediately involved, and the disorder assumes more closely the form of a peritonitis, its duration is much longer, according to * Dictionary of Practical Medicine, part xiii. PUERPERAL FEVER. 439 the treatment adopted. But it is important to be able to detect the first symptoms of the disease, and to apply the appropriate remedies in its earliest stages and on the very first appearance of the evil. II. Essential Nature.—Although possessing a various and re- markable local development, child-bed fever no less truly involves the entire body in its course, since, indeed, it must have orio-inated from causes no less universal in their influence upon the economy of the system. Since it appears in persons of dissimilar constitution, and is developed under various influences, it must necessarily assume very different forms, the principal of which are briefly mentioned here in order to present a clear view of the essential nature of the disease, reserving their more complete description to the subsequent section on Symptoms. In child-bed fever, then, there may be— 1. Inflammation of the peritoneal covering of the uterus and of the general peritoneal sac, constituting what is usually termed puer- peral peritonitis. 2. Inflammation of the uterus, or metritis; this may be either inflammation of the inner wall of the womb, endometritis, Math or without uterine phlebitis; inflammation of the whole mass or mus- cular coat of the uterus, with ramollescence, and even putrescence of its entire texture; or, finally, inflammation of the external peritoneal stratum. 3. Inflammation of and suppuration in the uterine sinuses, whose canals are converted into abscesses filled with pus. In some of these cases of metro-phlebitis the womb itself seems wholly to escape, while the suppurative process becomes very rapidly and insidiously developed. 4. Inflammation of the ovaries and Fallopian tubes. In some instances these uterine appendages have been found very much dis- eased, while the uterus itself remained comparatively unaffected. In one remarkable case pus, discharged into the abdominal cavity from the free extremity of the Fallopian tube, was found to have occasioned fatal peritonitis. That these varieties of inflammation may occur independently of each other, has been proved by repeated post-mortem examinations, but they are most frequently met with in different forms of combina- tion. Puerperal peritonitis seldom occurs without some degree of in- flammation of the uterine appendages, but both these structures may be severely affected, while the muscular coat of the uterus and the veins and absorbents remain wholly exempt from disease. In a similar 440 POST-PARTUM DERANGEMENTS. manner the vascular and muscular tissues of the Avomb are liable to severe attacks of inflammation, Avithout any corresponding affection of the peritoneum by which they are covered, although it more fre- quently happens that inflammation excited originally either in the veins, absorbents or muscular coat involves also the peritoneum. This form of inflammation in the vascular and muscular tissues of the uterus may be so malignant as to become fatal even before thus extending to the peritoneal membranes. This is important to be borne in mind, since absence of pain and of tenderness in the abdo- men does not preclude the possibility of a dangerous attack of child- bed fever. In cases of uterine phlebitis, purulent matter may be deposited not only in the veins of the womb, but in different parts of the body, and even in the lungs; and in puerperal peritonitis the pleura and other serous membranes may sympathize with the perito- neal inflammation. There can be but little doubt in the mind of any one that the severe and varying phenomena which mark its inception, course and termin- ation are due to blood-poisoning—the absorption into the blood of some poisonous matter, whether animal or vegetable; and it seems to be equally clear and reasonable that this blood-poisoning is first of the series of phenomena, if not their real cause, and not secondary and consequent. Dr. Stevens remarks that " this morbid condition of the blood is decidedly the first link in the chain of those phenomena which constitute fever, for even before the attack every drop of the vital current is changed in its properties; and Avherever this deranged blood can circulate, there fever extends its empire; for the cause which produces this disease is not confined to a part, but acts on every fibre and in every tissue of the living system; it disturbs every func- tion of the body and deranges every faculty of the mind." The blood drawn in some cases resembled that found in severe cases of typhoid fever. The quantity of fibrin is increased, although the solids are generally diminished in quantity; the red blood-cells are decreased, while the white cells are increased; the extractive matter, lactic acid and fat are increased, and there are traces of bile pigment. Very strong ground has been taken by some writers regarding the identity of puerperal fever and erysipelas, and Dr. Churchill states that he has observed that the children of mothers who have been at- tacked by child-bed fever during the prevalence of epidemic erysipe- las are very liable to be attacked by that disease. The late Sir James Simpson contended for the identity of puerperal and surgical fever. III. Etiology.—The causes of child-bed fever may seem suffi- PUERPERAL FEVER. 441 ciently obvious in many cases, but in numerous other instances they are decidedly obscure. A natural and easy labor does not necessarily preclude an attack, nor indeed are the majority of difficult labors fol- loAved by this disorder. The particular influences Avhich singly or in combination may lead to puerperal fever in any given case are not ahvays assignable. Sometimes this disease appears to rise spontane- ously, and without our being able to attribute it to any causes what- ever. In such cases, therefore, Ave are driven back to first principles, and compelled to seek in some profound dyscrasia of the individual constitution, or, in what may be nearly the same thing, some hitherto unmanifested exhaustion of the patient's system, for the efficient cause of an attack which may prove as rapidly fatal in its termination as it was sudden and unforeseen in its onset. As shown in a previous chapter, all the various forms of constitu- tional dyscrasia may develop themselves during pregnancy, so also may they—till then held as it were in reserve—finally ultimate them- selves in still more dangerous manifestations of disease immediately after parturition. There are cases in which these morbid influences es- tablish themselves, even before the full term, in the form offebris gravi- darum (fever of pregnant women), which by its continuance after de- livery becomes entitled to the additional designation of et parturientium, and of those lying in. Sometimes these morbid influences terminate the pregnancy before term, and thus destroy the child at the same time that they threaten the life of the mother. The influence which epi- demic, traumatic and gangrenous erysipelas, and the peculiar miasms of typhus and scarlatina, may exert in causing fever of lying-in Avonien has already been sufficiently indicated in the examples previously ad- duced. And the epidemic influence of puerperal fever itself in ex- tending its ravages is but too well understood. And all that is meant by contagion, by the personal transmission of the poisonous effluvia of child-bed fever by physicians and nurses from one patient to an- other, is but a more direct and perhaps more highly concentrated de- velopment of what in its diffused form corresponds to the same epi- demic influence. Every animal poison of a putrid nature, like that from post-mortem examinations of persons Avho have died from puer- peral fever, as Avell as that from dissections in general, seems equally capable of establishing this peculiar fever in lying-in women. In some cases it is evident that the direct application of such poisons to the genitalia of parturient women by means of the hands of accoucheurs, or even the presence of such infected persons in the lying-in room, has been followed in a very feAv hours by the most malig- 442 POST-PARTUM DERANGEMENTS. nant attacks of puerperal metritis and metro-phlebitis. Xot less fatal were those cases of puerperal disease which resulted from receiving the infection of this malady imparted through the respiration of persons who had indeed been exposed to the influence of this disorder, but had not visited such cases for days or months, or even years, as in the case of Dr. Rutter and in the instances above quoted from Drs. Merriman and Gooch. In these cases certain individuals are shown to have been endowed with the most unfortunate faculty of retaining and perpetuating in their OAvn persons a sort of concentrated miasm exactly corresponding to the general epidemic influence of this disease. And even as the raAV utero-placental surface possesses a Avonderful faculty of absorbing the subtle poison locally approximated to it, so the tissues of the peritoneum in the puerperal state seem endowed with a remarkable susceptibility of becoming specifically inflamed by means of the absorption into the general system of the epidemic influ- ence of the same particular poison, or of its personal influence as im- parted by the respiration of a person Avhose system has once been charged with it. Suppression of the lochia has been regarded as one of the most fre- quent causes of child-bed fever. But of the two most distinct and most common forms of this disorder, metritis and peritonitis, the former alone appears to be any more than incidentally connected Avith such suppression. In cases of pure puerperal peritonitis the lochial discharge will sometimes continue undisturbed, Avhile in cases of in- flammation of the uterus, either in that of its interior surface or of its muscular tissue, or of both, the lochia may be much diminished, or even entirely suppressed. And yet in these latter cases the young physician will be most woefully deceived who allows himself to believe there is no child-bed fever because he finds no particular swelling or tenderness of the abdomen. Still, suppression of the lochia by cold applications or by styptic injections administered in cases of uterine hsemorrhage may very rapidly bring on phlebitis, and even gangrene of the uterus. It would scarcely seem possible that styptic or even cold injections could fail to produce such a repulsion of the lochial discharge as Avould in effect be equivalent to its reabsorption. In damp, moist Aveather puerperal fever is found to be much more preva- lent—in part perhaps from the more ready and penetrating diffusibil- ity of the poison, and in part no doubt from the general debilitating influence of such Aveather upon the lying-in women themselves. Over- distension of the bladder, long-continued pressure of the fcetal head against the particular parts of the interior of the pelvis in difficult PUERPERAL FEVER. 443 labors, and compression and even rupture or laceration of the uterus itself, have been mentioned by different authors as capable of produ- cing child-bed fever. " The presence of inflammatory ulceration of the cervix during the first stage of the puerperal period has appeared to me powerfully to predispose the patient to puerperal fever. The uterus seems to retain a predisposition to inflammation in the puer- peral state, even in the cases in which ulceration, having existed during pregnancy, has been cured (allopathically) before parturition occurred. I have met with repeated instances of puerperal fever under these circumstances."—Bennett. But such a result can hardly ever arise from these accidents unless there is present some additional miasmatic influence. Fragments of the placenta still adhering to the uterine parietes and there decomposing may occasion utero-phlebitis. In like manner the open mouths of the uterine sinuses may become the receptacles of poisonous matters originating in the uterus itself; or even the form of adhesive inflammation by AAdiich these sinuses are naturally closed may, under certain conditions presently to be mentioned, lead also to phlebitis, and even to gangrene of the uterus. But since in many cases the influences exist without producing such results, since even the decomposition of portions of the membranes and of the placenta, occasioning an offensive lochial discharge, is not always followed by inflammation of the womb or any other form of child-bed fever, and since, as already abundantly shown, this disorder will spring up ap- parently from the slightest cause or from no obvious cause at all, the question arises, How are these discrepancies to be accounted for ? With regard to those cases Avhich arise from epidemic influence, or from any form of poisonous effluvia from without, nothing here needs to be said, since evidently the puerperal state is one Avhich renders the patient remarkably susceptible to all these influences. But do Ave not even here approach the solution of the mystery of the sporadic origin of this disease? That condition of a mass Avhich requires but the addition of a little external warmth in order to set it on fire is in no very remarkable manner different from that which presently leads to spontaneous combustion. The exhaustion of the vital forces, that which in surgical language is technically termed " shock," affords the real clue to much that is obscure and anomalous in puerperal fever. Nature always puts her best foot foremost, especially in this matter of gestation and parturition—the former a long-continued and all- absorbing function, of Avhich the latter may be an equally exhausting crisis. In some of these cases, where child-bed fever' arises from no 444 POST-PARTUM DERANGEMENTS. external cause, and proves rapidly fatal, we see reason to believe in such profound exhaustion of the vital forces as may lead to ramollisse- ment, putrescence and gangrene of the womb, Avhen such fatal degen- eration has been only developed Avithin a very few hours after delivery. To this final act of the grand function of reproduction are summoned all the remaining energies of the entire system; the Avork is indeed accomplished, but the instrument is destroyed and the worker is no more! The Avomb has been compelled to expend an amount of vital force in a few hours which ordinarily might have supplied the whole system for years. Or is it that these vital forces bear so near a rela- tion to electricity that their excessive development, through the nerves and muscles and blood-vessels of the Avomb, is followed by a disposition to putridity similar to that which is seen to take place when lightning strikes the whole body ? * Such are the ideas asso- ciated Avith the shock of lightning, and not unlike are the conse- quences Avhich follow such nervous " shock " as we have attempted to portray. What is most remarkable of all is, that in some of these cases nature gives no signal of distress till she thus hauls down her colors in sudden despair. Similar indeed is the case in some instances of paralytic shock, in which the apparently strong man is struck down in an instant and without a moment's warning. Such is the extreme pathological vieAV of what fortunately takes place but seldom. The physiological condition which we noAV pro- ceed to describe is that Avhich occurs in other cases in Avhich the above- described profound exhaustion does not obtain. Toward the one great end of sustaining the foetus in utero all the vital energies of the mother's system have been for months determined. In the fulfillment of this high use her own health may have been perfect and her strength not overcome. And even through the last critical act of the drama, that of parturition—in which all the muscles of her body and all the nobler powers of her system are called into action—she may pass Avith comparative ease. True, she is fatigued and Aveakened by such tremendous exertions. But a few days of rest would make am- ple amends for this, if this were all. But it is not, for hitherto we have given but a superficial picture of the physiological reality. All the mother's circulation and the entire economy of her nutrition have been made to assume one single direction, and the great currents of her life have but floAvn in unison with the lesser currents of the living * " In the most rapidly fatal cases nothing has been met with beyond non-coagulabil- ity, thinness and blackness of the blood. The blood in these cases resembles that of persons killed by lightning or by hydrocyanic acid."—T. Smith. PUERPERAL FEVER. 445 form within her. At once all this is stopped, the vital union between the two is rudely severed, and the living streams, floAving as before to supply the unborn babe, find in their place only the emptiness of desolation, and are themselves wasted. The whole physiological life of the mother receives a shock which if less fatally destructive than that already described as resulting from exhaustion of the vital forces, still profoundly disturbs her entire system. But a few brief hours before all her vital energies moved on in vigorous harmony, as a fair ship moves on under the influence of a strong and favorable breeze. But now all is changed, the cur- rent of her life is suddenly arrested, and her entire system, so far as it had been engaged in supplying the young life within her, comes to a sudden stand-still—in this respect resembling the condition of a ship taken aback in her course by failure of the Avind, or rather when on the tack she loses the wind and the empty sails flap idly against the masts, leaving her helpless and at the mercy of any adverse influence. The " shock" from exhaustion is as if a vessel struck upon a rock; this " shock " from sudden arrest of the great function of nourishing the foetus in utero is like that experienced by a vessel Avhich, losing the wind and having no longer steerage-Avay, drifts helplessly upon the waste of waters. In the former class of cases sporadic child-bed fever may be spontaneously developed in the most malignant form of metritis and metro-phlebitis; in the latter, the slightest breath of epidemic peritonitis, erysipelas, or of any other of the animal poisons, may suffice to kindle at once the flames of puerperal fever. Having thus at length shown how subject the puerperal Avoman is to influences from without or from within her OAvn body, which may develop child-bed fever, it remains only to state what may already have been foreseen, that in her helpless and peculiarly delicate period of transition from the energetic performance of the great function of nourishing the foetus in utero, in which she is safe as a ship at anchor, to that other and equally safe condition into which she subsequently comes of nourishing her babe, as in lactation,—during the whole of this transition state she is liable to be thrown into a fever which may prove a malignant puerperal metro-peritonitis, or assume any other of the various forms common to child-bed fever, by any of the influ- ences above enumerated. And the same result may also folloAV vio- lent mental or moral emotions. This latter class of influences is especially apt to be efficient in unmarried women, and particularly in cases of abortion. In such cases either the violence of the means employed to bring about the abortion, or the unsuitable external con- 446 POST-PARTUM DERANGEMENTS. ditions and attendant circumstances, or the profound disturbance of the moral sphere by fear and grief, or all these combined, very often lead to fatal uterine and peritoneal inflammation. IV. Symptoms.—The causes, phenomena and post-mortem results of puerperal fever have led authors to divide the disease into three forms—viz., 1. The inflammatory; 2. The contagious, zymotic or malignant; 3. The gastro-enteric. These divisions, however, can scarcely avail in the treatment, especially to the homoeopathic prac- titioner, and it is even doubtful whether the last mentioned is entitled to be called puerperal fever at all. Yet while the homoeopathic physician will always seek to give the remedy which most faithfully represents the totality of the symptoms, still, it will someAvhat conduce to a clearer understanding of this frightful malady if we arrange its more prominent symptoms with some reference to the three most common and often distinct forms of the disease in which they may be expected to appear; taking note also of the order of their appearance, as near as may be, in the rapid development of the disease. The symptoms may be local or constitutional; and in most cases the latter are the first to make their appearance. And their general character will usually indicate either the one or the other of the three principal forms of child-bed fever—that in which the womb is prin- cipally affected, that in which the peritoneum seems to be the primary and chief seat of the disorder, or that which is known by the name of uterine phlebitis. In some cases, however, the symptoms, from whichever source first arising, appear to involve all these structures as well as their adjacent organs nearly in an equal manner. In puerperal metritis, or that form of child-bed fever in Avhich the uterus is principally affected, the symptoms may vary in intensity and malignancy in the most remarkable manner, and the disease itself may rapidly involve also the uterine appendages and adjacent peritoneal tissues. The attack may begin before delivery or almost immediately after; such attacks are usually exceedingly malignant in character, and inclined to run with great rapidity to a fatal ter- mination. Usually, however, the disease begins on the second, third or fourth day, although it may occur still later. It may begin with distinct rigors, or there may be merely an imperfect and scarcely noticed chilliness. The pulse is very rapid, full and soft, varying from 120 to 150, or even more. In some instances there is neither pain, distension nor tenderness of the abdomen; in others the pain is very acute throughout, the distension enormous, and the tenderness PUERPERAL FEVER. 447 exquisite. There may also be pain and tenderness at the epigastrium with nausea and even vomiting. " Profuse sweating is a very com- mon and distressing accompaniment of this disorder. In some cases this is so strongly marked and constitutes so large a part of the disease that Dr. Blundell described it as a distinct form of puerperal fever under the name of hydrosis. The SAveat and the breath are very often accompanied by a sweetish, pus-like odor. The sweating of puerperal fever does not diminish the secretion of urine, nor does it abate the quickness of the pulse. An intolerable thirst prevails, and the patient drinks immense quantities of Avhatever fluid she may be allowed. Dark spots or ecchymoses appear upon the Avrists or other parts of the body." At first the lochia may be unaffected; they may even be increased in quantity, but more commonly they are entirely suppressed. The tongue is flabby, broad and slimy, and covered by a mucous or creamy coating. The countenance is pale and inexpres- sive, or, where the pain is acute, anxious and covered with perspira- tion. As the disease advances, usually about the third day, diarrhoea may supervene. The patient is nervous, depressed and fearful; the pulse is soft, small and increasing in rapidity; the respiration quick, hurried, high and often panting. And where this latter symptom occurs in connection with excessive distension of the boAvels, it must be regarded as a very bad indication, since the impossibility of prop- erly oxygenating the blood where the lungs have so little play, and the very rapidity of their movement—attempting to compensate by the number of the respiratory motions for what they lack in amount— combine to degenerate the physical organization and exhaust the vital forces with the greatest speed. The abdomen in many cases is swol- len, tympanitic and painful; sometimes, from the extension of the inflammation to the peritoneum, it is universally tender, sometimes tender in a particular part only. The lochia, if not entirely arrested, are generally, after a day or two, changed in quality and become foetid. The flow of milk is almost invariably checked ; in the Avorst cases sometimes it is entirely prevented; in other cases it is repressed after the secretion has taken place. When any of the appendages of the uterus are involved, such as the ovaries or the Fallopian tubes, the patient will describe a particular portion of the abdomen, on one side or the other, as the seat of special pain or sensitiveness to pressure. An examination per vaginam will serve to point out these complica- tions likewise. In an epidemic of puerperal fever described by Dr. Gooch the cases began a few days after delivery, and the leading symptoms 448 POST-PARTUM DERANGEMENTS. were " diffused pain and tenderness, Avith some SAArelling of the abdomen a quick pulse, which Avas generally at first full and vibrating. Some- times it was small, but still hard and incompressible; the skin was hot though not so hot as in other fevers; the tongue was Avhite and moist and the milk suppressed. As the disease advanced the belly became less painful, but more swelled, and the breathing short; toAvard the end the pulse Avas very frequent and tremulous, and the skin covered with a clammy sweat; even in this state the tongue continued moist and the mind clear, and death took place about the fifth day." In a subsequent epidemic which appeared in Paris the symptoms assumed the typhoid form from the first, beginning with a long and severe rigor, often a few hours after delivery; pain very intense over the whole -abdomen, which rapidly became swollen; pulse feeble, com- pressible, undulating, often 150 ; respiration hurried, anxiety extreme, severe frontal headache; countenance sunk, pale, and covered with clammy SAA'eat; constant vomiting of green matters; purging, stools foetid. The patients sank rapidly at the end of a few days, or even hours. There was no regularity in either lochia or milk." In the commence- ment of this form of child-bed fever the nervous system of organic life and the blood * appear to be suddenly and seriously affected, as shown by the general loss of vascular tone and of nervous power, by the disturbance of all the vital functions, by the rapid exhaustion of the powers of life, by the sudden death which often ensues, and by the accompanying softening and putrescence of the womb, as shown by post-mortem examinations. " Inflammation of the muscular tissue and lining membrane of the uterus is characterized by great disturb- ance of the nervous system, distressing cephalalgia, and is attended by fever of low type. Occasionally the cerebral symptoms are so intense as entirely to mask the uterine disease. It is ushered in by the same symptoms, as regards rigors, acceleration of the pulse and state of the tongue, as those which attend the other varieties of puerperal in- flammation. Its tendency is to produce softening, suppuration and gangrene of the substance of the uterus, and it is one of the most fatal of all the puerperal inflammations."—T. Smith. In puerperal peritonitis, or that form of child-bed fever in which the peritoneum appears to be primarily and principally involved, the dis- ease may commence before delivery, but it is more apt to arise in from tAventy hours to three days afterward. Sudden rigors usually consti- tute the first obvious symptom, or there may be instead severe pain, but * " In some of the worst examples, pathology has found no other change than fluidity and altered color of the blood."—T. Smith. PUERPERAL FEVER. 449 rising of the pulse generally precedes them both; then follow heat of the skin, thirst, flushed face and hurried respiration. Next there may be nausea, vomiting—which, by its spasmodic contraction of the ab- dominal muscles, greatly heightens the sufferings of the patient—pain in the head and increased sensibility of the abdomen. In some cases the tenderness of the abdomen is contemporary with the rigors, or im- mediately succeeds them. The weight of the bed-clothes is insupport- able, and the least movement of the body is attended with exquisite suffering. Sometimes there are pains, either slight or severe, contin- uous or paroxysmal, which, beginning in the hypogastrium or in one of the iliac regions, gradually extend over the whole abdomen. But while the excessive sensibility of the abdomen, aggravated by pressure and motion, is characteristic of the peritoneal form of child-bed fever the other distinct pains are not so constantly present. As the disease advances the abdomen becomes still more tender and sensitive to movement or pressure; not only is the weight of the lightest covering intolerable, but the patient lies on her back with her knees drawn up, in order as much as possible to avoid tension and pressure of the abdominal parietes. As the disease makes still further progress the abdomen becomes tumid and tympanitic. This may be followed by effusion into the cavity of the peritoneum indicated by a peculiar doughy feeling. The lochia are variously affected; in many cases this discharge continues undisturbed, or it may become fcetid, or diminished in quantity, or entirely suppressed. The secretion of the milk is much more positively affected; if the attack begins before the flow is estab- lished, it is prevented; if afterward, the secretion is suspended and the breasts become flaccid, and the patient may at the same time become entirely indifferent to the fate of her infant. Eapidity of pulse is cha- racteristic of this disorder; its range varies from 120 to 160, and the se- venty of the attack will be well measured by this symptom, since as the disease advances the pulse becomes contracted, thready, intermittent and toward the last almost imperceptible. The tongue generally has aAyhitish coating in the centre, Avith red around the edges; sometimes it is dry and brown in the centre, with yellowish or white fur at the edges. There may be nausea and vomiting of the ingesta, of bilious green, brown or black fluids; and there may also be diarrhoea, with dejections dark and foetid toward the close of bad cases. The urine is generally turbid or high colored, scanty, and in some cases passed with iftcu ty The heat of the skin may often be not much more than is natural, but toAvard the last the skin may become cold and clammy. 450 POST-PARTUM DERANGEMENTS. The countenance will usually mark the advance of the disorder by features drawn up'and expressive of great distress. The dark areola surrounding the eyes, the dilated pupil, the glassy surface and blood- less conjunctiva give a lustrous and unearthly appearance to the eyes in all cases of puerperal fever, Avhatever the special complication whenever the disease is fully formed. The intellectual faculties often remain unaffected to the last. Such are some of the most prominent symptoms which will appear in different cases of this disorder, in different forms and combinations; for while their variety is so great that all do not appear in any single case, scarcely any are constant, if we except the rapidity of the pulse and the abdominal tenderness. This abdominal tenderness, Avhen the substance of the uterus—metritis—alone is involved, is only made out under such firm pressure as will bear down the abdominal parietes and make the pressure direct upon the uterus, which is then found to be extremely sensitive; but in peritonitis the slightest pressure upon the abdomen gives intense pain. In this, as in the form of child-bed fever more immediately affecting the uterus, the disorder runs a rapid course, and the vital forces are manifestly very weak, even in cases which do not appear to assume the lowest or typhoid symptoms. In some cases, as already stated, this disorder is transferred or extends to the pleural sac; still more rarely does it involve the serous membranes of the brain; in either case the invasion of the inflammation will be marked by sharp, lan- cinating pains, worse on motion. In uterine phlebitis, or at least in its earlier stages, the symptoms do not seem to vary remarkably from those common to other forms of puerperal metritis; in some cases there may be a greater freedom from pain, the pulse alone, ranging from one hundred and ten to one hun- dred and fifty, indicating the great danger. This form of disease, in the common and gross pathology of the schools, has been attributed to reabsorption of purulent matter from the utero-placental surface. But, even if this be possible, it is probable that the mischief lies far- ther back and still deeper, in a primary disordered state of the blood itself. Puerperal fever, as described in its more malignant form under the head of puerperal metritis, may destroy patients in a few hours, even before there has been sufficient time for the occurrence of phlebitic inflammation; and in such cases, as already stated, no pathological changes are met with beyond a diseased state of the blood. And it is to this morbid condition of the blood in a milder PUERPERAL FEVER. 451 form, and not to reabsorption, that we should look for the real cause of uterine phlebitis. Before this form of disease is so far advanced as to be indicated by objective symptoms, by external suppuration, it may be recognizee!, according to the following observations of Dr. Meigs, by the (subjec- tive) moral symptoms: " In peritonitis, pure and simple, the mind is clear, the nervous system not being disturbed by the presence of pus- corpuscles in the blood; the woman recovers or dies without those hysterica], or rather hysteroidal and even maniacal, symptoms that invariably mark a purulent infection of the blood. The alarm I wish to awaken in your mind is one connected Avith the very great proba- bility that hysterical or hysteroidal affections, in women recently delivered and assailed with fever, are really the exhibitions of that curious influence that pus in the blood, or pyaemia, exerts upon the nervous system. In all the individuals, male or female, that I have attended in mortal illness from Avounds of veins in venesection, I have invariably noted this kind of hysterical intoxication, caused by purulent infection of the blood. As the disease advances the more palpable phenomena attendant upon the formation of pus in the veins are developed by the deposit of purulent matter in various parts of the body, especially in the vicinity of the large joints. We find in such cases SAvellings in the neighborhood of the articulations, ery- sipelatous blushes, and large suppurations in the vicinity of the joints, or patches of slough or gangrene form at the sides of the erysipelatous blushes." V. Diagnosis.—There can be little real difficulty in distinguishing child-bed fever, in any of its various forms, from any other disease. Its occurrence soon after delivery, the gravity of the symptoms and their rapid progress present a tout ensemble found in no other malady. And Avhile the homoeopathic physician will ahvays prescribe accord- ing to the symptoms and conditions present, without depending upon the name by which the affection may be characterized, still it is of the highest importance that he should recognize a case of child-bed fever at the earliest possible moment. And to this he will be im- pelled by the gravest considerations, that he may from the very first afford to his patient that devoted and intelligent attention which such a case requires, perhaps more than any other; that he may make sure himself of not becoming the medium of transfer of the puerperal poison from one patient to another; and that he may secure himself from suspicion of ignorance and incompetency. In most cases of child-bed fever, as shown in the preceding pages, 452 POST-PARTUM DERANGEMENTS. the disease will be ushered in either by rigors more or less distinct or by serious acceleration of the pulse. For the appearance of either of these symptoms the physician should therefore be on his guard especially if he has reason to suspect the possible presence of the epidemic influence of puerperal peritonitis, of erysipelas, or of any other of those influences already described as capable of developing fwer in the puerperal state. He should make sure that the nurse is intelligent enough to inform him at once if rigors, or even chilliness appear; and he should himself carefully observe the pulse at every visit. As long as this is below one hundred the patient is compara- tively safe, but when it suddenly rises above one hundred there is serious reason to apprehend the onset of child-bed fever, if it be not already insidiously at work within the pelvis. And in fact any severe symptoms arising in the puerperal Avoman should at once command the most careful attention. The pains of peritonitis may be distinguished from the after-pains by observing that the latter are attended by a perceptible contraction of the uterus, and that the after-pains are diminishing about the time—the third day—when the pains of puerperal peritonitis make their appearance; and that the last are particularly aggravated by pressure and motion, and that they become more and more severe. In like manner it will be observed that in child-bed fever the constitutional disturbance and hypogastric tenderness, and even the acceleration of the pulse, con- stantly increase day by day, instead of subsiding, as would be the case were these symptoms dependent upon after-pains or hysteralgia alone. VI. Course and Tendencies.—Child-bed fever in either of its forms runs a \rery rapid course; it is capable of terminating life in a few hours, or it may continue for several days, more or less, according to the nature of the patient's system, to the particular character of the attack, and to the kind of treatment employed; that form of the disease proving most rapidly fatal in which there is a profound " shock " of the nervous system; that in Avhich the vascular system is so disorganized as to induce softening and putrescency of the uterus coming next in order of sudden fatality; then the low, adynamic form of metritis or malignant child-bed fever; then the primary puerperal peritonitis; and finally uterine phlebitis. The general tendency of the disease is to a fatal termination, unless arrested by efficient treatment; but this tendency pursues in different cases a A^ariety of courses: in some the nervous system is "shocked' and destroyed; in others there is " dissolution of the blood," which SPURIOUS peritonitis. 453 may destroy life at once; in others there is disorganization of the tissues; in others, finally, the vital forces are exhausted by the intense suffering, by the gradual loss of oxygenation of the blood inseparable from excessive tympanites, and by the general severity of all the symptoms. VII. Treatment.—In treating cases of puerperal fever it is of the greatest importance to regard the moral state of the patient, both in the selection of the remedy and Avith reference to securing her against all disturbing emotions. The room should be as quiet and as cheerful and pleasant as possible; the diet should be carefully regulated; cooling drinks should be freely allowed; and the utmost cleanliness and purity of the patient's person, her clothing and bed- clothing, and the atmosphere, should be observed. The medicines specially adapted to the treatment of this grave disease will be found laid down under the article on Metritis. Spurious Peritonitis. Some authors have described under the title of false or spurious peritonitis an affection occasionally met Avith in puerperal women which in many of its symptoms bears a close resemblance to child- bed fever, and more especially to the peritonic form of that disease. It occurs mostly in women of nervous temperament, who are " delicate " and inclined to hysteria. The pain, Avhich is or appears to be very severe, is located by the patient in the region of the womb and its sur- roundings, but is probably seated in the muscular wall of the ab- domen, or in the musular fibres of the intestines. Although there may be evidences of a febrile condition, such as dry mouth, quick and jerking pulse and dry skin, yet the affection is evidently unconnected with inflammatory action, and is probably entirely neurotic in its character. The pain is described as unbearable and excruciating, so that the patient cannot bear even the most gentle touch or the pressure of the bed-coverings, and there is great mental excitement accompanying. It is important that this affection should be distinguished from true puerperal peritonitis. Its nervous and hysterical character is made apparent if, by withdrawing the patient's attention from the seat of pain by persuasive conversation or other means, considerable pressure can be made upon the abdomen by the hand without exciting remon- strance or increasing the suffering, and upon directing the Avoman's attention to her trouble the extreme pain and sensitiveness to pressure returns. Dr. Rigby thus Avrites: " If by soothing words and prom- 454 POST-PARTUM DERANGEMENTS. ises of cautious proceeding Ave induce her to let us apply our hand upon the abdomen so gently that it does not even rest its Aveight upon it, Ave shall find that Ave may noAV gradually increase the pressure until by degrees it becomes considerable, not only without her feeling any increase of pain, but with complete relief, the pressure of the hand appearing, as it were, to benumb the pain. If we Avithdraw the hand in the same gradual manner, no pain will be produced, but if' Ave remove it suddenly, a spasm of the muscles, Avith intense pain, is instantly excited," It is stated that this disorder may pass into a grave form of inflammatory disease, but this can scarcely happen under judicious homoeopathic treatment. A great variety of remedies may be indicated by the symptoms be- longing to this strange disorder, the principal of Avhich are—Acon., Bell., Cham., Coff., Cimicif., Coloc, Cup., Gelsem., Hyos., Ignat., Ipec, Kali c, Lach., Nux v., Opium, Phos., Puls., Spigel., Verat. vir., Zinc val. The article on Metritis may be consulted with advantage. CHAPTER XXIII. POST-PARTUM DERANGEMENTS.—CONTINUED. Puerperal Mania. A LTHOUGH puerperal mania is of itself seldom a fatal disease, ■£*- there is none in the catalogue of maladies to Avhich the pregnant and parturient woman is exposed more varied or more distressing, and at times alarming, in its phenomena. It is liable to occur during pregnancy, to set in suddenly and Avithout any apparent cause during labor, or to manifest itself subsequent to delivery. There are, how- ever, two periods during which the child-bearing Avoman is especially liable to its occurrence—viz., immediately after parturition and before the system has had time to recover its tone, and secondly, during lactation. Esquirol* observed that of ninety-tAVO women affected with puerperal insanity who were admitted into the Salpetriere, six- teen Avere attacked from the first to the fourth day after delivery; tAventy-one from the fifth to the fifteenth day; seventeen from the * Des Maladies Mentales. PUERPERAL MANIA. 455 sixteenth to the sixtieth; nineteen from the sixtieth day to the twelfth month of lactation; nineteen after weaning. In regard to the fre- quency of its occurrence, Dr. Haslam reports eighty-four cases out of sixteen hundred and forty-four insane women admitted at Bethlem Hospital; Esquirol reports ninety-two cases out of eleven hundred and nineteen admitted at the Salpetriere; Sir James Y. Simpson states that "the statistics of insanity appear to show that about ten per cent, of all the females found in lunatic asylums have become the inmates of these institutions in consequence of puerperal mania." " Of eight hundred and eighty-one AA'omen admitted to the Dixmont Hos- pital for the Insane at Pittsburg, Pa., the cause of insanity in one hundred and eight cases is ascribed to the puerperal state, constituting about tAvelve per centum of all the females Avho became inmates of this institution from 1856 to December 1, 1871. Of two thousand one hundred and thirty-three Avomen admitted to the Pennsylvania Hospital for the Insane at Philadelphia, the supposed cause of insanity in one hundred and eighty-five cases, or about nine per centum, was conditions superinduced by the puerperal state." * The pathology of puerperal insanity is quite obscure. Some authors have regarded it as a true phrenitis—inflammation of the brain and its meninges—while others maintain that it is due solely to exhaustion and the irritation consequent on the puerperal period. It is probable that there are various causes, both remote and proximate, which give rise to this disorder, the system being peculiarly suscept- ible to impressions during the parturient and post-partum period in consequence of its general depression ; the discrepancies of the various writers being accounted for by a want of proper discrimination in the results of their necroscopical researches. Amongst the predisposing causes Ave may mention hereditary disposition to insanity, frequent child-bearing, anaemia and exhaustion, albuminuria, excitation of the sexual system, puerperal convulsions and puerperal fever. The proximate causes may be divided into physical, such as prolonged and difficult labor, injuries from instrumental delivery, flooding, etc.; and such moral causes as have a tendency to excite or depress the mind, as fright, fear, joy, grief, anxiety, etc. It often happens, however, that cases of insanity occur in which no cause, either occa- sioning or exciting, can be fairly made out. Many authors, Gooch more especially, contend that the probability of a recurrence of the insanity in future labors is very remote, Avhile others, on the con- trary, assert that an attack, instead of giving immunity against future Dr. J. C. Burgher, in Transactions American Institute of Homoeopathy, 1872. 456 POST-PARTUM DERANGEMENTS. attacks, seems rather to render the woman more liable to a recurrence of the malady. The Avriter is cognizant of an instance in his own practice in Avhich four consecutive pregnancies Avere folloAved by puer- peral insanity of varying duration. Cases of puerperal mania may be divided into two classes, each of which may Arary as to time and cause of its appearance. These may be termed acute mania and melancholia, the first being characterized by a high degree of fever, violent delirium, great general disturb- ance of the system and all the indications of acute inflammation, while the other is marked rather by a depressed physical and mental condition. " The former occurs either immediately after delivery or at the commencement of lactation; the latter more often after suck- ling has been continued some time, and where the patient is becoming debilitated by it. The one is acute, both in its onset and progress, the other insidious and protracted. Death is not an infrequent result of the one, but it seldom happens in the other."—Meadows. Symptoms of Acute Mania.—The symptoms of this disorder are very variable and run through all the varied phases of insanity. The attack is usually ushered in by premonitory symptoms. Dr. Haslam asserts that " the first symptoms of its approach after delivery are— want of sleep, the countenance becomes flushed, a constrictive pain is often felt in the head, the eyes assume a morbid lustre and wildly glance at objects in rapid succession ; the milk is afterward secreted in less quantity, and when the mind becomes more violently disor- dered it is totally suppressed." This succession of symptoms is, hoAv- ever, not observable in every case; and the patient may even jump, as it Avere, from a condition of sanity to one of insanity without any noticeable warning. Insomnia, irritability of temper, pain in the head, restlessness, anxious expression of countenance, occasional loss of memory and consciousness, may be enumerated as amongst the most constant symptoms of the earlier stage. The patient may either sink into obstinate sullenness, occasionally interrupted by violent out- bursts of passion, or she may become furiously maniacal and threaten destruction to all around her. " The face is pale, features pinched, pulse small, irritable and usually accelerated; the temperature of the body rather below the normal standard; skin often clammy; Avith great debility she is blatantly noisy; stares Avildly at imaginary objects; instead of answering a question she repeats it, or she talks incoherently, uttering her Avords Avith great rapidity. She picks at the bed-clothes, grasps at anything or any one about her; curses and swears; objects to being confined to bed; complains of PUERPERAL MANIA. 457 being watched, and tries to escape. Occasionally obscene language and lascivious actions are indulged in to an extent that excites our amazement. Masturbation is sometimes noticed, but probably more from a Avish to allay irritation than a desire to excite it. The obscen- ity of Avord and manner often continues until convalescence is well advanced. She imagines that some calamity has befallen her husband, or that her babe is dead or has been stolen; and if brought to her she says it is not hers, refuses to nurse it, and even attempts to kill it if left Avithin her reach. Sometimes she is impressed with the idea that her husband is unfaithful, and has conspired with others to poison her. Confidence and affection give place to suspicion and hatred. Sometimes she will manifest great anxiety Avith regard to herself—fears that she will die, thinks that she has been poisoned, that she is flood- ing to death, that her blood has turned to water, etc. Suicide is often attempted by violently throAving herself on the floor, attempting to jump from a Avindow, strangle herself with a handkerchief or cap- string, etc.; the evident result of an abstract impulse without method or premeditation. She refuses to eat; the tongue is coated; the boAvels usually constipated, the secretion of urine diminished and the lochia sometimes suppressed." * The Diagnosis of this form of puerperal mania is readily made. Gooch very properly observes that the history of the case is essential to the forming of a correct diagnosis, but when this history is taken into consideration, and the phenomena above described, or other symp- toms indicative of insanity, are observed, the nature of the. disorder becomes apparent. NeA^ertheless, the disease may be mistaken for the delirium occurring during fever or acute phrenitis, or even for that of mania-a-potu. In cases, hoAvever, where any doubt as to the nature of the malady obtrudes itself, a very searching examination and com- parison of symptoms and conditions Avill set the matter in its true light. The Prognosis is not unfavorable. Dr. BurroAVs had thirty-five recoveries out of thirty-seven cases, Avhile Esquirol had but fifty-five out of ninety-two. The statistics furnished by old-school practitioners show about seventy-five per cent, of recoveries from this form of the disease. Symptoms of Melancholia.—This form of puerperal insanity differs very materially from that just described. It is usually characterized by debility and anaemia, and is generally occasioned by the drain upon the system in consequence of profuse hsemorrhage during or subsequent to labor, or of lactation. The face is pale, and the coun- * Dr. J. C. Burgher, loc. cit. 458 POST-PARTUM DERANGEMENTS. tenance has an expression of the deepest dejection. The patient usually sits quietly, and although she will speak Avhen spoken to, and answer questions, generally originates no conversation and gives ex- pression to no Avants or desires. The pulse is usually nearly normal; the temperature somewhat beloAV that of health ; the tongue is gener- ally coated, the boAvels constipated and digestion impaired. The de- rangement occasionally takes the form of religious melancholy, in which case she deplores her sinful condition and speaks in the most despondent manner of her soul's salvation. " In a case recently occurring in my own practice," Avrites Dr. Burgher, "the patient argued that her oavii damnation was necessary to secure the sanation of the other members of her family; and yet she manifested an in- difference toAvard her husband and a dislike toward her children, whom she Avould order from her presence, and even refused to nurse her babe." There is usually an entire absence of anything like ex- citement, the patient, on the contrary, being in a state of decided mental depression. Gooch says that there is an incipient stage, in which the mind is wrong, yet right enough to recognize that it is wrong; and in these respects it differs from acute mania. The course of this form of mania is generally more tedious than that of the acute form, and there is some danger of its becoming chronic; but this sad termination very seldom results, the restoration of the best physical health and strength being followed by the res- toration of mental and moral health. It seldom or never ends fatally. Women Avho have an hereditary tendency to insanity are most ob- noxious to this disease; and it is likewise apt to occur Avhere hysteria has manifested itself during pregnancy, especially during the latter months. The Treatment of puerperal mania requires the exercise of a great deal of common sense and sound judgment. All sources of irritation should be removed if possible; appropriate medicines should be given according to the indications afforded, and such diet and regimen pre- scribed as Avould be best calculated to support the strength of the patient and bring her into the most favorable physical condition. Especially in the second form of the disease—melancholia—the patient being in a condition of anaemia and debility, a good and nourishing diet is of great importance; and in both forms of the disease every effort should be made to secure for the afflicted patient such surround- ings as have a tendency to calm the disordered nervous system. She should have a suitable attendant, and should never be left alone; and everything by which suicide might be effected should be carefully PUERPERAL MANIA. 459 kept from her. It may even be necessary to resort to forcible re- straint, but this should be avoided if possible. If absolutely required, the " strait-jacket" should be used. Out-door exercise, other things agreeing, should be taken daily during favorable Aveather, and will be found beneficial, as will appropriate baths. The following medicaments will be found of service, according to the indications given, though many others not here enumerated may be used, either for the disordered mental condition or its accompanying physical derangements. The remedies Avith their indications men- tioned in the articles on Nymphornania> Hysteria and Metritis may also be consulted Avith advantage. Aconite. "Where there is much fear manifested—fear of death, of strangers, of getting up; if caused by a fright. Aurum. Very unhappy; continual thought of suicide; manifest weakness of memory and intellect; great sleeplessness day and night. Belladonna. Desire to escape or hide herself; paroxysms of rage and fury; sleepless nights; fear of ghosts ; sometimes desires other people to kill her, that she may be out of her misery; much moaning. Hyoscyamus. Indomitable rage and horrid anguish; does not know her relatives; complains of having been poisoned; complete loss of sense; desires to be naked; constantly throwing off her bed-covers or clothes; entire loss of modesty. Kali carb. Great sadness; weeps much, and is afraid she is going to die; great absence of mind ; seems at a loss to know how to begin to say or do Avhat she wishes to do; makes several attempts, but is finally obliged to give it up; can't express herself; abdomen dis- tended with flatulency; thirst, restlessness and tossing. Petroleum. Full of strange delusions, as—thinks there is another baby in bed with her requiring attention, or that she has a third leg or arm; has sharp pains shooting up the dorsal spine into the occiput. Platina. Has a sort of voluptuous crawling up and about the geni- tal organs; very haughty; looks doAvn very disdainfully upon her attendants; black, tarry discharge from the vagina. Pulsatilla. Sad, Aveeping mood; taciturn; very mild and gentle in all her Avays; Aveeps very easily. When closing her eyes sees pic- tures and all sorts of strange sights; hears all kinds of operatic airs. Stramonium. Nymphomania, with obscene gestures and language. Desires light and company; much Avorse in darkness and solitude; 460 POST-PARTUM DERANGEMENTS. very loquacious, in a prayerful, beseeching, imploring language; face often red and bloated. Sulphur. Disposition to meditate on religious subjects, Avith despair of salvation; forgets the names and words she Avants to use; flushes of heat; Aveak, fainty spells and cold feet; sleeps very lightly. Veratrum. Religious melancholy or nymphomania, Avith desire to embrace everybody, and even inanimate substances; much thirst for very cold Avater; constantly craving cool and refreshing things. Zincum. A marked degree of melancholy, Avith fear of thieves, demons and other frightful figures. It seems to be impossible for her to keep the feet still; they are in almost constant motion. For other remedies see Nymphomania, Hysteria and Metritis. Phlegmasia Dolens. There is no disease in the catalogue of those to which child-bearing vvomen are liable concerning the setiology and pathology of which greater diversity of opinion has been expressed by various Avriters, and even at the present day no satisfactory conclusions have been arrived at. It was formerly regarded as peculiar to the lying-in state, but this view is by no means correct, for it not unfrequently occurs at other times than after childbirth, attacks even men, and is not confined to the lower extremities, the upper being occasionally the seat of the disease. Necroscopical research has shown that there is usually free serous effusion into the limb, inflammation and sometimes suppuration of the lymphatics, and occasionally a plugging up of these vessels by plastic lymph, and inflammation and obliteration of some of the larger veins of the extremity. This last-named is apparently the most important and certainly the most constant condition, and has given rise to the opinion that the disease consisted essentially in an inflammation of the crural veins, proceeding, as Dr. Robert Lee believed, from the uterine branches of the hypogastric veins. This view, however, has been stoutly combated by Rigby, Mackenzie and others. It occurs after easy as well as difficult labors ; sometimes re- sults from puerperal fever; most frequently attacks the left leg, and occasionally recurs many times in the same person. When fully developed in parturient Avomen, it usually consists in a SAvelling of the affected extremity, especially of the thigh, the skin being someAvhat Avhiter than usual, tense and shining, and very sen- sitive of even slight pressure; but the SAvelling is not anasarcous and does not pit on pressure. An attack is usually ushered in by slight rigors and febrile phenomena; pain in the lower part of the abdomen PHLEGMASIA dolens. 461 folloAvs, which extends to the hips and back, passes under Poupart's ligament, and thence doAvn the thigh and into the calf of the leg. It frequently, hoAvever, proceeds from the calf of the leg upward. The whole extremity becomes excessively SAvollen, hot and painful, but not red, and hence the term phlegmasia alba dolens. The lochia and milk may or may not be suppressed; the constitutional disturbance and fever become greatly increased. The tenderness on pressure is most marked along the course of the femoral vein, and the veins of the affected region, together with the associated lymphatics, may be felt to be hard and cordlike, and are sometimes marked out by a faint red line. Denman describes the on-coming of the disease in the fol- lowing terms: "Before the appearance of any swelling or sense of pain in the limb about to be affected, women become very irritable, Avith a sense of great weakness, and grievously oppressed in their spirits, without any apparent sufficient reason, complaining only of transient pains in the region of the uterus; and from these the approach of the disease has been frequently 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 lymph- atics, stretching up to the ham, along the internal part of the thigh to the groin, occasioning a slight soreness on the loAver part of the abdo- men." It occasionally happens, hoAvever, that there are no premoni- tory symptoms, but the pain in the leg is the first indication of the disease, which rapidly becomes swollen, tense, stiff and excessively sensitive to the touch. As before remarked, the SAvelling does not pit on pressure, and if it be punctured little or no fluid escapes. Although the pain is greatly increased if the limb be allowed to hang doAvn, the swelling is not affected by position. The progress of the disease is usually very rapid, especially as regards the SAvelling, which frequently arrives at its height, doubling the size of the limb, in twenty-four hours, or even in a shorter period of time. As the disease advances the parts lying within the pelvis become more and more irritable; there is often difficulty in evacuating the bladder and rectum, and the constitutional disturbance is very great. The glands in the groin are sometimes affected, and become SAvollen and even suppurate, and abscesses may form in very bad cases in different parts of the limb. This condition of the parts and of the system may continue for a longer or shorter period. Sometimes after two or three days the con- stitutional symptoms subside, the pain is greatly lessened or almost entirely disappears, Avhile the limb remains swollen, though softer 462 POST-PARTUM DERANGEMENTS. and apparently cedematous, as it now retains the impression of the finger. Sometimes this does not take place for one or more Aveeks. Even after this subsidence of acute symptoms, however, the limb remains for a long time stiff and poAverless, and occasionally docs not return to a normal condition for months, and even years. Burns remarks that it 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, Avhich has sometimes suddenly proved fatal; or, after the leg appears to be getting better, daily shivering with Amounting, pain in other parts, and rapid pulse, with delirium (pyaemia), precede death." The prognosis, hoAvever, may be regarded as favorable especially under homoeopathic treatment, the remedies used being specifically adapted to the Avhole condition, and the strength of the patient not wasted by severe medication and depletion. The older Avriters associated this disease with a disappearance and " translation " of the lochia or milk. Dr. Hosack regarded it as an inflammatory disease, affecting not only the limb but the whole system, proceeding from suppression of the natural excretions, the effect of cold stimulating drinks and other causes, and not connected with the lochia. Dr. Tilbury Fox is of the opinion that both veins and lymphatics are obstructed, which is due simply to extrinsic pressure or to inflammatory changes in the coats of the vessels, leading to coagulation and depending upon virus action. Treatment.—The diet should of course be low and non-stimulating during the period of high inflammatory action and great constitutional disturbance, but Avhen resolution has fairly been established more generous food may be given with advantage. If abscesses form, they should be treated according to ordinary surgical rules. The following are the most frequently indicated medicines for the treatment of this disease, with their indications: Apis. Fever, with constant restlessness and tossing without relief; absence of thirst; scanty urine; the swelling has a whitish, transpa- rent look; the pain is usually stinging or there are sharp plunging pains. Arnica. If the disease sets in immediately after a very difficult labor. Arsenicum. Great restlessness, every motion producing a sensation PHLEGMASIA DOLENS. 463 of exhaustion; thirst for frequent sips of cold Avater; cold and chilly; Avishes to be covered up Avarm; burning pains; SAvelling pale and cedematous. Belladonna. Cutting pains as if Avith knives; sensation of heaviness in the thighs, hypogastrium and sexual parts; the least jar of the bed or floor is painful; fever, Avith burning thirst; cannot bear to be touched; much moaning and sleeplessness; throbbing of the carotids; injected eyeballs; cannot bear noise or light. Bryonia. DraAving or lancinating pains from the hip to the foot; aggravation from touch or the least motion; copious perspiration without relief; pulling in the abdomen and doAvn the legs as if the menses would appear; a pale pink swelling of the leg; dry lips and mouth, with desire for large quantities of cold Avater; aggravation in the evening and early part of the night. Calcarea carb. A Avhitish SAvelling of the foot and leg, with a sensa- tion of coldness, as though covered with a cold damp cloth; suppres- sion of milk, Avith a sensation of coldness all through the body; leucophlegmatic temperament; menses have always been too frequent and too profuse. Kali carb. Swelling of the foot and leg, Avith stitching and shooting pains; shooting and stitching pains in the abdomen; abdomen dis- tended Avith flatulency; distressing pain in the back, extending doAvn into the glutei muscles; restlessness, with tossing and thirst. Nux vomica. Red SAvelling of the leg Avith dark, painful spots; a powerless, bruised sensation in the leg; a bruised, sore sensation low doAvn in the abdomen, with frequent desire to urinate and frequent inclination to stool; loss of appetite; aggravation after three o'clock in the morning; great depression of spirits. Pulsatilla. Pale SAArelling in the foot and limb; suppression of the milk; mild, tearful, gentle disposition; a warm room aggravates all her sufferings; craves the fresh, open air; thirstless; a very offen- sive clammy taste in the mouth, particularly after sleeping. Lycopodium. Swelling of the foot and limb; the saphena vein is SAvollen very large, and it is very tender, and can be distinctly traced all the Avay up; there is much loud rumbling and moving of flatu- lency in the abdomen; red sand in the urine; pain in the back before urination; much restlessness and tossing at night. Rhus tox. At the very outset of the disease there is a marked de- gree of poAverlessness in the limb; cannot draw it up; there is often a red streak running up the course of the saphena vein; great restless- ness, relief being found for a short time after every change of posi- 464 DISORDERS OF LACTATION. tion; Avorse after twelve o'clock at night; Avorse from water and Avetting the part; usually Avants to be covered up Avarm. Sulphur. Frequent flushes of heat; weak, fainty spells; short sleeps, from Avhich she starts up wide awake; little papular eruptions on the leg and over the body. (For other remedies see Metritis.) CHAPTER XXIV. DISORDERS OF LACTATION. THE only injurious effect of pregnancy upon the milk of the nurs- ing mother is to render it less nutritious; consequently, the nurs- ling must suffer for want of that nourishment which would otherwise be devoted to its support; it feeds, as it were, upon the husks, and of course it becomes sickly and loses flesh. Sore Nipples. It is best to make preparation for nursing, so that the nipples shall not be troublesome by becoming tender, cracked or ulcerated. If they become tender or painful during pregnancy, some such remedy as Graphites, Lycopodium, Petroleum, Pulsatilla, Sepia, Silicia or Sul- phur will cure them, so that no trouble Avill be experienced during the nursing period. All these troubles of sore nipples arise from some dyscrasia developed by pregnancy and nursing; hence they are espe- cially curable even while nursing. Agaricus. If the patient be troubled with chilblains, which itch and burn very much and are red; or if the nipple itches and burns much and looks red. Arnica. When in the first days of nursing the nipples only feel sore, as if bruised. It is often indicated, and often cures in a few days when early applied. Calcarea C. An ulcer appears on the nipple, discharging pus; the patient is otherAvise a subject for this remedy. Chamomilla. The nipples are much inflamed and are very tender. She can hardly endure the pain of nursing. She feels irritable and cross, with impatience. SORE NIPPLES. 465 Castor equorum. In neglected cases, where the nipple is nearly ulcer- ated off; it only hangs as it Avere by small strings. Croton t. Every time the child draws at the nipple a pain runs through to the scapula of that side, which is excruciating. The nip- ples are very sore to the touch, but the chief suffering is the pain run- ning to the scapula. Graphites. The nipple seems to have little vesicles on it; at least it oozes out a thick, glutinous fluid, which forms a crust that is removed by nursing, when the same formation again occurs, and so on. Lycopodium. The nipple bleeds very much and is very sore, and the child draAVS so much blood from the nipple that when it vomits it seems to be vomiting blood. Lycopodium given to the mother will soon cause the nipples to heal. Mercurius. The nipple feels very raw and sore. She has sensitive gums, sore teeth, enlarged cervical glands, and other mercurial symptoms. Phosphorus. The nipples are hot and sore - the abdomen feels weak and empty; much heat in the lower part of the back across the region of the kidneys. Pulsatilla. In mild, tearful patients, who' weep at every nursing. The pain from nursing often extends into the chest, up into the neck, doAvn the back, and often changes from place to place. Sepia. The nipples crack very much across the crown in various places; deep cracks; very sore. Silicia. The nipple ulcerates very easily,, and is very sore and tender. Sulphur. After nursing the nipple smarts and burns very much. It chaps badly about the base and bleeds. Constitutional symptoms will sometimes determine the selection of this remedy in order to cure the nipples. The proper mode of administering the remedy is to give one dose dry on the tongue, and to dissolve a feAv globules of the same remedy- in Avater, or water and brandy, and apply the solution to the nipple immediately after nursing. In this manner all sore nipples may be cured more speedily and certainly than by any other means. As before remarked, the child should be put to the breast soon after being born. After being washed and dressed, it may be allowed to sleep for a Avhile, but Avhen it aAvakens it should be put to the breast, and not otherwise fed, unless it is not satisfied Avith the breast. In this case it may be fed with milk, or cream and water, two parts of the latter to one of the former. The child should be educated to 30 466 DISORDERS OF LACTATION. regular periods of nursing; it should not be put to the breast or fed every time it cries; let it be turned over or its position changed, and be patted and quieted, till the period has expired, say two hours, tAvo and a half, or three hours: some definite period of interval should be decided upon and most rigorously adhered to. If the mother has sufficient nourishment for her babe, no other need be added, provided she be sufficiently strong and healthy for the occasion. If from any cause it becomes necessary that the child should depend in part or entirely upon other nourishment, that should be provided Avhich most nearly resembles the mother's milk. Cream diluted with water is the best. After fiVe or six months, when the child requires more nourishing food, one of the most suitable articles is readily pre- pared as follows : Take a quantity of flour, tie it very tightly in a bag or cloth, then dip it quickly into water just to moisten the surface, and then roll it in dry flour, then dip it in again, and so on till it is quite thickly coated with a sort of paste; now put this into boiling water and let it boil for four or fivTe hours. The contents of the bag will then be thoroughly cooked, when it may be grated and made into pap as required for use; for this latter purpose water or milk may be employed. A small pinch of salt and perhaps a little sugar will be useful. Wheat bread thoroughly baked, dried in the oven, reduced to a powder and made into a pap, is also A^ery useful. As the child gets more and more teeth, its diet may be more and more varied and liberal, but until its first dentition is accomplished a meat diet should be as much as possible avoided. Sometimes children will not take milk; then cracked cocoa, made as ordinarily for table use, and an equal quantity of milk added, Avith a little bread, forms a very acceptable article of diet, both healthy and nutritious. Remedies for Abnormal Secretion of the Milk. The subject of the secretion of milk has been treated of on page 214, to which the reader is referred. It sometimes happens that milk is secreted more or less abundantly, but, owing to some derangement of the maternal system, it is of a quality not calculated to afford sufficient nourishment for the child, or even causes decided sickness. In such cases the mother should be carefully treated in accordance Avith homoeopathic principles, Avhen it will be found that as health is restored the lacteal fluid improves, no longer disagrees with the child, and nourishes it as it should do. The child should not be deprived of its natural sustenance for any light reason, nor until homoeopathic REMEDIES FOR ABNORMAL SECRETION OF THE MILK. 467 medication, acting on both mother and offspring, has utterly failed to bring about the secretion of a natural and healthful milk on the one hand, and a normal receptivity on the other. In all cases where it is suspected that the quality of the milk is not good, it should be care- fully examined and tested; and in conducting this examination the microscope will be found a very efficient aid. The folloAving remedies are confidently recommended: Aconite should be administered when there is hot, dry skin, much thirst, restlessness, discouragement, anxiety; breasts hard and knotted. ./Ethusa cyn. The child takes the breast Avith avidity; nurses plen- tifully, then vomits copiously and is exhausted, but soon rallies and cries for a fresh supply. The child's bowels are either costive or loose; it cries much, and does not thrive. The mother is not Avell; the lochia is too thin and watery; she is very nervous; has a bitter taste in her mouth; milk disagrees with her; the abdomen is SAvollen and hard. In such cases ^Ethusa should be administered to both mother and child. Agnus castus. The mother is very sad and depressed; frequently says she Avill die; the milk is very scanty. Belladonna. The breasts feel heavy, and appear hard and red, the redness often running in radii; flushed face and injected eyeballs; full, bounding pulse; drowsy, throbbing headache; sensitive to noise and light. From taking cold. Borax. The milk is too thick and tastes badly; often curdles soon after it has been drawn. Bryonia. The breasts feel heavy, a sort of stony heaviness—rather pale, but hard; dry lips and mouth; constipation of burnt, dry faeces; splitting headache; nausea and faintness on sitting up. Calc. c. The breasts are distended, the milk scanty; she is cold; feels the cold air very readily; there seems to be a Avant of vital activity to bring the milk forward; leucophlegmatic constitution. Carbo an. Painful nodosities of the mammse. Nursing causes stitching pains in the mammae, which arrest the breathing. She cannot bear to have the breasts touched or handled. The milk is thin, and has a saltish taste. Causticum. The milk has almost disappeared in consequence of over-fatigue, night-watching and anxiety. It is especially suitable for delicate, light-complexioned women. Generally constipation. Sen- sation in the stomach as though lime were slacking. Chamomilla. The breasts are very tender; the nipples inflamed and 468 DISORDERS OF LACTATION. SAvollen; she is restless; thinks she can hardly endure her sufferings; is fretful, sleepless and cross; Avhen caused by a fit of passion. China. The Avoman is very weak in consequence of loss of blood during labor, or too profuse lochial discharge. She feels worse every other day. Feeling of fullness in the abdomen. The milk is scanty thin and Avatery. Cina. GnaAving sensation in the stomach, as from hunger, which is constant. Itching of the nose; does not sleep well; feels cross and irritable, and is not easily satisfied. Croton t. The breasts may or may not be swollen, but the pain extends from the nipple through to the shoulder-blade every time the child draws at the breast; the suffering is excruciating. An excellent remedy, even if the breasts are hard and swollen. Dulcamara. The milk fails of being secreted, apparently in conse- quence of the patient having taken cold, which has settled in the breasts; the mammae are SAvollen, inactive, painless, and itch. Kali bich. The milk as it flows from the breast has the appearance of being composed of stringy masses and water. Lachesis. The milk is thin and blue, and is rejected by the infant. She feels disconsolate and sad on awaking in the morning, and throughout the day has a dissatisfied and unhappy feeling. The whole disorder may be the result of some long-standing mental trouble. Mercurius.. This remedy is especially suitable if there be a syphilitic taint of system. The breasts are swollen and hard, with a feeling as if they were raw and sore; ptyalism; scorbutic appearance of the gums, and other symptoms indicative of mercury. Nux v. Especially suited to Avomen who use habitually highly- seasoned and rich food, wines, etc., or if the disorder arises in conse- quence of an error of diet. Constipation and disordered condition of the lochia. Pulsatilla. The breasts are much swollen, and rheumatic pains ex- tend to the muscles of the chest, shoulders, neck, axillae, and down the arms, etc. She is feverish and tearful, but not thirsty. Feels better in a cool room. The milk is thin and Avatery, and the true milk-globule is almost entirely absent. Bad taste in the mouth in the morning. Fatty rich food disagrees. Craves cool, fresh air; the Avarm, close room causes her to feel ATery badly. Rheum. Sour-smelling diarrhoeic stools, with colic and shuddering during stool. The milk causes a similar diarrhoea in the child; almost immediately after nursing the babe has a loose evacuation, which is sour-smelling, and is accompanied with colic. FAILURE OR SCANTY SUPPLY OF THE MILK. 469 Rhus t. The breasts are painfully distended and red in streaks, and there is a rheumatic condition of the whole body. Stiffness of the joints; the first movement is painful and stiff, but she can move easily afterward. She cannot lie long in one position; she must change in order to find an easier place. Sepia. In women of very delicate and sensitiAre skin. Flushes of heat; painful sensation of Aveakness in the epigastric region; cold hands and feet; she is disgusted at the smell of food. Silicia. The infant refuses the breast or vomits immediately after nursing. It often refuses to nurse at first, but afterward takes the breast Avith hesitancy, and then vomits; it does not grow as it should. The mother is not well; she has the silicia constipation, or other symp- toms indicative of that remedy. Zinc. She is very fidgety, especially in the feet, which she cannot keep still. Failure or Scanty Supply of the Milk. When the mother has not a sufficient quantity of nourishment for her infant, the deficit is often owing to some unnatural state of her own system, and the proper homoeopathic remedy should be sought to change that condition, so that a natural supply may be afforded. The habit of forcing a supply by means of porter or other similar stimulant is alike injurious to the mother and to the child. The prop- er remedy will develop a healthy condition, and consequently a good supply of milk. Where there is a scarcity of milk from any cause, study the following medicines, and consult likeAvise those mentioned in the section immediately preceding: Aconite. The mamma? are congested, burning hot, hard and dis- tended, Avith little or no milk. Agnus c. Frequently indicated, particularly Avhen a despairing sad- ness is the predominant symptom. Asa f. When there is excessive sensibility of the vital organism, and the veins are unnaturally distended. More or less frequently indicated. Belladonna. The breasts feel large and heavy. Headache, and the eyes are congested. She does not sleep Avell; she lies half sleeping and half Avaking—betAveen the tAvo. Bryonia. Dry, cracked lips, dry mouth, constipation, as if the faeces were burnt. No appetite; nausea after eating. Calcarea c. In leucophlegmatic constitutions. Rather of a chilly 470 DISORDERS OF LACTATION. nature. Menses had been too often and too profuse; usually subject to leucorrhoea. Causticum. When, as an attendant symptom, threatened amaurosis exists. Pulsations and noises in the ears. Anxiety and despondency; the Avoman has been subjected to night-watch ing, care, trouble, etc. Chamomilla. When the mammae are hard and tender to the touch, with draAving pains. Insulting, cross and uncivil in temper. China. Where there is debility from loss of animal fluids—par- ticularly blood—or from diarrhoea or leucorrhoea. Much pain be- tween the shoulders. Coffea. Much excitability and sleeplessness. Dulcamara. Particularly when there has been suppression from exposure to the cold and damp air. The milk is scanty, the skin is delicate and sensitive to cold, and liable to eruptions from being exposed to the cold. Merc. sol. Milk scanty, with scorbutic gums, swelling of the glands, etc. Phosph. acid. Scanty milk, debility and great apathy. Pulsatilla. In mild and tearful women, in apparent good health, who have but little milk. This remedy is often called for in this affection. Rhus t. Entire want of appetite, mental derangement and thoughts of suicide. Vitiated lochia, lasting too long, and powerlessness of the lower extremities. Secale C. In women Avho are much exhausted from venous hsemor- rhage. In thin, scrawny women. The breasts do not properly fill with milk; there is much stinging in them. Sulphur. Flushes of heat, weak and faint spells, heat on the top of the head, cold feet, very faint and hungry at about noon, she cannot . wait for her dinner, etc. If the milk seems abundant, and yet the child does not thrive, the fault may be in the mother, or it may be in the child. Administer, according to your best judgment, such remedies to the mother as Calc. c, China, Cina, Mercurius or Sulphur; or to the child, Calc. c, Silicia, Baryta c, Borax, or Avhatever may seem most appropriate, according to the particular indications and conditions; or the same remedy to both at the same time. Galactorrhea and Excessive Lactation. In cases of spontaneous flow of milk, keeping the breasts constantly Avet, relief from such an uncomfortable state may be obtained by the GALACTORRHEA AND EXCESSIVE LACTATION. 471 appropriate remedy, according to the indications given beloAV. The function of lactation being one purely physiological, and provided for in the economy by suitable forces under the stimulus of the maternal instinct and affection, most Avomen enjoy perfect health during its continuance. Many indeed are never so well as when giving suck to their children. Under the influence of this process there arises a greater activity of all the assimilative functions at the same time, and in con- junction Avith a greater strength of appetite and corresponding energy of the digestive powers. The process of conversion of food is un- usually rapid, the excess going to form the milk. Where a greater amount is thus formed than is required, the system becomes gradu- ally exhausted, even in health, just as the preparation of a less amount may overtask the system Avhen in a condition already enfeebled. This OArer-production in the former case may be due simply to excess of vitality, while in the latter case it may result from a corresponding effort of nature to supply the required material support, even under difficulties. But there are cases in which an excess of the secretion of the milk seems just as much the result of some interior morbid condition as its more or less complete failure would be. This is especially seen in the intimate relation which such excessive flow of milk—or Avhat for all practical purposes amounts to the same thing, undue lactation— bears to insanity. And in the folloAving extract from the excellent work of Tyler Smith the reader will see the injurious effects which may arise from excessive lactation of either sort, and learn to antici- pate the mischief from the first symptoms: "The cases of insanity which occur as the result of undue lactation are very similar to cases of puerperal insanity, only that their symp- toms come on in a more gradual manner. When nursing women com- plain of loss of sight or hearing, or headache, either their nourishment and stimulus should be increased, or suckling should be at once dis- continued. Where there is any predisposition to insanity, mothers should not, if possible, be alloAved to suckle their children. In all cases of this kind the dependence of the mania upon exhaustion is abundantly evident. It is especially likely to happen when pregnancy and lactation are allowed to proceed simultaneously. "There are in the subjects of this form of disease the same suicidal and homicidal tendencies as in puerperal insanity. I once met Avith a case in which a mother delivered of twins became affected in her mind from suckling, and a Avet-nurse was procured in the person of a young girl Avho had given birth to an illegitimate child. She had 472 DISORDERS OF LACTATION. nursed her oavii infant for some time, and then, Avhile being drained by the twins, again became pregnant. Signs of insanity manifested themselves, and she was one day found dead, hanging behind the door of her room. This form of insanity comes on Aveeks or months after the close of lactation. I have no doubt that the woman Brough, Avho killed, two or three years since, several of her children at Esher, and who is noAV a confirmed lunatic at Bethlehem, had suffered from over- lactation. She had Aveaned a child not long before the dreadful trag- edy, had complained of loss of sight and severe nervous disorder, and had suffered in her head in previous lactations. The preventive treat- ment in this form of insanity consists, of course, in Aveaning as soon as any marked signs of nervous disorder are perceived. In the man- agement of such cases great care in guarding the patient is necessary, and the treatment of this disease must be a supporting and stimulating one, combined with perfect rest, and the avoidance, as far as possible, of all moral and physical excitement." Thus galactorrhcea, or excessive or undue lactation, is seen to be capable of producing the most destructive results in the mental and physical economy. The symptoms which indicate that lactation is morbidly affecting the mother are: " A sinking and fainting at the epigastrium, with a sense of emptiness, Avhich lasts a long time, and soon returns even after food has been taken; a general weariness and fatigue; a Avant of refreshment from sleep ; an aching and dragging in the loins, and pain between the blade-bones or in the side beneath the left breast; distressing exhaustion after the infant has been at the breast; the pulse is quick and feeble; the extremities cold; there are dyspnoea and palpitation on making the least exertion or ascending the stairs. If the cause is continued, headache and vertigo, noises in the ears, numbness of the extremities, impaired vision, exciting fears of amaurosis, loss of memory, irritability and despondency, Avith thirst, dryness of the tongue and night perspiration, ensue. Pulmonary con- sumption may be developed; the general appearances of anaemia, menorrhagia, leucorrhoea, oedema of the face and extremities, and neuralgic affections of various kinds supervene, and mania has not unfrequently formed the sequel. Thus organic disease of the brain, lungs and uterus may be added to the evils attendant on undue lactation."—Leadam. Except in the most extreme cases of exhaustion from excessive flow of milk, or protracted lactation, Ave do not advise the use of any other stimulus than the appropriate remedy. There may be cases in Avhich a little wine may be temporarily useful, but rest, cessation from nurs- MASTITIS—inflammation of the breasts. 473 ing, and, if necessary, from all the care of the child in any way, suit- able food and the true homoeopathic remedy, will do all that art can accomplish to restore exhausted nature. In cases of galactorrhoza, or excessive spontaneous flow of the milk, use, according to the particular attending symptoms and conditions, Belladonna, Bryonia, Borax, Calc area c, China, Conium, Phosphorus, Pulsatilla, Rhus or Stramonium. In cases of deterioration of health from nursing, undue or protracted lactation, where appear debility, loss of appetite, hectic fever, night- SAveats, etc., study Calcarea carb., Calcarea phos., China, Lycopodium, Phosphorus, Phosph. acid, Sulphur, Silicia, etc. Cramps in the stomach from nursing may require Carbo an., Carbo veg., China or Phosphorus. For great sense of emptiness in the pit of the stomach from nurs- ing, study Carbo an., Sepia, Ignatia and Oleander. Mastitis—Inflammation of the Breasts. Inflammation of one or both breasts, Avith a manifest tendency to suppuration, is apt to be of frequent occurrence in nursing Avomen. And in some persons this difficulty, originally arising from constitu- tional predisposition, becomes almost a confirmed habit, since they seldom or never can nurse a child without experiencing the exceeding distress and annoyance of a gathered breast. The inflammation may be located principally in the external mamma, affecting particularly the areolar tissue and partaking of the nature of erysipelas. Or the inflammation may be seated more deeply in the substance of the breast. Or, again, the inflammation may be developed principally and especially in the mammary gland itself. Finally, there are cases in Avhich the inflammation seems to involve the entire substance of the breast and structure of the organ in one indistin- guishable mass. More often, however, the pains scattered through the breast, and the various diverging painful indurations, lead to the conclusion that the gland Avith its ramifications is the particular seat of the disease. And in thus determining the nature of the affection, the cause of it, or the manner in Avhich it arises, will often be of service. For if the breast evidently became inflamed from undue exposure to cold air in the delicate state of early lactation, a general inflammation may be expected to ensue, Avhile difficulties belonging to the process of the secretion and discharge of the contents of the lactiferous tubes may sometimes be seen plainly to precede inflammation in those tubes and 474 disorders of lactation. in the gland itself. Much is due also to previous history and consti- tutional diathesis; influences which in some would prove perfectly innocuous, in others rapidly develop inflammation, Avhich no less rapidly tends to suppuration. In such cases the greatest care, assisted by a dose or two of the antipsoric which seems most suited to the patient's constitution, Avill go far to prevent the suffering inseparable from a gathered breast. Where the milk is copiously secreted, and either from inability on the part of the child, in its absence, or from obstruction of the milk-tubes, or from deficiency of the nipple, the milk cannot be freely drawn in the natural Avay, every effort should be made Avithout loss of time to secure this end by such other means as may be possible. Sometimes the breast may be drawn by another child, or by a friend, or by young puppies; the proper remedy in the mean time should be carefully selected and faithfully administered, in order as rapidly aa possible to remove all difficulty Avhich may be amenable to such medi- cation or Avhich may be resulting from the obstruction. In cold weather the inflamed breasts should be kept warmly protected; and besides this the less external application is made to them the better. If the inflammation is caused and kept up by a tender and ulcerated state of the nipples, let these be particularly attended to in accordance with the directions already given. Properly used, homoeopathic rem- edies may be made effectual in resolving the inflammation and avert- ing suppuration, in a great majority of cases that are attended to at once. Aconite. When a chill in dry, cold air has been the exciting cause, and a true synochal fever prevails. There is fear, anxiety and rest- lessness, thirst for cold water, etc. Belladonna. When the breasts feel heavy; there are red streaks run- ning like radii from a central point; she is occasionally chilly; a dull and stupid feeling prevails. Bryonia. Her breasts have a stony heaviness in them; they are hot, hard and painful, but not very red. She feels sick on first sitting up in bed or in a chair, and still more sick on standing up. Rough, dry lips, thirst and constipation; stools dry, looking as if burnt. She feels worse Avhen moving, and keeps very still. Carbo animal. Darting in the mamma, arresting the breathing and aggravated by pressure. She can scarcely tolerate the application of the child to the breast; it takes her breath away to apply it. Cistus c. Particularly indicated in scrofulous subjects, where there MASTITIS—inflammation of the breasts. 475 is the greatest sensibility to cold air. Inflammation and suppuration of the breast, with a sense of fullness in the chest. Graphites. In all cases Avhere there are so many old cicatrices from former ulcerations that the milk can scarcely flow. This remedy, high, Avill now cause the milk to Aoav easily and Avard off the impend- ing abscess; it has proved perfectly efficacious in many such cases. The same success is claimed for Phytolacca in similar cases. I have, however, the greatest confidence in Graphites; this remedy, although many times tried, has never failed me in a single case. Hepar. When suppuration seems inevitable, and there is no other particularly characteristic symptom. Give a single dose, high, and await the result, either in resolution or in suppuration. Lachesis. When the breast has a bluish or purplish appearance, and she has chills at night and flushes of heat by day. Mercurius sol. Hard swelling of the breast, Avith sore and raw sort of feeling; the milk is not good, so the babe refuses it. She has scor- butic gums and other general symptoms of Mercury. Phosphorus. Inflammation of the mammas, even threatening ulcera- tion, Avith stitching or cutting pain. (Hectic fever and night-sweats.) In fistulous ulcers Avith blue appearance. Phytolacca dec. Particularly where the hardness is very apparent from the first. Sensitive, and more or less painful; even after suppu- ration has taken place these characteristics continue. Silicia. In fistulous ulcers particularly, the discharge being thin and Avatery, or thick and offensive. The substance of the mamma seems to be discharged in the pus; one lobe after another seems to ulcerate and discharge into one common ulcer, often with pain; or there may be several orifices, one for each lobe. Sulphur. Inflammation running in radii from the nipple. Suppu- ration profuse, Avith chilliness in the fore part of the day, and heat in the after part. Some hsemorrhoids in complication. In old ulcera- tions, where the breast has raAv places on it. The breasts feel hot. She has night-sweats, flushes of heat, Aveak and faint spells, irresistible hunger at 11 a. m. Verat. viride. Bids fair to be serviceable in all cases where these troubles are complicated Avith great arterial excitement. In case the child vomits the milk soon after nursing, give the mother JEthusa, Calcarea c, Silicia or Sulphur. 476 disorders of lactation. Directions for Weaning. Weaning ought not to be attempted under ordinary circumstances until the child has become accustomed to other articles of diet. See in this connection the article on the Nutrition of Infants. If the mother's health cannot be kept strong and vigorous, the child may be gradually taught to depend upon other sources at the age of six months; and in a short time it may thrive while receiving but little from the mother for the three or four subsequent months. The mother should never allow the child from the first day to sleep at the breast. Once let the child acquire this habit, and it will terri- bly exhaust the mother by lying on her breast all night. For this reason it is important that children never begin to acquire the habit referred to. Other things being equal, it is better that the child should not be weaned until it has six or eight teeth. The process of dentition is accomplished in groups, and the child should never be Aveaned during the evolution of one of these groups. The first group consists of the two middle lower incisors; these usually make their appearance at about the sixth or seventh month, and within from one to fifteen days of each other. Then the child usually rests from four to six Aveeks. The second group consists of the two middle upper incisors, and after their appearance there is another interval of rest for a few Aveeks. From the sixth to the tenth month the lateral incisors appear, the two loAver first, and after a brief interval the tAvo upper ones. Now a longer period of rest intervenes —nearly two months and from the twelfth to the fourteenth month the anterior molars appear, tAvo beloAV first, then two above. There is now another and still longer period of rest, and from the fifteenth to the twentieth month the canine or stomach and eye-teeth come forth—the two loAver first, then the upper two. And again, after another period of rest, and by the time the child is tAventy-four or thirty months old, the last four molars are cut—making in all twenty teeth. This Avork being fully accomplished, the period of infancy is completely passed, and the limit of this period of teething ended. Yet if Ave are tempted to look a little farther, Ave shall see that childhood properly ends with the casting of the deciduous teeth, youth extends to the complete establishment of puberty and adoles- cence, and manhood and Avomanhood follow after. From the above revieAV it appears hoAV necessary it is that we select for so important an event as weaning one of these periods of rest from the evolution of teeth. For the infant to be deprived of its mother's ABORTION. 477 breast is a great change, morally and physically; and this change is much less shocking to the infant's system, and much more easily borne in all respects, if imposed when it is not cutting teeth. CHAPTEE XXV. ABORTION. A BORTION is said to consist in the separation and expulsion of -^*- the immature ovum from the uterus.* This very comprehensive definition covers the whole period from the moment of fecundation up to any time short of the complete fulfillment of the entire time of normal utero-gestation. In its more general acceptation the term abortion is made to refer to such degree of immaturity of the ovum as necessarily ensures its destruction on expulsion; in this sense the use of the term Avould be restricted to the period of non-viability. " An abortion may be possible at any time from the commencement of pregnancy to the end of the sixth month." But since there are successive stages of development, which exactly correspond to definite periods of time in gestation, it becomes desirable to assign more definite terms which may serve to indicate the particular period in which the abortion itself occurs. Accordingly, the abortion is prop- erly called ovular when the expulsion takes place in the first three weeks, or before the embryo can be distinguished in the ovum. The term effluxion was applied by the ancients to those cases in which the product of conception passed off or flowed away in the first week. The abortion may be termed embryonic Avhen it takes place prior to the third month, as if before quickening. When the abortion occurs after this time, and before the period of viability, or before the end of the sixth month, it may be termed fcetal. After the period of viability the expulsion of the fcetus, although more or less liable to be folloAved by its destruction according as it occurs at a period more or less remote from full term, is still not necessarily fatal. Hence the expulsion which occurs at any time after the period of via- bility, and before the completion of the full term, is called premature delivery. The term miscarriage is popularly applied to any expulsion or premature delivery which results in the destruction of the product of conception. * Tyler Smith's Obstetrics, p. 177. 478 ABORTION. Abortions are more frequent in the first two or three months than in those subsequent: thus, of 602 recorded cases, 275 occurred at three months and 147 at four months. It is believed that many cases of ovular abortion * or effluxion occur unnoticed and unsuspected, as Avell in those who have borne children as in those who are always sterile. Causes.—The influences which are capable of producing abortion include almost the entire range of those which injuriously affect the female economy. These causes of abortion may be from Avithout or from Avithin; external or internal; originating in the system of the woman herself or approaching her from the outer world. But in either case and in every instance they derive no small part of their efficiency from the delicate and sensitive nature or psoric condition of the constitution itself. Thus it is well known that some women undergo the severest forms of chronic and even of acute disease, and the rudest accidental or intentional violence, without aborting; Avhile in others this misfortune Avill often occur either spontaneously or from the slightest provoking cause, such as a misstep or strain in lifting, f Since abortion consists in the separation and expulsion of the ovum, as in ordinary labor, this must result from contraction of the uterus itself. This contraction of the uterine fibres is therefore to be considered as the immediate cause of the abortion in every case. All other causes may be termed either predisposing or exciting, and for convenience in study they may be classed under three heads: I. Pre-existing Conditions; II. Conditions principally Developed by the Pregnancy itself; III. Independent Influences. I. Pre-existing Conditions.—In this class must be enumerated all those disorders which in any given case may seem to determine the abortion, although the same causes may fail to be followed by this result in other instances. The great majority of cases of abortion, from whatever cause or combination of causes produced, occur from the second to the fourth month of pregnancy. Disorders of the uterus or of its appendages, Avhich were existent before pregnancy, often become causes of abortion. Displacements to which the uterus may be subject, and which do * Abortion is properly restricted to the loss of the product of conception; and it seems to be an unnecessary and useless complication of the subject to include under this head such discharges of unimpregnated ovules as may occur in women to whom sexual intercourse is a thing unknown, and such as have already been described under Ovular Menstruation. f Mauriceau, quoted by Davis, ii., p. 1031. ABORTION. 479 not prevent conception, may occasion the subsequent separation and expulsion of its product. In cases of habitual prolapsiis uteri the gravid uterus may become impacted in the pelvis before rising above the sacral promontory at quickening, and the irritation con- sequent upon such impaction will necessarily be followed by abor- tion. The same is true of retroversion, the most serious of all ute- rine displacements, and which becomes all the more formidable Avhen complicated with pregnancy. Retroversion in the preg- nant state may be gradual in its development, or may have ex- isted to some extent unnoticed till the increasing size of the uterus at the third or fourth month occasions serious difficulty. Or the gravid uterus may become suddenly retroverted by accident or over- exertion, but this accident can hardly ever result during pregnancy unless a predisposition to it had been established by former retro- version. Anteversion, by irritation of the neck of the bladder, may lead to abortion. Inflammation, ulceration and cancerous disease of the uterus may be- come the efficient cause of abortion. Severe leucorrhoea (especially that Avhich results from chronic inflammation of the cervix), ulcerations of the cervix, fissures and induration of the cervix, phagedenic, syphilitic and cancerous ulcerations of the cervix or of the parietes of the uterus, Avhile they do not ahvays prevent conception, will, in the great ma- jority of cases, powerfully tend to produce abortion. Syphilis in the mother, Avhether recent or chronic, Avhether present as an ulcerative affection on any part of the genitalia or existing as a constitutional taint in the system, will more or less invariably lead to abortion ; Avhile if the syphilitic poison be imparted to the OAoile by the fecun- dating semen of the male alone, the result may be seen in offspring born alive, indeed, but destined to wither and perish, decreasing in weight from the moment of their birth. In either case it seems an admirable provision of Providence that, in its severer forms at least, this awful malady should become self-limited, instead of being permitted to extend its destructive influence through all succeeding generations. Scrofula is stated by some authors to be an efficient cause of abor- tion, but this must needs be taken Avith some qualification, since it is Avell knoAvn that many women of most remarkable scrofulous habit are no less remarkably fruitful, raising in some instances large fami- lies of children, all of Avhom shoAV evident marks of the same scrofu- lous diathesis. When the scrofulous influence has resulted in a con- dition bordering on cachexia, abortion may result from general debil- 480 ABORTION. ity. And yet it should be remembered that tubercular consumption, the most common and fatal form of scrofulous disease, neither indis- poses to conception nor predisposes to abortion. Plethora, or a remarkably full habit of body, and obesity, or an abnormal accumulation of fat, may be considered forms of scrofulous development, and either of these conditions may lead to abortion. Plethora may promote abortion by inducing local and destructive congestion. This congestion may be either simply uterine, as seen in the menstrual nisus and in the greater tendency to abort at the men- strual periods, especially the first, second and third; or it may be placental, as in placental apoplexy or placentitis; or it may be um- bilical congestion, and destroy the foetal life, as it were, by strangulat- ing its circulation. Nervous irritability or sensibility of the uterus may be the determin- ing cause of the abortion. The irritability is so called because it forms a part of the constitution; such Avomen will abort from sympa- thy Avith affections of the bladder, rectum, kidneys, stomach and paro- tid, thyroid and mammary glands, or from disorders in other parts which in other persons would be followed by no such consequence- Ovarian irritation in Avomen who have been subject to dysmenorrhcea has a strong tendency to produce abortion at the catamenial dates. Lactation usually serves to prevent conception, but Avhere it does not the irritation of the mamma? from constant suckling, like any other long-continued irritation of these glands, may produce abortion. And, finally, a pre-established habit of aborting may of itself become a powerful cause of abortion in each succeeding pregnancy, women having been known to abort in tAventy or more successive pregnan- cies. If, hoAvever, the history of such cases be carefully inquired into, some efficient cause, such as syphilis, retroflexion, etc., will be discovered. II. Conditions principally Developed by Pregnancy itself.—Both the first-mentioned and the present class of causes of abortion are in- cluded by Dr. Whitehead under the general head of predisposing causes. " By predisposing causes are meant certain morbid con- ditions, local or constitutional, already in the system, or a particular susceptibility to morbid action during pregnancy, by the operation of which the process is liable to be prematurely arrested."* In some constitutions any one of the various disorders incident to pregnancy may threaten to lead to abortion, and in some cases sev- *On the Causes and Treatment of Abortion and Sterility: By James Whitehead, F. R C. S. London, 1847. ABORTION. 481 eral of these seem to combine to produce this result. Among these may be mentioned the different forms of gastric and intestinal disorder, from nausea and vomiting to the most obstinate constipation. Al- though it is not probable that these affections would result in abortion unless there were present some abnormal irritability of the uterus itself, and although they may have their origin in the same psoric miasm that occasions the uterine irritability, still these affections are entirely developed under and by the condition of pregnancy. Similar in their origin and influence are those local disorders of the uterus and its appendages Avhich appear for the first time in connec- tion Avith the state of pregnancy; among Avhich may be enumerated dropsies of the uterus, fibrous and polypous tumors, and all the uterine displacements Avhich result from the pregnant condition. Placenta prosvia may be the cause of abortion, although this is doubted by Cazeaux. Whitehead says: " When the placenta hap- pens to be implanted with its centre over the os uteri, abortion is inevitable; and this almost invariably takes place before the end of the fifth month." Disorders of the ovum itself in its different stages of development, and of its immediate appendages, may also be enumerated in this place as causes of abortion, since almost all of them are directly and necessarily the results of morbid conditions of the mother. The im- portant exceptions to this general remark are found in certain cases in Avhich the morbid condition of the ovum is derived from the fecun- dating semen of the male. The mother, for example, may be perfectly healthy; while yet in every instance the product of conception be- comes blighted in its earliest development or destroyed by abortion resulting from disease inherent in the ovum itself. In such cases the source of the mischief Avill be found in some taint in the system of the husband—syphilitic, for instance—which may thus be imparted to the ovum through the semen; sometimes also the wife becomes in this manner infected with constitutional disease. Suitable treatment di- rected to the husband AA'ill remove this cause of abortion, and the subsequent conceptions may terminate in healthy offspring. Disease of the ovum may excite the uterus to contraction before the actual death of the ovum has occurred. Moles, hydatids, and in fact every possible form of blighted ova, necessarily involve abortion. And the death of the ovum, rendering it a foreign body in the uterus, Avill be followed by its expulsion sooner or later, except in those not very uncommon cases in which the ovum is entirely reabsorbed. Diseases of the placenta, such as syphilitic or fatty degeneration, 31 482 ABORTION. inflammation, hypertrophy, induration, tubercular deposition, and apoplectic congestion and hsemorrhage, are the most fruitful causes of abortion acting through the foetus. The length of time elapsing after the establishment of the diseased placental condition and the on-com- ing of the abortion will depend greatly upon the extent and rate of progress of the disease itself. III. Independent Influences.—By this expression Ave mean simply those influences which appear subsequently to and independent of the pregnant condition. 1. Physical over-exertion of any kind, riding on horseback or in carriages over rough roads, raihvay traveling, laborious occupations, fatiguing exercises, long Avalks, violent efforts, such as lifting, run- ning, jumping, by exciting the circulation or straining the parts, may occasion uterine haemorrhage or pains, or both, Avhich unless arrested will inevitably produce abortion. 2. Accidental or intentional violence, directly applied to the geni- talia, leads to a similar result, by causing such rupture or separation of the membranes or disturbance of the ovum itself, or by reflex irritation, as arouses the contractile and expulsive action of the uterus. "On the other hand, though there seems in some persons a remark- able liability to abortion through the influence of reflex action, yet in others violent mental emotion, serious accidents, diseases, injuries, and operations even of great magnitude and on parts Avhich Avould ct priori be thought to be specially dangerous in this respect—such, for instance, as the breast, the uterus, vagina, and even the ovaries, as in ovariotomy—are endured without producing the slightest ill effects." Meadows. 3. Various drugs, administered intentionally, for other purposes, or accidentally, occasion the same result, either by direct action upon the uterus and neighboring organs, or by indirect action through the spinal cord. Among the most remarkable are Secale c, Cimicifuga, Sabina, Caxdophyllum, Apis, Aloes, Cantharis, Borax, Quinine, Mer- cury. There are many others, which in larger or smaller quan- tities are said to have produced abortion. Violently acting emetics and purgatives of any kind may lead to the same result from uterine sympathy with the gastric and intestinal irritation. 4. Excessive indulgence in coition, especially in the earlier months, by the passional excitation of the uterus and its appendages, disturbs the ovum and occasions its expulsion. 5. Moral over-excitement of every kind, paroxysms of sudden and violent anger, sudden surprises or affright, horrible sights, situations ABORTION. 483 of imminent danger, violent emotions of grief or despair for the de- parture or loss of friends, may produce abortion. 6. Local diseases of contiguous organs, such as diarrhoea and dys- entery, may produce abortion from sympathetic irritation. 7. Gonorrhceal inflammation of the uterus, Avhere pre-existing, should be classed in the first order of causes of abortion. In such cases it may give rise to the severest form of purulent uterine leucor- rhoea, to erosion, induration, ulceration, and even fissures of the cerATix uteri—conditions from Avhich, if they are not remedied by appro- priate treatment, abortion will almost necessarily result. In other instances gonorrhoea may have been contracted during the existing pregnancy, and may occasion, especially in strong plethoric Avomen, a high degree of excitement and symptoms of inflammatory fever, which may lead to abortion. Whitehead mentions some remarkable cases illustrative of the influence of gonorrhoea in producing repeated miscarriages. Syphilis as a primary infection may also cause abor- tion ; its powerful influence as a constitutional affection in destroying the product of conception has already been noticed. 8. Certain general disorders are very sure to produce abortion, often with very great danger to the mother. This is the case with intermittent fever, especially in its severest forms, the abortion which it causes being almost invariably fatal. Variola becomes a no less certain and dangerous cause of abortion. The same may be said of yelloAV fever and spotted fever. This is true principally of the allopathic practice: so far as these terrible diseases are made to yield more readily to their appropriate homoeopathic remedies, just so far the danger may be averted both from mother and child. Symptoms.—The symptoms which may indicate an impending abor- tion may be as numerous as are those of the various general or local disorders Avhich have been mentioned as its possible causes, and they Avill necessarily correspond in constitutional character and intensity to the nature and violence of the influences by AAdiich the abortion is im- mediately occasioned. In the earlier stages of gestation, the amount of disturbance of the system is less in proportion to the comparatively trifling amount of force expended in producing the abortion itself. When this results from pre-existing influences, chronic disease or bad health in the mother, there may be shiverings succeeded by heat, anorexia, nausea, thirst, spontaneous lassitude, palpitations, a sense of coldness in the abdomen, coldness of the extremities, pallid complex- ion, sadness, tumefaction and lividity of the eyelids or dark discolor- ation beneath the eyes, a sense of sinking at the epigastrium or an in- 484 ABORTION. describable deathly feeling, recession of the milk and consequent flaccidity of the breasts, from which a serous fluid sometimes exudes, and general malaise and profound melancholy. The more immediate and positive symptoms of abortion are— I. A sanguineous discharge, together with pains in the loins, the abdomen and the sacrum. The pains which precede abortion are very much like those which precede or accompany a catamenial period. They may also precede the hsemorrhage in cases of threatened abor- tion, and may subside and the danger pass away before hsemorrhage appears. But after the occurrence of this latter symptom, abortion will almost always result sooner or later, unless the progress of the mischief is arrested by suitable treatment. II. Bearing-doAvn sensation, or feeling of weight in the abdomen and pelvis. These sensations may be independent of the more posi- tive pains; some Avornen abort without having suffered much if any decided pain. After the rupture of the membranes by accident, by instruments and other artificial means, after the placenta or membranes become sepa- rated from the walls of the uterus, or after the death of the fcetus, chills or rigors make their appearance, the pains become more frequent and decided and the hsemorrhage more free. But before the expulsion of the fcetus the hsemorrhage is seldom very profuse. The placenta almost ahvays remains after the expulsion of the fcetus, and then, as in natural labor, the loss of blood may be severe until arrested by the removal of the placenta and subsequent more complete contraction of the uterine walls. Instances have been observed, however, in which the placenta or membranes have remained for weeks after the extru- sion of the embryo, occasioning an almost constant loss of blood during the entire period. In some instances the placenta remains in the uterus till decom- posed ; pysemia, uterine phlebitis and death may result from the reabsorption of particles of the putrefying mass. In embryonic abor- tion, however, after the expulsion of the embryo itself, the mem- branes may remain without danger of the putrefactive decomposi- tion which usually attacks the retained placenta of later months. In other cases, after the gradual death of the embryo from imperfect nutrition, organic ovular disease, or other constitutional cause, the placenta enlarges, assumes unusual forms and a singular structure, exhibiting a cavity in which the remains of the foetus can scarcely be found; or the entire ovum becomes transformed into a fleshy mole or hydatiginous mass. ABORTION. 485 Diagnosis. — An abortion may be deemed possible, probable, threatening or inevitable in any given case, according to the nature and intensity of the influences present and capable of more or less rapidly producing such a result. But it is necessary first to determine the existence of pregnancy; and when, as in the first two months, it becomes difficult or even impossible to ascertain this with absolute conclusiveness, the question arises whether the pains and discharge of ^ blood result from a return of interrupted menses or from an approach- ing abortion. And this question is the less easy to decide in advance since the pains and other consequences of an impending abortion at this early period greatly resemble those of irregular and difficult menstruation.* In general it may be stated that in abortion the os uteri is open, the hsemorrhage precedes the pains, and that the pains themselves are not sensibly relieved by the flow; while in difficult menstruation, the pains usually precede the hsemorrhage, the mouth of the uterus is closed, and the pains either entirely cease or sensibly diminish Avhen the discharge is well established. In some instances of dysmenorrhcea the pains continue during the entire period of the flow, but the fact of the occurrence of such severe dysmenorrhcea as a habit of the individual either removes at once the suspicion of her being preg- nant at any particular period, or entirely neutralizes this exceptional symptom as a sign indicative of pregnancy. Nor, indeed, is if essen- tial for the homoeopathic physician to determine with certainty the exact condition in any given case in order to do for his patient all that her case requires or all that it is possible to accomplish, since, prescribing carefully and accurately for the existing symptoms, he will moderate the \dolence of the suffering in dysmenorrhcea; or if the case is one of pregnancy and threatened ovular abortion, the same remedies Avill be the best to subdue the violence of the abnormal action, and thus preserve, if possible, the product of conception. It is of course unnecessary to recount here the indications already fully stated in a preceding chapter by which the existence of preg- nancy is rendered probable in the earlier months. If these are present in number more or less conclusive, especially if the patient, having formerly been very regular, and having noAV missed her courses for one or two or more periods, experiences a return of the discharge, accompanied Avith pains Avhich rather increase than abate *" Les douleurs qui accompagnent la menstruation difficile, surtout apres une suspension, de plusieurs mois resemblent beaucoup, par leur siege, leur intermittence, a celles de 1'avortement."—Cazeaux, p. 343. 486 ABORTION. as the floAV continues—the Aoav itself being more profuse than Avas usual Avith her in menstruating—and the mouth of the uterus suffi- ciently dilated to admit the end of the finger, there is every reason to believe her suffering from abortion rather than dysmenorrhcea. And this conclusion Avill be greatly strengthened or otherwise by the comparison of this attack Avith her usual monthly periods, and by con- sidering Avhether, in case she Avere actually enceinte, she had been sub- jected to any influences capable of producing an abortion. If the patient knoAvs herself to have menstruated Avhile pregnant on former occasions, this circumstance, Avhile it might to some extent predispose to abortion, Avould require a more particular examination of the condition of the os and cervix uteri, and of the coagula or other matters discharged. And the final detection of portions of an aborted ovum in such cases would become an important point of reference in the future conditions of the patient. So much for the diagnosis of abortion in the earlier months, as distinguished from dysmenorrhcea, where the existence of pregnancy had not been definitely ascertained. The diagnosis of abortion, in the more advanced stages, where there is no doubt of the existence of pregnancy, is a very different matter. Here an opinion must be given, usually, Avith the same caution that we should employ as to the recovery of a sick person in critical circumstances, the question being/ not Avhether it is impending or actual abortion or dysmenor- rhcea, but Avhether the threatened abortion must necessarily become absolute destruction of the product of conception. Here, except in cases already very far advanced, we should never affirm an abortion to be inevitable until we have faithfully employed all the means within our knoAvledge to arrest the destructiAre process. Dr. White- head relates some remarkable' cases of successful treatment in which the abortion seemed necessarily inevitable; one of them, a Avoman who had aborted in six successive pregnancies, and who Avas enabled to go through the seventh successfully, in spite of repeated attacks of venous congestion to the pelvis, Avith apparent death of the fcetus, by repeated bleedings and the employment of extract of hyoscyamus and camphor. And when such apparently desperate cases are rescued under the allopathic regime, hoAV much more ought we not to expect Avith the more varied and efficient resources at our command ? " When the pain comes on at regular intervals, with hardness of the uterus and dilatation of its mouth, this is a serious symptom, for it sIioavs that the uterus will no longer retain its contents, but is preparing to expel them."—Dr. Rigby. ABORTION. 487 A certain dilatation of the internal orifice of the uterus, in which, under the influence of the uterine contractions, the cervix gradually tapers from the os externum up to the body of the uterus, and can no longer be distinguished from the uterus, is mentioned by Cazeaux as having been originally observed by him to be a sign of inevitable abortion. Pain may set in at the first with but little or no loss of blood. This absence of hsemorrhage may be due to a separation taking place high up, and the blood being effused betAveen the mem- branes and the ovum. In such cases the loss of the foetus is almost inevitable. On the other hand, if the separation takes place near the os there is a chance for the escape of the blood, which does not remain to excite uterine action. Davis says, " Separation at or near the os uteri will not be so dangerous, and in all probability there will be hsemorrhage Avithout pain, which is the contrary Avhen it takes place near the fundus." But, generally speaking, abortion is only inevitable when the fcetus is already dead, or Avhen the separation of the placenta is so great that the remaining utero-placental attachments are incapable of sup- porting the fcetal life. Thus the diagnosis of abortion in the earlier periods of gestation is dependent upon the determination of two "un- known quantities "—that of pregnancy on the one side, which may or may not be actually present; and that of the power of the remedies used to arrest the progress of the mischief—remedies whose success or failure in any given case can only be determined by the experi- ment. But in the more advanced stages of pregnancy Ave escape, in many instances, both these sources of doubt, since the existence of the pregnancy itself is undoubted on the one hand, and the deter- mination of the death of the fcetus—Avhich is often possible Avith sufficient certitude—on the other hand removes all hope of change from the action of medicines. In all cases of threatened abortion, however violent the symptoms, we may still find some ground of hope in the administration of the indicated remedies so long as the fcetus continues to live. But the condition is manifestly different Avhere the symptoms either result from or indicate the death of the child. The principal circumstances which indicate the death of the foetus are— 1. The diminution instead of the increase of the size of the abdomen. 2. The flaccidity and shrinking of the breasts, the dragging sensa- tion in the loins and sense of Aveight in the hypogastrium. 3. The cessation of motion formerly perceived in the uterus. 4. The impos- sibility of hearing the sound of the fcetal heart becomes, after the fifth month, an almost infallible sign of the death of the fcetus. And 488 ABORTION. where this death occurs as a consequence of disease or failure of nutrition on the part of the mother, and so takes place in a gradual manner, the danger Avhich the fcetus is undergoing may be detected by observing the gradually increasing faintness of the beating of its heart. But this means of judging of the health and death of the fcetus, since it is hardly applicable before the fourth month of preg- nancy, is of no use in the majority of cases of threatened abortion. Prognosis. — The prognosis aauII depend very largely upon the period of pregnancy at which it takes place, the previous condition of the patient, to some extent upon the producing cause, but more especially upon the amount of blood wasted during the attack. As a general rule, the earlier it takes place the less danger to life; but this is not ahvays borne out, for fatal results have followed abortion occurring Avithin the first month of pregnancy. The danger results principally from the hsemorrhage, and thus it will be seen to Avhat extent the previous condition of the patient may influence the result; for a Avoman in robust condition may withstand a loss of blood that would prove very serious, and perhaps fatal, to one in a weakly and delicate condition. It should be borne in mind that until the ovular membranes and the placenta are expelled there is a liability, and in fact almost a certainty, of the continuance of the flow of blood, which if prolonged will produce such a disturbance in even the strongest woman as may be dangerous to life, not only by its immediate but by its after effects. Moreover, abortion, and especially repeated abor- tions, may give rise to a variety of diseases of the uterus, which grad- ually undermine health, and will lead to loss of life if not judiciously treated and cured. The Induction of Abortion or Premature Delivery. The practice of abortion in some so-called Christian nations, and not the least in our own country, is as extensive as infanticide ever was among the most degraded heathen nations. And while the former custom is in reality no less wicked than the latter, and should be no less revolting to the maternal feelings, it obviously exerts a much more destructive influence, often upon the life, always upon the health, of the mother. The civil laAV, in making a distinction between the criminality of the production of abortion before and after the period of quickening, opened the door for a very low estimate of the moral turpitude of the former act. And Avhile in fact the spirit of the laAV seems now to be improving, the tendency of the practice of many othenvise most the induction of abortion or premature delivery. 489 estimable physicians, and of some recent publications on this subject, serves rather to lower than to elevate the standard of moral sentiment in this respect. But since we are permitted to look into the most secret recesses of reproductive vitality, and to understand the true nature of conception as the wonderful marriage union of two distinct living forms into one, which, though still dependent, is not more so at that moment than it is after the jwiod of quickening, and since we realize that this new creation Avill, if undisturbed by the ruthless hand of the destroyer, become a new creature, we must reverence the higher laAV, and assume for ourselves, in this most important respect, the highest ground. These were noble words of our colleague: " From a child still-born we can hope nothing, but a child born alive, however feeble, may be- come a man!"* "Modern physiological researches have left us in no doubt as to the precise point and time Avhere and when the Avork of independent organization begins Avhich constitutes the distinct indi- viduality of the new being. It is from the fusion or junction of the male and female principles, represented by the ovule and the spermatozoa. From that hour, soul and body, the subjective and the objective, in their mysterious union, are being created. The pure instinct of primal Christianity voiced itself in the grand words of Saint Augustine: Homo est qui futurus est—What will be a man is one. The old civil laws taught it in their axiom: Infans jam conceptus pro jam nolo habetur—A child conceived is to be considered a child born. Modern science teaches it beyond all doubt. The British Parliament, in the neAv Salmon Act, discarding the old absurdities about quickening and viability, declares concep- tion to be the proper date from which human life, in its entire sanc- tity, is to be estimated." f These remarks and quotations are intended to show that there is the same moral guilt, as there is the same destruction of a living child, in the improper production of ovular, embryonic and fcetal abortion, as there is in such unjustifiable induc- tion of premature labor as would be acknoAvledged to be equivalent to infanticide. The moral aspect of the question of induction of abortion is thus forcibly presented by the same writer; and we transfer to our pages Dr. Holcombe's OAvn Avords, not only because they so admirably ex- press the sentiments Ave Avish to convey, but also from the hope that the name of one so widely known and so much esteemed in the homce- * Dr. C. Hering. f Dr. W. H. Holcombe, United States Medical and Surgical Journal, vol. i., p. 390. 490 ABORTION. opathic ranks may promote the adoption of principles Avhich avc can- not but regard as alike essential to the true dignity of the medical profession and to the best good of mankind: " The true moral posi- tion is this: The destruction of the ovum is always homicide—justifi- able, perhaps, under a few extraordinary and painful conditions, after the failure of all reasonable medical and surgical means; and then imposing such solemn and fearful moral responsibilities that it should only be accomplished after the mature deliberation and concurrent advice of several respectable members of the profession."—Holcombe. "The procuring of abortion under all circumstances is a direct viola- tion of the laws of the physical constitution, and almost ahvays a violation of that holy commandment, ' Thou shalt not kill.'"—Pro- fessor A. E. Small. The only substantial ground upon Avhich the conscientious physician can justify the induction of abortion or premature labor to himself and to the moral sense of his felloAV-men, is to be found in the necessity which may exist of saving the life of the mother by this as the only feasible means. And the legal aspect of the question is not different. " If the fcetus be already and from the very outset a living human being, and exist- ing independently of its mother, though drawing its substance from her, its destruction in every stage of pregnancy is murder. Every act of procuring abortion, rules Judge King of Philadelphia, con- trary to the usual interpretation of the laAV, is murder, Avhether the person perpetrating such act intended to kill the Avoman, or merely feloniously to destroy the fruit of her womb." * Without undertak- ing to give the various forms of laAV and practice in the different na- tions of Europe and States of our own country—many of which may be found in the treatise of Dr. Hale already referred to—suffice it to say that the induction of abortion can only become legally, as it is only morally justifiable, Avhen it becomes the only means for the preserva- tion of the mother's life. The conditions which may require the induction of abortion at any stage of pregnancy, and the means by which such a result may be secured Avith least danger to the mother, have been considered on page 283, under the heading, The Induction of Premature Labor. Treatment of Anticipated or Threatened Abortion. The anticipative treatment of abortion will consist in the removal by the appropriate medication of those constitutional dyscrasias— sometimes apparently local, but ahvays in reality constitutional and *Vide Dr. Hale's Treatise on Abortion, p. 315. treatment of anticipated or threatened abortion. 491 often hereditary—which either have before existed or have become developed under the influence of the pregnancy itself. In this con- nection therefore Ave have but to refer to the chapters on the Diseases Peculiar to Women and on the Disorders of Pregnancy. These include the first and second divisions of our classification of the causes of abortion. Those cases of still more imminently threatened abortion which arise under the operation of the third class, or inde- pendent influences, will in like manner require treatment especially adapted to each particular exciting cause and to each individual case. Those cases Avhich arise from physical violence, nervous irritability or moral excitement, Avill of course require the most perfect quiet both of body and of mind. When the symptoms of an impending abor- tion result from the operation of drugs, they should be remedied by the exhibition of such antidotes as are most strongly indicated by the symptoms themselves. The removal of the cause as rapidly as possi- ble will be found the best method of arresting the tendency to abor- tion Avhich may arise from the attacks of diseases primarily local, or of those more general fevers of infectious, zymotic or malarious origin. The principal object of the physician, of course, should be to remedy the abortive tendency, to anticipate and prevent the attack, and, Avhen for the first time consulted at a more advanced period, to arrest if possible the disorganizing and destructive process. But Avhen the physician is called in too late, and it is evident that abortion must take place, he should treat the case very much as if it were one of labor requiring especial attention. For abortion, particularly when resulting from any of the Avide range of causes enumerated above under the head of independent influences, is much more dangerous than ordinary labor. And in those most critical cases in Avhich the mischief to the ovum is already irreparable, the careful administration of the homoeopathic-ally indicated remedies will go far to moderate the violence of the symptoms, diminish the loss from hsemorrhage, and preserve the life and subsequent health of the mother. In abortion, as in labor, the principal danger—which is from hsemorrhage—arises after the expulsion of the fcetus, and from the retention of the membranes or placenta. In these cases the efforts of nature must be assisted by the appropriate medicines, or the finger may be used to remove the membranes or placenta; or, failing that, resort may be had to the placental forceps, of Avhich those invented by the late Professor Joseph G. Loomis are the best. It is desirable to remove the ovum entire if possible, both from the greater ease 492 ABORTION. Avith which this is accomplished by nature, and on account of the mis- chief which will inevitably result from the retention Avithin the ute- rine cavity of any portion of the ovular membranes. But "as a general rule the membranes remain after the expulsion of the fcetus, and the earlier the abortion, the longer the placenta or membranes have a tendency to remain. This is probably owing to the ex- tended adhesion of the ovum to the internal superficies of the uterus, and the feeble poAver of the uterus to contract on its contents."—T. Smith. Sometimes the membranes of an early ovum will remain for weeks, keeping up a more or less constant hsemorrhage, as before stated; and for this condition China has proved a most efficient rem- edy, being indicated by the very considerable loss of blood, and serving in a remarkable manner to arouse the expulsive action of the uterus. This indication for the selection of China has been strongly confirmed by the prompt results which folloAved its exhibition in some cases of long-retained membranes and consequent hsemorrhage in twin pregnancies. The folloAving remedies should be carefully studied, and if the proper homoeopathic simile to the case in hand is not to be found among them, the search should be extended through the Avhole Materia Medica, for the medicine which presents the most perfect picture of the tout ensemble of the case will not only do the most good, but will usually be the only one which—in bad cases especially—will do any good. And both the dose itself, and the frequency of its repetition, should be made to conform to the nature and exigencies of the case, according to the best judgment and experience of the attending phy- sician. The rule of Hahnemann, to wait for the exhaustion of the action of one dose before administering another, is as sound as it is universal in its application. But it is the particular application of this rule to each individual case which calls for the exercise of the closest observation and of the Avisest discrimination, since it must be evident that the action of a remedy adapted to relieve the most violent symptoms of an actual abortion, will be more rapidly ex- hausted than that of one calculated to cure in advance the consti- tutional taint or actual chronic disease which may predispose to abortion. Aconite. If a pregnant woman has fright and the fear remains, and she seems to not get over it, she must take Aconite at once. Or if she have hsemorrhage and fear of death, is sure she will die, or she is very giddy on rising from a recumbent position, she has to lie TREATMENT OF ANTICIPATED OR THREATENED ABORTION. 493 doAvn again, cannot remain up. In many cases there is an uncon- scious fear, Avhich seems to control the patient; she is afraid to get out of bed, to turn over or to move; or she is afraid to go from room to room, or to go out, and fears that something untoward will happen. Aletris far. Habitual tendency to abort, with a sensation of weight in the uterine region, and tendency to prolapse of the Avomb. Apis. Stinging pains occur in one or the other ovarian region more and more frequently till labor-pains are produced ; sometimes floAving, and finally abortion. The urine is usually scanty, and there is absence of thirst. Prolonged and difficult constipation is often connected Avith such cases.. Apis will invariably relieve these symptoms, and pregnancy may then continue to the full term. Arnica. In cases of shocks, falls, bruises or concussions a pregnant woman should ahvays take Arnica at once, more particularly if she commences to Aoav, with or without pain, or to have pains Avithout flowing. She has a bruised feeling, so that it hurts her to move. If the period of quickening has passed the motion of the child hurts her; she is sure the child is lying across the abdomen. Asarum. Indicated in threatened abortion from excessive sensibility of all the nerves, so that from even imagining something unpleasant might occur, a disagreeable sensation thrills through her, momentarily arresting all her thoughts and functions. Belladonna. A pressing toAvard the vulva, as if all the internal organs would issue therefrom. Pain in the back as if it would break. Flushed face, red eyes, throbbing carotids and heat in the head. More or less discharge of blood from the vulva, the discharge some- times feeling very hot. The least jar is unpleasant to her. She moans a great deal, which seems to afford relief. Bryonia. Discharge of dark red blood ; pain in' the back aggravated by motion; burning pain in the uterus; head aches as if it would split. Thirst for a large quantity of fluid. Pain all over, limbs and all; lips and mouth dry; thirst; desires to keep still; nausea on sitting up. Constipation, the stool being dry as if burned, and difficult to evacuate. Calcarea carb. Leucophlegmatic constitution. The history of her case reveals a disposition to hsemorrhage; menses too often, too abun- dant and too long; cold and damp feet; vertigo. If we noAV find her threatened with a miscarriage, labor-pains, floAving, etc., we shall be likely to arrest her troubles Avith Calc. c, unless there are more de- cided symptomatic indications for another remedy. 494 ABORTION. Camphor. Particularly indicated in seasons of epidemic influenza, when Avomen abort almost as generally as the influenza prevails. Especially if she have pale, loose and cold skin, Math general disposi- tion to catarrhal discharges. Cannabis. In cases where women have been or still are affected Avith violent gonorrhoea. Cantharis. The key-note for this remedy in such cases is an almost constant desire to urinate, sometimes ineffectual, but when successful only a few drops are passed, with cutting and burning pain. Carbo veg. When the menses are usually too pale and too scanty or too copious and premature, Avith a decided varicose condition of the genital organs. Caulophyllum. Severe pains in the back and loins, threatening abor- tion, Avith great want of uterine tonicity; the uterine contractions are feeble, and are attended with but slight loss of blood. Chamomilla. She has labor-pains, with more or less discharge of dark blood and frequent urination, the urine being profuse and pale. Her pains excite great restlessness and agony, and irritability of temper. Spiteful irritability; she is " snappish " when speaking. China. She has a sensation of distension in the abdomen, as if it were packed full; she wishes to discharge flatus, but its evacuation either upAvard or downward affords no relief. If she has haemor- rhages, see this remedy under Metrorrhagia. Cimicifuga. Habitual abortion, where cold chills and pricking pains in the breasts are attendant symptoms. Especially for abortions oc- curring in Avomen of rheumatic tendencies. Cinnamon. After a false step or a strain in the loins; the chief symptom is a profuse flow of blood. Cocculus. Much bilious vomiting; paralytic pain in the back, ren- dering the loAver extremities almost entirely useless. Conium. Much vertigo on turning over when lying down. Urine intermits at every micturition. Creasote. Her hsemorrhage seems to pass into a corrosive, ichorous discbarge, and then to freshen up again, and so on. Crocus. The discharge is composed of black strings; as fast as the blood flows from the vulva it is formed into black string-like masses; and if a quantity of blood has been discharged and a portion of the mass be raised on a slender instrument, it will present this black and string-like appearance, though knotted together to some extent. Dulcamara. Where the threatened miscarriage has been induced by exposure in a damp, cold place, as in a milk-house or cellar. TREATMENT OF ANTICIPATED OR THREATENED ABORTION. 495 Ferrum. Flowing and pain, with a fiery red face. She is very weak and pale. Gelseminum is a very valuable remedy, especially when the pains are inclined to run upward or upward and backAvard, are of sharp character and are quite distressing. Loss of will-power over the muscles. Hyoscyamus. She is delirious and rather spasmodic, Avith rigidity of the limbs. She loses her sight and hearing. She may at the same time discbarge bright red blood Avith labor-like pains. Ignatia. Much sighing and sobbing; suppressed grief has been the exciting cause; sensation of "goneness" in the pit of the stomach. Ipecac. The key-note for this remedy is one continual sense of nausea, Avithout a moment's relief, or pain about the umbilicus, pass- ing off into the uterus, or a continued and profuse Aoav of bright red blood. Either of the above symptoms is an almost positive indica- tion, and Avhen present this remedy Avill nearly always cure the entire case Avithout resort to any other remedy. Kali carb. If the labor-like pains commence in the back and pass off doAvn the thighs, or if the pains are more like stitches. Much backache Avhen Avalking. She feels that she must lie or sit down. Con- stipation ; the stools are large and are passed with difficulty. Stitches in the region of the kidneys; pallor; saculated swelling over the eyes. Lycopodium. The abdomen is in a constant state of fermentation, or her pains are shooting from right to left across the abdomen. Or she has intolerable pain in the back before passing water, with almost entire relief as soon as the urine Aoavs. The motion of the child is excessive and tumultuous; red sand in the urine; feeling of dryness of the vagina; borborygmus; weeping; sadness; leucorrhoea; faint- ness ; itching about the vulva. Mercurius. Where there is phlegmonous swelling of the labia, swell- ing of the inguinal glands, etc. Nux mos. Suitable to hysterical women who are disposed to fainting spells. Mouth and throat are very dry; the tongue sticks to the roof of the mouth. Nux V. Every pain produces a desire to defecate and to urinate, particularly the former; this is an almost certain indication. Fre- quent desire to urinate, with burning and scalding when urinating; brick-dust sediment in the urine. She is in a very irritable condition from high living, drinking wine, etc. Constipation of large difficult stools, or small and frequent stools, with pain in the anus. Sore feel- 496 ABORTION. ing in the region of the Avomb; she dreads being moved, and feels cross about it. Opium. Abortion threatening after a great fright; spasmodic labor- like pains. Especially suitable Avhen occurring in the latter part of pregnancy. Phosphorus. Particularly applicable in tall, slender persons. Great sense of Aveakness in the abdomen. Stools narroAV, long, dry and dif- ficult. Profuse and long-lasting Aoav of blood. Platina. Discharge of a quantity of thick black blood. A tremu- lous sensation extending from the vulva into the abdomen. The mons \-eneris and vulva feel cold and sensitive to the touch. Plumbum. Constipation, stools in balls like sheep's dung; much depression of spirits; pain drawing from the abdomen to the backbone as though the abdomen were draAvn upAvard. Podophyllum. Pain in the region of the ovaries, especially at night, disturbing sleep; she is very nervous and restless. This condition may recur night after night until finally symptoms of abortion set in. Prolapsus uteri; the womb is disposed to fall very low, even painfully so. Stools too frequent, although natural; Avith prolapsus ani Avith stool. Pulsatilla. When the discharge is arrested for a little, then returns Avith redoubled violence; this cessation and reneAval are frequently re- peated. Mild and tearful women of yielding temperament are most easily affected by this remedy. Cannot bear a close or Avarm room, and Avants air. Rhus. When the patient has been wrenched or strained, as Avhen she slips, and is strained in trying to save herself from falling, or in lifting. Her pains at first are Avorse at night, particularly the last part of the night; and she is restless, and must move frequently to find relief. Cramps in calves; metrorrhagia. Sabina. This remedy seems particularly applicable to cases of abortion occurring habitually at the third month. The pain extends from the back directly through to the pubes. The discharge is pro- fuse, with about equal proportions of clotted and of fluid blood, red or dark. Secale c. In feeble, cachectic women, having a wan, fearful counte- nance, pulse almost extinct, fear of death, copious flow of black liquid blood, and convulsive movements. Sepia. She has yellow spots on her face; a yellow saddle across the bridge of her nose. She has a sense of weight in the anus; constipa- tion, stools mixed with slime; great urging and involuntary straining, ABORTION. 497 often ineffectual. This sense of weight like a heavy ball, Avhen well marked, is almost an unfailing symptom, and is almost always present Avhen Sepia is indicated. Abortion occurring especially from the fifth to the seventh month. Frequent flashes of heat; motions of the fcetus are feeble; much itching about the vulva; inclines to faint; painful sensation of emptiness in the pit of the stomach. Silicia. Is particularly indicated Avhere there are spinal affections and constipation of difficult stools, as if the rectum had not poAver to expel them, and where the stool recedes after having been partially forced down to the anus. Stramonium. Threatened abortion, with unceasing • loquacity; she talks, prays, implores, sings, constantly uttering something in this line. Sulphur. She has frequent flashes of heat, cold feet, heat on the top of the head; weak fainting spells; eruptions upon the face and other parts of the body; leucorrhoea. Haemorrhoids, which bleed profusely, are sore to touch and itch very much. She sleeps badly, awaking often. Faint and hungry about 11 A. m. Vomits her food. Is in- tolerant of noise. A slight effort causes great fatigue. Veratrum a. This medicine is indicated where there has been nausea, vomiting and diarrhoea at every menstrual period, or exhausting diar- rhoea. With every pain there is a cold sweat upon the forehead. Retching. Zinc. There is much restlessness of the feet and legs, or a sort of fidgety condition attending her symptoms of abortion. 32 498 DISEASES OF WOMEN. CHAPTER XXVI. DISEASES OF WOMEN. IN describing the forms of disease to which Avomen are peculiarly liable, and especially in pointing out the remedies which may be required in their treatment, it will be seen that we do not attempt to give all the symptoms. And this is true also of all the forms of dis- ease and of all the remedies mentioned in this Avork. And since, in some instances, remedies are mentioned with scarce more than a single indication for their use, it seems important at the outset to guard against the serious error of supposing that Ave recommend a medicine from a single symptom—a practice especially deprecated by Hahne- mann. And it might be sufficient to state here that in all cases where remedies are introduced, whether with one symptomatic indica- tion or with many, they are so introduced as remedies which should be studied in connection with the class of disorders under consideration— not as remedies Avhich should be given one after another till the pa- tient is relieved, by death or otherwise. But some other considerations and explanations need to be intro- duced here. In the different forms of structural or organic disease, some of Avhich have no direct counterpart as yet in the pathogenesis of our remedies, we are compelled to look for the great characteristic constitutional symptoms, the most prominent and peculiar features of the case, even apart, if necessary, from functional derangements and from structural disorganization. Such symptoms—Avhich are purely constitutional, just the reverse of the local, since they may appear in connection with any form of disease—become the peculiar characteris- tics, the key-notes, of their respective cases. Such symptoms must be prominently contained in Avhatever remedy is suited to the case. We believe that each case has its head-symptom, which leads all the rest—its key-note, from which all the others take their pitch. And we believe also that the remedy which contains this characterizing head-symptom will invariably be found to contain all the other symp- toms of the case. Thus, if this be true, as Ave believe it to be, the clue then given will afford us the means of extending the curative action and sphere of the medicine far beyond Avhat it had reached, or could be expected to reach, by direct pathogenesis, as Avell as enable us to prescribe with greater certainty and facility. These distinguishing characteristics, these key-notes, which form DISEASES OF WOMEN. 499 the individual and constitutional symptoms of the patient, are sensa- tional symptoms, rather than such as are knoAvn as functional derange- ments or structural disorganizations. And the method we pursue in relying upon these in the absence of other indications, and of attach- ing very great importance to them, even where other symptoms are not Avanting, is sustained by tAvo substantial reasons: First, in many cases we can do no better, since, as already stated, few if any of our remedies either have, or can ever be expected to have, direct patho- genetic symptoms to correspond to the innumerable ultimate forms of structural disease which we are often called upon to treat. Second, this method has been found reliable by much experience, the purely constitutional symptoms, such as those of periodicity and the conditions of aggravation and amelioration, strictly sensational symptoms, being found to constitute infallible indications in the choice of the remedy, where all other guides are Avanting. Of course, under such circumstances it Avould be alike useless and impossible to repeat Avith the particular remedies, under the different forms of disease in Avhich they may be useful, a long detail of patho- genetic symptoms. Where the characteristic symptoms are present and recognized, they will suggest the corresponding remedies for more particular examination. So, on the other hand, we cannot attempt to give all the symptoms which may occur under the particular forms of disease described. The symptoms which may and even do arise under some of these forms of disease, such as hysteria, for example, would fill volumes. For nearly every part of the female system will be found to sympathize Avith the more purely local sufferings connected with uterine difficulties; and every possible kind of distress, every imaginable morbid sensation, and even the simulated appearance of every form of disease, may arise in connection Avith nervous disorders of the uterus. We do not Avish to be misunderstood as recommending a method of generalizing, by advising to pay particular attention to the constitu- tional symptoms, such, for instance, as aggraA7ation at three o'clock in the morning. That is indeed a very general indication and a ATery common symptom in a particular remedy. But in the individual case of our patient it is the very particular form of her system's vital and constitutional reaction against a special morbific influence. The local symptoms are the more common, and are those Avhich are alike common to many individuals and to many medicines; but the con- stitutional symptoms, as they are more remote, are also more especially the characteristic and individual symptoms, since they are confessedly 500 MENSTRUAL DERANGEMENTS. the indications of the profound reaction of the individual system itself. These constitutional symptoms, Avhile thus reflecting the profoundest reaction of the system against the morbid influence, and so estab- lishing their claims to be considered as of the very first importance, will also be found to carry Avith them, as it Avere, all the more import- ant local symptoms. Thus the remedy Avhich is found to answer best to such a form of periodic aggravation as has just been mentioned, at three in the morning, will also be found to cover the other symptoms sufficiently. And if we do not find in our pathogenesis all such symptoms, it is because the pathogenesis itself is necessarily incom- plete. This is Avell illustrated by a case which came under my obser- vation many years ago. A young physician had charge of a case of miscarriage in Avhich the subsequent hsemorrhage proved very in- tractable. The miscarriage Avas at three months in a tolerably healthy young Avoman, and was brought on by running to reach a ferry-boat. Every remedy known to the young physician Avas tried in vain. At last he resorted to the tampon in the latter part of the evening, in hope to save his patient's life, and remained during the night to watch its effect. This means proA7ed effectual for some hours, and he began to hope the danger Avas passed. But at three in the morning the hsemorrhage returned, with such \riolence as almost to expel the tampon. The remarkable character of the aggravation led him to give Nux vom., which was followed by immediate and perma- nent relief. Menstrual Derangements. As has been explained in a previous chapter of this work, men- struation is a physiological process appearing in the order of nature. (See page 69, et seq.) In those cases in Avhich it does not take place so easily and so effectually as is therein described, the deviation occurs because the condition of the patient is not that of the right line of perfect health in other and constitutional ways. From ill health, then, in one form or another, arise all the various forms of menstrual derangements. And in treating such cases we seek but to obey the call of nature for the re-establishment of good health; Ave give the proper medicament, and the function becomes established, re-estab- lished or properly established, as the case may be, because Ave thus cure the constitutional or other malady under Avhich the system is laboring. It is proper to remark, at this point, that it is the duty of practi- tioners of medicine to instruct their female patients in regard to the AMENORRHCEA. 501 importance of frequently changing the menstrual napkin, concerning which the vulgar and erroneous notion prevails that frequent chang- ing increases or prolongs the Aoav. Changes should be made often enough to secure cleanliness, Avhich is essential to the preservation of health. Amenorrhcea. Amenorrhcea, or absent menstruation, may result from very differ- ent causes, and may occur, under one or the other of its various forms, at any period of the pubertal life of the female. These various forms of amenorrhcea may be arranged in three distinct classes: First, emansio mensium, in Avhich the menses have never made their ap- pearance. Second, suppressio mensium, in Avhich the menses, hav- ing made their appearance, have subsequently ceased. And third, partial amenorrhcea, in which the menses are Avanting, perhaps for months in succession, but may appear occasionally and at irregular intervals. Each of these classes of amenorrhcea will need to be more particu- larly considered, Avith reference to its nature, causes, symptoms, con- sequences and treatment. Emansio mensium, or entire absence of the menses in women who have so long passed the first age of puberty that the case cannot be regarded as one of simple delayed menstruation, depends upon a very great variety of conditions of the system, of which some are entirely beyond the control of art, some do not need to be interfered with, the remainder only being amenable to medication. I. The first of these conditions is that which may be called congen- ital malformation, in Avhich the ovaries are either entirely wanting or have remained imperfectly developed or become atrophied. Similar to these are the cases in which these organs have been destroyed before puberty by accident or disease. The patients in whom this condition exists " may have the body generally Avell developed and healthy, the circulation active and regular, and the organic functions (save one) fully performed. But the breasts are not prominent, the genital characteristics and sexual propensities are not developed, the voice is deeper than usual, a slight beard appears on the upper lip, and there is a mixture of masculine with feminine peculiarities." Such cases are evidently beyond the reach of art. There are other cases of amenorrhcea from malformation of less serious nature, which may be relieved by suitable treatment. These 502 menstrual derangements. are instances in which the menstrual Aoav occurs internally, but can- not appear externally by reason of an imperforate hymen, absence of the vagina, adherence of its sides, or an impervious os uteri. The periodical efforts at menstruation enable us to determine in such cases that the ovaries are not Avanting. And where the menstrual nisus ap- pears Avithout corresponding discharge, a careful examination should be made till the nature of the difficulty is satisfactorily ascertained. The retention of the menses by an imperforate hymen is by no means dangerous, and admits of ready relief by a slight operation Avhen the diagnosis is satisfactorily established. The retention Avhich results from adhesion of the parietes of the A^agina or occlusion of the os uteri is far more serious, since, if not relieved by an operation of greater seA^erity, it must lead to fatal results. Inspection alone, or the touch upon the A^ulva, will discover the tumor Avhich indicates menses re- tained by imperforate hymen. But the introduction of the finger within the vagina, or even the exploration by the rectum, will be requisite to determine whether the uterus is wanting, its mouth sealed up, or Avhether obliteration of the vagina be not the cause of the re- tention. Congenital atrsesia of the uterus, complicated by retention of the menstrual blood, may be suspected in those cases in Avhich the hymen and vagina are pervious, but where at each menstrual epoch the sufferings increase in intensity—where the menstrual molimen is most violent, but no external discbarge appears. There may be a gradually increasing tumefaction of the abdomen, and with the men- strual periods real uterine colics, sometimes accompanied with chills, Avith frequent vomiting, syncope and convulsions. And if no arti- ficial opening is made for the exit of the blood, the difficulty must, sooner or later, become fatal, either by the rupture of the walls of the uterus, by an inflammation of the peritoneum, which is being continually irritated and distended, or by an attack of general maras- mus, exhausting, the patient weakened by such severe and prolonged sufferings. II. A second class of cases of absence of menstruation consists of those which need no. treatment. And it is important to discriminate these cases aright, since the female will perhaps suffer more from med- ication where none is required than from Avant of it where it really may be needed. And these cases, now stated to be such as do not need treatment, are the exact opposites of those already described as being beyond all treatment. For as those were cases of amenorrhcea from total absence of the OATaries and of ovulation, so these are cases of amenorrhcea in which the ovaries are present, but in Avhich their amenorrhcea. 503 functional action is so performed as to produce no menstrual flow. And to all appearance, and in fact so far as the present light of science and of experience shows, these cases are perfectly healthy, since many Avomen have been known to conceive and bear healthy children and rear families who never menstruated. And in all those cases in which young Avomen have entered upon the age of puberty Avithout having experienced the menstrual Aoav, but still remain to all appearance in perfect health—whether Ave regard them as cases of amenorrhcea from incomplete development (that is, retarded men- struation) or of ovulation Avithout corresponding menstrual flow—all these need no medical treatment so long as they present no positive morbid symptom. " In some cases it constitutes an idiosyncrasy. In certain families the establishment of this function will in every instance be delayed until the subject is fifteen or twenty years old. Its first ap- pearance is greatly influenced by external circumstances and surround- ings, education, exercise and associations. But more frequently its delay depends upon a depraved condition of the general health. In many cases there is a developing dyscrasia, as, for example, tuber- culosis, which interferes with and interrupts the coming on of the menses."—I/udlam. As we have already shown, those whose sexual development, and consequent ovulation and menstruation, occur late, may prove to be endowed with a corresponding longevity and power of bearing chil- dren long after the usual period of the change of life. This point should be well understood, in order that the physician, planting him- self on the ground of true physiology, may be able to allay the fears of anxious mothers, who are alarmed if their daughters fail to men- struate in their fourteenth year. It may be sufficient to state here that there must be other morbid symptoms and conditions than mere non-appearance of the menstrual Aoav to justify medical interference in the case of young women ; but when such general or special disor- ders of the system do occur, apparently in consequence of the delay of this function, then such treatment should be resorted to as may be suitable for the entire case, and thus serious disease may be warded off. III. The third class of cases of emansio mensium consists of those Avhich are amenable to and which require medical treatment. The first class was composed of those malformations in which ovu- lation, and of course menstruation, were simply impossible, by reason of the absence of the requisite organs. These cases admit of no treat- ment. The second class, in which the amenorrhcea is the result 504 menstrual derangements. of some peculiarity of the system by AAdiich perfect ovulation may be unaccompanied with menstruation, or in Avhich the amenorrhcea is simply the result of incomplete development, without morbid symp- toms (retarded menstruation), requires no medical treatment. But in the third class, the amenorrhcea—whether accompanying com- plete or incomplete sexual development—is a truly morbid condition, as shown by the attendant constitutional disturbances of the entire system. This class of cases is not only amenable to medical treat- ment, but affords some of the most brilliant illustrations of the truth of the homoeopathic principles and of the action of the homoeopathic remedies. We have been thus particular in recapitulating, because it seems of the first importance to understand the difference between that form of late development which may be the result of constitutional strength and which is unaccompanied by morbid symptoms, and that which is the consequence of constitutional dyscrasia, and which is always evidenced by symptoms indicating the anaemic or chlorotic condition, or by painful and ineffectual attempts at menstruation, or rather ovulation. For as we have shoAvn that ovulation is the pri- mary and menstruation the secondary function, so amenorrhcea is mostly to be considered to be the result of absence of ovulation, as in those cases in which the ovaries are entirely wanting, or identical with or the consequence of imperfect ovulation where these organs are present. Symptoms.—Those cases of amenorrhcea in young persons which are unaccompanied by any pain or other morbid symptoms, and for which therefore we are not called upon to prescribe, are doubtless due to incomplete development of the ovaries; while those cases of amenorrhcea which are accompanied Avith periodical but futile and painful attempts at menstruation, and in Avhich the general health evidently suffers, are in like manner to be attributed to failure of functional action on the part of organs already sufficiently developed. And this will appear the more evident from the consideration of the fact that the very late development of the ovaries, and consequently late menstruation, is not only entirely painless, but may be an attendant of more than usual health and strength. And this will still further appear from the nature of the two entirely opposite classes of sufferers from amenorrhcea. Those comprising the first of these two classes are weak, pale, delicate young women; spare and thin or fleshy and leucophleg- matic ; in either case having feeble circulation, as evidenced by gen- AMENORRHCEA. £05 eral chilliness and sensitiveness to the cold; imperfect nutrition, as shoAvn by their indifference to or disgust for food ; or, still worse, im- perfect assimilation, as shown by their insatiable appetite. Those composing the second class, on the contrary, show all the appearance of perfect and robust health ; they are plump; their cheeks red, their complexion florid and their habit plethoric. In the former of these classes of amenorrhcea the sufferings are more chronic and more generally diffused over the entire system; in the latter they are more acute and severe, and more concentrated in the form of local conges- tions. "In both, the attempt at menstruation may be made each month, accompanied by shiverings, pain in the back and loins, weight at the lower part of the abdomen, aching doAvn along the thighs, general lassitude and uneasiness, and sometimes pain in the thyroid gland." These symptoms, after continuing a few hours or a day or two, pass away without any menstrual secretion, to be repeated each succeeding month, or the proper secretion may be substituted by a leucorrhoea. " But the effects of this abortive effort are not so tem- porary ; severe headaches occur occasionally, sometimes with intoler- ance of light and sound; the patient complains of throbbing and a sense, of fullness in the head; pain is felt in the side; the stomach and bowels become irregular in their functions, the countenance pale and the strength much reduced." Paroxysms of dyspnoea and hysteria and hysteralgia come on, and the patient has the appearance of con- firmed ill-health—is sometimes said to be going into decline. There is general chilliness or disposition to attacks of fever, according to the plethoric or lymphatic temperament of the patient; pain in the chest; and if the patient be of the florid constitution her case may easily terminate in quick consumption; while if leucophlegmatic the same fatal termination may be reached by a somewhat more tedious course. A careful study of the different remedies mentioned at the close of this section will enable the physician to determine upon the medicine to be administered. Suppressio Mensium constitutes the second form of amenorrhcea, in AAdiich the menses having made their appearance have subsequently ceased. This may be sudden in its onset (violent, accidental suppression), or it may come on in a gradual manner. In the former case it may lead immediately to severe and dangerous forms of disease; in the latter, it may precede the development of some profound constitu- 506 MENSTRUAL derangements. tional disorder, such as phthisis, or it may result from organic de- rangement of the uterus or of the ovaries themselves. Acute Suppression of the menses may result from exposure to cold and wet, or both, immediately preceding the appearance of the menses or during their Aoav ; from violent shock to the nervous system, as in cases of fright; from sudden and severe mental distress; or from any profound disturbing influences, whether physical or moral, received during the menstrual period. Chronic Suppression of the menses may result from any sloAvly operating debilitating influences; from too close sedentary confine- ment, as in young girls at school; from too severe mental application; from lack of sufficient nourishment; from leucorrhoea ; and, as already stated, from the development of some constitutional dyscrasia, such as consumption, etc., or from morbid growths of the uterus, ovaritis or endometritis. It may likeAvise accompany or follow attacks of acute disease, especially inflammatory or febrile affections, and has been knoAvn to be a consequence even of removal from one place to an- other, emigrants being frequently thus affected. Symptoms.—The more sudden the suppression and the more severe and profound the causes which produce it, so much the more violent will be the resulting symptoms. In most cases there is more or less fever, headache, hot skin, quick pulse, thirst, nausea, and other indi- cations of general constitutional disorder. Or the ill effects of the suppression may be deATeloped in local inflammation, as in inflamma- tion of the lungs, uterus and ovaries. And in cases of nervous tem- perament and scrofulous diathesis there is often a remarkable disposi- tion to be attacked with inflammation of the brain from the menstrual suppression. In such cases the return of the menses would usually be followed by a subsidence of the cerebral symptoms. The appear- ance of the menstrual flux in other severe illnesses, where there had been no previous suppression, is regarded as constituting a very grave complication. Hysterical affections, or even neuralgic sufferings, in other instances may result from suppression of the menses, and these may successively attack the head, lungs and stomach. Sometimes the more profound consequences of nervous debility and disorder, such as fainting, loss of vision, amaurosis, apoplexy, and even paralysis, make their appear- ance in connection Avith such suppression. And the more violent dis- orders that follow acute, sudden suppression of the menses are very apt to terminate fatally. " Suppressed menstruation, either sudden or gradual, is not unfre- AMENORRHCEA. 507 quently folloAved, even when uterine inflammation is not developed, by serious general symptoms, obstinate vomiting, severe hysteria, and sometimes by the establishment in the economy of a supplementary hsemorrhage, to which the name of vicarious menstruation has been given. The mucous membrane of the nasal fossse, of the lungs, stomach and bowels is the most ordinary seat of this hsemorrhage, Avhich takes place in some instances Avith the regularity of normal menstruation, and in others at irregular periods. All the other mucous membranes, and also the skin itself in various regions, have been the seat of vicarious menstruation. It has not unfrequently been observed from the surface of Avounds or sores."—Bennett. This so-called vicarious menstruation constitutes a form of hsemor- rhage in general less grave than that from other sources. Where it attacks the lungs, for instance, it does not, like other haemoptysis, in- dicate the presence of tubercles, but rather a state of the system Avhich may sooner or later lead to them, if not remedied. The manner in Avhich the chronic or gradual form of suppression takes place should also receive consideration. The suppression may not occur all at once, but be first preceded by more or less irregularity of menstrua- tion in respect to time. One or more periods may be passed over, the menstrual flow returning again in a diminished quantity, and then finally ceasing. Or the irregularity may be more with regard to quantity alone, the menses with each preceding month becoming less, until they disappear altogether. Or the discharge for some time before its total suppression may have been growing more and more light-colored; this is said to be the most frequent manner in Avhich chronic suppression occurs. The menses may be supplanted by a per- fectly white discharge, or they diminish in quantity, become of a paler color and Avith shorter intervals ; then a menstrual period arrives in Avhich the fluid excreted is perfectly colorless, while the next period may be characterized by discharge of the natural color. Or, again, the leucorrhoea which so often causes amenorrhcea encroaches more and more upon the menses, both in the time and in the quality of the discharge, until it finally completely replaces the menstrual Aoav. The same gradual diminution of the menses may lead to their premature cessation, and this may be in reality the period of the change of life. In such cases, nature, after a few years of rest of the sexual organs, sometimes restores their activity; and Avomen Avho had supposed themselves to have finally passed the critical age are sur- prised to find a full and complete return of the menstrual Aoav. All this but serves to show that the amenorrhcea, from Avhatever cause or 508 MENSTRUAL DERANGEMENTS. combination of causes it arises, is not in itself a disease, or even neces- sarily a morbid condition, as during pregnancy and after the change of life the menses are wanting from causes which, although perfectly natural, are entirely opposite, the person remaining in perfect health. In other cases, howeA^er, the disappearance of the menses indicates a disordered state of the whole system, which may be unimportant and temporary or deep-seated and severe, according to the nature of the influences Avhich produced it. There are, hoAvever, cases of sup- pression of the menses which, arising from influences comparatively slight, do not so profoundly affect the system, and in which, even without particular treatment, the menses may spontaneously return after missing but one or two periods, or may continue to be suppressed for several years even, Avithout producing any apparent degree of ill- health. Treatment.—In all cases the treatment must be governed by the causes, as in cases of suppression from wet, from fright, etc., and by the totality of the symptoms. In the acute form of the suppression the appropriate remedy may be repeated oftener, according to the violence of the symptoms and the severity of the suffering, taking care to allow the first dose to exhaust its action before giving the second; while in the chronic form the remedy, chosen for its adaptability to the Avhole case, must be allowed to act for weeks, or even months, undis- turbed in its action by a second dose so long as improvement can be traced. If no improvement appears, the dose may be repeated or a neAv prescription made, according to the circumstances of the case. The proper treatment of the gradual, chronic form will result not only in the restoration of the menstrual Aoav itself, but also in the removal of the constitutional disorder of which the suppression was but the forerunner, and in the radical cure of the local, organic affections of the sexual organs by which, in other instances, the sup- pression may have been produced. And the same will be found true of the complications, such as leucorrhoea, haemoptysis, or other severe affections which may arise in connection Avith the amenorrhcea. Let the diet and hygiene of the patient be properly attended to, and then the less the attention paid to external treatment the sooner will the recovery be complete. Give the proper homoeopathic remedies, in the proper manner, in these cases, and all the paraphernalia of hip- baths, foot-baths, tonics, stimulants and misnamed emmenagogues may be dispensed with as worse than useless; the real object being not so much to compel the return of the menstrual flow as to cure the patient of that disordered condition of her system which led to its AMENORRHCEA. 509 suppression. In the Avords of Dr. William Hunter: " With regard to the management of the menses, my opinion is, that you should pay no regard to them, but endeavor to put her to rights in other respects. If you cure the other disorders, you cure the irregularity of the menses, which is the consequence and not the cause of her complaints." Partial Amenorrhcea, in which the menses are Avanting per- haps for months in succession, but may appear occasionally and at irregular intervals, constitutes our third form of amenorrhcea. This may also be termed irregular menstruation, in Avhich the catamenia are not suppressed, but occur irregularly as to quantity and quality, and especially as to time. In some cases of this form of amenorrhcea the health appears to suffer very little if any from the exceedingly irregular and uncertain manner in which the menses recur. In other instances the irregu- larity is complicated Avith more or less severe dysmenorrhcea. The irregularity may consist in the shortening of the intervals be- tAveen the menses, and in such cases the flow may also be too profuse, allied to menorrhagia. Or the irregularity may consist in the length- ening of the intervals, the menses returning with great regularity, and perhaps in normal quantity. The causes of such partial amenorrhcea must be similar to those constitutional influences Avhich result in gradual suppression of the menses, to which, in fact, many cases of irregular menstruation finally lead. And where the protracted amenorrhcea is complicated with pale, colorless menses, with too profuse menses or with painful menstruation, it will be seen that all the morbid influences Avhich may be brought to bear upon the constitution of the young or elderly woman may tend to produce a more or less complete cessation of the catamenia. Treatment.—The treatment of such cases requires a careful ex- amination of the patient, an elaborate collection of all her symp- toms, and a faithful comparison of them with the pathogenetic effects of our remedies. In this manner, and in this manner only, the physician may make such prescriptions as shall result in cures alike honorable to homoeopathy and profitable to himself. The partial amenorrhcea is but a single one among other indications of the poor health of the patient; this and other indications being met by the corresponding remedy, there will result in time such complete restor- ation to health as will at once surprise and delight the patient and her friends. 510 MENSTRUAL DERANGEMENTS. Remedies for Amenorrhcea. Delay of First Menses.—1. Calc. carb., Caust., Graph., Kali carb., Puis., Sulph. 2. Con., Magn. carb., Natr.. mur., Petrol., Sab. 3. Agnus, Amm. carb., Bry., Chel., Coca, Dig., Dulc, Lye., Sil., Valer. Amenorrhoea in general.—Cimicif., Con., Dulc, Gelsem., Graph., Kali carb., Lye, Nux mos., Puis., Sil., Sulph. 2. Aeon., Aletris, Amm. carb., Apis, Bar. c, Bell., Calc. carb., Caust., Cham., Chin., Cupr., Ferr., Lilium tig., Natr. mur., Phos., Podoph., Sabad., Senecio, Sep., Staph., Valer. 3. iEscul. hip., Agnus, Alum., Apocyn. can., Ars., Asclep. syr., Aur., Borax, Bry., Carb. veg., Coloc, Croc, He- deoma, Hell., Hyos., Ignat., Iod., Lach., Phos. ac, Phytolac, Magn. carb., Magn. mur., Merc, sol., Nux v., Rhod., Ruta, Sang., Sassap., Stram., Verat. alb., Xanthox., Zinc. Aconite. Amenorrhcea in young girls of sanguine temperament who lead a sedentary life. Tendency of blood to the head or chest. Ver- tigo or fainting on rising from a recumbent position. Amenorrhoea from taking cold by getting the feet wet, or from fright or chagrin. ^Isculus hip. Amenorrhcea, with great general prostration and malaise. Great Aveakness or giving out of the back when standing or Avalking, especially across the hips; constipation, with ineffectual urging to stool; hsemorrhoids, of purple color and accompanied Avith much burning. Agnus castus. Amenorrhcea, with drawing pain in the abdomen. Aletris far. Amenorrhoea, or delayed menses, in consequence of atony of the womb or ovaries. Weariness of both body and mind; fullness and distension of the abdomen, with bearing-doAvn sensation; general want of vigorous muscular action, with lassitude. Alumina. Amenorrhcea, with abundant leucorrhoea, which Aoavs only in the day-time, Avith weakness. Much straining is necessary to eA^acuate even a soft stool. Restless sleep, alwTays aAvaking Avith pal- pitation of the heart. Ammonium carb. Colic, and pain between the scapulse. Violent pain in the small of the back, Avith great coldness. Apocynum cann. Amenorrhcea in young girls, attended with bloat- ing of the abdomen and extremities. Apis mel. Amenorrhcea, with general anasarca ; irritability and pain of the ovaries, especially if the pain be stinging ; cardiac distress. Arsenicum. White, waxy paleness of the face and great debility, the least exertion causing fatigue. Painful lienteria. Cold Avater lies remedies for amenorrhcea. 511 like a load in the stomach. Sleep full of tiresome dreams. She is very chilly; wants more clothing on her or to be near the fire. Thirstless, or she Avants little drink, but often. Aurum. Amenorrhcea, Avith great depression of spirits and disposi- tion to commit suicide. Belladonna. Throbbing headache, and throbbing of the carotid ar- teries. Red face and eyes. She cannot bear light or noise. Much heat in the head. Weight and pressure in the abdomen, especially in the uterine region. Borax v. She cannot bear a dowmvard motion, as in a swing, in a rocking-chair or in running doAvn stairs. Pain in the right pectoral region. She is very nervous; she does not sleep well. Bryonia. Frequent bleeding of the nose, dry lips, thirsty and wants large quantities of drink; hard, dry stools, as if burnt. She wishes to keep quiet, as motion is painful and disagreeable to her. Calc. carb. Leucophlegmatic temperament. Vertigo on going up stairs. Her feet feel cold and damp. Swelling at the pit of the stomach. Spasmodic affections. Carbo veg. At the time the menses should appear violent itching of old tettery eruptions. Causticum. A yellowish complexion, weakly, scrofulous. Melan- choly ; she looks on the dark side of everything. Hysterical spasms and pinching pain in the sacrum. Leucorrhoea only at night, or worse then. Cham. She suffers on account of a checked perspiration or on ac- count of a fit of anger. She is very irritable and disposed to be quarrelsome; she can hardly keep her temper. One cheek is red, the other pale. Pressing toward the genital organs; passing of large quantities of colorless urine. Chelidonium. Constant pain under the inner and lower angle of the right shoulder-blade. Biliary derangements as a concomitant. China. Sensation of fullness and distension of the abdomen, par- ticularly after eating, Avith desire to eructate, which affords no relief. Cimicifuga. Amenorrhcea in rheumatic or neuralgic subjects. Ner- vous excitability, bordering on hysteria or chorea; dullness of the head and vertigo. Cocculus. Much paralytic pain in the small of the back. Leucor- rhoea in place of the menses. Discharge of a feAv drops of black blood. Whilst the effort is being made to menstruate she is so weak that she is scarcely able to speak. Hysterical symptoms very strongly marked. 512 MENSTRUAL DERANGEMENTS. Colocynth. In cases where severe chagrin has been the cause of the suppression. Colicky pains, causing her to draAv up double, Avith great anguish and restlessness. Conium. At every menstrual effort the breasts enlarge, become sore and painful. Much \rertigo, particularly Avhen, in a recumbent posi- tion, an attempt is made to turn over. The urine intermits in its flow. Complicated with ovarian or uterine diseases and chlorosis. Crocus. A sensation of motion like that of a child in the abdomen. A similar sensation is sometimes felt in the stomach. Epistaxis of black, stringy blood. Mental depression. Cuprum. Particularly in cases arising in consequence of suppression of foot-sweat. A strange tingling pain in the crown of the head. Frequent nausea and fearful vomiting. Convulsions, with fearful cries. Dulcamara. Suppression in consequence of exposure to cold and damp. She has urticaria, or some other cutaneous affection, every time she takes cold. Warts on her hands; her breasts are engorged and hard. Euphrasia. Ophthalmia, the eyes being suffused with tears, and a painful, dry ulcer on the right side of the bridge of the nose, which has been developed since the accession of the amenorrhcea. Ferrum. In weakly, chlorotic persons, Avith fiery redness of the face. Gelseminum. Amenorrhcea, with sharp darting and twitching neu- ralgic pains in the face and head; headache which causes great dull- ness of the head and vertigo, and affects vision. White leucorrhoea. Graphites. Occasional shoAv of the menses, which are very pale and very scanty, wdth abdominal pains and pains in the limbs. SAvelling in the hands and feet. Itching blotches here and there on various parts of the body, from which oozes a gelatinous fluid. Hedeoma. Amenorrhcea, accompanied with intestinal derangements, nausea and retching to vomit. Helleborus. In cases accompanied Avith ascites, the urine being scanty and dark, depositing a sediment looking like coffee-grounds. Hyoscyamus. Much loud and boisterous laughing at every men- strual effort. Hysterical jerking and twitching; disposed to nakedness. Ignatia. Much involuntary sighing and sobbing. Full of sup- pressed grief. The suppression itself may have been caused by some suppressed grief. Weak, empty feeling at the pit of the stomach. Iodium. Very, very much out of breath on going up stairs. Pale- ness, alternating with redness of the face. Frequent palpitation of the heart. REMEDIES FOR AMENORRHCEA. 513 Kali carb. At every menstrual effort sour eructations and swelling of the cheeks; oftentimes there are shooting pains all over the abdo- men. Organic disease of the heart. Erysipelatous eruptions. Dis- position to phlebitis. Lachesis. At every menstrual effort there are cardialgia, oppression of the chest and eructations. Vertigo, with headache. Discharge of a few drops of blood from the nose. Lilium tigrinum. Amenorrhoea, accompanied with cardiac distress, or with ovarian pains of a burning or stinging character. Amenorrhcea, complicated with prolapsed or anteverted uterus. Thin, acrid leucor- rhoea, Avhich leaves a broAvn stain on the linen. Partial amenorrhcea; the menses returning occasionally, to again remain wanting for some time. Lycopodium. A fright may have caused the suppression. Sour taste. Sour eructations and sour vomiting. A constant sense of satiety, so that the least quantity of food causes a sensation of fullness up to the throat. Much borborygmus, particularly in the left hypochondrium. Sense of dryness in the vagina; wind from the vagina. Magnesia carb. Every effort to menstruate is attended Avith a sore throat, Avhich only subsides Avith the other symptoms or on the appearance of the menstrual Aoav. Magnesia mur. She becomes very much excited at every menstrual nisus. There is a pressing down in the iliac regions at every men- strual nisus. She is very hysterical; and has constipation, with large, difficult stools, which crumble as they escape from the verge of the anus. A great deal of sleeplessness. Mercurius. Prolapsus of the vagina at every menstrual nisus. She has dry heat, and rush of blood to the head and congestion to the head at every menstrual nisus. Pain in the mammae as if they would ulcerate at every menstrual period. (Edematous swelling of the hands, feet and face. Nat. mur. At every menstrual nisus she feels anxious, melancholy and qualmish early in the morning for a few hours, with sweet risings from the stomach, and spitting of blood with the saliva. She awakens every morning with headache, which lasts a long time. Con- stipation of large, difficult stools; the anus being contracted, it be- comes fissured and discharges a quantity of blood. Nux mos. At every menstrual nisus the throat, mouth and tongue become intolerably dry, particularly when sleeping. Amenorrhcea from getting wet. In women subject to hysteria or to fainting fits. 33 514 MENSTRUAL DERANGEMENTS. Unconquerable drowsiness; is sleepy all the time. Rheumatic pains. Bloating of the abdomen after every meal. Phosphorus. Particularly in tall, slender, phthisical women. Spitting and vomiting of blood at the menstrual nisus; sometimes the haemop- tysis is profuse, or there is hsemorrhage from the anus or urethra. Stools small, dry and difficult. Great sense of weakness across the ab- domen. The feet and legs are cold, and sometimes they are paralyzed. Phosph. acid. In cases with ineteoristic distension of the uterus. Phytolacca. Amenorrhcea, complicated with ovarian irritation or disease. Rheumatic muscular pains or chronic rheumatism. Con- stipation. Platina. Particularly in emigrants. Painful pressing down, as if the menses would appear, with desire for stool, and pain in the small of the back. Constipation, with scanty, difficult stool; the stool often adhering to the rectum and anus like soft clay. Podophyllum. Suitable for women Who have frequent bilious attacks, or who suffer from prolapsus of the rectum at stool, with hsemor- rhoids ; fatigue and depression; sallow complexion and general sickly and wretched appearance; foul breath; leucorrhoea. Pulsatilla. Particularly suitable in mild, tearful, yielding dispo- sitions. Pale face; difficulty in breathing after slight emotions. Constant chilliness, eAren in summer when warmly clad. Leucorrhoea; vertigo; throbbing headache; pressure in the stomach; pain in the uterus, and dysuria. In cases which come on in consequence of Avet feet. With ophthalmia. From nervous debility. With morning sickness, and bad taste in the mouth in the morning; no appetite, nothing tastes good. Rhododendron. Her sufferings are particularly aggravated during rough and windy weather, or at the coming on of a thunder-storm. Every menstrual nisus is attended with fever and headache. Rhus tox. In consequence of a severe wetting, as in a rain-storm. Ruta grav. A corrosive leucorrhoea attendant, which is the conse- quence of the suppression. Sabadilla. The menses are suppressed immediately on their appear- ance, Avhen they appear again, sooner or later, but are again sup- pressed, and so on. Sabina. The sudden suppression is followed by a thick, foetid leucor- rhoea. Sanguinaria. Amenorrhcea in consequence of pulmonary disease; hectic flush of the face; noisy escape of flatus from the vagina. In REMEDIES FOR AMENORRHCEA. 515 Avomen Avho are subject to sick headache, with stiffness of the neck. Secale corn. Suppression of the menses in thin, scrawny married women, Avho suffer much at the menstrual nisus with a continual, long-lasting, forcing pain in the uterus. Senecio. Debility of the system, with nervous excitability and sleeplessness; lassitude; gastric derangement and loss of appetite; symptoms as though the menses Avould appear, but they fail to do so. Sepia. In feeble constitutions, with delicate skin. Acrid leucor- rhoea, with soreness of the vulva. A yellow saddle appears across the bridge of the nose. Sensation as though the vulva were very large. Pressure in the abdomen at the menstrual nisus, then soreness of the perineum and swelling of the vulva. Repeated shuddering the whole day during the menstrual nisus. Coldness of the hands and feet, and frequent flashing of heat to the head and face. Constipation and sense of weight at the anus. Painful sensation of emptiness at the pit of the stomach. Silicia. Great costiveness at the approach of the menstrual epoch. Smarting, acrid and corrosive leucorrhoea with the suppression. Dis- charge of a quantity of white Avater from the uterus, instead of the menses. Frequent attacks of momentary blindness or obscuration of vision. Staphysagria. When the amenorrhoea is the consequence of chagrin Avith severe indignation. Much pain in the teeth at the menstrual molimina. She is extremely sensitive to mental and physical im- pressions. Stramonium. Extreme loquaciousness at the menstrual molimina; tears and prayers and earnest supplications. Her face is puffed up Avith blood, and she is very fearful, and shrinks back with fear of objects on awaking from sleep. She desires light and society. Sulphur. Stitching headache; vivid redness of the face; violent pains in the uterine region and itching pimples on the chest at every menstrual molimina. Hsemorrhoids; flashes of heat; stitches in the side, and heat in the top of the head. Coldness of the feet, or burn- ing in the soles of the feet at night in bed. Weak, fainting spells. Very short naps at night, or very heavy, dead sleep the whole night. She feels unusually hungry from eleven till twelve o'clock; she can- not Avait for her dinner. Valerian. Especially suitable for hysterical women Avho have taken too much Chamomile tea. Nausea, with desire to vomit, as if a thread 516 MENSTRUAL DERANGEMENTS. or something were hanging in the throat, coming from Ioav doAvn in the abdomen. Veratrum alb. Nervous headache at every menstrual nisus, with cold SAveat upon the forehead; leaden color of the face, Avith frequent nausea and vomiting. Zinc. In those cases of amenorrhcea where alternate paleness and redness of the face is a strongly marked symptom. Dysmenorrhcea. Difficult, painful menstruation may be attended with profuse or with scanty Aoav, the latter in the greater number of cases. This affection is seldom confined to one or two menstrual periods. When it occurs it usually forms the principal characteristic feature of the entire menstrual life. The distress may be moderate and last but a few hours, and in these cases it is usually relieved by a tolerably free flow. Or it may be intensely severe, and continue in the form of a menstrual colic for several days; in such cases the flow is almost always very scanty. Dysmenorrhcea is capable of being divided into five distinct classes, according to the temperament and constitution of the individual, or to the causes from which it originates. These are the neuralgic, the congestive,, the inflammatory, the membranous, and the mechanical or obstructive forms of dysmenorrhcea. Neuralgic Dysmenorrhcea is usually seen in persons of a ner- vous temperament, and is considered to be strictly a symptom of irri- table uterus. " The sensations of fullness and Aveight, the bearing- doAvn sensations felt at the vulva, the perineum, the rectum and the coccyx, the frequent inclination to urinate, the fullness at the hypo- gastric region, the pain in the 'small of the back,' down the limbs, in the hips, around to the iliac and hypogastric regions, are all of the same type. At the period these symptoms of pain and distress become much aggravated and often intense; the irritation extends from the nerves to the muscles, hence the spasmodic pains, violent cramps of the uterus, of the vagina and of the sphincters. These spasmodic pains are often of the most severe character, usually occur- ring in paroxysms, for hours or even for days; and sometimes, although then more moderately, during the Avhole period. They simulate the pains and agony of labor, and they are equally if not more agoni- zing, for they are more protracted and the intervals are less decided; sometimes, indeed, the pain is almost continuous. Usually, after the DYSMENORRHCEA. 517 first twelve or twenty-four hours, Avhen the secretion of the menses is fully established, the pain and spasms moderate or cease. Frequently, tAvo or three days elapse before the poor woman returns to her usual state; and often the suffering is so severe and so prolonged that the Avhole interval does not afford her sufficient time for recruiting her prostrate energies. The succeeding catamenial period brings renewed neuralgia and spasms, and so on even for successive years, depriving the sufferer of all social and intellectual happiness."—Hodge, This form of the disease may present itself in persons who may be said to be of the neuralgic diathesis, and who are subject to neuralgias of the other parts and organs; or it may be due to the opposite states of chlorosis and plethora, or to luxurious and enervating habits of living, or accompanying such diseases as gout and rheumatism. It may likeAvise exist in consequence of excessive sexual indulgence or masturbation. Congestive Dysmenorrhcea is seen in women of a full habit and of a sanguine temperament; both the unmarried and those Avho have borne children are very liable to it. Young girls of florid complexion and plethoric habit suffer terribly in many cases before their men- struation is regularly established, and often in such cases the same congestive attacks follow them occasionally in after life "For some time before and after the catamenia appear the suffering is very great; the patient complains of pain across the back, aching of the limbs, weariness, intolerance of light and sound; the face is flushed, the skin hot, the pulse full, bounding and quick, often upAvard of one hundred." These sufferings are relieved by the menstrual Aoav, which, although sometimes scanty, is often very profuse. This form of dysmenorrhcea may result, as already remarked, from a plethoric condition of the system, or it may folloAV exposure to cold and Avet, or arise in consequence of exciting or depressing mental emotions. Again, it may be due to displacements of the uterus or to a variety of diseases of that viscus, such as subimTolution folloAving labor, areolar hyperplasia and fibrous tumors. " Any one of these causes, without exciting true infiammation, may keep up a state of hypersemia in the uterine vessels, Avhich, being augmented at men- strual epochs, creates pressure upon the neighboring nerves, and conse- quently pain." Inflammatory Dysmenorrhcea.—This form of dysmenorrhcea is usually due to inAammation of the mucous lining of the uterus, 518 menstrual derangements. whether of the cervix, of the body, or of both. It may likewise accompany and be caused by inflammation of the ovaries or of the cellular tissue lying around the uterus. The inflammatory condition of these parts may be such as to give rise to but little or no pain, until, Avhen the vascular erethism attendant on the menstrual epoch arrives, the additional vascular turgescence and general local excite- ment which occur give rise to much pain and suffering. The pains are not generally acute, but rather of a dull, heavy and fixed charac- ter ; and they may come on a day or tAvo prior to the commencement of the meustrual flux, and continue with but little or no abatement until its cessation, or even for a day or two longer. InAammatory dysmenorrhcea may be distinguished from the con- gestive variety by the fact that the inAammatory disease which gives rise to it will cause pain during the intermenstrual periods, and the detection of the existence of these inAammatory diseases Avill aid in effecting a correct diagnosis. It may readily be differentiated from the neuralgic, the membranous or the obstructive varieties. Membranous Dysmenorrhcea may appear in connection with the neuralgic or with the congestive dysmenorrhcea. This appears to be a complication of simple dysmenorrhcea, occurring in persons of some peculiar constitution, and consists in the expulsion at the menstrual period of the hypertrophied mucous lining of the uterus. These cases, not very common, are extremely painful, and especially where, as is sometimes the case, the membrane is discharged Avhole in the form of a sac, it is liable to be mistaken for the product of con- ception—a mistake that it might be very unpleasant for the physician to make Avith reference to an unmarried patient. In some instances this expulsion appears to hold over, passing the regular menstrual period, the menses intermitting, and the female deeming herself enceinte. But Avhen throAvn off in what was supposed to be an abortion, nothing ap- pears but the exfoliated mucous membrane of the womb. The peculiarity of constitution Avhich gives rise to such a condition is not definitely known. If the membrane come away entire, it will exhibit the triangular shape of the uterine cavity, and there will be found three openings, corresponding with the entrance to the Fallopian tubes on either side and the os internum. It usually is thrown off in pieces, however. The diagnosis of this rare form of dysmenorrhcea is by no means easy or certain, especially in the case of married women, where it may be apt to be confounded with conception and impend- ing abortion. But an attentive study and comparison of all the dysmenorrhcea. 519 symptoms will lead to a proper prescription: indications for mem- branous dysmenorrhcea will be found among the remedies at the close of this section. Mechanical or Obstructive Dysmenorrhcea is the name given to a class of cases in which the difficulty and consequent pain- fulness of the menstrual discharge arises from some mechanical ob- struction, such as the partial closure, from stricture or narrowing, of some portion of the cervical canal. This narrowing of the calibre of the cervical canal is a very frequent cause of obstructive dysmenor- rhcea, and is itself often occasioned by the use of nitrate of silver or other caustic in the treatment of diseases of the cervix. Or there may be actual obstructions lodged in the canal, such as coagula, thickened and hardened mucus, the formation of false membrane in the cavity of the body or neck of the uterus, uterine polypus, or cervical fibroid tumor; or finally the obstruction may arise from fiexion of the cervix uteri, as in retroversion of the uterus, and this is no doubt the most frequent and efficient cause of mechanical dysmenorrhcea. These various obstructions occasion painful spasmodic efforts to accomplish the evacuation of the menstrual blood. When the menstrual nisus has continued for some time—hours or days—and a quantity of blood is collected within the cavity of the uterus, in consequence of its ready Aow being hindered by the obstruc- tion from' whatever cause, violent spasmodic and contracted pains are excited, Avhich pass into violent expulsive efforts, such as occur during the progress of miscarriage; and by this means a greater or less quan- tity of the catamenial Auid is discharged, with more or less relief from suffering. Such attacks as these are termed " menstrual colic," and they constitute the principal feature of membranous dysmenorrhcea. And this phenomenon may repeat itself again and again during a menstrual epoch, as the uterus becomes filled and makes an effort to empty itself. In the treatment of this form of dysmenorrhcea, as in that of others, we must be governed by the symptoms and conditions; and if the cause can be removed entirely the cure may be complete, as in the case of uterine fiexions. The other mechanical causes of dysmenor- rhcea, such as thickening and turgescence of the lining membrane of the cervix, may also be removed by the remedies selected in accord- ance with the indications present. Nor do we believe that even " the cautious introduction of elastic bougies " can ever be necessary or use- ful in order to remove stricture of the cendx uteri. This stricture, 520 MENSTRUAL DERANGEMENTS. whether spasmodic or othenvise, is the result of inAammation, ner- vous irritation or some other morbid condition amenable to medica- tion, and is capable of being completely removed in time by the ex- hibition of the properly selected and truly homoeopathic remedy to the case. Such, at least, has been our own experience, as Avell as that of others. Dysmenorrhcea from displacements will be relieved under the proper treatment for Displacements (which see); that from constric- tion, contraction, etc. of the cervix or os uteri will also be cured by such constitutional treatment as is indicated by the prevailing symp- toms and conditions. All topical treatment with bougies, etc is worse than useless. In the treatment of dysmenorrhcea it is of great importance that attention be paid to proper diet, exercise, the use of baths, friction and such other means as have a tendency to improve the general health of the patient and add tone and vigor to her system. A cure of the menstrual difficulty will be greatly facilitated by a resort to these proper hygienic and dietetic measures; whereas, on the contrary, the most carefully selected and appropriate homoeopathic remedy may fail of producing good results from neglect of these important meas- ures. And these directions do not refer merely to dysmenorrhcea, but to all other forms of menstrual difficulties, and, in fact, to all other forms of disease Remedies for Dysmenorrhcea. Alumina. The menses delay, but finally appear, being too pale and too scanty. Before the menses she has many dreams, awaking from which she has heat in the face, headache and palpitation of the heart. Abundant discharge of mucus before the menses. During an evacu- ation of the bowels before the menses she has pinching, writhing and pressing like labor-pains. Pressing to stool aggravates her symptoms. During her menses corroding urine is frequently passed, day and night. After the menses she is so much exhausted in body and mind that a little exercise prostrates her. Ammonium carb. Menses are premature and abundant, preceded by griping, colic and want of appetite; or the discharge is blackish, in clots, and passes off with pain in the abdomen; constipation, tenes- mus, paleness of the face, sadness and toothache. Also colic, and pain between the scapulae. Ammonium mur. Menses premature, with pain in the abdomen and remedies for dysmenorrhcea. 521 small of the back, the Aow being more profuse at night. Passing of large quantities of blood at stool during the catamenia. Apis mel. When the dysmenorrhcea appears to be due to inAamma- tion or irritation of the ovaries, Avith tenderness of the ovarian region, and severe pain on deep-seated pressure; frequent desire to micturate, with painful passage of only a few drops of urine at a time. Asarum. Violent pain in the small of the back at the appearance of the menses, which scarcely permits her to breathe. Asclepias syr. "Labor-like, intermitting pains, accompanied by pale and profuse urination, headache, giddiness and nausea." Baryta carb. Menses very scanty. Before the menses toothache, with swelling of the gums, or colic, Avith swelling of the limbs. Dur- ing the menses a troublesome Aveight above the pubes in any position. Belladonna. Pressure downward, as if all the contents of the abdo- men Avould issue through the vulva. Violent pains come on sud- denly, and disappear as suddenly as they come. Pafns that cause redness of the face and eyes, throbbing of the carotids and in the head. Berberis V. The menses are scanty and very painful, Aowing much like grayish serum. The pain is often in the kidneys or doAvn the thighs and calves of the legs; again in the head, and sometimes all over the body. Borax. Stitching pain in right pectoral region before the menses. Pain from the stomach to the small of the back before the menses. During the menses lancinating pain in the groin. Bovista. Before the catamenia diarrhoea and painful bearing down toward the genital organs. Bromine. Violent contractive spasms during the menses, lasting from six to twelve hours, leaving the parts sore. Emission of large quantities of Aatus during the menses, with slight pain in the abdo- men. Membranous dysmenorrhcea. Bryonia. Tearing pains in the limbs during the menses. Epistaxis. All her sufferings are increased by the least motion. Cannot sit up from nausea. Membranous dysmenorrhcea. Calcarea carb. In leucophlegmatic constitutions. Vertigo on going up stairs. Menses too frequent and profuse. Involuntary emission of urine on taking exercise. She has cold, damp feet, and is very easily affected by the cold air. A variety of pains during the menses, Avith the above characteristic symptoms. Bad toothache after the menses. Membranous dysmenorrhcea. Cantharis. Dysmenorrhea, Avith the peculiar dysuria of this remedy. Membranous dysmenorrhcea. 522 MENSTRUAL DERANGEMENTS. Carbo animal. During the menses violent pressing in the small of the back, groins and thighs, Avith unsuccessful desire to eructate. After the appearance of the menses she feels so tired that she is scarcely able to speak, with stretching and yawning. Carbo veg. Before the menses much itching about the vulva; itch- ing of old tetters or of the skin about the neck and shoulders. Dur- ing the menses cutting pain in the abdomen, pain in the back and pain in the bones as if bruised. Castoreum. During the menses pain commences in the middle of the thighs, extending over the limbs, and in fact more or less over the entire body. Angry exclamations during sleep. Causticum. During the menses pain in the abdomen as if the parts were torn, Avith pain in the small of the back as if from a bruise, and discharge of large clots of blood. A sticking pain below the left mamma. Face very yellow. Chamomilla. Violent labor-pains, and tearing in the veins of the legs, with discharge of dark, coagulated blood. Desire to pass Avater frequently, it being profuse and pale. Out of humor, even quarrel- some. Membranous dysmenorrhcea. China. Feeling of distension and fullness, which is not relieved by eructations. In weakly persons who have lost much blood. Ringing in the ears and fainting fits; convulsions, with rush of blood to the head and chest, Avith throbbing of carotids. A good deal of colic, particularly in the P. m., with eructations without relief. Chininum S. Griping and tearing in the abdomen, extending to the chest, with pressing toAvard the groin during the menses. Cicuta V. Tearing and jerking in the os coccygis during the menses. Cimicifuga. Neuralgic dysmenorrhcea. Great excitability of the nervous system; headache; anxiety; restlessness; gastric disturb- ances. Spasmodic dysmenorrhcea, with pains like labor-pains and menstrual colic; heaviness, weight and bearing down in the abdo- men. Dysmenorrhea occurring in women of rheumatic tendencies. Cinnabaris. A few days before the appearance of the menses and during their continuance tearing pain in the forehead, sensation of weakness in the eyes, rending in the spine, tearing and cramp in the boAvels, with diarrhoea and great prostration. Cocculus. Dysmenorrhcea, always followed by haemorrhoids. Ab- domen distended, Avith sharp cuttings, or as if sharp stones Avere in the abdomen, at every motion. Her sufferings often cause fainting. REMEDIES FOR DYSMENORRHCEA. 523 Discharge fitful, scanty and irregular. Paralytic pain in the back and weakness in the lower extremities. Coffea. Exceedingly painful colic—so painful as to drive her to desperation. Continuous pinching pain in the iliac regions. Cold- ness and stiffness, Avith profuse Aoav. Colocynth. Cramping pain, causing her to draw her loAver limbs up to the abdomen, Avith restlessness, moaning and lamenting. These pains are sometimes increased by eating or drinking. Conium. Dysmenorrhcea, AAdth shooting pain in the left side of the chest. Pain in the mammae, Avhich often SAvell and become hard. Pressure from above downAvard and drawing in the legs during the menses. Vertigo during menses, particularly whilst lying down. Intermitting urine during micturition. Painful abdominal spasms during the menses. Creasotum. Difficulty of hearing before and during the menses, Avith buzzing and humming in the head. The menses are usually too frequent and too profuse; succeeded by an acrid-smelling, bloody ichor, Avith corrosive itching and biting of the parts; with more or less pain during the Aoav, but much aggravated after it has ceased. Crocus sativ. Dysmenorrhcea, Avith dark, stringy blood; sensation of bounding or rolling in the abdomen, Avith other symptoms. Sen- sation of commotion in the stomach upward and downward, hither and thither, during painful menstruation. Eugenia j. Acn6, with pain extending for some distance around the acne; the skin disease is worse during the menstrual epoch. Euphrasia. Menses last only one hour; time regular. Ferrum acet. Pale face and lips, or fiery redness, with scanty dis- charge of pale' blood, with violent colic. The menses intermit and then reappear. Gelseminum. Difficult menstruation, the period being preceded by sick headache, Avith vomiting, vertigo, and congestion of blood to the head, Avith a dark-red hue of the face. Graphites. The menses delay, are scanty, thick and dark, or else serous and pale blood, with griping and abdominal spasms, headache, nausea and pain in the chest. Morning sickness during menses. Con- stipation previous to and diarrhoea after the menses. Persons most suitable for Graphites are rather corpulent and subject to itching blotches here and there. Gratiola. Darting in the right mammse Avhen stooping, Avorse on rising, during the menses. Helonias. Is suitable to dysmenorrhcea occurring in delicate women, 524 MENSTRUAL DERANGEMENTS. of lax fibre, or who are chlorotic Sharp cutting and drawing pains during the period, passing from the back through the uterus; swelling of the mammse, with considerable tenderness of the mammae and nipples; painful soreness over the ovaries. Hyoscyamus. Violent, almost convulsive, trembling of the hands and feet during the menses. She is almost raging. Enuresis and sweat during the menses. Severe headache, profuse sweat and nausea at the appearance of the menses. Hypericum. Menses delay, with tension in the region of the uterus as of a tight bandage. Ignatia. Headache, with heaviness and heat in the head. Photo- phobia, contractive colic, anguish, palpitation of the heart, languor unto fainting during the menses. Weak, empty feeling at the pit of the stomach, Avith sobbing and sighing. Indigo. Burning in the mammse during the menses. Ipecacuanha. Pain about the navel, extending toward the ute- rus. Sharp continued cutting pain from left to right, Avith constant nausea. Iodium. Flow at every stool, with cutting in the abdomen; pain in the back and loins. Kali bichrom. Menstruation too soon, with vertigo, nausea, headache and feverishness. Obstinate suppression of urine, or small quantity of red urine. Kali carb. A good deal of stitching, cutting colicky pain during the menses. She feels badly for a Aveek previous to the menses. She is costive, and feels a distress an hour or tAvo previous to a passage. The menses have a bad, pungent odor, very acrid, excoriating the thighs and covering them Avith an eruption. Headache, with great heaviness during the menses only in the morning. Kali hyd. Great urgency to urinate, which disappears at the erup- tion of the menses. Sensation as if the thighs were tightly squeezed during the menses. Her abdominal sufferings extend into the groins and thighs. Drinking cold milk aggravates her complaint. Kali nit. Menstrual blood black as ink, with much suffering. Kalmia. Pain in the limbs, back and interior part of the thighs during the catamenia. Pulse very slow. Lachesis. Before the menses vertigo, headache, and the nose bleeds a feAv drops. The first day of the menses tearing in the abdomen, beating in the head, pains in the small of the back and bruised feel- ing in the hips, all relieved by a full Aow. Laurocerasus. Colicky pains in the afternoon, and tearing pains in REMEDIES FOR DYSMENORRHCEA. 525 the vertex at night. Suffocating spells about the heart, with a sort of gasping for breath. Ledum. Great Avant of vital heat, and dysmenorrhcea. Lilium tig. The menstrual flow continues only Avhen she is moving about, and ceases when she sits or lies down. Neuralgic pains in the uterus; pains in the ovaries, extending down into the inside of the thighs. Prolapsus or anteversion of the uterus. Cardiac compli- cations. Lobelia i. Violent pain, confined to the sacrum; sense of great weight in the genital organs. Lycopodium. Pain in the temples, as if they were being screAved to- ward each other, Avith a sort of stupor and compression during the menses. Much borborygmus, more in the left hypochondrium. Sense of satiety; the least quantity satisfies, or she is insatiably hungry. Shooting pain from right to left across the abdomen. Magnesia carb. FIoav only in the absence of the pain and during sleep. The menstrual blood is dark, acrid and thick; is washed out with much difficulty. Much pain in the head and in the right shoulder. She can hardly raise the arm. The knees are painful in walking, and the feet when lying in bed. Magnesia n»r. Pain in the small of the back and thighs during the menses. More severe in the back Avhen walking, and in the thighs Avhen sitting. Pressing down in the iliac region during the menses. Magnesia sulph. The menses stop for two days, then Aoav again. Bruised pain in the small of the back, with pains in the groin when sitting or standing, less when walking. Pain in the thighs Avhen Avalkinp;. Manganum. Discharge of blood between the periods, and pressing in the genital organs. Mercurius sol. Before the menses dry heat and rush of blood to the head. During the menses anxiety,, red tongue, with dark spots, saltish taste, scorbutic gums, teeth feel sharp, breath of a mercurial odor and salhration. Teeth sore and loose; some of them are too long. Moschus. Violent drawing and pressing pain toAvard the sexual organs till the menses appear. Murex p. Sore pain as if injured with a cut in the uterus, or violent pain in the right side of the uterus, extending to the chest. Muriatic acid. Sad and silent during the menses as if she would die. Varices of the anus, so sore as scarcely to bear the least touch. 526 MENSTRUAL DERANGEMENTS. Natrum carb. Pressing in the hypogastrium toAvard the genitals, as if everything would issue from the abdomen. Menses preceded by draAving in the nape of the neck and headache. During the menses tearing headache; painful distension of the abdomen in the morning, relieAred by diarrhoea. Tearing and bruised pain in right hip. Natrum mur. Waking in the morning with headache. Terrible sadness during the menses. Natrum sulph. Scanty menses, with hard, knotty stools, streaked with blood, accompanied and succeeded by smarting in the anus. Niccolum. Menses too scanty and short, with colic and pain in small of the back. Nitric acid. Violent cramp pains in the hypogastrium, as if it Avould burst, Avith constant eructations during the menses. Violent press- ing in the abdomen, as if everything were coming out of the vulva, Avith pain in the small of the back, through the hips and doAvn the thighs. Nux juglans. Menses preceded by violent pressing and drawing pains in the womb; finally an abundant Aow of blackish blood, often in large lumps. Nux mosch. Menses preceded by pain in the small of the back, as if a piece of wood stretched across there were pressing frofn within out- ward, with headache, pressure in the stomach, water-brash, pain in the liver and discharge of thick, black blood. Nux vomica. Griping and digging in the uterus, with discharge of thick, clotted blood. Nausea in the morning, with chilliness, fainting turns at the appearance of the menses, with spasmodic pains in the abdomen. Much headache; sometimes in the occiput, as if from an ulcer in the brain ; sometimes in the sinciput, as if the eye would be forced out. Tearing in the left arm and right hip. Oleum animale. Menses preceded and accompanied by cutting in the abdomen and small of the back, and sticking in the left side of the head and vertex. Scanty menses, black blood, and languor in the hands and feet. Petroleum. Menses cause an itching in the genital organs. There is heat in the soles of the feet and palms of the hands; singing and roaring in the ears; tearing in the thigh, and spots on the legs painful to the touch. Phosphorus. Very sleepy during the menses; she can hardly keep awake. Constipation, with a narroAV, stiff stool, difficult to evacuate. Stitches in the mammae, sour eructations and vomiting of sour sub- stances. Blue margins about the eyes. Cutting in the abdomen, REMEDIES FOR DYSMENORRHCEA. 527 chilliness and cold hands and feet. More suitable to tall, slim persons. Phosphoric acid. Meteoristic distension of the uterus. Pain in the liver during the menses. Phytolacca dec. Very painful menstruation in apparently barren women when occurring in connection with rheumatism. Shreds of membrane are passed Avith the menstrual Aow. Dysmenorrhcea accom- panying erosion or ulceration of the cervix. Platina. Painful sensitiveness of the mons veneris and of the vulva. Much threatening of the menses to come on. Finally, they make their appearance with pinching in the abdomen and pressure in the groins, alternating with pressure in the vulva. Plumbum. Cessation of the menses on the invasion of colic, but they reappear after the paroxysm, or not again till the next period. Sensation as of draAving from the abdomen to the back, often with great depression of spirits. Podophyllum. Bearing down in the abdomen and back during the menses; ovarian pain on both sides of the abdomen, Avith a numb and aching pain running clown into the thighs; prolapsus ani with stool. Pulsatilla. Particularly in mild, tearful, yielding temperaments. The pain is so violent that she tosses in every direction, with cries and tears. The blood is thick and dark or pale and watery; Aows by fits and starts. She feels worse in a close, Avarm room. Rhus tox. Membranous dysmenorrhcea, the rheumatic symptoms guiding the choice of this remedy; stiffness of the limbs, relieved by walking; stiffness of the limbs before a storm or in damp weather, relieved by a storm. Restless nights; must turn often to find a few moments' rest. Sabina. Dysmenorrhcea. Violent pain extending from the back through to the pubes. Sanguinaria c. Dysmenorrhcea. The pain rises into the head from the nape of the neck, and finally into the forehead, as if the eyes would be pressed out, the menses being scanty. SarsaparhTa. Itching eruption on the forehead previous to the menses. Soreness in the right groin, Avith desire to urinate at the ap- pearance of the menses. Griping in the pit of the stomach in the direction of the small of the back during the menses. Painful con- clusion in urinating. Secale corn. Menses are too frequent and last too long, Avith tear- ing and cutting colic, cold extremities, cold perspiration, great 528 MENSTRUAL DERANGEMENTS. weakness and small pulse. Especially useful in thin, scrawny wo- men. Senecio. Dysmenorrhcea, occurring from want of tone and vigor. The patient is pale and weak, drowsy in day-time; does not Avish to do anything or to think; irritable. Sepia. Before the menses violent colic, shuddering all over the body the Avhole day, acrid leucorrhoea; sensation as if the vulva Avere enlarged, Avith soreness in the perineum. During the menses tearing in the tibia, toothache and obscuration of sight, violent pressure in the forehead, with discharge oT plugs from the nose. Constipation, the stool being hard, difficult, knotty, insufficient, and sometimes min- gled Avith mucus. Sensation as of a heavy lump in the anus. Silicia. Before and during the menses she is costive. Stool com- posed of hard lumps, remaining long in the rectum, as if it had no poAver to expel it. Burning soreness of the vulva, and an eruption on the inner side of the thighs during the menses. Repeated paroxysms of icy coldness over the Avhole body at the appearance of the menses, and icy cold feet during the menses. Spongia. Violent drawing in the upper and lower extremities dur- ing the menses. Stannum. The malar bone is painful to the touch before the menses, and during their Aow it is painful even to move the muscles of the face. Dysmenorrhcea, Avith terrible headache, the pain gradually in- creasing to its highest point, and after remaining for a time as gradu- ally declines. Stramonium. Excessive loquacity during the menses. Drawing pains in the abdomen, upper and lower extremities. Sulphur. The menses are thick and black, and so acrid as to make the thighs sore. Every evening, just before the menses, she always has a cough. Pain in the abdomen during the menses, as if the in- testines were strung up in knots by threads. She has to take a sitting posture for relief. Flushes of heat on the top of the head, cold feet, etc. Sulphuric acid. She always gets a distressing nightmare before the menses. Is hurried about everything she does, and cannot go slowly; acid risings and heartburn; feeling of trembling Avithout actual trembling. Tart. e. Pain in the groins and cold creepings just previous to the menses. Thuya. Terribly distressing pain in the left ovarian and iliac re- gions, with scanty Aow. She has to lie down, the suffering is so great. MENORRHAGIA. 529 Veratrum. The sufferings during menses are attended with thirst for icy cold drinks; nausea, vomiting and diarrhoea, or simply diarrhoea. Cold sweat on the forehead from the pain. Great exhaustion. Zincum. During the menses heaviness of the limbs, Avith violent drawing about the knees, as if they Avould be twisted off. Sore eyes. Sudden oppression of the stomach, she has to loosen her dress. Menorrhagia. Menorrhagia is the term noAV employed to signify an increased or immoderate Aow of the menses, or profuse menstruation. Formerly it was understood to embrace uterine haemorrhage in general, but it is now very properly restricted as above, while by the term Metrorrhagia are designated those haemorrhages from the uterus which are not con- nected with the catamenia. The following very general division of the varieties of menorrhagia will simplify the Avhole subject, and at the same time render our brief description more clear and comprehensive. I. Functional Menorrhagia; in which the Aow is increased in quantity or in frequency, or in both. II. Organic Menorrhagia; in which the Aow appears in connection with some positive disorder of the sexual apparatus. III. Sympathetic Menorrhagia; in which the Aow appears in con- nection with severe forms of general disease. In Functional Menorrhagia the flow may be perfectly natural, except in its quantity and in the frequency of its return, or it may be occasionally mixed with clots of blood. In either instance the causes of this affection are to be found in the more or less plethoric condi- tion, habits of life, or even in the various anomalies of the blood itself. These and similar influences, some of them deeply seated and constitutional, may combine to produce such profuse discharge at the monthly periods, or even oftener, Avithout the intervention of any dis- tinct disorder, either of the whole system in general or of the sexual apparatus in particular. Only the earlier or milder forms of menor- rhagia can be included in this class—those which have not been pre- ceded by any actual disease, and in consequence of which no organic lesions have as yet arisen. And many cases Avhich in their initial stages would be classified here, subsequently become so complicated as to belong rather to the second class. In this same class of func- tional menorrhagia must also be included all those cases Avhich arise from general debility without positive disease, as in persons who fall into this "weakly Avay" from having too many children, or from 34 530 MENSTRUAL DERANGEMENTS. over-suckling them to prevent the too rapid increase of the family. And cases arising from excessh^e coition or any other form of over- exertion, or from some inherent constitutional weakness (especially in this respect), Avhich may be aggraArated and developed by various pro- voking influences, are all to be included in this class. In Organic Menorrhagia the Aow appears in connection with some positive disorder of the sexual apparatus. In the order of time this Aoav may precede or follow the appearance of the organic disease, but in either case there is such an established connection of the menor- rhagia itself with other disorders as renders the case very different from what is described under Functional Menorrhagia. Nor is the reality of this connection at all affected by the view we may take as to the question Avhether, in any given instance, the menorrhagia is due to the disease which may have preceded it, or to the structural change which in another case may have followed it. Thus in some instances the threatened onset of some organic disease is preceded by congestions, which, greatly aggravated at the menstrual period, render the Aow ab- normally frequent and profuse. So the actual presence of structural disorganization of the uterus or of any of its appendages, eA^en Avhen not very far developed, may produce such menorrhagia. And finally, these forms of profuse menstruation, whether too frequently or more rarely recurring, may sometimes not only be caused by some hitherto undeveloped change in the interior organism, but they may also re- main persistent as consequences of former diseased conditions of the various organs of the sexual apparatus. In the first of these three categories might be enumerated a very great variety of the disorders of the female organism, the majority of which are, in many instances at least, preceded by increased catamenia; in the second might also Avith equal propriety be mentioned almost the entire range of such diseases, from simple uterine congestion up to polypoid and cancerous tumors; while in the third the simple mention of the profuse menstruation which, unattended Avith any other disorder, sometimes appears after the period of the change of life, may supply all that is needed in the way of illustrative example. Some forms of uterine disorder are preceded or even caused by amenorrhcea, but it is easy to see that the deep-seated physiological tendencies toward active disease of the uterus and its dependent organs must to a certain extent consist in congestion, Avhich cannot but be greatly aggravated by the menstrual nisus, and Avhich consequently leads to a more profuse menstrual discharge. The same is still more plainly true of the actual presence of structural disease in any of these MENORRHAGIA. 531 organs; the constant congestion must necessarily be seriously enhanced by the added inAuence of the catamenia, and from this combination of pathological and physiological conditions a more than normal Aow results. And in those cases in Avhich structural disorders have ex- isted formerly, but have noAv subsided to all appearance, the proofs of their former existence still remain, in many instances, in the form of chronic congestion, Avhich is capable of producing menorrhagia, often of the severest form, and even of keeping it up and reviving it after the change of life. Of the various forms of disease affecting the several organs themselves Avhich induce menorrhagia, and Avhich may be termed local causes, we may mention granular ulcerations of the os and cervix: cancer; infiammation of the lining membrane of the uterus; retention of a portion of the secundines after parturition ; congested condition of the ovaries and uterus; fibrous tumor or poly- pus of the uterus; and subinvolution. Any of these may be sufficient of themselves to prolong each menstrual epoch and to render the Aow profuse. In regard to the last named of these local causes—subin- volution—menorrhagia in married Avomen occurs from the incomplete involution of the womb after parturition more frequently perhaps than from any other cause. We make these statements, not from any desire to give undue prominence to pathological vieAA^s, but to show the importance, the necessity, of most carefully studying all the symptoms, those preced- ing as well as those attendant, in order to prescribe correctly in such cases. The menorrhagia which Ave are called upon to treat is by no means such a hsemorrhage as that from an open Avound, which may be stopped as soon as convenient; we have, in fact, something to do very different from arresting an active or even a passive haemorrhage : we have a sick person to cure. And just as fast as by our prescrip- tions of advice and medicine her general health improves, just so fast Avill she find her catamenia approaching the normal standard. Nor when we have done for our patient in such cases all that our art admits and science requires, shall we have merely "set her courses right;" we shall have so restored her health that her courses will come right and remain right, since by curing the patient herself Ave shall have removed the causes of the menorrhagia. It is not intended to assert that all this can always be accom- plished in every case, but nothing less than all this should ahvays be the aim of the physician. And even if he should not succeed in restoring his patient to perfect health, he Avill have gone to Avork in the right way to do it; and if his success be but partial and 532 MENSTRUAL DERANGEMENTS. incomplete in a given case, eA^en if it should disappoint both his oavu hopes and the expectations of his patient and her friends, hoAV much greater will it not be than if he had gone to Avork in some other than the best possible method! How great is the difference, in chronic cases especially, between even a small improvement and a positive change for the worse ! In Sympathetic Menorrhagia the Aow appears in connection with severe forms of general disease. Examples of this variety of profuse menstruation are seen in some cases of variola, scarlatina, erysipelas, typhus, cholera, and during the appearance of certain acute infiamma- tions, especially those of the lungs. " Although experience has de- monstrated that during the course of these diseases, especially Avhen they determine a draining of the mass of the blood, the courses are often suppressed, still a great number of observations have proved that when the Aow persists, it may become so copious that it com- pletely exhausts the already feeble forces of the patient, and may even hasten a fatal termination. This is especially the case with the ex- anthemata. We have often observed that the appearance of a very copious menstrual haemorrhage during the course of these diseases is almost always the precursor of a fatal dissolution of the blood. Sanguineous discharges from the skin, the nose, the rectum, etc. soon supervene, and death occurs sometimes even in a few hours after the startling cerebral symptoms have come to complete the picture represented by the rapid decomposition of the blood."— Scanzoni. This fearful complication of disorders, already very grave, may well appall the allopath, the very largeness of whose experience in such cases serves but to assure him of their utter hopelessness. But the homoeopathic practitioner, conscious of the wonderful virtues of such medicines as Arsenic, Carbo veg., China, Lachesis, Rhus, Secale and others, to arrest even the rapid decomposition of the vital Auid itself, and mindful of the special and characteristic indications, which will enable him to give the right remedy Avith unerring exactness, can face even these profound degenerations of the organism with a patient, hopeful heart. It is necessary for the physician to realize the serious gravity of such cases, especially that neither himself nor the friends be taken unawares by the sudden and unexpected fall of the curtain; and then it is no less necessary that he should faithfully and perse- veringly study all the symptoms of the case, and never despair till satisfied of the actual closure of the scene; since in typhus, and even in cholera, some such patients have been rescued, as it were, from the REMEDIES FOR MENORRHAGIA. 533 very jaAvs of death, who most certainly would not have received the proper remedies up to the final turning-point of their apparently fatal disorder had not their physicians been inspired by the most patient courage and by the most hopeful and determined perse- verance. The coming on of the climacteric is frequently accompanied Avith menorrhagia. The periods will be missed for several months, and will then reappear in alarming profuseness, and often accompanied with pains, give rise to the opinion that the menses had ceased on account of pregnancy, and that the Aow was the haemorrhage of abortion. Diseases of the heart likeAvise give rise to profuseness of the men- strual Aoav, occasioned, no doubt, by congestion, in consequence of the retardation of the return of the blood to the right side of the heart. In these cases the profuse Aoav seems to afford relief. Chronic liver disease or congestion may occasion menorrhagia; and so, too, may Bright's disease; in this latter case the blood, having been deprived of its albumen, is in a condition favorable to exudation through the capillary walls. Remedies for Menorrhagia. Aconite. In plethoric women particularly. Vertigo on rising from a recumbent position; she has to lie down again. She is alarmed and excited; is sure she will die, although there is no' occasion for such an alarm. Agaricus. Menses too profuse, with titillation in the genital organs. Itching, burning and redness of the toes, Avith titillation, as if frozen. Menses too profuse. Aletris far. Menorrhagia, in consequence of a congested condition of the uterus or ovaries; profuse discharge of dark-colored blood with coagula; fullness and weight in the uterine region. Ambra grisea. Discharge of blood between the periods at every little accident; for instance, after a very hard stool or after a walk a little longer than usual. Ammonium carb. Menorrhagia after a long drive in the cold air. Ammonium mur. The Aoav is more abundant at night. A quantity of blood is passed at every stool during the menses. Antimonium crud. Menorrhagia, with a peculiar pressing in the uterus as if something Avould come out. Apis mel. Menorrhagia, Avith heaviness in the abdomen, faintness great uneasiness, restlessness and yaAvning. Apocynum cann. Very profuse Aoav of blood, preceded for a day or 534 menstrual derangements. two by a moderate discharge; shreds or pieces of membrane come away with the Auid blood. Argentum nitric. Menorrhagia, with cutting pain in the small of the back and groin. The head feels \^ery much enlarged and the loAver extremities \rery Aveak. Arnica. Particularly after cases of concussion, as from a blow, a fall or riding over rough roads. The Aow is of a bright-red color, mixed Avith clots. Heat about the head, extremities cool. Menor- rhagia, Avith pain in the small of the back, extending into the groin and down the inner side of the thigh and leg to the great toe. Arsenicum. Menorrhagia in feeble women; cachectic; affected Avith rheumatism, disorganization of the uterus or ovaries; in eruptive fevers, and when aphthae break out, indicating a low state of the system. Belladonna. The Aoav is bright red, imparting a sense of heat, with a sensation of pressing outAvard. Sometimes it has a bad odor, with lumps. Sometimes there is a congestion to the head, with throbbing of the carotids. Borax. The menses are too soon, too profuse, and attended Avith colic, nausea and pain, extending from the stomach to the small of the back. Too profuse menses, and she is very nervous; starts at the least noise, and dreads a doAvnward motion, like going doAArn stairs or the doAvnward motion of a swing or rocking-chair. Bovista. Menses too often and too profuse, Aowing more in the morning and less at night, with discharge of blood between the periods. Bromine. Menses too often and too profuse, of bright-red blood, particularly in women with affections of the chest, heart or eyes. The Aow is quite passive, and she only suffers from exhaustion. Bryonia. Menses too early and too profuse, of dark-red blood, Avith pain in the back and aching in the head, as if it would split; worse on the least motion. Nausea on sitting up and after eating. Cactus grand. Menses are premature, as well as too copious; the Aow ceases on lying down; cardiac complications; the menses are dark-colored or black, and thick. Calcarea carb. Menses too frequent, too profuse and last too long. She has vertigo on stooping, worse on rising or going up stairs. Damp, cold feet. Particularly applicable to leucophlegmatic tem- peraments. Profuse menstruation during lactation. Cannabis s. Too profuse menses, Avhen dysuria attends, with sensa- tion of soreness in the Avhole track of the urethra. REMEDIES FOR MENORRHAGIA. 535 Cantharis. Menses too early and too pro-fuse, of black blood. Dysuria, Avith burning, cutting pain. Frequent desire to urinate. More suitable to women who are sterile. Carbo animal. Menses too early, not too profuse, but last too long. Great weakness of the thighs. After the appearance of the menses she feels so tired that she is scarcely able to speak. Carbo veget. Menses too early and too profuse, preceded by itching of old tetters, or by an itching eruption on the nape of the neck and between the shoulders; also by a dragging pain from the abdomen to the small of the back. Caulophyllum. The uterus is soft and relaxed, and the blood flows profusely. Suitable for Avomen who have moth-patches on the fore- head and face. Causticum. She has a very yellow face; menses too early and too abundant, and after their cessation a little blood is passed from time to time for many days. The menses smell badly, and excite an itching in the vuhTa. She feels melancholy, and looks at everything upon the dark side. Discharge only during the day ; ceases on lying down. Chamomilla. Menorrhagia of dark coagulated blood, floAving more in paroxysms. There is great irritability of temper, so that she can hardly control herself. Frequent desire to urinate. Urine pale and profuse. Chelidonium. Menses retarded, but continue too long, Avith pain under the inner and lower angle of the right shoulder-blade. China. Menses too profuse, with a sensation of great distension of the abdomen, not relieved by eructations or dejections. Ringing in the ears and fainting spells. Losing of senses and sight. Also after the abuse of Chamomile tea; with Aow of dark clots and frequent desire to urinate; pale urine; and in weakly persons from the loss of blood. Cimicifuga. The discharge is profuse, dark and coagulated; great nervousness; pains like those of rheumatism in the back and limbs; bearing doA\m in the abdomen during the Aow. Cinchoninum sulph. Menses too early and too profuse. Cina. Menses too early and too profuse, particularly in women troubled with itchings of the nose or nightly restlessness. She is constantly tossing, even during sleep. Diarrhoea, ahvays Avorse after drinking. Cocculus. Discharge of blood from the uterus in pregnant women. Profuse menses, Avith a sensation as of sharp stones in the abdomen at every movement. 536 MENSTRUAL DERANGEMENTS. Coccus cacti. Menses too early and too abundant, of dark, thick blood, with a sensation of tension and constriction about the abdomen, and of something ascending toward the stomach, which makes her think she will vomit water. Coffea. Profuse menstruation, with excessive sensitiveness of the organs, and voluptuous itching. Collinsonia. Congested condition of the cervix uteri, with painful haemorrhoids and aggravated constipation. Creasotum. Menses too early, too profuse and lasting too long, but inclined to be intermittent; she thinks she is almost well, Avhen the discharge returns afresh. Crocus s. Menorrhagia of dark, stringy blood; as it discharges it forms itself into long strings. A sensation as if something alive were rolling or turning about in the abdomen. In the stomach a similar sensation is sometimes perceptible. Cyclamen. Menorrhagia, with stupefaction of the whole head, and obscuration of vision as if a fog were before the eyes. Erigeron. The Aow is so profuse as to be alarming, and consists mostly of bright-red blood; every movement of the patient increases the Aow. Pallor and weakness in consequence of the profuse dis- charge. Perrum. Menorrhagia/ in weakly persons, with a fiery red face. It occurs too frequently, is too profuse and lasts too long. Fluoric acid. Menses too early and too profuse, thick and coagu- lated. With an uncommon buoyancy of mind she fears nothing, and is well satisfied with herself. Hamamelis. Profuse discharge of dark-colored blood; the discharge ceases at night, occurring only in the day-time. Helonias. Very profuse Aoav at every period, so that her strength is exhausted, and she suffers from debility. Complexion pale, sallow, earthy-looking. Menorrhagia from ulcerated os or cervix, the blood being dark and bad smelling, and continuing a long while; the Aow is increased by the least exertion. Hepar s. c. Menorrhagia in women with chapped skin and rhag- ades of the hands and feet. A slight injury causes ulceration. Hyoscyamus. Menorrhagia, with delirium. She has uncommon foolish manners. Silly laughing, and inclines to uncover or undress herself. Ignatia. Menorrhagia, with sighing and sobbing, faint feeling at the pit of the stomach, she seems full of suppressed grief. REMEDIES FOR MENORRHAGIA. 537 Jodium. Premature and too copious menses, with great Aveakness; particularly indicated if she has goitre, or dwindling of the breasts, or if she has acute pain in the breasts. Ipecacuanha. Profuse menstruation, Avith a constant nausea; not a moment's relief, not even after vomiting. Lachesis. Menorrhagia, with chills at night and Aushes of heat during the day. Laurocerasus. Menses too early and too profuse, with nightly tear- ing in the vertex. Peculiar suffocating spells about the heart. Ledum p. Menses too early and too profuse, with a great want of vital warmth; she can hardly keep Avarm. Lycopodium. Menses too long and too profuse, with borborygmus, especially in the left hypochondrium; or a sense of satiety and full- ness up to the throat on the least quantity of food being taken; or an aggravation at four o'clock p. m. Magnesia carb. Menses too early and too profuse, Aowing decidedly more at night, and never during uterine pains. Mercurius sol. Menses too profuse, with scorbutic gums. Saliva- tion ; teeth feel sore and as if loose. Mucous stools, with tenesmus and oppression ; strong urine. Moschus. The menses are too early and too profuse, with intolerable titillation in the genital organs. Muriatic acid. Menses too early and too profuse, with extremely sore haemorrhoids, which sometimes itch terribly. Natrum carb. Menses too early and last too long, aggravated by a thunder-storm, and may even be reproduced by one. Natrum mur. Menses too soon and too profuse, with great heaviness in the eyes, or intolerable sadness. Craves salt. Has an aversion to bread. Dreams that robbers are in the house. Nitric acid. Menses too early and too profuse, with urine emitting an intolerably strong smell. The blood is very dark-colored and thick. Nux juglans. Menses too early and abundant, in large, blackish lumps. Nux mosch. Menses too early and profuse, with an intolerable dry- ness of the mouth, tongue and throat. Excessive disposition to laugh, particularly in the open air. Nux vomica. Menses too early and too profuse, particularly as a forerunner of the change of life; or attended Avith weak, faint spells, often as a consequence of high living or a sedentary life. Constipa- tion of large and difficult stools, or with frequent urging and dis- 538 MENSTRUAL DERANGEMENTS. charge of small pieces. During her menses she does not sleep after three or four a. m. Opium. Menorrhagia, Avith great sleepiness, yet she cannot sleep. The sheets are so hot she has to change to a cooler place every little while. Phosphorus. Menses too often, too copious and lasting too long. More applicable to tall, slim persons. Constipation, narroAv, dry, hard stools, difficult to evacuate. Sense of emptiness in the abdomen. Much heat up the back, and cold feet and legs. Phosphoric acid. Too early and too long-lasting menses, Avith pain in the liver; or rising frequently at night to pass large quantities of colorless urine. Meteoristic distension of the uterus. Phytolacca dec. Menses too often and too profuse, with a corre- sponding increase of the tears, saliva, bile and urine. Platina. Too long and profuse menstruation, with pressing from the groins to the genital organs. The blood is dark, and comes away partly fiuid and partly in clots. Plumbum. Menorrhagia, with the sensation of a string pulling from the abdomen to the back. Constipation, faeces composed of lumps packed together like sheep's manure. Pulsatilla. Menorrhagia in delicate women of tearful disposition. The least circumstance of joy or sorrow causes weeping. She feels better in the open air, and Avorse toward evening. Bad taste in the mouth in the morning; no appetite, nothing tastes good. Rhus tox. Menorrhagia from a strain; if in rheumatic Avomen, worse at night, demanding constant change of position to find relief. Sabina. Excessive, debilitating menses, Avith abdominal spasms. The blood is partly fiuid and partly clotted, and the pain runs from the back through to the pubes. Sambucus. Menorrhagia, with stoppage of the nose with thick, tenacious mucus. Secale corn. The menses are too profuse and too long-lasting, Avith violent spasms. All her symptoms are worse just before the menses. Particularly applicable to thin, cachectic Avomen. Sepia. Menorrhagia, with a painful sensation of emptiness at the pit of the stomach, or Avith foetid urine, or the urine has a sediment like clay burnt down upon the bottom of the vessel. She has yellow spots on her face, a yellow saddle across the ridge of the nose. Silicia. Menorrhagia, Avith paroxysms of icy coldness over the Avhole body. The menses have a very strong smell. Constipation before and during the menses of hard lumps, which remain long in the rec- METRORRHAGIA. 539 tum, as if it had no poAver to expel them. Sometimes, after long straining, the protruding portion suddenly recedes again into the rec- tum. Profuse menses occurring during lactation. Spongia. Menses too early and too profuse, preceded by colic, sore- ness in the sacrum and craving in the stomach. Chronic hoarseness and cough, the voice frequently giving out when talking or singing. Stannum. Menorrhagia in Avomen having a weak larynx. They cannot talk much, read aloud or sing before the larynx aches; they become hoarse and cannot proceed. The same sensation is sometimes perceived in the chest. Stramonium. Menorrhagia, with draAving pain in the abdomen, thighs and limbs. There may be excessive loquaciousness and a mul- titude of strange and absurd ideas. Sulphur. Menses too early, too profuse and lasting too long. There are Aushes of heat, folloAved by Aveak spells. Heat on the top of the head. Cold feet. Faintness from 11 to 12 o'clock. She cannot wait for dinner. Bleeding haemorrhoids. She sleeps lightly and aAvakens very frequently, or she sleeps a profound sleep the whole night—dead and heavy sleep. Sulphuric acid. Menses too early and too profuse, always preceded by a most distressing nightmare. Tremulous sensation in the Avhole body, Avithout trembling. Much general debility. Trillium. Profuse menses occurring every two weeks, and lasting a week or eAren longer; yelloAV and thick leucorrhoea occurring in the intervals betAveen the periods. Menorrhagia occurring at the climac- teric, of thick, dark and clotted blood. UstilagO maidis. Menorrhagia occurring at the climacteric period, with much pain in the top and side of the head. Menses occur too frequently, are too profuse and last too long, one period reaching almost to the commencement of another; Aow lasts for tAvo or three weeks; dark-colored blood, Avith many clots; vertigo, especially ac- companying menorrhagia at the climacteric. Veratrum. Menorrhagia, with diarrhoea or with nausea, vomiting and cold sweat on the forehead. Weak pulse. Zinc. Menses too early and too profuse. Lumps of coagulated blood, passing away mostly when walking. Fidgety feet and lower extremities. Metrorrhagia. The term Metrorrhagia is meant to signify hsemorrhage from the uterus unconnected Avith the menstrual Aow, whether profuse or othenvise. 540 MENSTRUAL DERANGEMENTS. This haemorrhage may be active—that is, composed of bright, arterial blood—or it may be passive, consisting of the darker colored, venous blood. It may arise from the general inAuence of predispos- ing causes; from accidents; from violence; from excessh'e exertions of body; from sudden shocks and violent emotions of mind; from the presence of Avorms in the intestines; from the presence of polypi or other tumors Avithin the pelvis; from cancer or ulceration of the uterus; from any of the causes which may produce abortion or mis- carriage, and from the abortion or miscarriage itself; from reten- tion of the placenta after parturition, or, otherwise, in consequence of parturition itself; from the cessation of the menses after the change of life; and from any of the causes mentioned in the pre- ceding section, whether local or general, as capable of producing menorrhagia. Those haemorrhages mentioned in the preceding section under the head of Sympathetic Menorrhagia which appear during the course of severe diseases, even if not developed at the usual catamenial period, are still considered as resulting, in persons Avho have not passed the menstrual age, from the profound disturbance of the sexual organism, and are therefore regarded as menorrhagic rather than as metrorrhagic And the same characteristic Avill be considered as belonging to all haemorrhages occurring between the ages of puberty and of the change of life, unless some strongly marked cause, such as one or the other of those above enumerated, can be discovered to operate independent of the catamenial function. And while every individual case of metrorrhagia must be treated with exclusive ref- erence to the symptoms and conditions found in connection with itself, a careful study of the causes of each case of such disorder must be absolutely essential to its successful treatment. This will be made sufficiently obvious by recalling for a moment the fact that the most violent and dangerous forms of uterine hsemorrhage may result from the most opposite conditions of body and of mind—from pleth- oric congestion, or from exhaustion and debility; from the highest emotional excitement, or from the most sudden and profound nervous and mental prostration. The Causes of Metrorrhagia require to be considered a little more in detail. And first, that most vague and common one of general predisposi- tion should never be lost sight of. Even as Ave sometimes see in children and others a remarkable disposition to. hsemorrhage from the slightest wounds or other causes, so in some women it must always METRORRHAGIA. 541 be remembered there exists a corresponding predisposition to uterine hsemorrhage. And this constitutional peculiarity should be carefully studied with reference to its connection Avith a psoric diathesis. In such cases the characteristic of the difficulty, and of course the key- note of the only homoeopathic remedy, may really consist in some far-off and apparently unimportant symptom. Our meaning here will be well illustrated by the instance of the picking of the nose as an indication for Cina in metrorrhagia arising from the presence of worms in the intestines, which has sometimes been known to have kept up for many months a constant stillicidium of blood from the uterus. Here we can readily see the relation between the com- paratively trifiing symptom of picking of the nose and the irritation of the bowel caused by the ascarides, and the consequent uterine irri- tation and hsemorrhage. The fact that in many cases it is entirely impossible to trace any such physiological connection between remote symptoms, which still seem to be characteristic, and the disorders themselves, should not therefore induce us to conclude that such con- nection does not exist. The manner in which violence, accidents, physical and mental excitement, and debilitating mental and bodily causes act in produ- cing metrorrhagia is very similar to that in which in other instances the same inAuences result in menorrhagia. But it is well to bear in mind that violence and excessive bodily and mental excitement tend to establish arterial haemorrhage, while exhausting and debilitating inAuences upon the physical organism, and depressing mental emo- tions, tend to produce passive or venous haemorrhage. Mental and bodily excitement go together, and equally stimulate the arterial action, while all depressing inAuences, Avhether physical or moral, tend to paralyze the peripheral nerves,.and thus arrest the capillary circula- tion. In the former case we may find violent and dangerous me- trorrhagia of bright-red blood; in the latter, a passive Aow of dark, stringy or perhaps clotted blood, which from its intractable per- sistence is no less alarming, since the greater the debility which re- sults from the Aow, the more difficult it becomes to arrest the Aow itself. In certain chronic diseases or disordered conditions of the blood__ such as are found in anaemic and in scorbutic patients; such as are seen to result from the excessive use of salt food, as in scurvy; and such as follow the long-continued use of potash, as in bread largely prepared with salaeratus—the blood is thin and Avatery, loses its rich color, its fibrine is dissolved, especially by the action of the potash, 542 MENSTRUAL DERANGEMENTS. and passive hsemorrhages readily make their appearance. This state of the system, resulting in many. instances from easily discernible causes, is analogous to the hereditary condition just referred to under the names of constitutional peculiarity and psoric diathesis. In either class of these affections the abnormal liquidity of the blood favors the extravasation; and it is easily understood that the losses of blqod, although replaced as to quantity by the absorption of water called for by the intense thirst so commonly seen after severe haemorrhages, do but still further aggravate the disposition to me- trorrhagia. In certain constitutions there is seen in connection with the cata- menia a remarkable disposition toward violent hsemorrhage. And the same thing is equally true in other cases unconnected Avith the menses. This disposition may be termed a constitutional metrorrhagic molimen, in which, under the influence of appropriate exciting causes, the blood rushes to the uterus and Aoavs from it, just as sanguineous congestion and haemoptysis result from corresponding excitement of the pulmonary organs. Cases of metrorrhagia of this class are mostly to be seen in persons of a plethoric habit, who are thus almost ex- actly the opposite of those above mentioned as anaemic, scorbutic and scrofulous. The alarming, frightful, and sometimes even fatal metrorrhagias which may arise from even very small polypi will be referred to in the description of these forms of uterine tumor. In cancer of the uterus the metrorrhagia is often periodical, even in those Avho have long passed the critical age; it is alarming both from its quantity and from the frequency of its recurrence; it may be very sudden and severe from the destruction of some important blood-vessel; it may alternate Avith a limpid, serous or extremely foetid discharge; it may form from time to time a sort of crisis in the cancerous disease and congestion; it often augments during the Avhole course of the case, but may some- times suddenly cease, leaving the patients entirely free during the lat- ter part of their existence. The metrorrhagias which arise from placenta praevia, from retained placenta, and from other causes in connection Avith parturition, have been already particularly considered in the description of the difficul- ties of parturition itself. Those which arise from abortion may be due either to the violence or other causes of the abortion itself, or to the prolonged retention of the ovum and placenta. The latter has been knoAvn to haAre remained for weeks, keeping up a more or less constant hsemorrhage during the THE CHANGE OF LIFE. 543 Avhole time. This subject, hoAvever, has already been fully referred to when treating of Abortion and Premature Delivery. Still another most important class of metrorrhagias is found in those Avhich appear after the change of life. These may arise in some instances from disorganization of the tissues of the womb itself; but in most cases the haemorrhage is believed to be due to the real metror- rhagia molimen already referred to, or to the continuance of the same scorbutic or psoric inAuences in the system Avhich have been described as producing metrorrhagia in the earlier periods of the female life. In these cases the haemorrhage may be more or less constant, or it may alternate in various ways with a watery or a leucorrhoeal discharge. For even in those persons Avho have long passed the critical age a certain amount of periodicity is observable. But the subject will be again considered in the subjoined article on the Change of Life. The attendant symptoms, although always to be taken into consid- eration in prescribing for a case of metrorrhagia, need not here be recited. They are mostly symptoms of debility and prostration in various degrees and forms; it should be borne in mind, however, that some patients bear A^ery severe losses of blood Avith comparative im- punity, Avhile others suffer very greatly from every slight haemorrhage. Treatment.—The treatment of metrorrhagia requires the utmost quiet on the part of the patient, and the strictest attention to all the circumstances and conditions on the part of the physician. For the remedies suitable to the treatment of metrorrhagia the reader is referred to those given in connection Avith the chapter on Puerperal Haemorrhage, on p. 406. The indications given for the use of remedies in the chapter on Abortion and the preceding article on Menorrhagia may likewise be consulted with advantage. Metror- rhagia in connection with polypus will be hereafter treated of in con- nection with the treatment of these growths. The Change of Life. The Change of Life, or menopause—by which is meant the cessation of the double function of ovulation and menstruation—does not usually occur all at once or at any definite time. The critical age—another of the phrases employed in this connection—may embrace a period of several months or extend over tAvo years or more. During the whole of this period the menses will occasionally make their appear- ance, being in many cases as disorderly in other respects as they are irregular in their periodical return. It occasionally happens, however, almost suddenly. 544 MENSTRUAL DERANGEMENTS. Some women cease to menstruate, and consequently to be capable of fecundation, as early as their thirty-second year, while others are regularly "unAvell," and even bear children, when they are already fifty or even sixty years of age. But Avhile such extreme cases are rare on either side, the possibility of their occurrence in any given instance should always be borne in mind. There is no rule absolute, and noAvhere do circumstances more remarkably alter cases than in these affairs of the change of life. It is observed, hoAvever, that, other things being equal, the average duration of the period of ovu- lation and menstruation, and consequently of the susceptibility to fecundation, is about thirty-tAVO years. Still, those Avho commence to menstruate early in life do not lose the function at exactly the corre- sponding period, since in these it continues two years longer. So those who commence to menstruate quite late in life are found to con- tinue this function but little over twenty years.* The average period at which menstruation first makes its appearance being at about the age of fourteen, the general average of the period of the change of life will be found to correspond to the above statement, and to be therefore about the forty-fifth or forty-sixth year. But there are many inAuences, as well in health as in disease, which accelerate or retard the change of life in individual cases. There are persons Avho seem to have a sort of hereditary idiosyncrasy in this respect—to experience the change of life at a very early period, or to menstruate to an unusually advanced age. Others, Avho have borne several children in rapid succession, seem to have exhausted their vital powers in this respect, and to have fallen into a sort of premature marasmus, and consequently arrive at the change of life much sooner than is common to those in health. And very many forms of dis- ease, especially such as induce an anaemic condition, and all that large class of functional disorders and structural diseases of the or- gans of generation and of those connected with them, exert a remark- able inAuence in determining the change of life at an early age. On the other hand, those who commence to menstruate late in life, as well as those Avho are naturally endowed Avith an unusual degree of vitality and longevity, may be expected to retain the function of menstruation to a much later period. Those wdio—othenvise in per- fect health—menstruate for the first time at tAventy, may be expected to continue this function till they are fifty, or even older. And even where we are unable to discern any such particular reason to suppose a patient is about experiencing the change of life at an earlier or later * E. J. Tilt, M. D.: Change of Life in Health and Disease, London, 1867, p. 47. THE CHANGE OF LIFE. 545 period than is usual, we ought ahvays to be on our guard ; for many cases of apparent change of life are in reality nothing more than ir- regular menstruation which we may cure, and which Ave ought to cure, therefore, without first subjecting our patient unnecessarily to the imputation that she is " an old woman"—for Avhich Ave should receive but little thanks—and without subjecting ourself to the odium of being lacking in judgment. For the physician who tells a patient she is having the change of life—she afterward entirely recovering and becoming regular, and even bearing children, and such things have occurred—commits a blunder no less palpable than that of the dentist who pulls the Avrong tooth. In proportion as Avomen enjoy good health, and especially in pro- portion as the menses are normal in quantity and regular in their recurrence, may we expect them to pass through the trying season of the change of life at about the usual age or a little later, and with comparatively little suffering; while in proportion as their health has been poor, and their menses imperfect and irregular, shall we have reason to apprehend that for them the change of life will prove indeed a critical age, and that it will require all our care and skill to bring them out of it in safety and Avith health improved, instead of being rendered much worse. For the change of life once well passed, the Avoman settles doAvn with a new form of life, and it may be with a new lease of life, and has a right to look forward to a happy old age; Avhile on the other hand, if this critical period is not thus suc- cessfully passed, our patient may experience a long train of suffer- ings, which Avill either render her whole life wretched and miserable in the extreme, or presently develop some rapidly fatal organic disease. "Another peculiarity worthy of note is, that many diseases are cured or disappear in consequence of the climacteric. The ovarian atrophy and paralysis remove a constantly recurring source of dis- ease. The monthly cycle, with its attendant excitement of the nervous, vascular and glandular systems, is AvithdraAvn. A season of continued quiet and comparative tranquillity supplies a favorable condition for the restoration of health. And Avhen the critical period has passed it is found to have been the scape-goat of a thousand ills. Slender Avomen may become corpulent, and even obese, bed-ridden invalids get up and Avalk, and an entire and radical change of physical con- dition is the consequence in those who escape the perils of this period. They enter upon a new phase of life, with ne\v hopes and relations toAvard the present and the future."—Ludlam. 35 546 MENSTRUAL DERANGEMENTS. In many cases the change of life comes on so gradually that the system accommodates itself to the new order of things with no shock to the nervous system, and without disturbing the accustomed har- mony of the general circulation. In such cases the intervals betAveen the menstrual periods become more and more prolonged, and even the menstrual discharge itself may gradually diminish in quantity. " The most frequent and least dangerous symptom is an irregular return of the menstrual Aoav every Aveek, or every two or three weeks, or every two, three or four or six months, and being more or less irregular as regards the quantity or quality of the menstrual blood. Serious and alarming haemorrhages frequently set in, especially among plethoric and nervous women, or such as have indulged in sexual excesses. Sometimes these hsemorrhages alternate with whitish or yellowish leucorrhoea, Avhich often has a foetid smell, is acrid and extremely copious. This leucorrhoea may continue long after the men- strual discharge has entirely ceased to appear. At this period Ave like- Avise meet not unfrequently Avith colic, uterine cramps, pains in the sides, Aveight in the loins or distressing itching of the parts. In some cases the abdomen swells as during pregnancy, Avith sympathetic de- velopment of the breasts, until the SAvelling suddenly disappears after the expulsion of a mole, or after the emission of a quantity of gas, or after a haemorrhage or a profuse discharge of serum."—Jahr. Symptoms of Change of Life.—These vary in different individuals, according to their respective temperaments; for in the change of life, as Avell as in other conditions, women present the plethoric, the chlorotic or the nervous type Thus, in those of the plethoric type the symptoms will resemble those of congestion; there may be Aushes of heat, rush of blood to face and head, uterine and other hsemor- rhages, leucorrhoea, and even diarrhoea. In those of the chlorotic type the symptoms which at or near the proper age Avould indicate the approach of the change of life are the sallow complexion, semi- chlorotic skin, weak pulse, and various other indications of debility. In those of a nervous type there is, as the change of life approaches, an evident disturbance of the nen^ous equilibrium, not unlike that Avhich in similar cases precedes the original accession of the men- strual function. Hence the over-anxious look, the brimful eye, the terror-struck expression as if apprehensive of seeing some frightful objects, the face bedeAved with perspiration, and the remarkable tend- ency to hysteria, which are sometimes to be met with. The unusual development of hair on the chin and upper lip gener- ally coincides with final cessation of the menses; so does an unusual THE CHANGE OF LIFE. 547 poAver of generating heat, indicated by the habit of throwing off the clothing and opening doors and Avindows. There are a large number of more or less distressing symptoms or forms of disease Avhich in fact result from the change of life, and Avhich thus cer- tainly indicate that the system is either actually undergoing that change, or under the infiuence of causes Avhich if not arrested will finally bring it about, and that too in a manner by no means safe for the patient. Among these may be mentioned the long list so admirably summed up by Jahr: " Haemoptysis, bloody urine, piles, nose-bleed and other haemorrhages; pulmonary phthisis likeAvise takes a fresh development, and frequently terminates fatally. In other cases Ave meet with diarrhoea, Aveakness of the stomach, fiatu- lence, Amounting and other derangements of the digestive canal, which are sometimes accompanied by consumption and profuse sweats. Some women complain at this period of attacks of rheumatism of the shoulder or thigh, or a considerable swelling of the joints; others experience attacks of hysteria, hypochondria, and even nymphomania; others again are attacked Avith various eruptions, such as tetter of the genital organs, acng rosacea or erysipelas. The most distressing maladies which break out at this period, and often terminate fatally, are ulcers and polypi of the uterus, and carcinoma of this organ and of the breasts." Temporary cessation or irregularity of the menses, when such symp- toms arise in connection with chlorosis, inAammation of the neck of the Avomb, uterine polypi, uterine fibrous tumors, uterine hydatids, uterine cancer, and even pregnancy, have all been mistaken for the change of life. Puberty, " pregnancy, parturition, lactation, are all critical periods, curing some complaints and giving greater activity to others ; and when, after having lasted thirty-two years, the action of the reproduc- tive organs is withdraAvn from the system, prolonged ill-health is the frequent result. Then arises a series of beautiful critical movements, the object of which is to endoAV the Avoman Avith a greater degree of strength than she had previously enjoyed." Thus, the fioodings, leucorrhoea, diarrhoea and perspirations Avhich occur in the great majority of cases of the change of life are eminently critical, and restore to health a large proportion of those Avho are judiciously treated. And there are many women who have suffered in various ways for years with general poor health, who, upon the occurrence of the change of life, may either spontaneously recover, or will oftener be entirely cured by means of the appropriate medication. 548 MENSTRUAL DERANGEMENTS. What is called by some authors the dodging time covers the period which extends from the first beginning of declining and irregular menstruation till the final cessation of this function. This period may vary from a feAv months to six or seven years; and while it affords a most important season for the application of homoeopathic remedies, it Avill be very much abbreviated by their skillful em- ployment. But in addition to those forms of disease which, as purely critical, may be regarded as the salutary results of vital action, such as the occasional haemorrhages, leucorrhceas and diarrhoeas already referred to, there are other and more positive disorders, developed under the general influence of the profound disturbance of the nervous and san- guineous systems Avhich, in many instances, is inseparable from the abrogation of the long-accustomed nervo-sanguineous function of ovu- lation and menstruation. All these require to be treated in the usual manner by remedies carefully selected to meet the existing condi- tions, and with strong hope of success, even in the severest cases—a hope all the greater from the fact of the temporary nature of the in- Auence which stimulates and sustains these forms of disease. And this remark applies even to those malignant and cancerous forms of dis- ease which are so frequently developed at the critical age. Unless the system has been previously exhausted by the hardships and sufferings imposed upon a constitution originally feeble, there is ahvays hope for success in the early application of homoeopathic medicines in these cases. Treatment.—In this place it will be sufficient to refer to the differ- ent disorders already described, such as Haemorrhage, Flooding, Diar- rhoea, Cancer, etc., and to their corresponding medicines, for the treat- ment of the various forms of disease that arise at the change of life. Let the similar remedy he always found for the existing symptoms and conditions of the individual case; let it be given in the best form (not too low); and let its full action be patiently aAvaited, and the physician will have the unspeakable satisfaction of seeing permanent health take the place of the most complicated, distressing and protracted forms of disease at the critical age. The remedies most frequently useful in disorders of the critical age will be found indicated under the head of Menstrual Disorders and other affections, which may be the most prom- inent of those Avhich attend the change of life. The remedies which are remarkably adapted to relieve the disorders incident to change of life, and Avhich therefore are found to be most frequently called for, are Lachesis, Cocculus, Pulsatilla, Sulphur, Crocus, Conium, Sepia, NYMPHOMANIA AND HYSTERIA. 549 Ignatia and Sanguinaria. But whatever remedy includes the symp- toms of the patient in the most characteristic manner—i. e. has as its own characteristics the characteristics of the patient—will prove curative. And in the more severe forms of tumors, cancers or other organic disease which may be developed subsequent to or in connection Avith the change of life, endeavor always to find the remedy Avhich has all the constitutional and characteristic symptoms and conditions of the patient, as well as those relating to the particular form of structural disease which presents. CHAPTER XXVII. NYMPHOMANIA AND HYSTERIA. Nymphomania. THIS formidable disease may be properly reckoned as one of the disorders of the external genital organs, since its principal seat is in the vulva, nymphae and clitoris, although these organs may only be thus affected in consequence of some morbid condition of those more interior. Nymphomania consists in an uncontrollable passion for sexual intercourse, which sometimes overcomes all the restraints of modesty, propriety and decency, and amounts to an actual insanity or monomania on this single subject. Taking its rise in functional disorders of the sexual system, or in more general constitutional in- fluences, which are thus ultimated upon the external generative organs, this disease changes the entire moral character from the most attrac- tive modesty to the most shameless and repulsive profligacy; and it may lead to paroxysms Avhose violence rapidly exhausts the vital energies, and Avhich terminate only in death. Nymphomania is to be distinguished from erotomania. The former is a purely sensual passion, alike physical in its origin, in its local influence, in its development and in its much-desired forms of grati- fication. The latter, although still to be considered sensual in a strictly moral point of vieAV, from a physical point of view AArould seem rather spiritual, as neither requiring sensual means of gratification nor dependent upon physical ability. Erotomania is a psychical state, which may find its highest if not its only gratification in the reveries 550 NYMPHOMANIA. and dreams of amorous imagination and fancy by day or by night. Nymphomania is a physical disease, whose progress may be traced through a period of internal incubation, of external, reluctant and partially restrained development, to a final condition of open, unre- strained manifestation, characterized by a most intense, all-control- ling sexual desire, and by an equal unconsciousness of shame and of decency. This disease has repeatedly appeared in strongly marked cases, where there Avas one constant characteristic of the temperament or constitution, and that was " an unusual susceptibility of the skin to tettery affections." In these cases the disorder is so profoundly con- nected with the entire system that it induces paroxysms of convul- sions, which indicate that the entire cerebro-spinal nervous centre is in- volved. The actual monomania, with entire obliteration of all feeling of modesty and unconsciousness of all the duties and proprieties arising from the domestic relation, indicates also an equally complete subjec- tion of the purely cerebral functions and moral feelings to the same morbid influence; Avhile the spasmodic closure of the oesophagus and impossibility of deglutition, and consequent destruction of organic life, show also that the same disease has possessed itself of the or- ganic nervous centre, and so completely invested the whole of the organism. True nymphomania may be considered as a most remarkable illus- tration of the psoric diathesis, as a most astonishing proof of the truth of the psoric principle; for if we obsen^e this malady to arise from the more immediate influence of ascarides or onanism, these latter are but intermediate steps in the chain of causation, being themselves the results of the same psoric influence in the system. The same may be said of the enlarged, hypertrophic condition of the clitoris so often seen in connection Avith this disease. The nymphomania is more apt to make its appearance at either one or the other of those two epochs of the female life in Avhich the constitution is stirred up as it were in its profoundest depths—that is, at the accession of puberty or on the cessation of the menses, but more particularly at the former of these tAvo periods. And in addition to the influences already mentioned as constitutional or provoking causes, and which will thus exert an im- portant influence in determining the choice of the remedy, we may men- tion suppression or great disturbance of the menstrual function and organic diseases of the uterus. But in prescribing for this truly distressing complaint the various attendant symptoms, as well as the peculiar constitutional indications, REMEDIES FOR NYMPHOMANIA. 551 must be carefully considered. It will not be necessary to enumerate here all the varied symptoms, and morbid moral, mental and physical conditions, which may accompany a case of nymphomania. As in hysteria—and in fact what is this disease itself but a most violently aggravated hysterical affection or morbid excitement of the entire sexual system of the female ?—so in nymphomania, an endless succes- sion and variety of symptoms may present. There may be leucorrhoea of more or less peculiar kind; pruritus of the external organs; intense lasciviousness; inflammation and excitation of the sexual parts; fever with foetid breath; nocturnal restlessness; sleep Avith dreams Avhich renew the sexual excitement; paroxysms of spasmodic closure of the oesophagus; general and exhaustive convulsions; diarrhoea, etc. And these attacks and symptoms of the disease may appear in consequence of onanism, or be attended with irresistible disposition to it; they may accompany menstruation or appear in its absence; and finally may be relieved or brought on by pregnancy. We have devoted con- siderable space to this not very frequent form of,disease, because the homoeopathic remedies—as in the somewhat analogous caseof delirium tremens—have been found capable of producing the most salutary re- sults, and thus of saving from destruction and of restoring to society some of its most valuable and important members. And the indica- tions given for the remedies may be useful also in the milder and more common forms of amorousness and erotomania, for the relief of which the physician is often consulted. Remedies for Nymphomania. 1. Bell., Canth., China, Mosch., Nux v., Phos., Plat., Puis., Verat. 2. Ant. cr., Calc. carb., Carbo veg., Coff., Graph., Lach., Merc, Natr. carb., Natr. mur., Op., Sabina, Sil., Stram., Zinc 3. Agar., Ars., Aur., Bov., Cann., Cocc, Coloc, Con., Dig., Dulc, Hyosc, Ignat., Iod., Lye, Meny., Plumb., Ruta, Staph., Sulph., Thuy. Agaricus. Itching and irritation of the genital organs, with strong desire for an embrace. Great selfishness. The patient is subject to chilblains, Avhich are red and itch greatly. Antimonium c. Tenderness over the ovarian region, with nausea, vomiting and Avhite tongue. Sentimental mood in the moonlight, particularly ecstatic love. Arsen. a. Sexual desire, with an involuntary discharge of mucus as a particular symptom. Restlessness. Thirst for cold water; a very little satisfies her. Unhappy, fatiguing dreams; nothing comes out 552 NYMPHOMANIA. right in her dreams. She Avishes to be in a warm room or to be cov- ered up Avarmly, and cannot bear the cold air. Symptoms become Avorse after midnight. Aurum. Feeling of desperation; hysterical mood, laughing one minute and crying the next. Bovista. Burning and voluptuous feeling in the sexual organs. LeAvcl dreams. Calc. carb. Pale, leucophlegmatic. Much headache. SAvelling over the pit of the stomach, like a saucer turned bottom up. Menses too often and too profuse. Vertigo or a pressing headache, as if some- thing Avere pressing up into the head, on ascending. Sleeplessness in the early part of the night; she lies awake for hours. Cannabis s. Great excitation of the sexual instinct, the female being sterile. Aggravation of the symptoms after midnight, Avhich become still Avorse in the forenoon. Vivid lascivious dreams after midnight. Cantharis. Pruritus of the vagina, with strong sexual desire. She must urinate very frequently, Avith cutting, burning pain. Carbo veget. She is troubled much Avith varicose veins in the vulva. Itching at the same time of both the vulva and the anus. Much belching of wind, which affords relief for a short time only. China. Sensation as if the abdomen were too full after eating, with desire to eructate, which, however, affords no relief. Troublesome itching and spasmodic contraction in the inner parts. Nymphomania of lying-in women. Cocculus. Particularly in chlorotic females. Shivering over the mammae. LoAver extremities very weak. Bloody leucorrhoea. Coffea. Voluptuous itching in the genital organs. She is in a state of ecstasy. Sleeplessness. Conium. Shriveling of the mammae, with increasing sexual desire. She is much troubled Avith vertigo, particularly Avhen lying doAvn and when turning over in bed. The urine Aoavs and stops, and Aoavs again, at each intermission. Digitalis. Lascivious state of the fancy day and night. Remark- ably slow pulse. Stools of a very light color. Dulcamara. Heat and itching in the genitals, with desire for an embrace. All her symptoms are aggravated by a cool change in the weather. Her sexual desires are also increased by this change. Graphites. Inclination to obesity. Enlarged ovaries, Avhich become more tender and more enlarged every time she takes cold or gets her feet damp. Menses delay. Itching blotches here and there over the REMEDIES FOR NYMPHOMANIA. 553 surface of the body, from Avhich oozes out a colorless, glutinous fluid. Gratiola. Gnawing about the umbilicus, as if of worms. Tingling in the hypogastrium and around the umbilicus. Gnawing at the pit of the stomach after eating, as if of hunger. Irresistible droAvsiness and involuntary closing of the eyes as the other symptoms abate. Hyoscyamus. Excited sexual desire Avithout excitement of the fancy. Laschdous furor Avithout modesty. She inclines to uncover and expose herself. Coiwulsive trembling. Immoderate loud laughter. Ignatia. Strongly inclined to solitude, and to be very secretive, and to be passive. Sadness and sighing, with an empty feeling in the pit of the stomach. Jodium. Dwindling and falling away of the mammse; they hang down heavily and lose their fatness. Heaviness of the mammse, as if they would fall off. All her symptoms are relieved by eating. Lachesis. Tickling and jerking, extending from the thighs to the genital organs, Avith sexual excitement. Her symptoms are usually worse after sleeping. She feels extremely sad, unhappy and dis- tressed in mind on waking in the morning. Lycopodium. Much borborygmus in the abdomen, or gurgling in the left hypochondrium. Discharge of wind from the vagina. Sense of dryness in the vagina. Red sand in the urine. Delay, and severe pain in the back before the emission of the urine. Sense of fullness up to the throat on eating a small portion. Mercurius. The symptoms are more constitutional than local. Hence this remedy must be given rather from its general character- istic indications. The symptoms are usually aggravated at night, and are still worse AArhen in bed. Moschus. Violent sexual desire, Avith intolerable titillation in the genital organs. Nat. carb. Motion as from a foetus in the uterus. She has a variety of sufferings, all of Avhich are aggravated during a thunder-storm. Nat. mur. Falling off of the hair from the mons veneris and from the labia majora. Much itching of the vulva. She aAvakens every morning Avith a bad headache. Great aversion to bread, of Avhich she Avas once very fond. Longing for salt things. Nux vom. Burning in the vulva, Avith desire for an embrace. She Avakens at three or four in the morning Avith sexual desire; does not sleep much afterAvard. Constipation of large and difficult faeces. Opium. Very sleepy, but cannot go to sleep. Constipation; the evacuations are composed of round, hard black balls. The sex- 554 NYMPHOMANIA. ual excitement and other troubles all disappear from a feAv doses of opium. Phosphorus. In a pregnant Avomen at the seventh month nymph- omania appeared, Avith spasms; the symptoms were a Aveak, empty feeling in the abdomen, cutting pains in the abdomen, a narroAV, dry, long and difficult stool, like a dog's stool. One dose of Phosph. 19 m. completely cured the nymphomania: she Avent her full time, and Avas happily delivered. Platina. Excessive sexual desire, particularly in virgin Avomen. Voluptuous tingling in the vuh^a and abdomen. Stool difficult, be- cause it adheres to the rectum and anus like soft clay. Hysterical cough from stifling beneath the upper fourth of the sternum. Plumbum. Sensation of draAving from the abdomen to the spine. Constipation; stool like sheep's manure. Severe stretching, proceed- ing from the abdomen. Pulsatilla. In Avomen Avith blue eyes, very affectionate, easily ex- cited to tears, and of a very yielding disposition. She cannot sleep in the early part of the night; sleeps late in the morning. No thirst. All her symptoms are worse toward evening; they are relieved in the open air, and worse on returning to a close and warm room. Sabina. An almost insatiable desire for an embrace. A sensation of drawing or dragging from the sacrum to the pubes. Music is intolerable to her. Silicia. She feels nauseated during an embrace. Spinal affections and constipation, Avith increased sexual desire as a consequence. Staphysagria. Extreme sensitiveness to mental and physical im- pressions. She feels mentally and very acutely every little circum- stance. The teeth turn black. Stramonium. Excessive loquacity during the menses. This was ahvays the case. Stramonium removes also abnormal sexual excite- ment. During the menses the smell of semen is very apparent. Her face is bloated with blood. A great many strange fancies come into her mind. Sulphur. A weak feeling in the genital organs. Sore feeling in the vagina during an embrace. Sterility. Also in cases which present the general characteristic indications for sulphur; which see under head of Hysteria. Thuya. Fig-Avarts, condylomata, or other excrescences of a similar nature on or about the genital organs. Her symptoms are Avorse after three P. m., and at night, preventing her from falling asleep. Veratrum. Nymphomania, particularly of lying-in women. Mania, HYSTERIA. 555 with leAvdness and lascivious speeches. Thirst, Avith craving for the coldest drinks. Menses preceded or accompanied by vomiting and diarrhoea, or by diarrhoea alone. The bed aggravates all the symptoms. Zinc. Sexual desire several times at night. Irresistible desire for onanism. She always feels best during the menstrual flow. Boring pain in the left ovary, requiring pressure for partial relief, excepting when the menses are flowing; then there is complete relief. Such diet should be prescribed in cases of this nature as is perfectly plain and unstimulating; all stimulants, including tea and coffee, being positively prohibited. Exercise in the open air Avill be of bene- fit, and every effort should be made to divert the mind of the patient from the consideration of subjects of a sexual nature. Hysteria. Hysteria is a purely nervous affection, Avhich may arise and con- tinue without any functional or organic derangement of the female sexual system on which it is based, and Avhich does not necessarily produce such derangement or disorganization. Hysteria bears the same general relation to the nervous apparatus of the reproductive system that chlorosis does to that of nutrition, and has no more exclusive connection with the uterus or other particular sexual organ than chlorosis has with the stomach or other particular digestive organ. As a purely nervous affection, not necessarily painful, hysteria must be distinguished from irritable uterus on the one side and from hys- teralgia on the other. In irritable uterus, although there is neither disorganization nor structural change—except perhaps that of dis- placement, which is the most frequent cause of the irritability itself— the uterus is excessively sensitive to pressure, or even to the touch, which is not necessarily the case in hysteria. In hysteralgia the pain, sometimes mild, lingering, Avorrying, and sometimes violent, severe and acute, is ahvays positive and decided. But in the location of the disease itself may be found another im- portant distinction betAveen hysteria and the someAvhat analogous forms of uterine disease Avith which it is so apt to be confounded. In irritable uterus and in hysteralgia, from Avhatever cause these disorders arise, their actual location, principal seat and ultimate development appear to be in the uterus itself. This, however, is not the case with hysteria. The uterus indeed has usually been considered the seat of hysteria (hence the name), but the ovaries, as the centre of the sexual 556 HYSTERIA. system, must noAV be regarded as the real fons et origo of a majority of cases of hysterical affections.* Thus pressure upon the ovaries will invariably bring on hysterical attacks in persons predisposed or subject to the disorder. Hysteria extends its influence over the entire sexual apparatus; from its profound connection with the sympathetic system it may extend its influence to all the involuntary organs, and by its final extension to the cerebro-spinal nervous system it may involve also all the voluntary muscles. Hysteria, again, has been found to co-exist Avith the most perfect performance of all the functions of the uterus and its dependent organs, such as menstruation, conception, utero-gestation, parturition and lactation, although this is perhaps true rather of the milder than of the severer forms of this disorder. Still, as not necessarily disturbing the functions, still less involving the structure of the sexual organs, and as not being invariably painful, hysteria estab- lishes its claim to be regarded as a purely nervous affection, capable of being distinguished from irritable uterus and from hysteralgia, both of which are also nervous affections, although of quite another sort. This distinction will appear more strongly marked when we come to notice the differences in the nervous systems principally in- volved. And this definition of hysteria is still further strengthened by the well-known influence of imagination and sympathy in ex- tending this disorder from one person to others, as in the hospitals, Avhere many are simultaneously and sympathetically affected from seeing a single one attacked by hysterical convulsions. And it is still more fully confirmed by the poAverful influence of fear in pre- venting and allaying such convulsions. In this respect, as Avell as in some others, hysteria bears a very remarkable resemblance to epilepsy. The neuralgic and the convulsive forms constitute two distinct varie- ties of hysteria, but this distinction, although sufficiently well marked, is one of degree rather than of kind. In what is termed the neuralgic form of hysteria the symptoms " are merely manifestations of nervous susceptibility," Avhile in the convulsive form they are more intense, permanent, regular and periodic. And the principal apparent distinc- tion between this latter condition of periodic menstrual convulsions and that Avhich presents in uterine epilepsy is to be found in the loss * It must not be forgotten that a corresponding irritation of the nervous system belonging to the sexual apparatus of the male may sometimes occasion a similar hysterical condition in men. HYSTERIA. 557 of consciousness, which manifests itself in the latter form of disease, but not in the former. A corresponding distinction may be seen in the nervous centres involved in hysteria. For in the milder, so-called neuralgic form of the disease, which yet may be of hereditary origin, the ganglionic or sympathetic nervous system seems principally concerned; while in the severer or convulsive forms of hysteria the original, predisposing, hereditary influence is by provoking causes extended to a full devel- opment in the cerebro-spinal nervous centre. In this case, then, we find the discordant influence extending itself to the muscular apparatus, and in consequence Ave have occasional spasms or regular and period- ically recurring convulsions. And it will be observed that these spasms first appear in those parts of the body and muscular tissues which are in immediate relation with the abdominal, the cceliac and the thoracic ganglia. From these remarks it may be concluded that hysteria is a purely nervous affection, which, being to a great extent hereditary in its origin, finds its primary seat in the ganglionic or sympathetic ner- A'ous centre; Avhich finds its secondary and ultimate development in the cerebro-spinal nervous system; which in this extended develop- ment occupies the motor rather than the sensory nerve-filaments; and which thus finally results in spasmodic contractions rather than in poignant sensations. And here is to be found perhaps the last, most important and reliable distinction between hysteria and hysteralgia. In their constitutional origin, in their primary ganglionic seat of development, and in the provoking causes of their extension to the cerebro-spinal sphere, they may show but little difference; but here they diverge, for where hysteria seizes upon the motor filaments of the nerves, and so leads to convulsions, hysteralgia inATolves the sen- sory filaments, and occasions the intense pain which characterizes this affection. This distinction is exactly the same as that between asthma and angina pectoris, the former affecting the motor nerves, and the latter the sensory nerves of the chest, so that in asthma we have severe constriction, with little if any other pain, while in angina pectoris we find the most poignant distress, but no constriction. Hysteria thus becomes an affection principally (although not exclu- sively) of the female system, which, constitutional in its origin, and so underlying the organic nervous system, is also capable of extending itself over the entire nervous organization, and of simulating almost every form of disease, with the single exception, perhaps, of accelera- tion of the circulation; for some of these states of hysterical excite- 558 HYSTERIA. ment can hardly be distinguished from inflammatory fever, except by ascertaining that the rapidity of the pulse does not correspond with the other apparently febrile symptoms. Symptoms.—To attempt to enumerate all the legions of symptoms which may appear in hysterical cases AA'ould be a hopeless task. Hence our description of this multiform affection must be confined to the statement of the more prominent symptoms only, and to a general division and classification of those Avhich make up the principal forms of the disease. And the first and most general division of the symptoms of hysteria will be into those which belong to the mental and moral sphere, and into those Avhich are purely physical sensations. And in each of these two divisions there will be found the same variety and even di\rersity of conditions. Thus among the moral symptoms there may be great depression of spirits with involuntary tears, or equally great exaltation of spirits and meaningless laughter; in these cases the exaltation and the depression being alike incapable of being attributed to any appar- ent cause. There may be sudden changes, and even frequent alterna- tions from one extreme to the other, and ah\Tays an uncertainty and Avant of fixedness, and even positive mobility of character. And these revulsions are not confined to the individual states of joy and sorrow in the persons affected; they extend also to their affections toAvard the members of their families and toward others. And in addition to those changes which arise from no perceptible cause, there is a remark- able susceptibility Tto impressions, many of Avhich, although in reality of the most trifling nature, appear to exert a fixed and powerful influ- ence. Other and no less remarkable changes in feeling and in affec- tion arise from purely imaginary causes. Thus, in hysterical persons it is not uncommon to see personal dislike unaccountably take the place of previous affection, and the most violent and furious parox- ysms of jealousy arise from the influence of imaginary and baseless sup- positions. As in the personal condition of an hysterical woman there may be alternations of gayety and of gloom, of frolicsome levity and of melancholy seriousness, so in her relations to others, and, if married, to her husband especially, she will at one time be full of affection and devotion, while at others sentiments of aversion and positive dislike obtain the entire SAvay. One day she Avill express herself as the happiest of Avives, and assure her friends that her husband is as good as he can be; the next she pours into the gaping ears of all the gossips her peculiar condition gathers around her long HYSTERIA. 559 tales of suffering, neglect and abuse, and represents the man Avho has the misfortune to be her husband as the most detestable monster. This form of hysteria is a real monomania with lucid intervals, but which may become a fixed insanity in relation to the married state, and so not only destroy domestic peace, harmony and affection, but even break up the family. But hysteria, in all its most aggravated moral forms, is distinguished from insanity by the fact that the personal consciousness is never lost sight of. There is ahvays a sort of alienation of the personality in cases of insanity, a forgetfulness of self, Avhich never appears in hys- terical cases. In these latter, on the contrary, there is the most re- markable and persistent prominence of the self-love. Egotism, espe- cially in married Avomen as opposed to their husbands, is the most prominent and the only constant moral symptom of hysteria. Such persons entertain their hearers with marvelous tales of the greatness and exploits of their past lives, and of the richness and abundance of their possessions, of the number of their friends and of the distin- guished consideration they have ahvays received in society in their former places of residence. These accounts are uttered Avith an air of sincerity Avell calculated to deceive the honest listener; and such un- bridled license of the imagination and total obliviousness in regard to the truth, which are vulgarly attributed to entire want of principle and the most inordinate A^anity, are in reality due to that morbid con- dition of the female organism Avhich is designated by the comprehen- sive term hysteria—a condition Avhich, if it were properly understood, would prove far less mischievous in society and less frequently destroy the family tie. The second part of our division of the symptoms of hysteria in- cludes all those which have relation to the physical system. These physical symptoms may be again divided into the sensational and the convulsive. Among the former may be ranked all those various un- easy sensations Avhich appear at different times in different parts of the body, as in the abdomen, in the pit of the stomach and in the throat— sensations Avhich are not very positively painful, but which are for that reason perhaps all the more distressingly annoying, and Avhich in the most aggravated forms become developed into actual spasmodic contractions in those parts. These sensations do not appear to exert any direct influence upon the organic functions; still, they are attended Avith disturbances of the appetite, indigestion and general languor and debility, Avhich are no doubt the consequences of the nervous derange- ment. These sensations are innumerable, variable or fixed, and either 560 HYSTERIA. constant or excited by the slightest influence, and even by the least touch. As there is a constant indecision, want of fixedness or persistence in the mental sphere, rendering the mind liable to be SAvayed by the slightest breath of external influence, so in the physical system there is a corresponding want of permanency in the animal spirits. The same mobility that appears in the mental and moral states, and in the affectional relations toAvard others, appears in a corresponding degree in all the bodily conditions. And as the merest fancy will often bring on a paroxysm of jealousy in hysterical women, so the slightest direct touch, or the reflex influence from ordinary func- tional action, may give rise to a long train of hysterical sensations, or even occasion the most determined convulsions. This remarkable sensitiveness of the physical system to external impressions, and no less remarkably increased reflex excitability, form the chief characteristics of the first or sensational variety of the physical symptoms of hysteria. The convulsive symptoms of hysteria begin in the hypogastric region, and gradually pass up the abdomen like the ripple of a wave, through the chest to the larynx and pharynx. First comes on a strange sensa- tion, as of pain, in the hypogastric and ovarian regions, followed by suffocative feelings in the pit of the stomach, and then by the globus hystericus, which is characteristic of the complete hysterical passion. These form the precursory symptoms of the true hyster- ical convulsions, and are analogous to the aura which precedes the accession of an epileptic attack. And from appearing at the first in this mild form of semi-spasmodic contractions these attacks may momentarily or hourly increase in severity till trismus or lockjaw supervenes. And as the hysterical attack in its successive forms of development involves the different nervous branches and ganglionic centres, corresponding symptoms appear. Thus, from the disturbance of the nerves of the pharynx there results dysphagia, globus hysteri- cus ; from the larynx, an affection, with the most imminent danger of suffocation, not to be distinguished from croup, except that there is no false membrane, and that Nux vomica, rather than Aconite or Spongia, may prove curative; from the bronchia, dyspnoea and cough; from the heart, attacks of palpitation, irregular beating and sense of anxiety; from the stomach, hiccough, retching and vomiting; from the bladder, ischuria or dysuria. And finally, as the paroxysms ex- tend through the voluntary and involuntary muscles, there are devel- oped tonic and clonic spasms of every kind and degree of violence, from mere tremor or nervous quivering to the most convulsive move- HYSTERIA. 561 ments and contortions. " The masticatory and histrionic muscles of the face take part; trismus, chattering of the teeth as in the rigor of fever, the sardonic laugh and a rolling of the eyeballs upward, occur. After a duration varying from ten minutes to several hours, the paroxysm often terminates suddenly Avith a Aoav of tears or a copious discharge of urine, but not unfrequently it passes off gradually." * The globus hystericus, which has already been mentioned, merits a fuller description, since it forms one of the most characteristic symp- toms of the invasion of the hysterical paroxysm. It consists in an obscure sensation as of a globular body, which gradually ascends from the pelvic cavity, or at least from the hypogastrium, to the throat, where it seems to be arrested, and to produce a most painful sense of constriction and suffocation. This causes a peculiar choking sensation, which may be attended Avith sobbing. It is not confined to women, but may sometimes appear in those of the opposite sex, especially in young persons about the age of puberty, whose naturally delicate and sensitive temperament is agitated in a particular manner. Globus hystericus may arise from mentally or morally caused inter- ruption of the delicate currents of the nervous fluids ; and may, par- ticularly in males, be at once removed by such relief and revulsion of these feelings as Avill again permit the free and unrestrained flow of these most interior and subtle fluids, of which we know but little more as yet than their hypothetical existence. Causes.—The causes of hysteria are as various as they are numer- ous. No doubt very many cases of this disorder, especially of the convulsive form and most obstinate kind, are originated and main- tained by functional derangements, displacements or structural disor- ganizations of the uterus or other parts of the sexual system. But since in these instances the hysterical affections are but the conse- quences or attendant symptoms of other and primary disorders, we do not consider them in this place. They require to be studied in connection with all the accompanying and causative conditions. But in all cases in which hysterical symptoms appear as part of the tout ensemble of the disease, the remedies advised in the present chapter for hysteria itself should be carefully compared, since these various nervous, mental and moral states should ahvays be covered by the medicine to be administered. To hereditary predisposition we may assign, then, the first place among the causes of idiopathic hysteria. This may exist in the form of (otherAvise) latent psora, Avhich thus irritates the organic or * Romberg: Diseases of the Nervous System. 36 562 HYSTERIA. sympathetic nervous system in its relation to the sexual system. And the connection of the hysterical affection Avith such con- stitutional psora may be traced in the eruptions known to have appeared in the parents, or Avhich may have been temporarily man- ifested in the hysterical patient herself. " A predisposition to hys- teria is no doubt to be ascribed in many cases to congenital inherit- ance of physical conformation and temperament. The greater num- ber of sufferers from this disease, observes M. Georget, have descended from parents, or have been members of families, remarkable for their liability to nervous diseases in the several forms of hysteria, epilepsy, maniacal affections, hypochondriasis, nervous headaches, deafness, blindness, palsies," etc.* This hereditary constitutional predisposition to hysteria is very greatly aggravated by the personal influence of the mother if she still remains subject to similar affections. And just in proportion as such predisposition exists in greater or less degree, will the patient be more or less liable to have it developed by the ordinary provoking influences. The sexual organization itself, in its various conditions and crises, exerts a powerful influence in producing or developing the hysterical affection. As long as the sexual organs remain undeveloped, hysteria does not appear, except perhaps in persons whose constitutional incli- nation to this form of disease is so great as to retard the sexual devel- opment. In like manner, after the cessation of the menses, when the sexual organs return to a second-childhood state of abeyance, hysteria does not appear, except as the result of some organic disease of the uterus or ovaries. But after the accession of puberty, the re- tention or tardy appearance of the menses and all the various derange- ments of the catamenial function — the excitement incident to coition, conception, abortion, miscarriage, utero-gestation and par- turition — may become capable of developing the constitutional predisposition to hysteria, or perhaps of originating the disease itself where such predisposition did not exist. So sensitive and delicately organized are some constitutions in respect to the sex- ual system that the enforced continence of protracted virginity, the imperfect, incomplete performance of sexual intercourse in the married, and the deprivation of such intercourse in those who sud- denly become widowed, are alike capable of giving rise to hysterical affections; and even the moral sufferings of disappointed love, un- requited affection and inconsolable grief have in many instances been known to lead to the same result. * Davis's Obstetrics. TREATMENT OF HYSTERIA. 563 The influence exerted in the production of hysteria by the uterine life of the female is as unquestionable as it is unlimited. And this includes all the organs of the sexual system, but more especially the ovaries, of Avhich mention has already been made in this connection. And even as inflammation will extend from one serous or cellular tis- sue to another Avith great rapidity, even Avhere the tissues themselves are not adjacent, so Avhere the ovaries are in this chronic state of irritability they exert by sympathy such an influence upon other ner- vous centres that the slightest irritation of their peripheral extremities may induce hysterical paroxysms. Thus in persons subject to hys- teria the reflex action from irritation of the gastric, the intestinal or the uterine mucous surfaces, or even of the external cutaneous surface, is often sufficient to throw them into the most violent hysterical convulsions. Treatment.—Both moral and remedial measures are necessary to the successful treatment of hysteria. Scarcely any disease that the physician meets taxes in a greater degree the energy and the resources of the practitioner; and if he be not equal to the exigencies of the case in the moral view of it, his remedies may fail of producing any effect. The disease being chiefly of an emotional nature, it is of great importance to obtain a controlling influence over the mind of the sufferer and to secure her confidence, while she assures herself of her physician's sympathy. " I am so confident," writes Dr. Ludlam,* " that a lack of sympathy, a dearth of feeling, a real incompatibility of temper and taste betAveen the physician and his hysterical patient, may cause his treatment to result in more of harm than of good, that, in case this obstacle cannot be otherAvise removed, I think it better to Avithdraw and to let another physician be called..... Under similar circumstances we would not hesitate to discharge the nurse whose every movement was annoying to the patient and antag- onistic to her comfort and welfare." During the occurrence of a " fit of hysterics" all tight clothing about the patient should be loosened, and she had better be laid upon her back on a bed, a sofa or the floor. Cold water has been recom- mended to be dashed into the face, as by the shock the paroxysm will be broken up; but it will be better to bathe the face and forehead with cold Avater, and alloAV her to have a plentiful supply of fresh air. The remedies which may be used in cases of hysteria are very numerous. Indeed, there are but few in the Materia Medica Avhich have not in their pathogenesis some reference to this varied and ever- * Lectures, Clinical and Didactic, etc., page 308. 564 HYSTERIA. varying form of disease. Great care should therefore be exercised to prescribe the proper remedy at the commencement of the treat- ment ; then very great caution should be observed in regard to repeat- ing the dose, and still greater in changing to another remedy. The habit of changing the remedy to suit the different phases of the disease is a most pernicious one, and this is still more especially true in cases of hysteria, where a single disorder of the system assumes at different times such an infinite variety of forms. Some one or more of those grand characteristic symptoms that are nearly always present, and that are observable by the patient herself or by her attendants, should govern the choice of the remedy. And when once thus carefully selected, the medicine must be allowed to act for days or weeks—or perhaps even months in cases where the improvement continues so long—without repetition of the dose, and still more especially with- out changing the prescription. And in cases of hysteria, as also in epilepsy or other chronic spas- modic affections, never prescribe for the convulsive stage per se; rather let it pass off by itself Avithout medication. But observe closely all the symptoms, for it may be that here, in the very last ultimation of the disorder, we may detect the symptom which shall conclusively indicate the remedy for the entire case. The character- istic symptom of a case—that which corresponds to the key-note of the appropriate homceopathically indicated remedy—may appear in the course of the convulsi\re attacks or at their close; it may be the precursory herald of their approach, like the aura epileptica; it may appear only in the interval of comparative quiet; or, as in those cases which have no positive spasms, it may be a more or less constantly attendant symptom; or, finally, it may even be merely a condition of aggravation or amelioration of time, place or circumstance. Only a few of the leading and more frequently indicated remedies for hysterical affections can be mentioned here. The entire Materia Medica has sometimes to be ransacked to find the true similimum for some of the forms of this disease—a disease Avhose forms are as numerous as the individual constitutions and temperaments of its sub- jects, multiplied by the innumerable physical, mental and moral influ- ences Avhich become the means of provoking, exciting or developing the original constitutional delicacy or hereditary predisposition. Remedies for Hysteria. 1. Aurum, Cocc, Con., Natr. carb., Nux vom., Mag. mur., Plat., Valer. 2. Anac, Asaf., Bell., Caust., Ignat., Jod., Lye, Mosch., REMEDIES FOR HYSTERIA. 565 Natr. mur., Nux mosch., Phos., Puis., Sab., Sep., Stann., Staph., Sulph., Yerat. alb. 3. Agnus c, Arn., Ars., Calc. carb., Cann., Cham., China, Coff., Cycl., Euphr., Graph., Hell., Hyos., Ipec, Lach., Merc, Mezer., Palad., Rheum., Solan., Sil., Stram., Viol, od., Zinc. Aconite. She has much fear—fear of going into places of business, into croAvds, or anyAvhere where many persons are actively passing and repassing. Vertigo on rising from a recumbent position. She dreads too much activity about her; she complains much of her head; she is possessed with a great and distressing fear of death. Predicts the day of her death. Aconite will remove all these symptoms, and with them, probably, the whole train of morbid sensations, if allowed to act a long time, with occasional repetitions when the improvement seems to have ceased. Anacardium. Where great forgetfulness seems to characterize the case. Loss of memory. Uses profane language. Arsenicum. Where a real hysterical asthma seems to be developed at every little excitement. Worse at night, particularly the latter part of the night. She cannot lie down for fear of suffocation. She wants a little water every few minutes. Great fear of death. She has many other troubles, but these seem to predominate. Asafcetida. There is much trouble about the oesophagus; every ex- citement that brings on hysterical symptoms points thither. Dryness and burning in the oesophagus. Sensation of pressure, or as if a body or lump were ascending in the oesophagus, obliging frequent deglu- tition to keep it down. This feeling in the oesophagus often causes great difficulty in breathing. Soreness in the oesophagus, preceded by burning. Dartings upAvard toward the oesophagus from the chest. When the hysterical symptoms develop themselves in this direction Asafcetida Avill cure the case. Globus hystericus. Aurum. The more her hysterical troubles are developed the more her thoughts run on the act of committing suicide. This act is more or less constantly and forcibly in all her thoughts. In such cases, under the influence of Aurum, the patient will cease thinking of suicide, and she will get well. This remedy is also indicated by a fine eruption on the lips or face and forehead, and by thoughts of suicide, with palpitation of the heart. Belladonna. There is a general tendency of blood to the head, with redness of the eyes and face, Avhich is still more developed in the spas- modic attacks. She moans very much, even at night, without much 566 HYSTERIA. sleep. She is very despondent. She will sit and break pins into pieces half a day at a time. She is very much troubled with throb- bing headache, particularly over the eyes. She has a Avild look. Sleepiness, but cannot go to sleep. Calc. carb. This important remedy will be particularly indicated in hysterica] as in other affections, where the symptoms correspond, in persons of a leucophlegmatic treatment. She has a SAvelling at the pit of the stomach, like a saucer turned bottom upward. She has many spasms per day. She is easily chilled. She suffers from cold, damp feet. Vertigo on going up stairs. Her menses are too frequent and too abundant. She is often unable to sleep after three o'clock in the morning. Cold feet at night in bed. She cannot go to sleep, her mind turning on the same thought all the time. CausticunL One of her chief troubles is, she cannot keep her upper eyelids up y they are paralyzed or nearly so, and will fall down over the eyes. She is very apt to have piles, which are made almost intol- erable by walking. Chamomilla. Great tendency to quarrel, to speak in an obstreperous manner. She has to restrain herself much in order to give civil answers to questions. China may be useful in cases which are usually worse every other day, and in such as are attended with unusual strong appetite. Sen- sation of distension in the abdomen. Cocculus. In the fullest development of this disease this remedy points to a choking constriction in the upper part of the fauces, with difficulty in breathing and an irritable cough or disposition to cough. Retarded menses, which finally appear, Avith great Aveakness, so much so that she can hardly talk, or she feels nausea even to faintness. A sensation of roaring in the ears, as though there were shells before the ears. Coffea. Great sensitiveness, with general excitability; she is in a state of ecstasy. Headache, as if a nail Avere driven into the brain, or as if the brain were torn or dashed to pieces. Conium will be particularly indicated Avhere much vertigo is devel- oped, especially when in a recumbent position; she cannot turn in bed Avithout occasioning distressing vertigo. During micturition her urine alternately flows and stops. The breasts swell, become bard and pain- ful before the menses, when her hysterical symptoms increase very much; the vertigo often becomes very severe at these times, and she may also have constipation, Avith constant and ineffectual urging to stool. Globus hystericus. REMEDIES FOR HYSTERIA. 567 Euphrasia. In cases where there is dimness of vision as a result of the hysterical condition, Avith great suffering from profuse lachryma- tion. Tears acrid. Hyoscyamus. There is some resemblance to epilepsy in the remark- able jerking and twitching of her spasms; still,they are less regular in their form. She is disposed to uncover herself and to be naked; she indulges in much silly laughter and many foolish actions. Ignatia. When a state of anguish is developed in which she shrieks for help, Avith suffocating constriction of the throat; difficult deglu- tition, and she finally comes out of the spasm with deep sighing. She frequently complains of an emptiness at the pit of the stomach, with frequent sighing and much despondency, simulating grief. Mental symptoms change very often—cheerfulness with great despondence. Silent grief. Inclination to start. Ipecac. Every fresh development of the hysterical symptoms brings on a sensation of continual nausea; there are many other symptoms, but the nausea is constant—she feels it every moment. Jodium. There is a remarkable and unaccountable sense of weak- ness and loss of breath in going up stairs. Leucorrhoea, corroding the linen. Lachesis. Sensation as if a lump were rising in the throat, which does not particularly incommode her, but merely feels unpleasant. But she cannot bear the least pressure externally about her throat— she would suffocate—or even about the chest, stomach or abdomen. She is almost constantly relieving herself of the pressure. She awakes from sleep distressed and unhappy, as if from loss of breath. Lycopodium. She has a constant sensation of satiety; she takes no food, and if asked Avhy, replies she wants nothing because she is so full, and that the least morsel causes a sensation of fullness up to the throat. Cutting pains across the abdomen from right to left. Much borborygmus, particularly in the left hypochondrium. She becomes worse at four in the afternoon. Red sand in the urine. Frequent and abundant micturition ; urine pale, especially during the night. Magnes mur. This is one of the most important remedies in hysteri- cal conditions. She has many spasms day and night, Avith great sleep- lessness. Constipation of large, difficult stools, crumbling as they pass the verge of the anus. Fainting fits at the table, nausea and trembling, relieved by eructations. Merc. sol. She has a profuse Aoav of saliva, and her breath has a mercurial odor. The gums bleed, and are inclined to ulcerate about the teeth. She is disposed to perspire much; the perspiration does 568 HYSTERIA. not relieve; it is cold and clammy, particularly about the loAver ex- tremities. She is very sensitive about the epigastrium or pit of the stomach. Moschus. Violent, long-continued, inveterate scolding, until she falls doAvn in a SAVOon. Great anguish, as if she had to die; she talks of nothing else except that she will die. She exclaims, It is my death, and then falls down in a savooii. Frequent swooning. Great desire for beer or brandy. Constriction of the chest. Nat. mur. This remedy is indicated in all women whose menses delay and decrease more and more. She aAvakes in the morning with a bad headache. Vivid, painful dreams during a light sleep. Dreams at night of robbers being in the house, so vividly that she will not be satisfied till the house has been searched. Somnambulistic rising and sitting about in the room. A constant desire for salt. Great aArersion to bread. All her symptoms are relieved as soon as she gets into a perspiration. Great debility, excessive thirst, great in- clination to weep. Nux mosch. Sudden change from grave to gay, from lively to serene; excessive tendency to laughter. Enormous distension after meals. Vicarious leucorrhoea in place of the menses. Excessive dryness of the tongue and mouth after sleeping. Nux vom. She seldom sleeps after three A. m., but after five A. m. and late in the morning; she feels \vorse in the morning. Constipa- tion of large, difficult stools. Very dyspeptic. She is much excited by coffee, spirituous liquors or highly seasoned food. She feels much better on plain and simple food. Menses irregular, never at the right time. Palladium. She imagines herself neglected ; wounded pride. Phosphorus. Particularly indicated in tall, slender females. The stools are long, narroAv, dry, hard and voided Avith much difficulty. She feels a great sense of weakness in the abdomen; this distresses and aggravates all her other symptoms. She eructates vast quanti- ties of Avind after eating. She is sleepy, particularly after dinner. Sexual desire very much increased. Platina. Self-exaltation, and contempt for others. Violent crampy pain at the root of the nose. A strange titillating sensation extending from the genital organs upward into the abdomen. Stools difficult, adhering like soft clay to the rectum and anus. Spasms with wild shrieks. Menses in excess, dark and thick. Chilliness predominates. Thirstless. Amelioration in the open air. REMEDIES FOR HYSTERIA. 569 Pulsatilla. The forms of her symptoms are very changeable. She is easily moved to laughter or to tears. She is very well one hour or half hour, and very miserable the next. She is timid and fearful, and yet extremely mild, gentle and yielding. She is sometimes silent and melancholy. She has a bad taste in her mouth, especially in the morning. Nothing tastes good to her, or she has no taste. Sabina. She is very nervous and hysterical, and if she becomes pregnant she is almost sure to abort about the third month. Now if Sabina is administered she will not abort any more, and if kept a long time under the influence of this remedy she Avill eventually and entirely recover. Sepia. Paroxysms of something twisting about in her stomach and rising toAvard the throat; her tongue becomes stiff; she becomes speechless and rigid like a statue. Painful sensation of emptiness in the pit of the stomach. Urine very putrid; it deposits a clay-like sediment, which adheres with great tenacity to the vessel. Icy cold hands and feet. Sudden fainting, with profuse sweats and undisturbed consciousness, without being able to speak or stir. Involuntary fits of Aveeping and laughter. Sensation of coldness between the shoulders, folloAved by general coldness and convulsive twitchings of the right side and difficulty of breathing. Stannum. Great sensation of faintness after going doAvn stairs, although she could go up stairs well enough. She can hardly sit down; she must drop down suddenly; she can get up very well. Very much exhausted from talking or reading aloud. All her pains increase gradually to their highest point, and then as gradually dis- appear. Staphysagria. She is very sensitive to the least impression; the least word that seems wrong hurts her A7ery much. She throws everything given her in her hands away indignantly; pushes things away from her. The sound teeth, as Avell as those decayed, are very painful to the touch of food or drink. Stramonium. She is full of strange and absurd fancies. She is fear- ful, so that she starts back and stares wildly at the first sight even of familiar objects. Very great loquacity. She desires light and society. Her face is puffed up with blood. Sulphur. She comes out of her spasms feeling very happy, and everything seems very beautiful to her. She discharges large quan- tities of colorless urine at the termination of the spasms. Her attend- ants have learned to recognize this as a sign that her spasms are at an end. She has flushes of heat, coldness of the feet, heat on the top of 570 DISEASES OF THE EXTERNAL GENITAL ORGANS. her head, and cannot Avait for her dinner as usual, she is so faint and hungry. Valeriana. A sensation as if something Avarm were rising from her stomach, arresting her breathing, with tickling deep in the throat, and cough. She feels a sensation as if a thread were hanging down the oesophagus from the pharynx. Fearfulness, tremulousness and palpitation of the heart. The intellect predominates over the mind. Veratrum. In addition to other symptoms she has cold sweat on the forehead. Cold sweat all over her, and a very weak pulse—so weak that it can scarcely be counted. Viola odor. Much Aveeping, without knowing Avhy; distress in the chest; difficulty in breathing; anxiety and palpitation of the heart. Zinc. Incessant and powerful fidgety feeling in the feet or lower ex- tremities. She must move them constantly. Among the new remedies the following may be mentioned as likely to prove useful in hysteria, according to their indications : Gelsemi- NUM, ClMICIFUGA, CYPRIPEDIUM, CAULOPHYLLUM SENECIO. CHAPTER XXVIII. DISEASES OF THE EXTERNAL GENITAL ORGANS. Inflammation of the Vulva—Vulvitis. ALL the external parts are liable to attacks of acute inflammation. This inflammation may be developed principally in the labia, may be confined to these or some other particular parts, as the nymphse, clitoris, etc., or it may extend more or less generally over all the connecting tissues. This acute inflammation may arise from sudden and severe exposure to cold air; it may be the result of acci- dents or mechanical injuries, of violence; or it may result from the extension, doAvnward and outward, of disorders primarily developed in the internal genitals, or from irritation caused by morbid secretions or by acrid and excoriating urine. From the very delicate, sensitive and vascular nature of the tissues composing these external organs, they are remarkably disposed to such forms of disease, although very much protected by their situa- INFLAMMATION OF THE VULVA—VULVITIS. 571 tion; and the same vascularity and delicacy of their structure renders this acute inflammation very apt to terminate in the formation of an abscess or in more diffused suppuration. The abscess or more gen- eral suppurative process may in all cases be cured by the appropriate remedies. Acute inflammation of the external genitals, from whatever cause it arises, runs a very rapid course; may be attended by remarkable ex- citement of the sexual passion, especially where the clitoris is involved; the SAvelling, heat and redness in the parts may be very great, and the pain severe in proportion. The most favorable termination of such inflammation is, of course, in resolution and subsidence of the local fever. Next to this may be regarded an abscess in one or the other of the labia. But where the disorder is the result of violence, such as contusions, the parts may presently assume a dark color; or if the violence have been very severe, or where the constitution of the patient, the plethoric and vas- cular nature and generally full development of the parts, and perhaps other attendant and depressing circumstances, combine to produce such a result, gangrene may make its appearance. It should be remembered that in the greater prominence given to some symptoms by the inflammatory action Ave may obtain a clue to the true homoeopathic remedy for the whole case, at least for the rem- edy most completely indicated at that time, and which, being given, must be waited upon till its action is entirely exhausted before another .prescription is made. The proper remedy for each particular case of acute inflammation, and also for the consequences of it, may be found among the following, and should be selected in accordance with the indications here given: 1. Ambra, Sepia, Thuya. 2. Calc. carb., Carbo veg., Con., Creos., Ferr., Kali carb., Merc sol., Nitr. ac, Staph., Sulph. 3. Arn., Ars., Bell., Canth., Graph., Lye, Natr. mur., Nux vom., Petrol., Rhus., Sec. corn., Sil., Calend., Ledum. Arnica. For inflammation from mechanical injuries Avhich are con- tusions merely. Ambra grisea. Pain as of soreness and violent itching of the vulva, with SAvelling. Belladonna. The parts have a hot, dry sensation; there is much throbbing; they get worse at three in the afternoon. Calc. carb. Inflammation, redness and SAvelling of the vulva, with purulent discharge. Stinging, burning tubercles on the margin of the 572 DISEASES OF THE EXTERNAL GENITAL ORGANS. labia. Much moisture betAveen the labia and the thighs, with biting pain. Calendula. For those inflammations which result from cutting or tearing the parts. Cantharis. Very frequent desire to urinate, Avith cutting, burning pain on passing a few drops of urine, or with complete strangury. Burning in the. vulva, with frequent desire to urinate, and burning cutting in the urethra. Carbo veget. Simultaneous itching of the vulva and anus. Heat and redness of the vulva. Much soreness in the vulva in the evening. Aphtha? of the vulva. Sore places about the vulva, itching without pain. Conium m. In all cases of indurations from injuries. Large pimple on the mons veneris, painful to the touch. Cutting pain between the labia on micturition. Severe stitches in the vulva. Violent itching of the vulva. Creasote. Corrosive itching within the vulva. Violent itching, with biting, between the labia and the thighs, with soreness and burn- ing after urinating. Ferrum. In weakly females with fiery-red face. Graphites. Itching, smarting; painful vesicles on the labia. Painful soreness between the vulva and thighs, the part being covered with pimples, vesicles and ulcers. Kali carb. Tearing in the left labia, extending through the abdomen to the chest. Pinching pain in the labia. Stitches through the vulvas- Soreness, gnawing, burning and itching in the vulva. Lycopodium. Darting in the labia on lying down, often extending around each labia. A great deal of itching of the parts after the menses. Mercurius. Sensation of raAvness. Long-lasting itching of the labia. Terrible itching, which is made worse by the presence of urine remaining on the parts after urinating; it has to be Avashed off. Worse at night. Perspiration affords no relief. She may even be worse during perspiration. Salivation. Soreness of the gums, teeth, etc. Nat mur. Pimples on the mons veneris. Itching of the vulva and falling off of the hair. Nitric acid. Violent itching of the entire vulva toward evening j dry burning heat of the vulva. Nux vom. Inflammation of the labia, with frequent calls to go to stool or to pass urine, often Avith little or no discharge. ERYSIPELATOUS INFLAMMATION OF THE VULVA. 573 Petroleum. The labia? perspire and itch excessively. Phosphorus. Dull tearing pain in the labia? during and after a walk in the open air. Heat extending up the back. Feeling of weakness across the abdomen. Rhus tox. Inflammation of the external genitals, with itching, burning and great restlessness. Secale. Suitable for women Avho are scrawny and thin. Sepia. Violent stitches, sometimes extending as far as the umbili- cus. Severe itching of the vulva. Swelling and humid itching eruption of the inner labia. Foetid urine, depositing a clay-colored sediment, Avhich adheres to the chamber with great tenacity. Trou- blesome itching of the vulva, Avith pimples all around. Painless vesicles in the outer parts of the vulva. Also compare the indica- tions given for Sepia in other diseases peculiar to the external genera- tive organs, such as varices, burning of the vulva, etc. Staphysagria. The inflammation produces a stinging, itching or smarting sensation, or causes the formation of vesicles on the internal surface of the labia, Avhich are very tender to the touch. Sulphur. Where the predominant symptoms of the inflammation are those well-known characteristics of this remedy—flashes of heat, hot soles of the feet, weak, faint spells, heat on top of the head, etc. Sulphuric acid. Great exhaustion. Tremulous sensation in the whole body, without trembling. Thuya. Swelling of both labise. All the itching, burning and pains are excited and aggravated either during or after a walk or from touching the parts. Cramp pain in the vulva and perineum on rising from a seat. Erysipelatous Inflammation of the Vulva may result in certain constitutions from causes which in other persons would pro- duce only the simple form of inflammation above described. In phlegmonous inflammation the deeper tissues appear invohred; or where suppuration sets in—as it may very suddenly—instead of being confined to a single abscess, it may assume the diffused form common to erysipelas. This variety of inflammation is in reality a general erysipelatous affection, which is constitutional to the woman herself, but which some provoking cause has sufficed to develop locally in these parts. Both the skin and the subcutaneous cellular tissue are involved; and in Avhatever particular organ of the external genitals the disease first makes its appearance, it presently includes them all, and even 574 diseases of the external genital organs. extends to the inguinal glands. The parts immediately affected become hot, swollen and red, Avith severe throbbing pain, especially as the suppurative process extends through the tissues. All the neighboring organs sympathize more or less; and the pain is so great that it is almost impossible for the patient to remain quiet, and yet the distress is seA^erely aggravated by movement. In the more rapid forms of this variety of inflammation the suppurative process may be established in from twenty-four to forty-eight hours, and it is usually ushered in and attended by chills, which, if not very strongly marked, still afford a reliable indication of the progress of the disease. Remedies for Erysipelatous Inflammation. 1. Aeon., Apis, Bell., Croton tig., Graph., Merc, sol., Rhus tox. 2. Amm. carb., Arm., Ars., Bry., Calc. carb., Camph., Carb. an., Hep., Jod., Lye, Nitr. ac, Phos., Sulph., Thuy. 3. Ant. cr., Baryta c, Borax, Canth., Carbo veg., Hyos., Lach., Magn. mur., Natr. c, Petrol., Plumb., Puis., Ran. bulb., Samb., Sil., Spong., Stram. Aconite. When real synochal fever accompanies the affection ; rest- lessness, anxiety and fear; tingling and shooting pains, and great heat in the parts affected. Ammonium c. When there is an evident tendency toward gangrenous degeneration of the parts. Apis mel. Stinging pains through the parts. Absence of thirst; scantiness of urine; great restlessness and sleeplessness. Belladonna. Great redness of the parts; redness extending in radii. Heat and throbbing. Calcarea carb. Hard and inflamed swellings in the affected parts, separate from each other, Avhich are very sore and painful. Camphora. Coldness, paleness and sinking, with aversion to being covered. Carbo an. Much burning, with induration of the affected parts. Croton t. Vesicles—very small—itching terribly. The itching is partially relieved by slightly tickling the vesicles. These minute vesi- cles may extend far around on the inflamed parts and those adjacent. Graphites. A vesicular eruption which is very painful, Avith itching and oozing. Hepar s. c. Tendency to the formation of abscesses. Lachesis. Tickling and jerking in the affected parts. Worse after sleeping. Bluish color of the affected parts. CUTANEOUS AFFECTIONS OF THE EXTERNAL GENITALS. 575 Mercurius. The parts are much swollen, Avith raAv, sore feeling, and the Sufferings are much Avorse at night. Pulsatilla. The erysipelatous affection changes from one part to another, and inclines to spread far around on the buttocks and thighs. Rhus tox. The mons veneris is most affected, the inflammation extending downward; intense itching and burning; large vesicles, which are not particularly troublesome. Catarrhal Inflammation may attack the mucous lining mem- brane of the external organs of generation. This form of disease is more apt to appear in children, and may be attributed in most in- stances to exposure to cold and Avet, and perhaps to want of cleanli- ness. The inflammation itself is of a mild form, although, from the well-knoAvn disposition of disease in the mucous tissues to spread, it may extend to the vagina, and thus a catarrhal discharge may be established in the vagina as well as from the vulva. The treatment for this affection will not be different from that for catarrhal leucor- rhoea. Cutaneous Affections of the External Genitals. Eczema—Pruritus.—Many and distressing forms of skin diseases develop themselves on the external organs of generation in the female. These are either the local manifestations of constitutional taint, Avhich the extreme tenderness of the parts and the acrimonious discharges and other irritating influences to Avhich they are subject cause to make their appearance in this vicinity, or they are the exter- nal manifestations of some severe, perhaps obscure, irritation Avhich infests the internal organs. The former come under the general head of eczema, and, like some forms of leucorrhoea, may immediately result from too free indulgence in stimulating and highly-seasoned food. The latter are commonly knoAvn as prurigo or pruritus, and may consist in a most intolerable itching, Avith little or no exanthema- tous appearance, except what is developed by the scratching itself. In addition to the intense itching, there is usually present an equally intolerable burning, stinging and pricking. It is impossible to resist rubbing the affected parts, although all the sensations are rather aggravated than relieved by such friction. The prurigo is always the result of some deep-seated affection, usually in the internal gen- erative organs, and in many instances it is one of the first indica- tions of the invasion of cancer of the womb. Thus, a careful atten- N 576 DISEASES OF THE EXTERNAL GENITAL ORGANS. tion to this severe irritation, and its cure by remedies suited to its special symptons and to those which are attendant and constitutional, may be the means of arresting and preventing the most painful, dis- tressing and, in its advanced stages, incurable malady which can attack the female organism. Pruritus is also said to be the precursor, as it may likewise prove the developing cause, of nymphomania. From the constitutional nature of the eczema or other actual erup- tions which appear on the external genitals, it must be evident that all attempts to remove them by external applications must be injurious just in proportion as they are successful; while as regards the pruritus, in so far as that may be due to irritation caused by actual disease in the interior genitals, it must be apparent that all attempts to remedy it which do not embrace the cure of its provoking cause must be futile. And in fact so it is found, in the allopathic treatment directed against the prurigo itself, that it is exceedingly intractable, if not absolutely incurable, by such means; while in the homoeopathic treat- ment, guided by these external forms and by the attendant constitu- tional symptoms, Ave may often prevent or remove important dis- orders, of whose threatened onset or actual presence we were not posi- tively aware. These tAvo forms are the most frequent and the most severe of the eruptions which attack the labia, vulva and adjacent external organs. But besides these may be more particularly mentioned— 1. Erythema, which consists merely in diffused redness, more superfi- cial than that of erysipelas, but still connected with constitutional disturbance, either directly or indirectly, as the consequence of some peculiarly acrid and irritating secretion, such as leucorrhoea. 2. Herpes, in which the " vesicles leave behind them superficial excoriations, which soon become covered with crusts," and underneath which fresh vesicles appear. 3. Lichen, "characterized by papula? ocqupying an erythematous base; they cause an intolerable pitching, which increases toward even- ing or at night, and which, after scratching, is followed by excori- ations that secrete a bloody serum and then become covered with crusts." Lichen differs from prurigo principally in its papilla? being somewhat smaller, and in the voluptuous itching being less intense. Apis m. Eruptions, stinging, like bee-stings. Bryonia a. Hard, black pustule on a swollen portion of the labia. Calc. carb. Itching and stitches either in the internal or external CUTANEOUS AFFECTIONS OF THE EXTERNAL GENITALS. 577 vulva, or both at the same time. Also in cases which present the usual constitutional symptom of this remedy. Cantharis. Burning and violent itching, particularly if there be the cantharis dysuria ; frequent micturition, with burning and cutting. Carbo veget. Itching at the vulva and anus at the same time. Red and sore places about the vulva, Avith itching and leucorrhoea. Coffea. Excessive sensitiveness about the vulva, with voluptuous itching. Would like to scratch or rub the part, but it is too sensi- tive. Conium m. Violent itching of the vulva, followed by pressing down of the uterus. Violent itching, the urine flowing and stopping alter- nately at every emission. Violent itching after the menses. Creasote. Corrosive itching of the vulva, with soreness and burning after scratching. Croton tig. Intense itching, relieved by very gentle scratching. Dulcamara. Herpetic eruptions on the vulva, aggravated by every cold change of the Aveather or by exposure in cold, damp situations. Ferrum. Much itching of the vulva in delicate, weakly women, with very red faces. Graphites. Itching vesicles and pimples on the labia, which smart and are painful. Painless pimples on the inside of the labia. Itch- ing, smarting, painful vesicle on the vulva. Itching pimples on the vulva. Itching on the vulva, always before the menses. Kali carb. Soreness, gnawing, itching and burning of the vulva. Lycopodium. Great sense of dryness of the parts, and much itching. Itching of the parts during or after the menses. Mercurius. Long-lasting itching of the vulva shortly before the menses. Itching of the vulva aggravated by a single drop even of urine; it has to be washed off. Pimples or tubercles on the labia, which are more troublesome at night. Nat. mur. Itching of the vulva, particularly if there be much falling off of the hair. Itching of the vulva, with pimples on the mons veneris. Nitric acid. Violent itching of the vulva, always worse toward even- ing. Itching of the vulva when walking, with soreness. Swelling and burning itching of one side of the vagina and of the nympha?. Nux vom. Corrosive itching eruption on the vulva. Petroleum. Itching in the meatus airinarius during micturition, pre- ceded by an urgent desire to urinate. Platina. Voluptuous tingling in the vulva and abdomen, with oppression, anxiety and palpitation of the heart. 37 578 diseases of the external genital organs. Sepia. Swelling and humid itching eruption on the inner labia. Very much itching of the vulva. Weight in the anus. Silicia. Itching of the vulva, particularly if there be acrid leucor- rhoea. Constipation, stool slipping back Avhen partly evacuated. Staphysagria. Stinging itching of the vulva. Sulphur. Troublesome itching of the vulva, with pimples all around. Violent itching of the clitoris. Tart. em. Pustules from a variety of causes, mostly the result of translations from other parts. Thuya. Itching of the vulva when walking. Zinc. Itching of the vulva during the menses. Baptisia, Caulophyllum, Collinsonia, Cornus cir, Cala- dium, Hamamelis and Hydrastis may likeAvise prove useful in eczema, pruritus or other similar affections of the external genitals. Chancres, Syphilitic Ulcers. We give no special description of this form of disease, preferring to refer to other works on the subject. The constitutional and attend- ant symptoms will prove the best guides in prescribing for such cases; which, however, are always very amenable to homoeopathic treatment. The chief remedies to be employed in this class of affections are the various preparations of mercury, such as Cinnabar, Mercurius SOL., JODAT. or VIV. CORRALIA RUB., HEPAR., NlTRIC ACID, Ja- caranda, Kali bich., Kali hyd., Nux juglans, Thuya, Phos- phorus, Silicia, Sulphur, etc. Condylomata. These may be regarded as local manifestations of a constitutional dyscrasia, and as such require constitutional rather than local treat- ment. They are frequently of syphilitic origin, but the practitioner should not fall into the error of regarding all such excrescences of the genitals as resulting from this poison. The following are the prin- cipal medicaments required for their treatment, but others not here mentioned may be required: Euphrasia. Stitches and itching of the condylomata, especially when walking. Phosphoric acid. Heat and burning in the condylomata. Sabina. Soreness and burning of the condylomata. Thuya. Moist, suppurating, itching, stinging, bleeding, painful con- dylomata. TUMORS OF THE VULVA. 579 Consult also Calc. C, Cinnabar, Lycop., Nitric acid, Phyto- lac. dec, Chromic acid and Staph. Excoriations. Consult the remedies mentioned under Prurigo and Leucorrhoea. QEdema of the Vulva. Consult the remedies under Inflammation. Abscess of the Vulva. Abscess of the vulva is to be treated in the same manner as abscess occurring elsewhere. See the remedies designated under Inflammation. Tumors of the Vulva. Encysted Tumors.—These tumors are painless, and not* very common. They are circumscribed, semi-transparent, and from being scarcely perceptible may grow to the size of a fist. They contain a glairy, colorless or thick yellowish fluid, or, in some instances, an unhealthy sanies or dark-colored purulent matter. Unless from the inconvenience which may result from their larger growth, they are not of so much importance of themselves as from the fact that they indicate some more serious disorder in the interior organs of gen- eration. From hernia encysted tumors may be distinguished by being incapable of reduction, by their not being changed in size by the different states of the bowel, and by their affording no gurgling or rumbling sound. When they break spontaneously they show an indisposition to heal, but may continue to discharge an irritating matter. Encysted tumors of the external genitals of the female seldom require surgical interference from a homoeopathic practitioner, their reabsorption or removal, and at the same time the radical cure of the morbid condition from which they originate, being usually quite practical with homoeopathic remedies. Should they give rise to a great deal of pain and inconvenience, however, and prove intractable to medication, they should be carefully dissected out and removed, and proper means taken to secure granulation and cicatrization that will not afterward interfere with the performance of any of the func- tions of the genital organs. The following remedies should be consulted : Baryta carb. Is especially suitable for dwarfish women. Tearing 580 DISEASES OF THE EXTERNAL GENITAL ORGANS. in the vulva or in the affected parts—so violent at intervals that she Avould like to scream. Calc. carb. In leucophlegmatic constitutions. Menses too often and too abundant. A constant aching of the parts, made worse by pres- sure. A sense of cold air passing over the part. Graphites. There are itching pimples on the labia, itching blotches on different places of the body. Constipation; stools large, lumpy, difficult, with soreness in the anus. Hepar s. c. In cases Avhere suppuration has taken place. Kali carb. Stitching pains pass through the cyst, or through the parts near the cyst. Nitric acid. In cases where a syphilitic taint is present. Itching of the part when Avalking or otherwise irritating it, when it feels very sore. * A pricking pain prevails. Sabina. The cyst becomes swollen, red and painful to the touch, or there is tearing pain during rest. Sepia. Throbbing, burning and itching of the part. The urine deposits a clay-colored or red sediment, which adheres to the vessel very tenaciously. Constipation. Silicia. The suppuration is increased by motion. The part is very sensitive to the touch. In cases where the general characteristics of Silicia are present. All her symptoms are worse at the neAv moon. Sulphur. In cases which present the general characteristics of this remedy. A very sore feeling, and disposition of the affected parts to excoriate. Both the flow of urine and the discharge of faeces are painful to the parts over which they pass. Erectile Tumors, or enlargement and hypertrophy of the vascular tissues of the external genitals, require general aud constitutional treat- ment. Every exciting influence should be removed from such cases as far as possible; then perfect rest; and the remedies must be selected Avith especial reference to all the symptoms of the patient and to the whole history of her case, for these delicate, sensitive and exceedingly irritable and exposed parts may be made the outlet of the constitu- tional dyscrasia. Thus difficulties of this kind and other structural diseases of the external genitals sometimes appear insignificant, and yet absolutely incurable by all ordinary treatment. To the homoeo- pathic practitioner the method is plain, and in many instances the means are at hand. He will give the remedy appropriate to the dyscrasia which infests his patient, and all these minor, but vexatious and sometimes painfully distressing, local affections will vanish TUMORS OF THE VULVA. 581 gradually, instead of developing Avith advancing years into malignant and incurable forms of disease. Arsenicum. The constitutional symptoms of this remedy will point out its use, if the local symptoms do not. The tumor may be painful, with burning or lancinating pains, or it may be painless. Carbo animal. The tumor has a tendency to become indurated, with a burning sensation. Also in cases which present the constitutional characteristics of this remedy. Carbo veget. The tumor has a bluish look; is very hard, with shooting pricking pain. Creasote. The tumor has a corrosive itching and burning. Spas- modic pains extending from above downward. Lycopodium. Tearing stitches in the affected parts. Sensation of dryness. Inclined to grow worse at four p. m., and to be better at eight p. m. Borborygmus in the left hypochondrium. Nitric acid. Much itching of the tumor, with sticking pain. Phosphorus. Stinging and burning of the tumor. Worse during or after a walk. Suitable especially for tall and slender persons. Platina. Painful sensitiveness, with inward coldness of the vulva. Sepia. Burning, itching, throbbing or jerking in the tumor. Red- dish sediment in urine, which adheres to the vessel with great tenacity. Silicia. Violent burning and soreness of the part, with an eruption on the inner side of the thigh. Sulphur. Troublesome itching of the part, with pimples all around. General symptoms of sulphur. Thuya. The sufferings are increased during motion and immediately afterward. The pain during motion is at times so severe that she is compelled to lie down. Haemorrhage from these erectile tumors may require— Arnica. If the bleeding be the result of coition or of a blow or other injury. And the remedy that will cure the hemorrhage may also cure the tumor itself if allowed to act a long time. Carbo veg. If the blood be of a venous appearance or very pale. Coccus cacti. Pain in the vulva, so severe on going to bed that she is obliged to sit up in bed and go to sleep in that position. The tumor of the vulva increases, gets hard and is sensitive to the touch. Throbbing and burning in the tumor of the vulva, and excoriated feeling on Avalking. Creasote. If the bleeding be continuous, Avith marked intermissions; DISEASES OF THE EXTERNAL GENITAL ORGANS. at times becoming pale and almost entirely ceasing, and then recom- mencing afresh. Lachesis. The hemorrhage seems to be vicarious; the pain increases in intensity until relieved by the flow of blood, then as the hemor- rhage subsides the pain returns. Phosphorus. The blood flows profusely for a Avhile, and then ceases for a time, when it flows again, and so on. Pulsatilla. The blood is very changeable in its appearance. It is more apt to flow in the day-time, when walking. It is intermittent. Sulphur. Flushes of heat; weak, fainting spells; hot feet; heat on the top of the head; very hungry from eleven till twelve in the fore- noon—cannot wait for her dinner. For Inflammation of these Erectile Tumors study the remedies under Inflammation of the Vulva. Bloody or Oozing Tumors.—These are most apt to occur in persons who have passed the middle period of life, and who may have received constitutional and even local injuries from too frequent childbirth or from similar causes. These tumors are not so well defined and circumscribed in size as are the encysted tumors; they seem rather enlargements of some dependent portion of the labia or vulva; and they may arise even in virgins from accidental violence to the parts. From their size and situation they may occasion no small suffering, and be made to exude a watery or even bloody dis- charge, which is much increased by walking. For the treatment of these study the remedies given in the preceding sections, and also those under Vaginal and Uterine Tumors in subsequent chapters. Varices of the Vulva (see page 352). Hernia of the External Genitals. Hernia of the Vulva, Perineal Hernia or Oystocele are generally asso- ciated with pregnancy, although they may occur in women who are not pregnant. Vulvar or perineal hernia consists in the descent of a portion of intestine, forcing its way downward through the areolar tissue of these parts; in cystocele it is the bladder that is involved in the descent and protrusion. In Cystocele the protrusion will be found in the vagina or vulva. The finger may be passed beyond and above it, and the cervix uteri made out, but it cannot be passed in front of the tumor, for it seems ASCARIDES OF THE VULVA. 583 to be attached to the inner surface of the symphysis pubis. There will likewise be considerable irritability of the bladder and frequent desire to urinate. Cystocele complicating labor has already been treated of, and the method to be resorted to for its relief already laid down. (See page 235.) Where pregnancy does not exist the bladder must be evacuated by means of the catheter — the male catheter may have to be used — and the protrusion reduced and kept in place by means of a proper bandage or other support. The patient should retain the recumbent position for a long time, and the urine should not be allowed to accumulate in such a quantity as to cause vesical distension. In true hernial protrusion, by placing the patient in the horizontal position the hernia may easily be reduced; and the gurgling sound which accompanies the reduction, as well as the re- duction itself, sufficiently indicates the nature of the difficulty. Perin- eal hernia is to be distinguished from an encysted tumor by this facility of reduction. For the strictly medical treatment required in these cases study such remedies as are mentioned under Prolapse of the Vagina and Uterus. Neuralgia of the Vulva. Neuralgia in the external genitals usually appears in connection with a similar affection in the vagina. Under this latter head we shall speak more particularly of the causes and treatment of this painful disorder. ASCARIDES OF THE VULVA. The Parasites Avhich infest the external genitals of the female are of two kinds—ascarides and lice. The former may escape from the rectum, and, lodging in the folds of the vulva, cause there an intense pruritus, or even nymphomania. And even where it is impossible to detect their actual presence in the external genitals, so strong is the sympathy between the mucous membrane of the rectum and vulva that the irritation in the latter is equally intense Avith that in the former organ, ami no less distressing than that Avhich results from their presence in the vulva itself. The presence of ascarides Avithin the vulva in little girls often gives rise to a distressing leucor- rhoea. The intense itching may lead to masturbation. Lice mostly infest the roots of the hair upon the mons veneris and labia majora. Calc. carb. In leucophlegmatic constitutions. Terrible itching of the parts toward evening or after going to bed. 584 diseases and derangements of the vagina. Ferrum. Much itching, and a red, fiery face. Ignatia. A great deal of itching. Much sighing, and empty, faint feeling at the pit of the stomach. Nux vom. In those Avhose complaints are attributable to or aggra- vated by highly seasoned food, wines and liquors. Constipation, Avith frequent urging. Frequent micturition, with scalding and brick-dust sediment. Worse after three A. M. Silicia. More or less itching and fever all night. Emaciation and gradual failing of health. Sulphur. Much itching and crawling. Flashes of heat; coldness of the feet; very short naps all night; feels very Aveak in the morn- ing. Weak and empty from eleven till twelve; she cannot Avait for her dinner—a very unusual circumstance for her. The free use of lard on the parts around the anus may be found to be a great help in'the treatment of these cases. Lice may be removed from the vulva and adjacent parts by de- stroying them with essence of bergamot, or with fine snuff made into a paste with pure glycerine CHAPTER XXIX. DISEASES AND DERANGEMENTS OF THE VAGINA. Prolapse of the Vagina. PROLAPSE of the vagina is an affection resulting in general from a relaxed or weakened state of the vaginal parietes. It may easily be mistaken for prolapsus of the womb, but a careful attention to the history of the case and to the conditions present Avill conclusively determine the matter. The vagina may be wholly or partially prolapsed. Thus there are three forms of vaginal prolapsus which require to be considered and distinguished : First, complete prolapse or inversion of the vaginal canal; second, prolapse of the anterior wall of the vagina; and third, prolapse of the posterior wall of the vagina. In connection Avith a brief notice of each of these three forms of vaginal displacement we mention the most active pro- ducing causes and mode of distinguishing each from the others. prolapse of the vagina. 585 I. Complete prolapse or total inversion of the vagina is, perhaps, the least common of these three forms, as it is also the worst, especially where the parietes are actually protruded. This form may appear in connection with parturition; as the result of Aveakness or looseness in the walls of the vagina; of too great size or too rapid descent of the fcetal head; of mechanical interference, especially turning; or it may come on gradually, from the combined influence of Ararious similar causes, especially in Avomen who have borne many children. It is important to understand clearly the nature of the change which takes place in this displacement, and which is properly called inversion, although the term may fail to convey the full idea. Suppose a long stocking to be suspended with the anterior part of the foot upward ; now let a heavy weight be laid upon its apex (the toe of the stocking) and alloAved to sink down through the foot and leg of the stocking; this will cause an actual inversion, and by the time the inverted point of the apex has made its appearance at the open extremity of the leg one-half of the stocking will have become inverted. In such a manner the vagina may be prolapsed and inverted where the entire circle of its canal is involved, although the circle of im7ersion may not begin at the apex of the vagina. The puckered orifice, composed of the folds of the mucous coat of the vagina, which appears in the centre of the projecting tumor, should be distinguished from the regularly formed os uteri, which is narrower in structure, and marked by a fissure which separates the anterior from the pos- terior lip. In these cases of complete inversion of the vagina the finger pressed upon either side of the tumor Avill be arrested at the bottom of the cul-de-sac formed by the doubling of the wall of the vagina upon itself. In any event, the finger introduced into the orifice of the prolapsed vagina may be made to reach the os uteri above, and thus remove all possible ground of doubt as to the exact nature of the case. This form of prolapse of the vagina is usually connected Avith some degree of corresponding displacement of the uterus. There is also an increased discharge, which is the result of the displacement itself and of its producing cause. II. Prolapse of the anterior portion of the vagina is usually connected with a similar displacement of the bladder. The same influences which weaken and relax the anterior portion of the vaginal parietes are exerted in a similar manner upon the attachments of the urinary bladder; and the undue accumulation of urine in the bladder, result- ing from its too long-continued retention, suffices to cause the parts to yield still more to the constant and increasing pressure. 586 DISEASES AND DERANGEMENTS OF THE VAGINA. This form of displacement is evidenced by the sensation of Aveight in the vagina, followed by an actual fullness and intumescence or swelling in the front of the vagina just Avithin the vulva. At the same time there is a painful dragging sensation in the loAver part of the abdomen, frequent and painful micturition, in addition to the difficulty of passing Avater: it may sometimes be impossible to do so until the parts are in some measure replaced. On attempting to in- troduce the finger into the vagina immediately beneath the pubes, it reaches the bottom of a cul-de-sac, Avhile, if the finger be introduced behind the protuberance, the os and cervix uteri can be found nearly in their natural position. These symptoms can hardly fail to deter- mine the nature of the difficulty. The tumor formed by the anterior or vesical prolapse of the vagina presents a round, elastic, fluctuating appearance at the orifice of the vagina, and may usually be much diminished in size by draAving off the urine with the catheter where there is any considerable dysuria. And as the water again accumu- lates in the bladder the vaginal tumor becomes at the same time larger and more painful. This last-mentioned circumstance alone, Avhere it appears, will of course conclusively determine the nature of the difficulty. The prolapse of the anterior parietes of the vagina, attended as it usually is by that of the bladder, may be distinguished from prolap- sus uteri by the fluctuating nature of the tumor and by its broader shape at its apex—that of the uterus being hard, firm and pointed. The passage of the finger into the vagina behind to the tumor will distinguish it from prolapsus of the posterior wall of the vagina. This prolapse of the anterior portion of the vaginal walls, Avhether caused or merely accompanied by prolapse of the bladder, is some- times called cystocele or hernia of the bladder. III. Prolapse of the posterior wall of the vagina. In this form of vaginal displacement the rectum is usually involved, as the bladder is in the anterior form just described. In some rare instances both these forms of prolapse of the vagina appear in the same person and at the same time. The sensations attending displacement of the posterior parietes of the vagina are similar to those Avhich arise from that of the anterior wall, except that they are rather referable to the rectum and call to stool than to the bladder and desire to pass water; and the tumor diminishes after the evacuation of the boAvel. The finger passed up anteriorly to the tumor will reach the os uteri, and this circumstance will distinguish this difficulty from that PROLAPSE OF THE VAGINA. 587 involving the anterior Avail of the vagina; while the tumor itself, although compressible, has not the fluctuating sensation discernible in that caused by the descent of the urinary bladder. The relative position of the apex of this tumor, as well as its variable size and more yielding character, enables us to distinguish it from prolapse of the Avomb, and in addition, by introducing the finger in front of the tumor, the os uteri and cervix may be found in their natural position. In this as in the other forms of the vaginal prolapsus the unusual ex- posure of the delicate mucous surfaces and their irritation from fric- tion against the adjacent parts cause leucorrhoea and more or less inflammation of the organs. This displacement of the vagina is termed rectocele. In the treatment of complete prolapse of the vagina the prolapse should be carefully reduced by manipulation, and the recumbent posi- tion strictly adhered to for some time. The general health should be attended to. In prolapse of the anterior wall the treatment elsewhere laid doAvn for cystocele should be resorted to. In displacement of the posterior wall care should be taken to prevent the accumulation of feces in the rectum. Arnica m. When it is the result of violent shock or concussion. Mercurius. When the sufferings, such as pain, itching, smarting, etc., are worse at night, all night. Sepia. When burning with sharp-shooting pain is experienced in the affected parts. The sensations are Avorse Avhile sitting quietly, particularly in the forenoon and evening. Sense of weight in the anus. She has to cross her thighs, as if to prevent the escape of the inner parts. Stannum. Much inconvenience is felt during a hard stool. Great lassitude when Avalking. Great anguish and melancholy during the week previous to the menses; the distress of mind ceases as soon as the menses begin to Aoav. Contusive pain in the region of the malar bone during the menses. Sulphur. Rectocele. Stools flat or thin. Other characteristic symp- toms of sulphur are present. Veratrum alb. The fecal mass is flattened and thin like a ribbon. The article on Prolapsus Uteri may be consulted for other remedies. Strangulation of the prolapsed portion of the vagina, whether it involve either the bladder or the rectum within the stricture, is a complication worse than the original difficulty. As in cases of 588 DISEASES AND DERANGEMENTS OF THE VAGINA. strangulated hernia, the obstruction of the bowel or of the bladder may very suddenly give rise to most distressing and alarming symp- toms. These are best relieved by remedies selected in accordance with the constitutional symptoms, which, by removing as it were the spasmodic constriction of the parts, allay the inflammation, and enable the return of the circulation to take place in season to prevent mor- tification. Aconite. In highly inflammatory constitutions with hot, dry skin and intense thirst and restlessness. Much mental distress. She thinks she cannot get well, that she will die. Apis mel. The parts have a stinging like that of bee-stings as their most prominent sensation. Arsenic. The parts have a black look and burn like fire. She has thirst for cold water, but drinks little at a time and often. Great anguish and restlessness. Belladonna. A constant sense of weight and pressure, as if the parts were falling out. The parts have a scarlet-red appearance. Lachesis. The parts are of a deep purple color. The patient wakens often in much distress. Nux vomica. The patient wishes to urinate and defecate very often, but small quantities, if any, being discharged from the bladder or bowels. Opium. The patient is very sleepy. She lies in a soporous con- dition. Plumbum has been highly commended in the treatment of strangu- lated hernia. It will be indicated by the intense pain and other symptoms of the remedy. Sulphur. Frequent flushes of heat and weak, fainty spells. Heat in the soles of the feet. Sulphuric acid. The parts have a greenish look. They smell badly, and the patient is very weak. Veratrum album. An exhausting diarrhoea attends the other troubles. There is cold perspiration on the forehead. Spasms, Cramps and Constrictions of the Vagina. The muscular structure of the vagina may become subject to spasm in consequence of irritation arising in the vagina itself, or in conse- quence of the extension to the vaginal walls of similar affections in the neighboring organs. And it may be the result of local, vaginal irritation in persons of a general nervous temperament or of an SPASMS, CRAMPS AND CONSTRICTIONS OF THE VAGINA. 589 ^irritable or hysterical constitution. Or it may be occasioned by dis- placements or organic diseases of the adjacent structures. Thus, in persons predisposed to such affections by a nervous irrita- bility of constitution, spasms of the vagina may arise from the local irritation of coitus, from riding on horseback or from Avalking. In hysterical Avomen these spasms may as readily be induced by violent mental emotions or disturbed moral feelings, and by the periodic excitement of the menstrual nisus; and they are very frequently found among the spasmodic affections common to the hysterical state. A careful study of all the symptoms, causative influences and attend- ant conditions will be necessary in order to prescribe for this trouble- some affection, a thorough cure of Avhich may Avell imply an entire restoration of the general health. For the real seat of \Taginal as well as of uterine spasms, and of all their intermediate causes, such as displacements, ulcerations, irritability and dysmenorrhcea, may often be found in nervous, functional or organic disease of the ovaries. Hence, Avithout an intelligent consideration of all the symp- toms and conditions which make up the tout ensemble of our patient's case, we shall find ourselves entirely unable to relieve her of those which are most distressing, or for Avhich she more particularly seeks relief at our hands. And until the general irritability of the system is remedied by appropriate medication it will be indispensable for the patient carefully to avoid all those local influences, such as coitus, riding, walking, etc., Avhich may tend to bring on the spasms. For while these spasmodic disturbances are the result of nervous debility, either constitutional and general or local, or both, they tend also, by still further weakening the parts, to perpetuate themselves. Besides, habit and the frequent recurrence of such cramps or spasmodic affec- tions no less powerfully combine to perpetuate them in the system, by making them a second, morbid nature, as fungous growths override and overpower the original normal structure. These strictures of the vagina may be cured without artificial dila- tation, by the aid of the homceopathically indicated remedy. Belladonna. In plethoric individuals, disposed to phlegmonous in- flammations. The symptoms often come on suddenly, and disappear with equal suddenness. A sense of heat and dryness is felt in the parts. Cocculus. Aggravation at every menstrual period, particularly when the periods are attended by such Aveakness that she can hardly talk. 590 DISEASES AND DERANGEMENTS OF THE VAGINA. Ignatia a. She is troubled with a weak, empty, gone feeling at the pit of the stomach, which is not relieved by eating. She is inclined to brood over her troubles. Full of grief. Mercurius. The parts have a strong tendency to excoriate, to swell and become inflamed. A raw sensation is felt in the parts. Nux vomica. In women who indulge in high living, wines, etc. Habitual constipation of large and difficult stools, or small stools Avith frequent urging. Platina. In very nervous, spasmodic temperaments, and where there is much tenderness of the vul\ra. Pulsatilla will often be indicated in persons of a very tearful, mild, yielding disposition. Neuralgia of the Vagina. 0 This exceedingly painful affection of the vagina bears exactly the same relation to this organ that irritability, or rather hysteralgia, does to the uterus. As in irritable uterus, so in neuralgia of the vagina, the parts are exceeding sensitive to the touch. Neuralgia of the vagina may arise from any cause, such as exces- sive coition or other influences of that kind, which may weaken the nerves of the parts, and so excite in them an irritable and hyper-sensi- tive condition ; or it may result from suppression of external exanthe- mata or of vaginal discharges; or from injections of cold water for a particular purpose after coition. In whatever manner this affection is directly caused,"it is of course necessary for the patient to avoid such influences as the first step toward the cure. So also in those cases which may result indirectly from other morbid conditions of the in- ternal organs of generation, all such primary diseases must be strictly attended to, and this not exclusively or necessarily with reference to the local symptoms alone. All the morbid conditions, all the consti- tutional affections and attendant circumstances must be carefully taken into consideration Avhen prescribing for this disorder. The neu- ralgia of the vagina may make its appearance, like many other similar affections, in other parts of the'system, whenever the patient becomes fatigued; its pains may be of a peculiar character, lanci- nating or burning—worse from motion or touch or exposure to cold, or relieved by seA^ere pressure or friction, as in those cases which appear connected with pruritus. For those persons who are subject to this excessive irritability and hyper-sensitiveness of the nervous system, it is important to inquire if something connected with their diet, habit of living or other REMEDIES FOR NEURALGIA OF THE VAGINA. 591 external circumstances may not be instrumental in maintaining this painful condition. The use of coffee will often be found to cause the excessive sensitiveness to pain, the neuralgic condition of the nerves, in which certain peripheral surfaces (very apt to be the external genitals in females) may become as sensitive to pain and as intoler- able to the least touch as are the parts affected in cases of gout. Tea, on the other hand, especially if taken too strong, will more often occa- sion the excessive irritability of the nervous system in general, and so lead the way, as in the case of coffee, for local exciting influences to develop such an affection as neuralgia of the vagina. In short, whatever influences tend to weaken and depress the nervous system may occasion irritability of the peripheral extremities of the motor fibres, and a still more distressing neuralgic condition of the corre- sponding sensory filaments; such influences, therefore, should be as carefully avoided as possible, in order to obtain a perfect cure by the use of the appropriate medicines. Merely the local symptoms belonging to each remedy are men- tioned here, but as scarcely any two of them are alike, the indication will in most cases be sufficient; in others all the symptoms of the case may have to be compared. Remedies for Neuralgia of the Vagina. 1. Calc. carb., Kali carb., Sep. 2. Bell., Canth., China, Creas., Ferr., Lye, Merc, sol., Nux vom., Puis., Rhus., Sulph., Thuy. 3. Ars., Aur., Carbo veg., Caust., Cauloph., Cimicif., Cocc, Coff., Con., Cypriped., Gelsem., Graph., Natr. m., Nitr. ac, Petrol., Phos., Plat.^ Sab., Sec. corn., Staph. Alumina. Stitches in the left side of the vulva, extending as far as the chest. Beating, throbbing pain in the vagina. Arsenicum. Lancinations from the abdomen into the vagina. Belladonna. Stitches in the vagina, Avith sensation of great heat and •dryness. Pains that come on suddenly, continue violently, and disap- pear as suddenly as they came. Berberis. Intensely painful vagina, burning and soreness as if ex- coriated. Sudden lancinating pain in the vagina, causing her to start, with soreness of the wall of the vagina to the touch. Bromine. Loud emissions of flatus from the vagina. Pain in the vagina as if sore. Calc. carb. Aching in the vagina. Leucophlegmatic tempera- ment. 592 DISEASES AND DERANGEMENTS OF THE VAGINA. Cantharides. Violent itching in the vagina. Dysuria; sharp cutting, a few drops at a time and almost constant desire to urinate. Caulophyllum. The vagina is excessively irritable, and the pain and spasm are intense and continued. Chamomilla. Burning in the vagina as if excoriated. Very impa- tient ; can hardly ansAver one civilly. Cimicifuga. Vaginal neuralgia, occurring in women who are subject to rheumatism. The pains are intense, but intermitting, and are attended Avith cramps in the lower limbs. Complicated with hysteria. Colocynthis. Swelling of the labia, with dragging pain and heat in the vagina. Conium. Stitches in the vagina, and pressing from above downward. The urine intermits during its flow. Creasote. Stitches in the vagina, coming from the abdomen, causing her to start. Voluptuous itching deep in the vagina. Cypripedium. Irascibility and fitfulness; hysterical symptoms; sleep- lessness ; agitation. Irritability of the vagina. Graphites. Smarting in the vagina. Kali carb. Pinching pains in the vagina during an embrace. Sore pain in the vagina during an embrace. Lycopodium. Violent burning in the vagina during and after an embrace. Sensation of chronic dryness in the vagina. Itching, burning and gnawing of the vagina. •Mercurius. Inflammatory swelling of the internal surface of the vagina. Muriatic acid. Pricking pain in the vagina. Natrum mur. Dryness of the vagina and painful embrace. Nitric acid. Stitches in the vagina from without inward when walk- ing in the open air. Nux vom. Internal swelling of the vagina, with burning pain, making contact intolerable. Rhus tox. Sticking pain in the vagina, not increased by contact. Pain in the vagina, as if sore, shortly after an embrace. Sore pain in the vagina, hindering an embrace. Sabina. Severe stitches in the vagina, deep, from before backward. Sepia. One of the most frequently indicated remedies for painful coition. Jerking pain in the vagina from below upward in the morning on waking. Contractive pain in the vagina. Almost con- tinual stitches in the vagina. Silicia. Labor-like pain in the vagina, which is very tender to the touch. VAGINISMUS. 593 Sulphur. Burning pain in the vagina; she is scarcely able to sit still. Sore feeling in the vagina during an embrace. Thuya. Burning and smarting in the vagina when walking and sitting. She is so sensitive in the vagina that she cannot possibly bear an embrace. Vaginismus. By this term is meant an extraordinary hyperesthesia of the nerves supplied to the mucous membrane of the vagina, at or near the site of the hymen, resulting in spasmodic constriction of the sphincter vagine muscle. In its most severe form it is doubtless seldom met with, but milder cases are of by no means infrequent occurrence. OAving to the extreme sensitiveness of the parts and the spasmodic closure of the vaginal orifice upon the slightest touch, sexual inter- course becomes excessively painful, and in many cases impossible, and even the attempt to introduce the finger or a small instrument Avithin the vagina arouses the resistance of the sphincter muscle and causes intense suffering. It occasions great distress to its unfortunate vic- tims, who are mostly married women of highly nervous tempera- ment or subject to hysteria. Sterility is frequently a result of this painful affection. The causes of vaginismus are various. It may arise from a general hyperesthesia of the nervous system, such as exists in some hysterical women, or it may be produced by some local derangement, itself of insignificant character. The principal causes may be enumerated as follows: hysteria, fissures or excoriations of the anus or vulva, erup- tions on the external genitals, chronic endometritis or vaginitis, irritable tumors at the mouth of the urethra, etc. Its diagnosis is easy, inasmuch as it differs from any other affection of the vagina. Dr. Marion Sims writes concerning it, " The super-sensitiveness is diagnostic, the spasm pathognomonic." The treatment should be conducted according to homoeopathic prin- ciples. The use of the knife, formerly so freely resorted to, is noAv generally denounced by old-school practitioners, while the very ques- tionable procedure of dilating the canal by graduated dilators, although claimed to be very successful, does not appear to be necessary. Should the vaginismus be dependent upon some local difficulty or disease, that must be removed before we can hope to accomplish a satisfactory and permanent cure. Coition should be strictly prohibited, and all ex- citation of the parts by motion should be avoided by enjoining perfect rest. Lavements of tepid water will be found very grateful. 38 594 DISEASES AND DERANGEMENTS OF THE VAGINA. For the medicines suitable to this disorder consult the remedies laid down under the foregoing article on Neuralgia of the Vagina, page 590, and, as well, those recommended for Spasms, Cramps and Constrictions of the Vagina, page 588. The local affections upon which this affection may depend should be treated in accordance with the indications given for each respectively, and their cure Avill be marked by the abatement and final cessation of the vaginal hyper- esthesia and the spasmodic stricture. In vaginismus the diet should be strictly attended to. All use of coffee, tea, spirituous liquors, stimulants and spices of all kinds should be positively prohibited. As much out-of-door exercise should be taken as possible. Vaginitis—Inflammation of the Vagina. The vagina is subject to many influences which produce inflam- mation, especially of its mucous tissue. This inflammation, at first acute, unless promptly treated by the administration of appropriate remedies, almost always assumes the chronic form. Many cases of chronic vaginitis, however, deArelop themselves so gradually and in- sidiously from the very first that they can scarcely be stated to have originated in acute inflammation. Married Avomen, particularly those who have borne children, are most frequently the subjects of acute vaginitis, while the unmarried, either in their earlier or in their later years, are more liable to suffer from the chronic variety. Vaginitis will seldom exist apart from vulvitis, as the inflammatory process originating in the vagina itself is apt to extend sooner or later to the vestibulum, and vulvo-vaginitis is the common condition. And, indeed, the cervix uteri may be and often is involved, especially in long-continued cases of chronic inflammation. A variety of forms of vaginitis may exist. Thus, erysipelatous and erythematous inflammation may occasion in the vagina intensely red, painful, elevated and more or less extensive patches. True vesicular inflammation may result from the extension of the eczema from the vulva to the vagina, and thus herpes phlyc- tenoides may be deA^eloped in the interior of the vagina and upon the cervix uteri. In like manner, pustulous vaginitis may result from the appearance of pustules in the vagina of persons affected with impetig- inous eruptions, especially when pregnant. Papulous vaginitis may be considered present Avhen the vagina and the neck of the Avomb are covered with papule or follicles more or less developed, assuming the shape of small spots of the size of a pin's head, or resembling fleshy VAGINITIS—INFLAMMATION OF THE VAGINA. 595 granulations. Finally, glandular vaginitis may be diagnosed Avhen the follicles alone seem affected, when the mucous membrane shows no traces of change, and when the secretion appears more copious and of a yelloAvish-white or grayish color. " It is generally dependent on an inflammatory condition of the blood at this period, and the intense irritation Avhich it excites so often occupies the mind of the patient that it amounts to nymphomania. Its situation is more frequent upon the external parts, but it also exists within the labia and in the neighborhood of the urethral orifice. This pruriginous affection is often symptomatic of serious disease of the uterus or its appendages, in which case its removal can only take place in concert with relief to the graver malady." An important distinction to be made in cases of vaginitis is, whether the disease be a primary affection, or whether it be secondary to or a consequence of some other disease; thus, for instance, violent vaginitis may result from the pouring out of a virulent secretion from the inte- rior of the uterus. In such a case it is evident that curative means should have in vieAV the treatment and cure of the original lesion. These specific forms of disease in the vagina seem to be but local developments of constitutional or psoric dyscrasia, and require for their cure such remedies, for the most part, as are applicable to similar forms of disease in other parts of the body; although it should not be forgotten here that those antipsorics should be preferred Avhich, in addition to possessing such specific cutaneous indications, are knoAvn to possess also especial relation to the female organs of generation. Symptoms.—The symptoms arising from acute vaginitis are the fol- loAving: A feeling of heat and burning in the vagina and vulva, the latter especially if it be involved in the inflammatory process; a feel- ing of aching and sense of Aveight in the perineum; frequent desire to urinate; pain and throbbing in the pelvic portion of the abdomen; profuse leucorrhoea, Avhich may be purulent, offensive and acrid; ex- coriation of the vulva and external parts adjacent. In the chronic variety the same set of symptoms exist in a lower degree, and in very mild cases there may be only a slight burning, more or less itching, and leucorrhoea. Vaginitis may be confounded with endometritis, ulceration of the cervix and gonorrhoea. From the latter it is wellnigh impossible to distinguish it except by the history of the case; but from endometritis or cervical ulceration differentiation may readily be made by touch or the use of the speculum. 596 DISEASES AND DERANGEMENTS OF THE VAGINA. The leucorrhoea is the most marked symptom of vaginitis. Indeed, the disease has been described by numerous authors as Vaginal Leu- corrhoea, Blenorrhoea and Blenorrhagia. Although not a disease per se, we shall now proceed to a description of it, in consequence of its im- portance as an index to the disorder of Avhich it is a consequence, as well as an index to its treatment. Vaginal Leucorrhcea. According to the nature, the degree and the intensity of the vagin- itis the discharge will differ from the natural mucous secretion of the parts, either in increased quantity only, or in color, consistence and actual character. In color the discharge may be simply what its name implies—a white mucus—or it may be yellowish or greenish, or pre- sent a mixture of both these colors. Its consistency may be that of pure mucus; it may be much thicker, of a creamy nature; it may be viscid, tenacious and stringy, or very thin and Avatery. In its actual character it may be catarrhal, as if simply an excessive flow of the natural secretion of the vagina; it may be either mucus or pus or muco-purulent, presenting all the different forms of variation from simple, healthy mucus, merely increased in quantity, up to the unde- niable pus from ulcerated mucous surface. Thus it may also be mild in its influence upon the sensitive external parts, or it may be more or less acrid and irritating, cause pruritus, and even corrode and blis- ter the external surface with which it remains in contact. In this form the leucorrhcea is known to become contagious, and to develop a similar inflammation and consequent discharge in the parts of the male from sexual intercourse. From this cause innocent women haAre been accused of infidelity to their husbands. The discharge may be and usually is inodorous, or it may be foetid and exceedingly offensive. In quantity this discharge may vary from the smallest amount that can escape the absorbents within the vagina and appear exter- nally, perhaps for a few days only at a time, up to a flow so constant and copious as to render cloths indispensable, and seriously weaken the patient. Symptoms.—At the first appearance of leucorrhcea there are usually the indications of acute inflammation—pain, heat and redness of the parts involved—which may subside as the discharge becomes more fully developed. With this discharge, whether acute or chronic, there will usually be more or less pain in the groins and hypogas- trium, and in the sacral region and small of the back. The urethra VAGINAL LEUCORRHCEA. 597 will often become implicated, causing painful micturition, or even dysuria, especially in the more severe acute forms and in the most aggravated chronic cases. The morbid symptoms which appear in connection with chronic vaginal leucorrhcea are innumerable, and present every possible vari- ety in their intensity and in the parts of the system in which they are developed. Very many of these attendant symptoms of chronic leu- corrhcea should be regarded as the consequences of the primary dis- order and of the original causes of that disorder, which combine to break doAvn in succession the principal organic functions of the sys- tem. Thus, the menstrual irregularity which so constantly attends the more severe forms of leucorrhcea, and especially those cases in which the discharge arises from the cervix, and even from the body of the womb, is seen to be the natural and direct result of the leucor- rhoea and of the causes which produced this discharge. Or if such menstrual irregularity be not the immediate and direct result of leu- corrhcea, it can hardly fail to become a final consequence of the gen- eral debility of the entire system Avhich severe forms of this discharge must sooner or later produce. In like manner the appetite fails and the digestive powers become enfeebled, and inveterate constipa- tion follows from such weakness of the digestive apparatus, and from the general nervous debility, and still further complicates the case. The circulation is feeble, the respiration impeded, and the tempera- ture of the whole body reduced, as indicated by constant and gene- ral chilliness. The nervous system is impaired, the animal spirits depressed, and the natural buoyancy and cheerfulness of tempera- ment and disposition replaced by irritability, fretfulness and settled melancholy. All these and other long trains of symptoms, whose name is legion, are the results of the combined influence of the producing causes of the leucorrhoeal discharge and of the debilitating effect of the dis- charge itself. And this important distinction should always be borne in mind, for if we think the leucorrhoea alone causes all these innumerable and various sufferings, we should naturally be disposed to seek principally to remove the discharge, expecting the conse- quences would then readily disappear; but such expectations Avould be disappointed even if we could succeed in curing the leucorrhcea by attending to that alone, which is not the case, as will more plainly appear Avhen Ave come to study the causes and treatment of this dis- charge. The constitutional predisposition to leucorrhoea is but another name 598 DISEASES AND DERANGEMENTS OF THE VAGINA. for psoric diathesis or scrofulous taint in general. This is much more strongly manifested Avhen it has become hereditary, not only as a general predisposing influence, but also by previous local develop- ment of this form of scrofulosis in the mother. Thus, a young Avoman of decided scrofulous constitution may Avell be considered to possess a constitutional predisposition to leucorrhcea. But this predisposition will easily be understood to be very much intensified if her mother —and still more her grandmother also—had leucorrhcea. This heredi- tary predisposition to scrofula in general, and to leucorrhcea in particu- lar, will require a greater or less amount of incidental influences to de- velop it, according as it is thus more or less strongly marked in the constitution itself. And in proportion as the vaginitis and leucor- rhcea are the results of such constitutional predisposition they will prove more inveterate and more difficult to cure. The psoric taint in the system tends to develop and ultimate itself either on the external surface of the skin or in the superficial and other glandular structures, according as its original nature is analo- gous to pure psora or to scrofula. But in either case, after puberty, and in many strongly marked cases before puberty, this psoric miasm reverts from the cutaneous or glandular system to the mucous surface. And in such as have this constitutional predisposition still more re- markably and specifically developed (as if from such local hereditary influence as has just been mentioned) the psoric and scrofulous taint attacks the mucous surfaces of the female genitals in the first instance. Such are the cases of young girls, and eA'en very young children, in whom the leucorrhcea seems to have developed itself almost spon- taneously—that is, Avithout the co-operation of any particular inci- dental influences that can be discovered. Among the incidental influences Avhich may produce leucorrhoea may be enumerated almost everything Avhich is capable of injuriously affecting the female organism. This remark, however, applies rather to the chronic than to the acute form of the disease. The causes which principally excite acute vaginitis, and conse- quently acute leucorrhcea, may all be embraced under a feAv general heads. Exposure to cold, from which many women suffer more than they are aware or are willing to acknowledge, may occasion a true vaginal catarrh or acute inflammation, followed by a copious catarrhal discharge. Violence of any kind may produce an inflammation, the discharge from Avhich will exhibit more of a muco-purulent appear- ance. A very similar effect may result from excessive sexual indul- gence. As already stated, inflammations from the vulva, and even VAGINAL LEUCORRHCEA. 599 from the adjacent tissues, may extend themselves into the vagina. These, however, are less apt to be followed by leucorrhcea. Among the unpleasant sequele of parturition, and especially of miscarriage, acute inflammation of the vaginal membranes and accom- panying leucorrhcea are the most frequently observed. This may result from the violence Avhich these delicate tissues have experienced, and also from the impatience of the woman in attempting to get about too soon. Sudden and violent attacks of vaginitis and leucorrhoea have been observed to arise from causes Avhich may be designated as metastases. Such are those which folloAV sudden suppressions, as of perspiration, of the hemorrhoidal discharge, of diarrhoea, of the lacteal secretion, of chronic suppurations, of cephalic or bronchial catarrh, of spon- taneous vomitings, and retrocessions of arthritic, gouty inflammations, and of recent or long-established cutaneous eruptions. The gonor- rheal virus excites perhaps the most violent acute inflammation and copious discharge of all. But the discussion of this class of disorders is foreign to our present purpose. The influence of cold, damp weather, or exposure to cold and damp from the location of the residence in a marshy district, from the nature of the house itself (stone, with walls constantly moist on their inner surface), and from water standing in the cellar, especially when long continued, is a poAverful promotive of leucorrhoea. And in many cases resulting from such influences the physician will find all his prescriptions vain as long as he fails to explore or remove the cause; for in very many constitutions the susceptibility to such injurious influences is one of the principal features of their case, and such persons must cease taking the poison before the antidote can have the desired effect. But aside from the absolute necessity of guarding against the depraving influence of long-continued exposure to dampness, especially from wet cellars or large open cisterns imme- diately under the family sitting-rooms, Avhere the leucorrhcea is the direct result of such exposure, the true homoeopathic remedy may easily be overlooked so long as the cause of the complaint remains unknown. An entirely opposite but not less numerous class of causes of this disease may be found in the high living, stimulating spices, condi- ments and drinks in which many women indulge. As, on the one hand, in cases of exposure to wet and cold, a Ioav form of mucous inflammation may produce a still more constant and debilitating dis- charge from the vagina, so, on the other hand, in those persons Avho 600 DISEASES AND DERANGEMENTS OF THE VAGINA. over-stimulate. Nature seeks an outlet through the profuse vaginal secretion, attended of course by a higher range of inflammatory action, for the surplus of unhealthy food and drink. Treatment.—Acute vaginitis will require such remedies as Aconite, Apis, Belladonna, Cantharis, Rhus tox., Pulsatilla, Sepia, Veratrum viride, etc. Study the medicines recommended for the treatment of vulvitis and the various forms of inflammation of the womb. For chronic vaginitis, and especially for vaginal leucorrhea, study the remedies laid down under the head of Uterine Catarrh, Avhere may be found the constitutional and special indications for all the medicines for leucorrhoea, whether arising from the mucous mem- brane of the vagina alone, from that of the uterus, or from both, as is usually the case in the severer and long-continued forms of the in- flammation of which the discharge is merely the consequence. Indurations of the Vagina. Inflammation of the cellular tissue of the labia, vagina or other parts of the generative apparatus may lead to induration, Avith or without hypertrophy. These indurations occasion adhesions, and often result in contraction of the vagina, which may interfere Avith coition. Induration of the vaginal Avails sometimes appears in conse- quence of the extension of the same morbid condition from the os and cervix uteri. The simple thickening of the mucous membrane, which comes on gradually and almost imperceptibly, in some cases may constitute the entire induration. In others it arises in connec- tion with phlegmonous inflammation and infiltration of the deeper tissues. In others still a syphilitic or schirrous taint in the system may be the cause, but in these latter instances the indurated surface is very rough to the finger, sometimes ulcerated. " Almost always the patients complain of pain at the outset, of smarting, itching and increase of heat, and in proportion as the affection develops itself the vagina becomes contracted, and sometimes almost obliterated." These indurations may be removed entirely by radically curing the disorder from Avhich they result, and Avithout having recourse to dila- tation, as sometimes employed. Observe carefully all the conditions, circumstances and symptoms of the patient. The true similimum of the entire case may be found under one of the folloAving remedies: Belladonna. Sense of heaviness and of fullness, and bearing down in the parts. Sense of heat and dryness in the affected parts. Sensation of pressing out of the internal parts. Throbbing sensation. EXTREME NARROWNESS OF THE VAGINA. 601 Calc. carb. Temperament leucophlegmatic. Calcarea complexion. Her feet feel as if she had on cold, damp stockings. China. The slightest contact causes darting, tearing pain, or tearing with pressure. The system has been debilitated by losses of fluids, especially of blood. Clematis erecta. Suitable to torpid, cachectic conditions. Swelling and induration of the glandular system. Syphilitic taint. Conium m. The induration is very hard. The urine intermits, stops and Aoavs again. Particularly suitable to women with tight, rigid fibre, and easily excited, as Avell as to those in the opposite con- dition. Lycopodium. Borborygmus, especially in the left hypochondrium. Much pain before passing Avater. Great delay in the flow of the urine. Red sand in the urine. Magnesia mur. Where there are present hysterical symptoms and spasmodic paroxysms. Constipation, with large, hard stools, which crumble as they pass the verge of the anus. Mercurius. Will be required Avhere Ave find the well-known indica- tions of the mercurial diathesis; more or less salivation; scorbutic gums; moist skin; soreness of the throat; soreness of the inguinal glands. The indurated tumor may have a raAV, sore feeling. All the symptoms are Avorse at night. Perspiration, which does not relieve. Petroleum. Tenderness in the swollen parts. The labia majora perspire and itch very much. Unhealthy skin; even small wounds ulcerate and spread. Pulsatilla. Mild temperament. The patient is moved to tears in giving her symptoms. Sepia. Small, stitching, burning pains in the parts; great sensitive- ness of the parts; foetid urine; putrid urine. Sediment from the urine adhering to the vessel like reddish clay burnt on. Sulphur. Flashes of heat; coldness of the extremities, especially of the feet. Burning in the soles of the feet at night. Spells of weak- ness and faintness. The general, characteristic sulphur symptoms. These, like the other great indications for polychrest remedies, will recur again and again in many forms of disease. Sulphur will always do good Avhere it is indicated, and it is very often indicated in chronic inflammations and other disorders Avhich may be considered as the ultimate developments of internal psoric taint. Extreme Narrowness of the Vagina from congenital anatomi- cal malformation may be best treated by the cautious use of graduated 602 DISEASES AND DERANGEMENTS OF THE VAGINA. dilaters, similar to those recommended by Dr. Marion Sims for the treatment of Vaginismus. Vaginal Fistula. Inflammation, abscesses, accidental wounds or the use of instru- ments may occasion fistulous openings through the walls of the vagina into some one or more of the adjacent organs. Thus there may be an opening from the vagina into the urethra—urethro-vaginal fistula; from the vagina directly into the bladder—vesico-vaginal fistula; from the vagina into the rectum—recto-vaginal fistula; from the vagina into some other portion of the intestines—intestino-vaginal fistula ; or finally from the vagina into the peritoneal cavity—perito- neo-vaginal fistula. Recto-vaginal fistula is most frequently the result of violence from the use of instruments in labor, or it may arise in connection with rupture of the perineum. This unfortunate condition will be at once recognized if the patient complain of the involuntary escape of half liquid fecal matter, of intestinal gas, or of both, through the Angina. In addition to those cases which may arise from mechanical vio- lence, urethro-vaginal and vesico-vaginal fistulas are more frequently the result of the extension of cancerous or other ulceration to the walls of the bladder. The same result may sometimes succeed the strangulation of the parts by the long-continued pressure of the head of the fcetus in labor against the inner border of the arch of the pubes. The involuntary and constant flowing of the urine through the lower part of the vulva, and the consequent urinous odor which is diffused from the person, but too manifestly indicate the existence of one of the most serious and distressing misfortunes that can befall the female. These distressing lesions are neither very rare nor are they easily or always susceptible of cure by surgical means. The failure here arises in part from considering these ulcers too exclusively as local affections, when in fact they are often in their persistence as much dependent upon a constitutional support as are ulcers in any other portion of the body. Fortunately, these fistulas are more amenable under homcepathic medication, which is capable of reaching the con- stitutional taint lying at their foundation, and at the same time of including within its influence all the morbid and symptomatic condi- tions of the system. Thus it happens that some so-called hopeless cases of vaginal fistula have been completely and permanently cured by medication. But to secure this end perfect rest will in many cases be VAGINAL FISTULA. 603 indispensably necessary, and the proper medicines should be carefully administered before resorting to surgical means, which, hoAvever skill- fully employed, are often insufficient, and leave the patient in a Avorse condition than before. The guides in the selection of the remedy must be found principally in the constitutional and accompanying symptoms, and in their conditions of aggravation and amelioration. These may seem but far-off and indirect guides, but in many instances they have been proved amply sufficient. And when the symptoms are found to be improving under the use of a certain remedy, we should Avait patiently, and in a fe\v weeks the fistulous ulcer will be found to have taken on the healing process. For the strictly surgical treatment of the various forms of vaginal fistula we would refer the reader to the more recent publication on Gynecological Surgery. Remedies for Vaginal Fistulas. 1. Calc. carb., Lye, Puis., Sil. 2. Asaf., Bell., Carbo veg., Con., Nitr. ac, Sulph. 3. Agaric, muse, Ant. cr., Aur., Caust., Creas., Hep., Lach., Petr., Ruta, Sep., Thuy. Asarum. The patient has a great want of vital heat. She feels cold continually. Belladonna. Will often be required in the case of Avomen of delicate skin and red complexion. Aggravation of the symptoms at three o'clock in the afternoon. Calc. carb. Will be found especially indicated in leucophlegmatic temperaments. Feet constantly cold and damp, as though she had on cold, damp stockings. The least cold air chills her through and through. She cannot sleep after three o'clock in the morning. Carbo veg. Burning in the fistulous ulcer, Avith much belching of wind, Avhich affords relief for a short time only. Conium. The urine when being discharged flows and stops, and then Aoavs again. Ledum. Absence of vital warmth. Still she is made very much worse Avhen warm in bed, or from getting warm by the fire or over the register. Lycopodium. The ulcer bleeds frequently. Much borborygmus, particularly in the left hypochondrium. Red crystals or red sand in the urine. Always feels Avorse from four till eight o'clock in the evening. Nitric acid. The urine has an intolerably strong smell, like that of 604 DISEASES AND DERANGEMENTS OF THE VAGINA. horses. May be suitable in cases Avhere allopathic doses of mercury have been given. Pulsatilla. Tearful disposition. Scanty urine and no thirst. She has always a very bad taste in the mouth early in the morning. Craves fresh, cool air. No sleep till after twelve at night, and then sleeps late in the morning. Sepia. The urine is so putrid that it cannot be suffered to remain in the room. The urine deposits a reddish, clay-colored sediment, which adheres to the bottom and sides of the vessel as if it had been burnt on, like burnt clay. Silicia. General scrofulous diathesis. Much tenderness of the ulcer or of the parts adjacent to it. Sulphur. Constant heat in the crown of the head. Flushes of heat, passing off with moisture and debility. Burning in the soles of the feet at night. Short naps of sleep all night, and dead, heavy sleep. Sense of hunger and faintness daily from eleven o'clock till noon. Thuya, Causticum, Antimonium crudum and Mercurius should likeAvise be carefully studied, as they may prove valuable Avhere their characteristic symptoms are present. Concomitant Symptoms of Vaginal Fistulas.—For some of the most distressing of the concomitant symptoms of these afflic- tions compare the following medicines : Aurum. Where there is much pain in the bones, day and night. A sensation of internal emptiness and weakness of the Avhole body. Lachesis. Where there is much pain of an aching character in the shin-bones only. The patient feels unhappy and distressed after sleeping. Petroleum. If diarrhoea is apt to occur very frequently and through the day only. Gangrene of the Vagina. Gangrenous degeneration of the vagina may be the result of pressure and contusion produced during difficult or protracted par- turition, or from the pressure produced by a neglected pessary, and it may occur in the form of gangrenous eschar and gangrenous fusion of the mucous and submucous layers. The same form of destruction of the tissues of the vagina is liable to occur in consequence of stran- gulated hernia or prolapse of some portion of the vaginal walls. As in other forms of tissue degeneration and sloughing, homceo- morbid growths of the vagina. 605 pathic remedies are capable of exerting a most astonishing influence in aiding Nature to get rid of the decaying tissue or to arrest the gangrenous process and repair the loss of substance with neAv groAA'th. The folloAving remedies should be carefully studied, and one or the other of them will be found, without any doubt, sufficient to effect the requisite change : Arsenicum. The parts burn like fire. The characteristic arsenic thirst is present. Foetid smell. Apis mel. Stinging pains about the parts; no thirst. Belladonna. Throbbing about the parts and sense of Aveight. Calc. carb. Leucophlegmatic temperament. The cold air strikes through her. Her feet feel as if she had on cold, damp stockings. China and Secale may be indicated, and should be studied in such cases. Creasote. An offensive smelling ichor discharges from the part. Lachesis. Much distress after sleeping. Sulphuric acid. Much debility, with sensation of tremor all over the body. These indicating symptoms disappearing under the influence of the corresponding remedy, there is reason to expect complete restoration. The course of the improvement should be most carefully watched: we wait patiently till the improvement has entirely ceased before we repeat the dose or resort to another remedy; and then, the latter course being decided upon, make a new prescription according to the totality of the symptoms and leading indications present. Morbid Growths of the Vagina. Morbid groAvths in the vagina are not very frequent. When present they almost always coexist Avith similar growths in the uterus, as they spring from an internal dyscrasia which pervades the entire system indeed, but which finds its greatest facility of de- velopment on the mucous membrane of the genitals—a dyscrasia Avhich is always of a very suspicious character, and which in many instances appears nearly allied to the cancerous. These so-called morbid groAvths are in reality but hypertrophies or overgrowths as to their structure, and therefore they are truly homo- logous groAvths. But they are animated by a perverted physiological or vital principle. Thus a purely scrofulous tumor may be looked upon as merely an enlarged gland, Avhich is inspired by AArhat we may term the scrofulous diathesis. So a fibrous tumor, whether hard or 606 DISEASES AND DERANGEMENTS OF THE VAGINA. soft, pendulous or adherent, is but the abnormal or unlimited devel- opment of fibrous or fibro-cellular tissue, with its accompanying secre- tion, but inspired by a morbid principle which may be constitutional, and possibly related to that Avhich appears in cancer. In like man- ner serous cysts appear to be but hypertrophic glands, or follicles even, which in their magnified condition still retain their former power of secreting serous fluid, and whose hypertrophic condition is due to the /act that some morbid principle—it may be the influence of some neighboring tissue affected Avith cancer—has vitiated, per- verted its normal vitality. And even the so-called granular vege- tations Avill thus appear to be but hypertrophic developments of still more minute anatomical structures, influenced by some specific poison, as the sycosic These formations may be briefly described under the heads of fibro-cellular tumors, including soft polypi; fibrous tumors, including hard polypi; serous cysts, encysted tumors and granular vegetations. I. " The softer kinds of polypi (or of adherent tumors), growing from (or upon) the mucous membrane, consist of rudimentary or more nearly perfect fibro-cellular or connective tissue, which is made suc- culent by serous or synovia-like infiltration in its meshes." * These tumors bear some resemblance to the serous cysts to be subsequently described, and also to the soft or colloid cancerous growths ("gela- tinous sarcoma ") with Avhich they have sometimes been confounded. But they do not appear to originate in the same minute glandular structure Avith these cysts, nor yet do they present the same positively malignant characteristics with the colloid cancer. These fibro-cellular tumors take their name from that of the sub- mucous tissue from which they spring, and of which they are princi- pally composed, and they retain their name of tumor exclusively as long as they remain closely adherent to or embedded in the neighbor- ing parts. But A\*hen they become outgroAvths, pendulous, suspended by narrow pedicles, they are termed polypi. These morbid groAvths, of which the suspended or polypoid variety is much the more numerous, may appear upon any part covered by mucous membrane. " The peculiar yelloAv color of the basis-substance of these tumors makes them look at first like fat; it is due, however, not to fat, but to a serous, or synovia-like, or very viscid fluid, which is infiltrated through the substance of the tumor. Among the most frequent seats of these tumors in the female are the labia and vagina." f * Paget, Path. Anat., Art. "Fibro-cellular Tumors." f For a full exposition and some examples of these tumors, consult Paget. VAGINAL POLYPI. 607 II. The fibrous tumors are more exclusively pendulous, or polypi. These are not unfrequent in the uterus, sometimes perhaps in the vagina, and sometimes even in the pelvis external to the vagina. In this latter situation they may consist of cysts, fleshy or fibrous tumors, Avhich groAV underneath the mucous membrane of the vagina, in the cellular membrane behind the vagina, or they may be more immediately attached to some part of the osseous framework of the pelvis, Avhether the product of diseased periosteum or not.* These interpeh'ic tumors may not attract attention until from their size they impede the free action of the rectum or the bladder, or render parturition difficult by occupying an important portion of the pelvic cavity. In some instances these tumors are of the nature of fungous or cancerous groAvths. But ordinarily the tumors of fibrous form which appear in the vagina, and still more especially in the uterus, are attended with serious inflammation in the adjacent tissues. And the inflammatory disease Avhich arises in connection with uterine fibrous tumors or polypi must be the great cause of the local and general painful symp- toms and hemorrhages which arise in such cases. Thus, in the allo- pathic practice it has been discovered, by the hard experience of the ill-success Avhich has so often attended the removal of these tumors of the vagina and uterus, Avhether pendulous or still adherent, that the tumor is not the disease, but rather merely the result of it. And high authority cautions against removing these tumors before first curing the disease Avhich causes them, if possible. " In cases in which the polypoid tumor (Avhich is the easiest of extirpation) can be re- moved the patient is only half cured if extensive inflammatory mis- chief is allowed to remain."—Bennett. Vaginal Polypi. Under the head of Fibro-cellular Tumors of the vagina were de- scribed those formations, usually vascular, which are principally adherent to the vaginal mucous membrane, but which sometimes become pendulous outgrowths, such as are termed soft polypi. These pendulous groAvths, or polypi, are perhaps more frequently found within the vagina than those which continue adherent, although in most cases they arise from the uterus; and in many instances in which they thus originate in and still draw their support from the uterus, they are found occupying the vagina, having been expelled from the interior of the uterus, to which, however, they still remain attached * Churchill. 608 DISEASES AND DERANGEMENTS OF THE VAGINA. by their fibrous pedicle or stem. Under the head of Uterine Polypi these tumors will be more fully treated of in a subsequent section. We hereAvith present, at one vieAV, the principal indications for all the remedies which may be most frequently called for in the treat- ment of these various tumors or growths, Avhether arising from the vaginal walls, from the peri-uterine cellular tissue, or from the cervix or body of the uterus, for their treatment will depend not so much upon their exact location as upon the local and constitutional symp- toms presented in each case that comes under our treatment. Remedies for Vaginal Growths. 1. Calc. carb., Calc. phos., Conium, Phos., Staph. 2. Aurum, Hepar, Lye, Merc, sol., Mezer., Sil., Thuya. 3. Bell., Graph., Natr. mur., Nitr. ac, Phos. ac, Sulph., Sulph. ac, Petrol., Puis., Sep. Aurum. The mind is tending more or less strongly toward self- destruction. She thinks much about it, even if she does not intend it. Calc. carb. Leucophlegmatic constitution. The patient cannot sleep after three A. M. The pit of her stomach is convex, like a saucer turned up, instead of being concave. Feet feel constantly as though she had on cold, damp stockings. Menses too often and too profuse. Vertigo on Avalking up stairs. Conium. Intermission in the flow of urine. Soreness and swelling of the breasts preceding the menses. Vertigo on turning in bed, or on turning the head when lying in a recumbent position, or on going down stairs. Lycopodium. Urine containing red sand as a constant symptom. Much borborygmus, particularly in the left hypochondrium. Aggra- vation of symptoms at four p. m. ; amelioration at eight p. m. Varices of the lower extremities. Also in cases in which sharp pains are occasionally running round each labia. Mercurius. In cases where there is evidently a mercurial condition of the whole system. The mouth and teeth show it—the glandular system, the urine and the skin show it. The symptoms are worse at night. They are worse also in damp, cold Aveather. Mezereum. (Compare with Mercurius.) All the joints feel as if bruised ; they feel weary, as if they would give Avay. She often has violent toothache at night. A fearful burning pain runs along the left malar bone from the right to the left. Nitric acid. Urine exceedingly strong, like horse urine. Sleeps SEROUS CYSTS OF THE VAGINA. 609 badly the latter part of the night. Leucorrhcea of mucus which can be drawn out. Flesh-colored, green leucorrhcea. Pressing in the abdomen, as if everything Avere coming out at the pudendum, Avith pain in the back, through the hips, doAvn the thighs. Petroleum. Much diarrhoea through the day, never at night. Moisture and itching of the hairy surface of the labia. The men- strual blood causes an itching of the genital organs. Phosphorus. Tall and slim persons. Occasional attacks of violent haemorrhage. Great sensation of emptiness and weakness in the ab- domen. Constipation, the stool being slender, dry and difficult to evacuate. Sour eructations and belching of quantities of Avind. Feejs very sleepy after meals, particularly after dinner. Phosphoric acid. A remarkable state of indifference, from which she cannot arouse herself. Great sense of weakness. (Compare also Phos., Sepia, Pulsatilla.) Platina. Constipation. The stool always being difficult, because it inclines to adhere to the parts like clay. Much tenderness of the vulva. Hysterical—spasmodic. The physical symptoms disappear and the mental symptoms appear, and vice versa. Pulsatilla. Very tearful; she Aveeps at everything, Avhether it is joyful or sorroAvful. Menstrual irregularities, which see for further indications characteristic of this remedy. Silicia. She ahvays gets worse at eArery new moon. See indications for Silicia, as given under the head of Leucorrhoea and Menstrual Irregularities. Staphysagria. The patient is very sensitive to the least mental impression. Her teeth turn black, and cannot be kept clean by much brushing. They exhibit black traces and streaks through their middle. She has much trouble with her teeth. Teucrium marum verum. Irritated, tremulous sensation in the whole body. Frequent biting, as if of insects, in the various parts of the body. Creeping sensation in the vicinity of the polypus. Thuya. The patient often feels as though she could not exist any longer. " Sensation as if the whole body were very thin and delicate, and could not resist the least attack—as if the continuity of the body would be dissolved." Serous Cysts of the Vagina. These are comparatively rare formations in the vagina, or rather they are developed in the cellular tissue external to the vagina. They contain usually a thin or honey-like liquid, of a yelloAV, broAvn, green 39 610 diseases and derangements of the vagina. or other tint, and they are most frequently seated in or near the secreting glands or the vulvo-vaginal glands. But wdiatever may be the exact appearance of the different fluids, they are all secreted by the membranes Avhich contain them. These membranes may be only enlarged hypertrophic glands, as in the mammary gland, where the cyst appears to be a portion of a lactiferous duct enlarged and de- generated as to its secreted contents. And where these cysts appear in connection with cancerous disease they seem to be the result of the disturbance of the natural groAvth and function of the minute glands in which they originate. Like other abnormal growths, serous cysts may attain a very great size. The following remedies may be studied in these cases, and others Avhich may appear to be indicated by the peculiar characteristics of the case: Graphites, Lycopodium, Pulsatilla, Rhododendron, Silicia, Sulphur. These cysts are always the result of some internal dyscrasia, which being removed the cysts themselves Avill presently disappear. Granular Vegetations, Condylomata. These are new growths of cellular tissue which may occur upon the mucous membrane of the vagina or vulva. Some of them, the true condylomatous excrescences particularly, are the results of some • especial taint of a syphilitic nature. Where there is reason to suspect this to be the case, Thuya will be most strongly indicated. Nitric acid, Staphysagria, Calcarea, Lycopodium, Mercurius and Tartar emetic may also be studied. Consult Condylomata of the Vulva. DISEASES AND DERANGEMENTS OF THE UTERUS. 611 CHAPTER XXX. DISEASES AND DERANGEMENTS OF THE UTERUS. Displacements of the Uterus. AMONG the most common of the numerous derangements to Avhich the uterus is liable are displacements of the organ. These displacements, in all their different degrees and A^arieties, may be included under the five heads of Prolapsus, Retroversion, Ante- version, Lateroversion and Inversion. As falling of the Avomb is more or less complete, it is denominated prolapsus or procidentia, the latter term signifying the complete settling doAvn of the womb, so that in some cases the whole viscus makes its appearance Avithout the vulva. Again, the term retroArersion of the womb is more properly applicable to the turning backward toward the sacrum of the entire womb, the fundus lying in the holloAV of the sacrum while the cervix is forced upAvard behind the pubes, without any bending of the organ ; while retroflexion is the term applied to that condition in Avhich there is a bending backward of the fundus alone, the cervix maintaining its normal or nearly its normal position, the flexion taking place at the juncture of the cervix with the body. The same distinction is made betAveen displacements in the forward direction—viz., into anteversion and anteflexion—while displacements of the organ sideAvays are termed respectively lateroversion and lateroflexion for the same reasons. Thus, we may have the following displacements: Prolapsus, Procidentia, Ret- roversion, Retroflexion, Anteversion, Anteflexion, Lateroversion, Latero- flexion, Inversion. A displacement upAvard, or ascent of the unimpreg- nated uterus, is of rare occurrence, and is ahvays dependent upon the presence of morbid growths. The relative frequency of occurrence of some varieties of these displacements, and other circumstances con- nected Avith them, are fairly exhibited in a statement made by Dr. Alfred Meadows, Avho thus Avrites : " Referring to the cases of uterine displacement of all kinds Avhich have come under my care in hospital and private practice during the last three years, to the end of 1867, and of Avhich I have careful notes, I find that the total number ob- served Avas 84. Of these 14 occurred in single women, 70 in married. Of the latter, 15 Avere sterile, and 55 had been pregnant; of these last, 27 had aborted. The total number of abortions Avas 63, or an average of 2£ to each person Avho aborted. The total number of children born 612 DISEASES AND DERANGEMENTS OF THE UTERUS. was 171, or an average of 3^ to each mother, and the total number of pregnancies Avas 234, or an average of 4^ to each of the fertile women. The frequency of the several varieties of displacements was as follows: Retroflexion occurred 34 times; in 8 the patient Avas single, in 26 married. Retroversion Avas met with in 18 cases; 3 were single, 15 married. Anteflexion occurred 20 times; only 1 of these Avas single, the rest Avere married. Anteversion was noticed in 12 cases; 2 of these were single, and 10 married." * We shall uoav proceed to give a description of these forms of dis- placement, Avith an account of the symptoms, causes and mode of treatment proper for each variety. At the close of the chapter will be found arranged in alphabetical order the remedies Avhich are prin- cipally indicated for their medical treatment. Prolapsus Uteri—"Falling of the Womb.'* This is one of the most common forms of uterine displacement. It occurs in three different degrees, to each of which some Avriters on the subject ha\Te affixed a different name. Thus, relaxation or simple descent of the womb is understood to indicate the first and least dis- placement downward, and to consist only in a simple bearing-down of the womb upon the upper portion of the vagina. In prolapsus uteri the organ comes still loAver down, and may present at the orifice of the vagina. In procidentia uteri there is actual protrusion of the organ, even the entire body of the Avomb being in some cases ex- truded from the Amlva. These are but different degrees of descent of the uterus in the line of the vagina. Upon examination of the same displaced uterus at different times of the day, it may be found to be more or less prolapsed, according to the condition of active exercise or quiet in Avhich the parts may have been for some hours previous. Symptoms.—The principal and primary symptomatic indications of the descent of the Avomb are: dragging and aching pains in the small of the back; pulling and bearing-down pains in the lower part of the abdomen; sensation as if something would issue from the vagina; sufferings much worse from walking or other exercise; the pains are often remarked to have come on immediately after some exertion of an unusual kind, and after some more than ordinary muscular effort; frequent calls to urinate; dysuria, or even retention, of the urine. In the more fully developed forms of prolapsus the history of the case, the attendant circumstances, and the external appearance of the os, cervix, and even of the entire body of the uterus itself, can hardly fail * London Lancet. Fig. 86. NATTJBAL POSITION OF THE PEIATIC VISCERA. The above represents the normal relative position of the contents of the pelvis. The plane of the superior strait is represented by a line running from the superior border of the pubes to the promontory of the sacrum. The plane of the inferior strait, by a line from the superior arch of the pubes to the point of the coccyx. The other lines are all denned in the cut. The fundus of the uterus is on a level with the plane of the superior strait, and its axis the same as that of said plane. The peritoneum is seen sustaining the uterus by its anterior superior three-fourths, by its fundus and by the whole of its posterior surface. The succeeding engravings exhibit the uterus in its various displacements, making a striking contrast with its normal position. (See also the cut on page 52.) 613 614 DISEASES AND DERANGEMENTS OF THE UTERUS. to render the diagnosis at once easy and certain. And if the falling of the womb is not so far developed as to give any such external signs, the severe aggra\7ation from Avalking and from lifting, together with the relief experienced from lying down, render the case suffi- ciently clear. Should there be any doubt, however, the vaginal touch Avill verify the diagnosis. Causes.—The causes of prolapse of the womb may be regarded as of two kinds—the more immediate, in which are included direct re- laxation of the proper supports of the uterus, and the more remote, in which are included the incidental or constitutional influences Avhich result in such relaxation. Fig. 87. PROLAPSUS. The peritoneum forms the great suspensory ligament or membrane common to the contents of the abdomen. This is the grand function of the peritoneum, to sustain in their proper places and in their proper relation to each other the various organs which are grouped together above and to some extent within the pelvis. The peritoneum is the true uterine supporter, the other ligaments tending rather to steady the uterus in its upright or inclined position than to prevent it from PROLAPSUS UTERI—"FALLING OF THE WOMB." 615 sinking doAvn in the pelvic cavity. This membrane, as already de- scribed, is reflected from the bladder upon the Avomb in such a man- ner as to sustain it in front from its anterior surface; and it is so reflected from the uterus upon the rectum posteriorly as to sustain it in that direction from its posterior surface. Thus it is evident that the uterus can sink in the pelvis only so far as is permitted by the relaxation of the peritoneum, its suspensory ligament. And this relaxation may be due to undue pressure from above, to influences Fig. 88. prolapsus witii flexion. excited upon it from beneath, or to its own inherent weakness from disease. Next to the peritoneum, the broad ligaments, which in fact are but processes of the peritoneum itself, are influential in supporting the womb; and they will necessarily sympathize therefore with any in- herent or constitutional Aveakness of the parent membrane, and at the same time be subject tb the same adverse influences from above and from below. So far as the bladder, the rectum and the muscular parts of the pelvis are engaged in supporting the Avomb, it is evident 616 DISEASES AND DERANGEMENTS OF THE UTERUS. that such support is all derived through the medium of the perito- neum and broad ligaments by which the Avomb is connected Avith them. The inherent Aveakness of the peritoneum and broad ligaments, Fig. 89. The above is an illustration of complete falling of the womb, the projection of the organ out of the orifice of the vagina. In these cases the vagina is completely in- verted, thus forming a conoid pouch, containing the supra-vaginal portion of the neck of the womb, its entire body, the ovaries, the Fallopian tube, a large portion of the broad and round ligaments, of the small intestines, of the bladder, and perhaps some- times of the rectum. The os and the infra-vaginal portion of the neck alone are seen, all the rest being covered by the inverted vagina, although protruding beyond the vulva. PROLAPSUS UTERI—" FALLING OF THE WOMB." 617 AA'hich seems one of the most prominent causes of falling of the Avomb, is usually such Aveakness only as corresponds to the debilitated tone of the rest of the system ; and hence the slightest additional strain brought to bear upon the womb from above by exercise, or unusual exertion, or by dress, once causing these supports to give Avay, their stretched and strained condition, continually borne upon more and more by the superincumbent organs, allow little opportunity for them to recover themsel\7es. Consequently, prolapsus uteri is rather apt to increase more and more than to recover spontaneously. Subinvolution of the uterus, or intra-mural or other enlargements, may produce prolapsus by increased Aveight; and the presence of tumors Avithin the abdomen may occasion it by their pressure upon the organ either directly or indirectly. Chronic leucorrhcea is set doAvn by some authorities as one of the causes of prolapse of the Avomb. But this is hardly correct, for in many cases the leucorrhoeal discharge will appear only after the oc- currence of more or less serious displacement of the Avomb, and in other cases, of persons of lymphatic temperament—that is, of psoric or scrofulous constitution—the debilitating influence leads at the same time to the leucorrhoeal discharge and to the uterine displacement. The same thing is true of constipation, Avhich is recognized as an im- portant and frequent cause of falling of the womb. The same con- stitutional influence that renders the bowels incapable of expelling the faeces renders the suspensory ligament and membranes incapable of retaining the Avomb in its proper position; and the violent action of purgatives, and the still greater Aveakness of all the connecting parts that invariably folloAvs their use, still further aggravates the constipa- tion and the uterine prolapse. The pressure from aboAre of the organs contained in the abdomen is often considered to cause descent of the womb. But it is against just such pressure from above doAvmvard that the peritoneum is intended to sustain the uterus. And except perhaps in cases of great over- exertion or undue violence it is not thought that the peritoneum yields to such pressure, unless previously Aveakened by some morbid influence. This is especially seen in those cases of prolapse Avhich appear in connection Avith ascites or ovarian dropsy. Thus it is that the great majority even of the Avorst and most fully developed forms of prolapsus uteri may be regarded as disorders properly amenable to homoeopathic medication, rather than as mere local displacements to be remedied by mechanical appliances. The ease of Mrs. O., Avhich came under my care some years since, illus- 618 DISEASES AND DERANGEMENTS OF THE UTERUS. trates the principle here inculcated, and at the same time shows what can be accomplished by the use of homoeopathic remedies. This lady had been subject to complete procidentia uteri for at least ten years. The organ Avould protrude entirely without the vulva, and neither pessaries, supporters nor perineal pads could prevent it from thus making its unwelcome appearance externally. I requested her to take to her bed, carefully washed and replaced the uterus, and gave Conium. A frightful leucorrhcea set in, but in the course of a single Aveek this disappeared, and with the help of Platina the induration of the womb and prolapsus were completely cured. The organ came doAvn no more; in fact, she never has since had any trouble of the kind. She has borne three children since and is a well woman at this day. The Conium and the Platina were all the medicines used in this case, and no bandages or mechanical applications Avhatever were employed in the treatment or subsequently used. The same principle holds true Avith reference also to the vagina. So far as the descent of the uterus may be fairly attributable to re- laxation of its Avails, this relaxation is itself an evidence of morbid Aveakness, requiring appropriate medication. And even in those cases in Avhich the prolapse of the uterus may seem to be owing to an un- usually large pelvis, the natural supporters of the uterus can by proper attention be rendered capable of performing these functions in a far better and more satisfactory manner than we can do it for them by the aid of pessaries or supporters. In like manner, all that large and important class of cases of prolapse which come on after confine- ment can be prevented by observing suitable directions, or cured by appropriate homoeopathic medicines. Inversion of the Uterus. This is the rarest as well as the most formidable and dangerous form of uterine displacement. It occurs principally as an accident in connection Avith delivery. In sudden and unexpected descent of the fcetus through an unusually large pelvis, when the patient is walking or at the Avater-closet, or from too violently drawing upon the cord, the fundus of the womb has been known to be inverted and brought doAvn with the placenta. This accident and complication of labor has been referred to in its proper place in connection Avith delivery. In- version of the uterus is here described, because, although very unusual in the unimpregnated state, it may occur in consequence of the pres- ence of polypus or other tumors of the womb. Inversion of the Avomb is analogous in its appearance to simple inversion of the uterus. 619 prolapsus of the entire circumference of the vagina. In either case the change begins above, and consists in the inversion and depression of the affected part. In the Avomb the fundus is at first simply de- pressed, and in this first stage the inversion is comparatively slight, and may be difficult or incapable of detection. But as the change in- creases, the fundus sinks down more and more within the body of the womb; and in this second stage the inner surface of the fundus may be felt and recognized as a tumor by introducing the finger within the os uteri. In the complete form of inversion the Avomb, entirely turned inside out, may be protruded without the vulva. In this case the mucous lining membrane of the uterus in its natural position becomes its external covering. Thus, as in the case of prolapsus of the vagina, there are three different degrees of the inversion of the uterus, which may be designated as simple depression of the fundus; partial inver- sion, in AA'hich, hoAvever, the tumor formed by the inverted fundus does not reach the os uteri; and complete inversion, in which the Avomb is entirely turned inside out and protruded externally, consti- tuting at the same time complete inversion and entire procidentia. This is a very serious complication of all the uterine organs, for the vagina must be more or less compromised, and the Fallopian tubes, ovaries and bladder draAvn down from their proper positions. Here not only the actual displacement of the womb and its appendages forms a serious difficulty, but the mere dragging upon those append- ages on the part of the Avomb must also cause great distress and de- rangement in the organs themselves, and profound depression of the nervous system and vital strength. The presence of a polypus in the inverted Avomb may render the diagnosis comparatively easy. But it must be borne in mind that the inversion itself is due not so much to the actual weight of the tumor as to its morbid influence upon the womb, and to the efforts Avhich the Avomb makes to free itself by expelling the foreign body. Complete cases of inversion in connection with polypi constitute a very grave form of disease, partly from the occurrence of haemor- rhages, and from the severe functional and constitutional derange- ments to which this condition may give rise, and partly from the unhealthy nature of the cause itself. For even if the polypus be not considered a malignant growth, it takes its rise in some depraved state of the system, and it may be the index of more serious forms of dis- ease yet to be developed from the original dyscrasia. Treatment.—The inverted Avomb should be carefully reduced and the whole organ replaced in the pelvis, with as little and as gentle 620 DISEASES AND DERANGEMENTS OF THE UTERUS. manipulation as possible. The patient should remain in bed in such position as is found most comfortable, receiving such medicines as are best suited to the entire group of symptoms—sensational, functional and structural. So profound is the relation of the laAV of the similars to the human constitution that even comparatively unimportant sen- sational symptoms, Avhich, however, are peculiar to and characteiistic of the case, may lead directly to the true homoeopathic remedy for the entire disease. This simple fact, the stone which the allopathic and the chemical builders, and even those of the so-called physiological school, haATe rejected, bids fair to become the head of the corner in homoeopathic therapeia. And this profound principle, confirmed bv the constant experience of many careful observers and experienced physicians, should encourage the young physician to rely upon his Materia Medica, and not to despair even in the presence of serious functional derangements, and even structural changes, for Avhich he can see no direct and sufficient homoeopathic analogue. In many forms of disease the sensational symptoms, Avhich occur first, are in- tended as warning voices, forerunners of the evil to come; and even in the more advanced stages of disease these sensations are still the most unfailing key-notes to the real remedies in the case—indices to the remedies, not for the severe sufferings alone, but for the func- tional, and even structural disorders, Avhich cause them and which they represent. Select the remedy in accordance Avith all the symptoms present, having reference also to the constitutional history of the patient. Anteversion and Anteflexion. Anteversion.;—This is a displacement comparatively rare in the unimpregnated uterus, although it does occur, and is e\ren found in nulliparous women. The natural position of the Avomb is one of slight anteversion, and this is always increased in degree in the early months of pregnancy. But this forward inclination may be so in- creased as to constitute a morbid condition, and gi\re rise to some very unpleasant and painful symptoms. The uterus may be regarded as in a condition of unnatural anteversion Avhen it lies in its long axis across the pelvis, with the cervix in the hollow of the sacrum, and the fundus near the symphysis pubis and encroaching more or less upon the bladder. Anteversion may be combined Avith flexion at the junction of the cervix with the body; and in this case the fundus is throAvn still more forward and dowmvard, while the cervix is not directed so far backAvard toAvard the sacrum. ANTEVERSION AND ANTEFLEXION. 621 Symptoms.—This form of displacement may come on gradually; and in this case it can be distinguished from simple prolapse only by the vaginal touch. On passing the finger up to the fornix vaginae, the cervix will not be found occupying its usual position, but on ex- ploring posteriorly toward the holloAv of the sacrum it will be found occupying that position, and higher up than natural. From this point the finger may trace the body of the Avomb lying almost on a horizontal line across the pelvis, until the fundus is found at the posi- Fig. 90. . tion just mentioned, near the symphysis. The uterine probe, very much bent, may be passed into the cavity of the uterus, thus verifying the diagnosis; but this procedure is unnecessary, inasmuch as it is almost impossible to mistake an anterior for any other form of dis- placement. Anteversion may also occur suddenly; and in this case the symptoms very nearly resemble those occurring from falling of the Avomb, but the derangement may readily be made out by the vaginal touch. This displacement may exist without giving rise to any symp- toms that direct the attention of the woman to' her condition, though 622 DISEASES AND DERANGEMENTS OF THE UTERUS. such cases are, in the nature of things, rare. Pressure of the os against the posterior wall of the vagina may occasion dysmenorrhcea and sterility. The pressure of the fundus upon the bladder gi\Tes rise to a variety of very unpleasant urinary symptoms, which differ greatly in degree in different women, and which, in some cases, are so severe as to simulate those of cystitis. The pressure upward and backAvard of the cervix occasions more or less rectal irritation, constipation and hsemorrhoids. In some cases locomotion is greatly interfered with, Fig. 91. ANTEFLEXION. and even rendered wellnigh impossible. But the disturbances of the urinary apparatus are the most marked symptoms of anteversion, and are those which generally cause the woman to consult her physician. Causes.—The causes of anteversion are predisposing and exciting. The predisposing causes are those which occasion a relaxation of the uterine supports, such as parturition, indolent habits, improper dress, etc. The exciting causes are, direct violence or muscular effort; any- thing which increases the weight of the uterus, such as pregnancy, ANTEVERSION AND ANTEFLEXION. 623 subinvolution, tumors, etc. ; abdominal tumors, pressing the uterus downward and forward. The enormous accumulation of faeces may sometimes operate as a displacing influence, and the combination of other causes may then easily serve to throw the fundus of the womb still farther down in the pelvis, or even press it beneath the symphysis. Anteflexion.—This form of displacement is of common occur- rence. It differs from anteversion in this, that while the fundus and body of the uterus are abnormally directed downward and forAvard, the cervix retains its proper position or nearly so, although flexion of the uterus forAvard may comprise a bending in that direction of both body and neck at the point of junction of the two, the bending being in some cases nearly at an acute angle. Or, in other cases, Avhile the body of the uterus retains its normal position, or nearly so, the cervix is bent and extended forward toward the pubic symphysis. Symptoms.—The symptoms produced by anteflexion are similar to those of anteversion, though usually rectal and vesical irritation are not so great. In consequence, however, of the bending of the womb, very serious symptoms may arise, Avhich are the results of various diseases which this abnormal position may give rise to. Dysmenor- rhcea is an almost necessary attendant; congestion of the womb may occur, and occasion a variety of diseased conditions; endometritis, both corporeal and cervical, may be set up, and by pressure or other cause even peritonitis may result. Causes.—The same causes which occasion anteversion may operate . to produce anteflexion, previously existing weakness of the uterine tissue at the junction of the cervix and body of the uterus being premised. Treatment of Anteversion and Anteflexion.—In the treatment of these forms of displacement desire the patient to remain quiet, or even, in severe cases, to keep her bed and lie on her back a feAv days; administer the remedy best indicated by all the symptoms, and a com- plete cure may be looked for in a very short time. In those cases only in which the fundus is actually thrown beneath the arch of the pubes will there be any necessity for any manual in- terference to remedy and cure this displacement. And also observe that the woman suffering Avith this form of dis- placement should not urinate too often, since by moderately distend- ing the bladder it will assist in replacing the womb; and Avhen in the recumbent position she should lie upon her back as much as pos- sible, since this position will also aid the reposition. The general 624 DISEASES and derangements of the UTERUS. health being restored by the proper internal remedy, there will be no more trouble Avith the anteversion. Retroversion and Retroflexion. Retroversion.—This is a form of displacement Avhich probably occurs next in frequency to prolapsus. As a disease per se it is perhaps of rare occurrence, but as an accompaniment of the various forms of inflammatory disease of the uterus or of increase in its size and Aveight, it is very frequently met with. It may occur, however, as the result of Fig. 92. RETROVERSION. violent succussion, and give rise to very urgent and painful symptoms. The natural position of the uterus being Avith the fundus inclined over toAvard the bladder and symphysis pubis, in retroversion it assumes di- rectly the opposite direction. By an exact examination by the touch the fundus Avill be found turned back toward the sacrum, and even pressed down beneath its promontory, and the os uteri will be found turned toAvard the pubes. As in simple prolapse of the uterus, so also in retroversion, there may be three different degrees or stages of dis- placement, according as the fundus is directed toward the upper, the retroversion and retroflexion. 625 middle or the lower portion of the sacrum. In all cases in which the -womb has been so depressed backAvard that its fundus is thrown down beneath the sacral promontory this forms an insuperable bar- rier against its return, unless replaced by art. And the best method and the means of replacing it will be pointed out and described, to- gether with the remedies which may be found useful in such cases. PARTIAL RETROVERSION. Symptoms.—The most strongly marked symptom indicative of ret- roversion of the uterus is found in the difficulty of emptying the bladder, accompanied with pain and tenesmus, which in greater or less degree is always present in complete cases of this displacement. Next to this is the pressure on the rectum, and consequent more or less fre- quent call to stool, Avith great difficulty or impossibility of evacuating the bowels. These two complications, especially the retention of urine, render cases of complete retroversion of the Avomb dangerous as Avell as painfully distressing; Avhile the retention and consequent accumulation of faeces serves to make the restoration of the uterus to its natural position a work of much greater difficulty. A fixed gnaAv- ing or other variety of pain in the back, backache and difficulty in 40 626 diseases and derangements of the UTERUS. AA'alking, with inability to stand for any length of time Avithout suf- fering, are also common accompaniments. Nausea and vomiting, even stercoraceous vomiting, may set in, and unless the patient is promptly relieved she may sink under the accumulation of her sufferings. In suddenly occurring retroversion in consequence of a fall or other injury the symptoms are more marked and severe. "The patient falls to the ground and is unable to rise, experiences the severest pelvic pain, suffers from suppression of urine and faeces, and is often in such agony that the face is bathed with perspiration and the pulse becomes weak and fluttering." Causes.—The fundus of the uterus being loaded as in pregnancy, or in consequence of subinvolution, areolar hyperplasia or other en- largement, Avill readily tend to sink down, either anteriorly or poste- riorly, more and more, Avhen from any reason it has been turned from its natural position. As occurring most frequently in early preg- nancy, the chief cause of retroversion must be an unduly distended bladder, which may gradually raise the fundus of the womb from its natural inclination forAvard, and cause it to assume more nearly a perpendicular position; then the still further increase in the size of the bladder from accumulation of urine, or some slight muscular ex- ertion as in coughing, or any mechanical violence or pressure, may suffice to throAv the fundus of the womb still farther backAvard and downward till it passes beneath the promontory of the sacrum. This result may come on suddenly, and be immediately made known by very serious and painful and even alarming consequences. Or it may be much more gradual in its onset, and for a while unsuspected in its nature. Retroversion may likeAvise occur in consequence of the use of the obstetric bandage, Avhich has a tendency to press the Avomb doAvnward and backAvard at a time when its muscular and peritoneal supports are Aveakened and relaxed, and it is enlarged and heavy from uncompleted involution. It may likewise occur from a variety of other causes. It is evident, from the consideration of the inclina- tion forward of the fundus of the womb in its natural position, that it can be made to assume such an inclination as to render it possible for it to be throAvn backward and doAvmvard only by some mechani- cal influences, and by such mechanical method it must be replaced; and the more especially since the sacral promontory presents such decided structural hindrances toAvard its restoration. The vaginal touch readily discloses this form of displacement. " The finger, being introduced into the vagina, discovers an absence of RETROVERSION AND RETROFLEXION. 627 the cervix from its usual place, and upon further investigation finds it near the symphysis pubis. Upon passing the finger backward to the sacrum it meets a resisting ridge, which ends in a hard, round mass resting upon the rectum. The size, rotundity and distinctness of this Avill depend upon the degree of the displacement. In the first degree the resisting line but no tumor will be felt; in the second, a slightly rounded mass; and in the third, the fundus with its charac- teristic form Avill be perceived. Should doubt remain as to the nature of the mass thus felt, rectal touch, the uterine probe and conjoined manipulation Avill remove it."—Thomas. Retroflexion.—This form of displacement bears the same rela- tion to retroversion that anteflexion does to anteversion. It consists in a bending backAvard of the fundus and body of the uterus toward the hollow of the sacrum, the womb being bent upon its own axis at a greater or lesser angle, by which the cervix is not removed from its Fig. 94. RETROFLEXION. normal position, or deviates from it but slightly. It is generally the result of a Aveakness of the uterine tissues, in consequence of which 628 DISEASES AND DERANGEMENTS OF THE UTERUS. the body of the Avomb, either through its inherent weight, Avhether natural or preternatural, or in consequence of some force or pressure applied to it, is flexed at the junction of the body and cervix. Retro- flexion occurs most frequently in AvomenAvho have borne children, and rarely happens to the virgin uterus. Causes.—The principal causes which occasion retroflexion are similar to those which giA7e rise to retroversion, such as pregnancy and partu- rition, hyperplasia, endometritis, subinvolution, tumors either Avithin the abdomen or upon the uterus itself. An habitual distension of the Fig. 95. PARTIAL RETROFLEXION. bladder from retaining the urine too long, or the accumulation of large quantities of faeces above the fundus, may likeAvise be the occasioning causes of retroflexion, the uterine tissues being weakened and yielding, as aboATe remarked. Symptoms.—Irritability of the rectum is one of the chief symptoms of retroflexion, and if the pressure upon the gut be great, retention of stool will be a matter of course. Neuralgia of the Avomb may occur as a consequence of the natural congestion and nervous com- pression, and so-called uterine colic may result from a retention of TREATMENT OF RETROVERSION AND RETROFLEXION. 629 the secretion of the intra-uterine mucous membrane. If the retro- flexion exist in a great degree, so as to occlude the uterine .canal, dysmenorrhcea and sterility Avill be the consequences. Vaginal and rectal touch are the best means of diagnosticating retroflexion, and if there be any doubt remaining, the careful use of the uterine probe. A resort to these means of diagnosis will ensure against mistaking retroflexion for impacted faeces, an enlarged and prolapsed OAmry or uterine tumors, Avith Avhich it may othenvise be confounded. Treatment of Retroversion and Retroflexion. These forms of displaced uterus demand a resort to mechanical measures to ensure reposition in a great majority of cases, and espe- cially in those occurring during pregnancy. This may be attained by the folloAving means : The Uterine Elevator for Retroversion.—This instrument, of Avhich an accurate representation is given below, is composed of an ivory ball, a steel rod and an ebony handle. The diameter of the ball is about five-eighths of an inch; the rod, seven inches in length, and curved as in the cut, is firmly inserted into the ball at one extremity and into the handle at the other. Originally designed by the writer. and constructed for him for use in retroflexion or retroversion of the uterus, this little instrument has been found capable of affording very valuable assistance in such cases. Fig. 96. The very unsatisfactory manner in which these displacements have generally been managed by physicians has led the Avriter to adopt a new and very simple method of treatment, and to offer it to the pro- fession in all such cases when an operation or mechanical interference is necessary. And for the folloAving reasons: 1st. It is less painful and less disagreeable to the patient. 2d. It ahvays ensures a more perfect reposition of the organ, which, consequently, is less liable to relapse. 630 DISEASES AND DERANGEMENTS OF THE UTERUS. 3d. This plan will be found successful Avhen all others adopted by skillful and experienced physicians have failed. 4th. This plan will succeed in cases in which it has hitherto been deemed necessary to produce abortion in order to replace the retro- verted uterus. In these identical cases reposition is readily effected by this method, and pregnancy continues until the full term of gestation. As soon as a case of this form of displacement is clearly diagnosed, if the urine or faeces are retained the usual means should be at once adopted for their evacuation. The patient should then be placed on the bed, near its edge, upon her knees and elboAAS, so that the force of graAdty may assist in the reduction. The ball of the instrument, well lubricated, is to be brought to the anus, Avith the convex surface of the rod upAA'ard, then gently pressed till Avithin the sphincter, Avhen the handle should be slightly ele\rated, so as to bring the ball against the anterior wall of the rectum. The instrument is now to be firmly and carefully pressed up the rectum, Avhen the ball will elevate the fundus, care being taken to raise the handle of the instru- ment more and more as progress up the rectum is made, and presently the uterus will regain its normal position immediately posterior to the symphysis pubis. In cases of long standing—and the writer has recently replaced one of fifteen and another of thirty years' continuance—the reduction is not so quickly or so easily effected. The ball, engaging and par- tially elevating the fundus, will slip over and pass above it. The instrument must then be sufficiently withdraAvn to engage it again, and, if necessary, the operation should be repeated until the Avork is proved to have been entirely completed by the instrument's meeting no obstruction as it is pressed Avith some degree of firmness against the anterior AArall, and so passed up the rectum. After the reduction is effected the patient should be kept in a recumbent position for a longer or shorter time—from tAvo to twelve days, according to the more or less recent nature of the case—that the Avomb may become accustomed to its position; such remedies being administered in the mean time as may be indicated. The principal of these are Nux, Belladonna, Sepia, Sulphur, Calc. carb., Lycopodium, Calc. phos., Kali carb. We give for each of these medicines the prin- cipal indications; each symptom being a key-note Avhich may be found a reliable guide. These, and other remedies which may be indicated in particular complications of retroversion, may be found at the latter part of this chapter, arranged in alphabetical order. TREATMENT OF UTERINE DISPLACEMENTS. 631 Lateroversion and Lateroflexiox. These forms of uterine displacement are of rare occurrence, and do not give rise, usually, to symptoms of any note. They may be con- joined Avith ante and retro displacements. They result either in con- sequence of inflammatory conditions of the Avomb, unnatural Aveight of that organ or direct pressure. Vaginal touch and the use of the uterine probe are generally sufficient to detect the nature of these rare malpositions of the Avomb. Treatment.—Study the remedies mentioned at the close of this chapter, in order to learn which are best adapted to the attendant symptoms. As an auxiliary to the medical treatment, the patient should be instructed to lie as much as possible upon the side opposite to that of the obliquity, and to keep at rest as much as possible. Treatment of Uterine Displacements. The medical treatment of these various forms of uterine displace- ment Avill depend in a great measure upon the selection of remedies according to their principal characteristics, and to the corresponding characteristics and constitutional symptoms of the individual cases. For this reason we have combined in one schema the principal reme- dies for all the various displacements, believing that each variety and case of this disease Avill thus lead to its own appropriate remedy. The uterus is held in its proper position in the centre of the cavity of the lesser pelvis, and in a line with the axis of the superior strait, simply by the round ligaments and a double fold of the peritoneum. When in a healthy state the round ligaments hinder its retroversion, while the peritoneum, Avhich covers its superior three-fourths ante- riorly and its entire posterior surface, serves principally to prevent it from sinking doAvn into the vagina, and at the same time assists also in preventing retroversion. Thus, it is very plain that the womb cannot become displaced so long as the peritoneum and round liga- ments are in a normal condition, and these ligaments can only lose their normal condition in connection Avith other disorders of the gen- eral system. Hence, the remedies beloAV—or others which may be called for in special cases as they are indicated—by restoring the normal condition of these appendages, will cure all uterine displace- ments, Avhen no mechanical obstruction, such as is necessarily present in complete prolapsus or complete retroversion, intervenes. These appendages are usually relaxed in consequence of some constitutional ailments, AA'hich are shadowed forth by the symptoms indicating the 632 DISEASES AND DERANGEMENTS OF THE UTERUS. proper remedy. The right interpretation of these symptoms, and the consequent administration of .the corresponding remedy, will usually be folloAved therefore by a radical cure. The practice of applying pessaries, or uterine supporters of any kind, is rapidly becoming obsolete. A feAv years more and all these barbarous appliances, as useless and degrading as they are disgusting to the female sex, Avill be finally laid upon the same mouldy and musty shelves Avith the cups and the blisters, the leeches, the lancet and the actual cautery. There is scarcely any remedy in the Avhole Materia Medica that may not be found useful in these displacements, but the following are the medicaments most likely to be required: 1. Bell., Cham., Kali carb., Nux vom., Plat., Puis., Sabina, Sepia. 2. Aurum, Carb. an., Canth., Con., Croc, Ferr., Lil. tig., Op., Po- doph., Sec. corn., Sulph. 3. Aeon., Ant. cr., Arn., Asaf., Bry., Calc. carb., China, Coca, Coff., Creas., Graph., Hyos., Ignat., Ipec, Magn. mur., Mosch., Natr. carb., Natr. mur., Phos. ac, Sulph. ac, Thuya, Zinc. Aconite. If the prolapsus has occurred suddenly, and there is in consequence great inflammation of the parts, with burning pain as if from hot coals; excessive sensibility to the least touch ; bitter, bilious vomiting; anguish and cold perspiration, or hot and dry skin; fear of death. Ammon mur. A \-ery characteristic symptom is discharge of a quan- tity of blood from the bowels at every catamenial period. During the catamenia the discharge is more profuse at night. Arnica. Where the prolapsus has been caused by a concussion, and a bruised, sore feeling remains. She cannot Avalk erect on account of a bruised, sore feeling in the uterine region. Asterias rubens. Sensation of pressure on the loAver abdominal organs, impeding locomotion. General feeling of distress in the womb, as though something were pushing out. Anrum. Heaviness in the abdomen, with icy coldness of the hands and feet. DraAving pain at the pubes. Quarrelsome disposition. Melancholy, and thoughts continually running on self-destruction. Belladonna. Pressure as though all the contents of the abdomen would issue through the genital organs. This is particularly felt early in the morning. Sensation of heat and dryness in the vagina. Draw- ing pain in the Avhole circumference of the pelvis. Pains in the pelvic region, Avhich come on suddenly and cease as suddenly, or feeling in TREATMENT OF UTERINE DISPLACEMENTS. 633 the back as if it Avould break, hindering motion. Suppression of stools and of urine. Bryonia. Pinching and uneasiness in the distended abdomen, as if the menses Avould appear. Frequent bleeding from the nose Avhen the menses should appear. Constipation of hard, dry stools, as if burnt. Lips parched and cracked, and thirst. She desires to keep still, she feels so much better. Calc. carb. This remedy is especially indicated in pale, leuco- phlegmatic temperaments. She feels a sort of imvard coldness. The least exposure to cold air chills her through and through. She feels as if she had on cold, damp stockings continually. She has vertigo on going up stairs, and she is often all out of breath also, being obliged to sit doAvn eA-en before she reaches the top. The menses are too frequent and too profuse; the least excitement will often cause their return. Heaviness and painful weight in the limbs and great fatigue on walking. Constant aching in the vagina. Calc. phos. When every cold causes rheumatic pains in the joints and in various parts of the body. This is a positive indication, and when this occurs the exhibition of Calc phos. will at once remove the rheumatic affection and prevent the reappearance of the uterine dis- placement. Cantharis. Burning in the vulva and violent itching in the vagina. Almost constant desire to urinate, with cutting, burning and passing of a few drops of urine, sometimes bloody, sometimes followed by a discharge of bloody mucus. Carbo animal. Great languor in the thighs, particularly before and during the menses. The menstrual function seems to exhaust her remarkably, so that she is hardly able to speak during its continuance. Chamomilla. Frequent pressure toAvard the uterus like labor-pains, Avith frequent desire to urinate, often passing large quantities of color- less urine. Frequent discharge of coagulated blood, with tearing pain in the veins of the legs and violent labor-like pains in the uterus. Contrary to her condition in health, she is always out of humor, par- ticularly at her menstrual periods, Avhen she is headstrong even unto quarreling. She can hardly speak a pleasant Avord, and has to restrain herself in order to do so. China. In cases Avhere the prolapsus and attendant symptoms were superinduced by losses of fluids, particularly of blood. She has much ringing in the ears, painless lienteria and leucorrhcea. A sense of distension in the abdomen, Avhich is not relieved by eruc- tations. 634 DISEASES AND DERANGEMENTS OF THE UTERUS. Cocculus. Much paralytic pain in the small of the back, rendering walking quite difficult and sometimes impossible. Irregularity of the menses, and at their appearance nausea and faintness. Colocynth. A constant heat and dragging pain in the Angina. Chronic and repeated attacks of colic, drawing her double, Avith great restlessness and lamentation. Conium. Induration and prolapsus at the same time. Much nausea and vomiting. Vertigo, particularly when in a recumbent position and in turning over. Intermittent Aoav at every emission of urine. The breasts become sore, enlarged and painful at every menstrual period. Principally with Conium, fifteen years ago, I cured per- manently a case of prolapsus of six years' standing, in which all pessaries and abdominal supporters had failed to keep the uterus within the vulva. The prolapsus was complicated with induration, ulceration and, profuse leucorrhoea. This lady has since borne several children, and has never experienced a return of the malady. Dulcamara. The patient has always, as a forerunner of the menses, a rash upon the skin. All her symptoms are aggravated when the weather suddenly becomes colder, especially if the Aveather is damp. Ferrum. The patient is weakly and complaining, yet her face is fiery red. The menses intermit tAvo or three days and then return. Previous to the menses she has stinging headache, ringing in the ears, and discharge of long pieces of mucus from the uterus. Graphites. The menses always delay. They are too pale and scanty. Before and during the menses cough throughout the day, fatiguing the chest; no cough at night. Constipation of large, difficult, knotty faeces, and itching blotches on various parts of the body, from Avhich oozes out a watery, sticky fluid. Morning sickness during the menses. Pain in the epigastrium during the menses, as if everything Avould be torn in pieces. Ignatia. Menses scanty, black and of a putrid odor. Cramp pains in the uterus, with lancinations. A very Aveak, empty feeling at the pit of the stomach, Avith sighing respiration. She is full of suppressed grief, Avith AA'hich she seems to be weighed doAvn. Kali carb. Very much heavy, aching pain in the small of the back. Pain like a Aveight in the small of the back during the menses. Violent itching of the whole body during the menses. Stitching pains in and about the uterine appendages. Much distress in the abdomen for about an hour or two previous to an evacuation of the bowels. Kali bich. More particularly indicated in fat, light-haired persons. TREATMENT OF UTERINE DISPLACEMENTS. 635 Often where the prolapsus seems to have been produced by hot weather. Especially suitable if there be also leucorrhcea so tough as to be draAvn out in long, ropy strings. Lachesis. Pain in the uterine region, as if swollen. The uterus does not bear contact, and has to be relieved of all pressure. The patient feels constantly as if she must lift her dress from the abdo- men. Suitable Avhere the displacement occurs in connection Avith (or in consequence of) change of life. Violent pain of long standing in the right groin, extending either toward the genital organs or upward toward the liver or chest. Painful oblong swelling and induration in the right ovarian region, aggravated by moral emotions, rapid movements, prolonged walks and over-exertion. Ledum. Abundant leucorrhcea; pale face; abundant urination, even at night. Ledum is especially indicated where the sufferings are greatly aggravated by warmth, as in bed or over the register. Great sensation of coldness all through her; she cannot keep Avarm; she appears deficient in vital heat. Lilium tigrinum. Debility. Sensation as if she Avere falling to pieces, particularly in the lower part of the abdomen and back; she feels as if she Avants to be held up. Sense of Aveight and doAvn- ward pressure in the abdomen. Bearing down in the region of the womb, as if the contents of the abdomen would be pressed out through the vagina if not supported. Anteversion, retroversion and prolapsus. Lycopodium. Sensation of pressure through the vagina on stooping. Sensation of great dryness in the vagina. Much borborygmus, espe- cially in the left hypochondrium. Much red sand in the urine. Ter- rific pain in the back previous to every urination, Avith relief as soon as the urine begins to flow. Magnesia mur. Hysterical complaints and spasmodic turns. Much weakness in the limbs. Constipation of large, difficult stools, which crumble as they pass the verge of the anus. Poor sleep. Mercurius. During every menstrual period anxiety, red tongue with dark spots, and burning, salt taste in the mouth, sickly color of the gums and the teeth are set on edge. This remedy is indicated in Pro- lapsus of the Vagina, Avhich see. It is a very valuable remedy for all displacements where it is indicated. Cold and clammy sweat upon the thighs every night. Natr. mur. Pressing and pushing toward the genital organs every morning; she had to sit down to prevent prolapsus uteri; she aAvakens every morning Avith violent headache, Avhich lasts a long time. Con- 636 DISEASES AND DERANGEMENTS OF THE UTERUS. stipation, Avith sensation of contraction of the anus. Difficult expul- sion of stool, Assuring the anus, with Aoav of blood, leaving a sensa- tion of much soreness in the anus. Nitric acid. Violent pressing, as if everything Avere coming out of the vulva, Avith pain in the small of the back, through the hips and doAvn the thighs. Very painful stools, Avith profuse discharge of blood, the pain lasting a long time and exhausting her. Nux mosch. Enormous distension of the abdomen after every meal. Greatly troubled Avith dryness in the mouth and throat Avhile sleep- ing. Great pressure in the back from Avithin outAvard during the menses. Nux vom. Prolapsus uteri from straining by lifting. Pressure to- ward the genital organs early in the morning, in bed, or during a Avalk, with a sensation of contraction of the abdomen. Constipation of large, hard, difficult stools, or small stools with frequent urging. Dyspepsia from high living. Cannot sleep after three A. m. Pain in the small of her back, preventing her from turning over in bed. Frequent urination ; she passes little and often, with much burning pain. The prolapsus of long standing is often accompanied Avith dry cough and a sense of constriction around the hypochondria. Opium. Among the Aveaknesses, eAren of long standing, produced by fright, prolapsus uteri is one, which is amenable to Opium, given very high. Also in constipation of many years' continuance, if charac- terized by hard, black balls, in connection with prolapsus, Opium, high, Avill be found to be the remedy. Petroleum. This remedy will be indicated in cases where the patients have been reduced in strength, so that the prolapsus seems to result from a chronic diarrhoea, Avhich occurs only in the day- time. Phosphorus. Great sense of weakness and emptiness in the abdomen. Great sense of heat running up the back. A long, narrow, hard, dry stool, very difficult to expel. Sour stomach; belching up of great quantities of Avind after eating. Platina. Painful sensitiveness and continual pressure in the mons veneris and internal organs, with internal chills and coldness. Scanty stool, and difficult expulsion on account of its sticking to the anus and rectum like soft clay. Podophyllum pelt. Prolapsus uteri, particularly folloAving parturi- tion. Prolapsus ani as an accompanying symptom. The stools are very frequent, several daily, but they are natural and yet exhausting stools. TREATMENT OF UTERINE DISPLACEMENT-. 637 Pulsatilla. Pressure in the abdomen and small of the back, as from a stone, Avith disposition of the lower limbs to go to sleep Avhen sit- ting, and attended with ineffectual desire for stool. Menstrual colic, Avith great restlessness, tossing in every possible direction. Mild, tearful, yielding disposition. She cries at everything, is sad and desponding. Very bad taste in the mouth in the morning; nothing tastes good. She is pale and feeble. Rhus tox. Particularly suitable for very rheumatic persons; worse before a storm and in damp weather. She cannot lie long in any one position, but must shift about to obtain relief; the relief lasts but a short time, when she must change again. Walking at first is diffi- cult, but as she proceeds she AA'alks better and better. The Rhus in such cases will cure both the rheumatism and the prolapsus. Sepia. Painful stiffness, apparently in the uterus. Pressing in the uterus, oppressing the breathing; sensation as if everything would come out of the vagina; she had to cross her limbs to prevent it. Prolapsus of the vagina and uterus. Sensation of AA'eight in the anus, not relieved by an eA'acuation. Great sense of emptiness at the pit of the stomach. The urine deposits a clay-like sediment, AA'hich it is difficult to remove from the chamber. Secale corn. Prolonged bearing-down and forcing pain in the uterus. She is of a thin, scrawny formation. Silicia. A pressing-down feeling in the vagina. Great constipation before and during the menses. Prolapsus in consequence of myelitis. Very difficult stools being an accompanying symptom. Stannum. Great anguish and melancholy the week previous to the menses, ceasing as soon as the menses make their appearance. Old, neuralgic headache is an accompanying symptom. Each attack begins lightly, and increases gradually to its highest point, from Avhich it is equally long in declining. The larynx and chest give out in talking, singing or reading aloud; such exercise induces so great AA'eakness that she is compelled to desist. Staphysagria. A feeling of Aveakness in the abdomen as if it Avould drop. She is weakly and sickly, very sensitive to impressions; her teeth ache much, and have black streaks running through them. Sulphur. Weak feeling in the genital organs. Burning in the vagina; she is scarcely able to keep still. She finds it difficult to Avalk erect; she must stoop on account of debility. She sleeps a heavy, dead sleep, so as to exhaust her; or she sleeps lightly and aAvakens frequently, and this Aveakens her. She feels very weak and faint from eleven till twelve in the forenoon; she must have her 638 DISEASES AND DERANGEMENTS OF THE UTERUS. dinner. Heat on the crown of her head ; cold feet; hot and frequent flushes. Terrible sick headaches, which Aveaken her. Sulphuric acid. Great Aveakness, Avith sense of general tremulous- ness, but without actual trembling. She wishes to do everything in a great hurry; can scarcely get her Avork done rapidly enough, and is dissatisfied Avith herself when she has finished. Great deal of acidity of the stomach. Thuya. A terribly distressing pain occurs in the left iliac region when Avalking or riding; she must lie doAvn to get relief. The same pain occurs during her menstrual periods, and extends into the left groin. Veratrum alb. Dysmenorrhcea, with vomiting and purging, or simply an exhausting diarrhoea with cold SAAreat, in cases of pro- lapsus uteri. One dose of Veratrum is often sufficient to cause the succeeding periods to be comfortable and to cure the pro- lapsus. Zinc During the menses heaviness of the limbs, Avith violent draAving around the knees, as if they would be twisted off. Again, she is never well except during the menstrual flow. At other times she has boring pain in the left ovarian region, which is only partially relieved by pressure. Caulophyllum, Cimicifuga, Helonias may likewise prove of service in cases in Avhich they are indicated. CHAPTER XXXI. DISEASES OF THE UTERUS—CONTINUED. Acute and Chronic Inflammation. THE varieties of inflammatory disease which attack the uteru9 may be subdivided in the first place into acute and chronic. Other subdivisions have been made by gynaecologists, however, which are founded upon the locality of the inflammatory action and the uterine tissue attacked. Thus we have acute and chronic inflamma- tion of the endometrium or mucous lining of the Avomb, comprising the following subdivisions: Acute General Endometritis, in Avhich in- flammation affects the mucous membrane (and the tissue immediately subjacent thereto) of the cervical canal and of the body of the womb ; acute endometritis. 639 Acute Cervical Endometritis, in Avhich the inflammatory action is limited to the lining membrane of the canal of the cervix; and Acute Corporeal Endometritis, in Avhich the mucous lining of the body alone is affected. Of these three forms of disease, acute cervical endometritis is most frequently met Avith, and has been variously described and named by various authors, Avhile acute general endometritis is the variety least frequently observed. Chronic Endometritis is likewise subdivided into general, cervical and corporeal. Inflammation of the parenchyma of the Avomb, or Metritis properly so called, is almost always an acute affection Avhen it occurs as an original disease. It commonly presents itself as a secondary affection, in consequence of the inflammatory process of endometritis extending itself to the parenchyma of the Avomb. Puerperal metritis is by no means rare, hoAvever, and, as has been already described, is a very serious disease. Acute Endometritis. This diseased condition has been named by^ different writers Acute Uterine Leucorrhcea, Internal Metritis, and Acute Uterine Catarrh. It is usually ushered in by some precursory symptoms indicating a general febrile condition, and by others which point to the local development of the disorder. Thus Ave find general debility, headache, feverish- ness, and even chilliness, folloAved by severe pains in the pelvic region —" very Ioav doAvn," as it is sometimes expressed—which often extend into the surrounding parts. There is pain, weight and a dragging sensation in the back, and bearing-doAvn pains; and very frequently vesical and rectal tenesmus, especially prior to the establishment of the discharge. In the more violent cases the inflammation involves the vagina, and may even show evidences of its presence in the SAvollen and sensitive condition of the mucous surfaces of the external parts. The discharge, or uterine leucorrhoea, may make its appearance in a very feAv days, or even hours, after the first onset of the precursory and inflammatory symptoms. " At first the discharge is serous and bloody, but it soon becomes thick, yelloAvish or greenish, ropy, fluid or purulent; after drying up it leaA'es yelloAV or greenish stains on the linen, and stiffens it as if it had been starched; afterward the discharge becomes Avhiter, milky and mixed Avith transparent pieces of thick mucus. If this change of the discharge sets in, the inflammatory condition is almost entirely dispersed, Avhich may take place at the end of thirty-six or forty days, or even sooner, Avhen the discharge becomes chronic, or reappears again at the time of the menses, after sexual excesses, over-eating or 640 DISEASES AND DERANGEMENTS OF THE UTERUS. drinking, or even Avithout any apparent cause. As a general rule, the more acute the inflammation the thicker and darker the discharge In uterine leucorrhcea the discharge has ahvays an alkaline reaction, while vaginal secretions always react like acids. Examined by the microscope, the discharge looks homogeneous, thick, containing globules resembling those that float in pus or healthy mucus. " As regards the course of this affection, Ave may distinguish four periods. The first period sets in with a rather slight itching at the vulva, in the interior of the vagina, and sometimes in the uterus, with a sense of heat in the uterus, pains in the small of the back and in the back, increase of the sexual desire, and frequent urging to urinate. In the second period, which may set in about the third or fourth day, a serous discharge takes place, Avhich is at first scanty, but soon becomes more profuse, assumes a greenish or yelloAvish, rather dark appearance, and is accompanied Avith increased burning urination. In the third period, which generally commences about the ninth day, the inflammation becomes less intense; the discharge is still very copious, thickens, becomes more and more Avhitish, and then decreases, with diminution of Aoav of urine. In the fourth period, when the disease inclines to become chronic, the discharge disappears and reappears again repeatedly and frequently, without any known cause."—Jahr. As already remarked under the head of Vaginal Leucorrhcea, some constitutions are much more predisposed to the catarrhal form of disease than others; that is, in some it Avill make its appearance under the influence of provoking causes Avhich in others Avould have no such effect. Thus, all the influences Avhich may directly or indirectly lead to acute inflammation of, and consequent catarrhal discharge from, the mucous lining membrane of the womb, may be regarded as either predisposing or provoking. Many of these causes of either class are identical with those Avhich result in acute inflam- mation of the mucous lining membrane of the vagina. And indeed very many cases of this form of endometritis are nothing more than the extension of the mucous inflammation from the vagina to the uterus. But as very many of these morbid influences are so gradually developed as to result in chronic mucous inflammation or uterine catarrh, Avithout evincing any very noticeable acute symptoms, Ave reserve a more particular enumeration of the causes of inflammation of the mucous coat of the womb in general till, in the succeeding section, Ave come to the consideration of the chronic variety. CHRONIC ENDOMETRITIS. . 641 The discharge itself, Avhich results from the inflammation of the mucous surfaces of the cervix and fundus uteri, is easily distin- guished by its alkaline reaction from the slightly acid secretion poured out by the vaginal membrane. But while in ordinary cases of uterine leucorrhcea the cervix uteri constitutes the exclusive seat of the disease, in the more severe cases, both acute and chronic, the inflammation extends also to the fundus, and at the same time invades also the mucous coat of the vagina. And in fact very few cases of leucorrhcea are met with in which the vagina fails to participate, so that in general the secretions Avhich appear in leucorrhoea are found to be composed of the products of both vaginal and uterine mucous inflammation. Should the discharge be very acrid, it is apt to pro- duce excoriation of the parts Avith which it comes in contact, and to give rise to intense itching. The irritation of the skin, together with that engendered by scratching, from which the patient cannot refrain, may give rise to extensive prurigo. The following are the physical signs revealed by an examination: " An examination by touch reveals the vagina hot and dry or cov- ered by the discharge. The os uteri is found gaping, the cervix swollen and very sensitive to pressure, the body slightly enlarged, and the whole organ lower than normal in the pelvis. Through the speculum the cervix is found to look swollen, cedematous and red, • and from the pouting os pours forth either a clear albuminous- looking fluid, muco-pus, or long, tenacious shreds of cervical mucus." This form of disease may affect the lining membrane of the entire uterine canal, or it may be confined to that of the cervix or of the body alone. In the latter case it generally results from sudden sup- pression of the menses, while endometritis following childbirth or abortion is apt to attack the entire uterine mucous tract. Causes.—The disease may occur as a consequence of direct injury, or it may be an extension of inflammation of the vagina, whether gonorrhoea! or simple. It often occurs as a consequence of taking cold during menstruation, even without suppression of the menstrual flux; and may arise from excessive sexual indulgence or other causes. Chronic Endometritis. Chronic endometritis, as before remarked, may be general, cor- poreal or cervical. General chronic endometritis is usually associated with chronic inflammation of the parenchyma of the womb, and is connected with areolar hyperplasia. Chronic corporeal inflammation 41 642 diseases and derangements of the uterus. of the endometrium is of rather infrequent occurrence, while chronic cervical endometritis is one of the most frequently occurring diseases to Avhich the uterus is liable; and although not of a Arery serious nature per se, yet it lays the foundation for, or has following in its train if neglected, numerous other disorders of a more troublesome and even dangerous character, and which render miserable the lives of their unfortunate victims. It frequently follows an attack of acute endo- metritis—the latter subsiding into the chronic form—but still more frequently approaches insidiously, and may haAre become a confirmed disease before any symptoms are manifested which call the attention of the patient to the fact that something is Avrong with the womb. This warning symptom is generally a leucorrhcea, or it may be a severe dragging pain in the back and loins, Avhich is aggravated by Avalking and standing, or both these conditions are conjoined. Men- strual irregularity of one kind or another soon shows itself; mental depression, ill-temper and hysteria are frequent accompaniments, or all these symptoms and many more may exist in a single case. The uterine discharge which forms the principal symptomatic in- dication of chronic endometritis, especially cervical inflammation, varies in quantity in different persons, and at different times in the same individual. Like vaginal leucorrhcea, it may be so scanty as scarcely to become perceptible externally, or it may be so profuse as to require the application of several napkins daily. The discharge varies also in color, character and general appearance and effects. It may be colorless and semi-transparent, or it may assume a greenish- brown or even darker hue, as if, in the severer forms, it were mixed with blood; or it may be so thick and tenacious as to be with great difficulty detached from the mucous membrane to Avhich it adheres. In the same manner its character and equality may be very different in different persons, or in the same individual at different times. Thus, it may be mild, bland and unirritating, or it may be acrid, and so cause excoriation of the labia, or even of the skin of the surround- ing parts. So also in its direct effects it may vary in a remarkable manner. When very profuse it becomes rapidly exhausting. And Avhile in the first instance due to some dyscrasia, some morbid influ- ence or diseased condition of the system, it still further aggravates the general ill-health by the profuseness of its flow, as well as by the im- portant functional derangements which sooner or later follow in its course. The causes of chronic endometritis or uterine leucorrhcea—for these terms are used synonymously—may be divided into two classes. CHRONIC ENDOMETRITIS. 643 The first may be grouped under the head of constitutional predisposi- tion; and in this class also Ave include all those cases which result from the influence of other forms of constitutional or functional dis- orders, such, for example, as menstrual irregularities or organic dis- placements. From causes and morbid influences of this nature arise the great majority of the cases of uterine leucorrhcea which appear either in young or in older unmarried females. The second class of causes of chronic endometritis we may term the provoking or special causes. These are most numerous in the married state, as arising from the great excitements and sudden and extensive organic changes to which the uterus and its appendages are constantly liable. The constitutional predisposing causes are in general similar to those which result in chronic vaginal leucorrhcea. They are such as are implied in the terms leucophlegmatic temperament or scrofulous diathesis. Persons who come under this description may be thin or quite fleshy. In either case such persons are remarkably prone to suffer from the least exposure to cold, damp weather, and the imme- diate consequence of such suffering and exposure appears in the form of some blennorrhcea. These two circumstances, of sensitiveness to the cold dampness, and blennorrhagic discharge in consequence of it, are characteristics of this particular temperament. This constitutional predisposition is the one which most frequently leads to leucorrhcea, whether vaginal or uterine, or both, in young girls. But after the accession of puberty the same constitutional influ- ences may, and indeed constantly do, induce leucorrhceas, but in a less direct manner. The principal diagnostic characteristic of uterine leucorrhcea is its relation to menstruation, those forms of leucor- rhcea which appear to be unaffected by the menstrual function being supposed to be purely vaginal, AA'hile those Avhich are greatly aggra- vated either immediately before, or during, or immediately after the menses or menstrual period, are considered to belong more especially to the uterus. And there are several varieties of uterine leucorrhcea considered with reference to the menstrual function. Thus, in young Avomen of a delicate constitution the accession of the catamenia may be pre- ceded by tAvo or three monthly attacks of leucorrhoeal discharge. This may be considered as a forerunner, and a truly uterine if not a vicarious secretion. Again, in many cases of suppressed menses the proper menstrual flow is replaced by a leucorrhcea, Avhich appears regularly at the proper monthly periods, coutinues the usual number 644 DISEASES AND DERANGEMENTS OF THE UTERUS. of days, and perhaps discharges about the quantity Avhich Avould cor- respond to natural menstruation. Where the menses themselves are normal and regular a leucorrhcea may appear in the intervals, Avhich will greatly increase in quantity immediately before the appearance or immediately after the subsidence of the menses. In some of these cases the leucorrhcea encroaches more and more upon the menstrual Aoav, until it finally supersedes it altogether; and in the severer forms of this leucorrhcea it may produce menorrhagia, or true ute- rine haemorrhage, Avhich, like the former variety of leucorrhoea just mentioned, may also occupy the intervals and increase just before and just after the monthly periods. Again, as at the accession of the menses, so also about the time of the cessation of the menses, the few last periods are often marked by the occurrence of leucorrhoeal dis- charges, either alternating Avith or appearing in the place of the usual menstrual flow. In many persons of a chlorotic temperament, leucor- rhcea replaces the menses entirely, and finally, after child-bearing or after abortion a white, inodorous discharge will sometimes make its appearance and continue for months. In the case of spontaneous abor- tion this discharge will either tend to prevent subsequent conception, or, Avhere that takes place, it will predispose to successive abortions. But this result will not be so much due to the discharge itself, although apparently its immediate cause, as to the morbid condition of the womb which produces the discharge. Those forms of leucorrhcea which appear under the above-men- tioned conditions may be considered as arising from the uterus, and chronic endometritis, whether general, corporeal or cervical, will be discovered upon making an examination by means of the speculum. In the great majority of cases the uterine leucorrhcea is complicated with a similar discharge from the vagina; and, on the other hand, those disorders of the vaginal mucous membrane which induce ute- rine leucorrhcea and chronic endometritis may be included among its constitutional causes. Among the special or provoking causes of chronic endometritis and uterine leucorrhcea are to be ranked principally those influences Avhich are incidental to the married state. Of these, excessive sexual inter- course is perhaps the most frequent and efficient. Similar in effect are the cold water and other injections resorted to by many for par- ticular purposes. Child-bearing, abortions, and in fact all other in- fluences capable of producing acute inflammation of the mucous coat of the womb, and consequent acute catarrhal discharge, are also to be classed as causes of similar chronic disorders. This is equally true REMEDIES FOR LEUCORRHCEA. 645 whether we consider the less violent and longer continued action of such influences to have resulted in a chronic inflammation, or Avhether this latter form of disease be but the continuation of the acute inflam- mation itself. And in general all those influences—mechanical, func- tional or sympathetic—which disturb the womb without exciting inflammation of its deeper tissues, may result in these varieties of subacute mucous inflammation, of which the leucorrhoeal discharge is at once the evidence and the consequence. Treatment of Endometritis and Leucorrhcea. The remedies herein laid doAvn will be found applicable to the various forms of endometritis and leucorrhcea. These cases are to be treated according to homoeopathic principles—the case examined in its totality, and that remedy selected which is the nearest simile in its pathogenesis of the pathological and symptomatic*array presented by the patient. Remedies for Leucorrhcea. 1. Alum., Calc. carb., Creas., Merc, sol., Puis., Sep. 2. Amm. carb., Bov., Carbo veg., China, Ferr.-, Graph., Lye, Phos., Sabina, Sil., Sulph. 3. Agaric, Aletris, Aralia, Ars., Borax, Canth., Carbo an., Caust., Cham., Cocc, Erigeron, Gelsem., Hedeoma, Helonias, Hydrastis, Hypericum, Iodium, Kali carb., Leptand, Lil. tig., Magn. carb., Mez., Natr. c, Natr. m., Nitric ac, Phos. ac, Podoph., Ruta, Stann., Sulph. ac, Zinc, Zizia. Aconite is the only remedy in those forms of this disease where there is much irritability of the system, with fevrer and fear, thirst and vertigo in rising or sitting up. iEsculus hippo. Leucorrhcea, with lameness in the back, across the sacro-iliac articulations, and great fatigue from walking, because that part of the back gives out in Avalking even but a little way. Agaricus mus. Where there is much itching externally and inter- nally, with very profuse and dark-colored leucorrhcea. Aletris far. General and local debility from protracted illness, loss of fluids or defective nutrition. Alumina. Where the leucorrhcea occurs either before or after the menses; it is acrid and profuse. Relieved by cold washes. Trans- parent and mucous, running down to the heels in large quantities. Ambra grisea. Leucorrhcea only at night. Stitches in the vagina before the discharge. Leucorrhcea of bluish-white mucus. 646 DISEASES AND DERANGEMENTS OF THE UTERUS. Ammon. c. Violent acrid leucorrhcea, sometimes burning, watery dis- charges from the uterus. Ammon. mur. Leucorrhoea, with distension of the abdomen. Leu- corrhcea like the white of an egg after a pinching pain around the navel. BroAvn, slimy leucorrhcea after every discharge of urine. Anacardium 0. Great loss of memory. Leucorrhcea, Avith itching and soreness. Antim. crud. Discharge of an acrid water from the vagina, which causes a sensation of biting down along the thighs. Aralia. Leucorrhcea of an acrid character and offensive odor. Arsenicum. Leucorrhcea Avhilst standing and emitting flatulence; leucorrhcea thick and yellow, corroding the parts which are touched by it. Baryta carb. Sanguinolent mucous leucorrhcea, with beating of the heart, pain in the back and weakness even unto fainting. Belladonna. Leucorrhcea, with colic; the pains come suddenly, and finally cease as suddenly as they came. Borax v. White, albuminous leucorrhcea, with a sensation as if warm water were flowing down. Bovista. Leucorrhcea after the catamenia like the white of an egg, coming away whilst walking; or it may be yelloAvish-green and corrosive. Calcar. carb. Leucorrhcea like mucus or like milk; it may be dis- charged more Avhilst urinating, and there may be heat and itching of the vulvra. Cantharis. Discharge of bloody mucus after urinating. Carbo animal. Watery leucorrhcea, particularly when walking or standing. It may be burning or biting, and may stain the linen yellow. Carbo veget. Profuse leucorrhcea only in the morning when rising. Milk-colored, excoriating the parts. It may be thick and yellow- ish, or white. Rawness and soreness of the vulva during the leucor- rhcea. Causticum. Leucorrhcea, particularly at night. Chamomilla. Yellowish, smarting leucorrhcea, particularly after a meal. China off. Leucorrhcea before the menses, with painful pressing toward the groins and anus. Bloody leucorrhcea, with occasional discharge of black clots or foetid, purulent matter, with itching and spasmodic contraction in the inner parts. REMEDIES FOR LEUCORRHCEA. 647 Cinnabar. Leucorrhcea, causing during its discharge a pressing in the vagina. Coccus cacti. Leucorrhcea, consisting of mucus, preceded by draw- ing and thrusting pains in the inguinal, vesical and pubic regions. Cocculus. Scanty, irregular menses, Avith leucorrhcea between the periods, or leucorrhcea instead of the menses. Leucorrhcea like serum, mixed with a purulent, ichorous liquid. Coffea. Profuse discharge of mucus and sometimes blood from the genital organs, which are very sensitive and itch voluptuously. Conium m. Leucorrhcea of white, acrid mucus, causing a burning or smarting sensation. The leucorrhcea may be milk-colored and pain- ful. Excoriating leucorrhcea. Creasote. Leucorrhcea, with great debility, particularly of the lower extremities. It may be mild or acrid, causing much itching. Drosera. Leucorrhcea, with labor-like pains. Erigeron. Profuse, with spasmodic pains, and irritation of the blad- der and rectum; usually scanty menses. Ferrum. Leucorrhcea like watery milk, smarting and corroding when first appearing. Gelseminum. White leucorrhcea; heaviness and fullness in the ute- rine region; aching across the bottom of the back. Graphites. Profuse leucorrhoea is the great characteristic for Graph- ites, also great weakness in the small of the back. Hedeoma. Yellow leucorrhcea, causing itching, burning and ex- coriation. Helonias. Leucorrhcea, with pain in the lower part of the back, soreness and tenderness of the breasts and nipples, particularly at the catamenial period. Hydrastis. Yellow leucorrhcea, of a very tenacious character; long threads or pieces in it; sometimes offensive. Hepar s. c. Leucorrhcea, with smarting of the vul\7a. Hypericum perf. Leucorrhcea, with delayed menses, palpitation of the heart, pressure in the small of the back and heaviness in the lower part of the bowels. Ignatia. Violent labor-like pains, followed by a purulent, corrosive leucorrhcea. Low-spirited women, who sigh a great deal. Weak feeling at the pit of the stomach. Iodine. Leucorrhcea, corrosive even of the thighs and the linen. The leucorrhcea is aggraA'ated at the menstrual period. Kali bi. Leucorrhcea which may be drawn out in long strings. It is often yellow, stiff and ropy. 648 DISEASES AND DERANGEMENTS OF THE UTERUS. Kali carb. YelloAvish leucorrhoea, with itching and burning in the vulva. , ' Kali hyd. Thin, watery or acrid, corrosive leucorrhcea, Avith itching in the vulva. Lachesis. Leucorrhcea from three to eight days before the menses, copious, smarting, slimy, stiffening the linen and staining it green; also in cases Avhere the menses are too short and feeble, although they appear at the regular time. Leptanuria. Leucorrhcea, with ulceration of the os uteri; " it is sometimes foetid, with shreds of mucous lining in it; irritation of the bladder and rectum; frequent pain at the bottom of the bowels; general languor and prostration; heat and dryness of the skin." Lycopodium. Profuse leucorrhoea at intervals; it may be milky; it may be blood-red, particularly before the full moon. The great cha- racteristic is a cutting pain, attending the leucorrhcea, across the hypo- gastrium from right to left. Magnesia mur. Leucorrhcea immediately after every stool; certainly if the stool be hard and crumbling as it escapes from the verge of the anus. Leuoorrhcea at intervals, followed immediately by a discharge of blood. Manganese. In Avomen whose bones are affected in a manner to be very sensitive to the touch. Mercurius. Leucorrhcea always worse at night; it may be itching, burning, smarting, corroding, with sensation of rawness, but the symptoms are always Avorse at night. Discharges of flocks, pus and mucus as large as hazel-nuts. Mezereum. Albuminous leucorrhcea, chronic and malignant. Muriatic acid. Leucorrhcea, with exceeding soreness of the anus, either from piles or from fissures. She cannot bear the slightest touch upon the anus, which often itches violently, and is not relieved by scratching. Nat. carb. Leucorrhcea yellowish; putrid leucorrhcea, ceasing after urination. Nat. mur. Leucorrhcea early in the morning after colic; it may be transparent, Avhite, thick mucus. Greenish leucorrhcea, particularly when walking. Nitrum. White leucorrhcea, with lameness in the small of the back. Nicolum. Profuse, Avatery leucorrhcea, particularly after urinating. Nitric acid. Leucorrhcea consisting of mucus which can be draAvn out; flesh-colored ; leucorrhcea of greenish mucus; cherry-broAvn and foetid leucorrhcea. REMEDIES FOR LEUCORRHCEA. 649 Nux mosch. Leucorrhcea of women who always awaken Avith a very dry tongue. , Nux vom. Foetid leucorrhoea, tinging the linen yellow. Petroleum. Profuse leucorrhcea every day; also with lascivious dreams at night. Phosphorus. Smarting leucorrhcea, drawing blisters. Profuse leu- corrhoea, with great sense of weakness in the abdomen. The leucor- hoea is often corrosive. Phosphoric acid. Profuse, yelloAvish leucorrhcea, with itching, some days after the menses. Leucorrhoea after the menses. Platina. Albuminous leucorrhoea only in the daytime, particularly in Avomen who have difficult stools from the glutinous nature of the excrements. Plumbum. Leucorrhoea, with a continued sense of drawing in from the abdomen to the back. Podophyllum. Leucorrhoea consisting of thick, transparent mucus. Leucorrhoea, Avith constipation and bearing down in the genital organs. Prunus spinosa. Leucorrhoea, making the parts sore and tinging the linen yelloAV. Pulsatilla. Burning leucorrhcea, thin and acrid. Milky leucorrhoea, with swelling of the vuhra, particularly after the menses. Leucorrhcea of thick, white mucus, especially when lying, or before and during the menses, with cutting in the abdomen. Ranun bulb. Leucorrhcea at first mild, afterward acrid and cor- rosive. Ruta g. Corrosive leucorrhoea after suppression of the menses. Sabina. YelloAvish, ichorous, foetid leucorrhcea and painful discharges of foetid blood every two weeks. Leucorrhcea after suppression of the menses, inclining to be corrosive. Leucorrhcea, with itching of the pudendum. "Corrosive leucorrhcea, making the thighs sore, and causing intense itching during pregnancy and after delivery." Sanguinaria c. Leucorrhcea of the climacteric period; it continues after the menses have ceased. Sarsaparilla. Leucorrhcea on walking, particularly in Avomen AAmo have a sharp pain in the urethra at the close of urination. Secale corn. Leucorrhcea in thin scrawny Avomen with prolapsus uteri. Sepia. Leucorrhoea, with stitches in the neck of the uterus. Leu- corrhoea, with much, itching in the vagina. Sanguineous-mucous, yellowish, watery or mucous leucorrhcea. Discharge of green-red 650 DISEASES AND DERANGEMENTS OF THE UTERUS. fluid from the vagina during pregnancy. Leucorrhoea Avorse after urinating. Leucorrhcea like pus, like milk, floAving only in the day- time, excoriating the thighs. Profuse mucous leucorrhoea, having a foetid smell, with drawing pains in the abdomen. Silicia. A painful smarting leucorrhoea after taking acids. Leu- corrhcea during urination. Milky leucorrhcea in paroxysms, pre- ceded by cutting around the umbilicus. Stannum. Leucorrhcea, with great loss of strength; it may be transparent mucus, it may be yellowish. Strontiana. Leucorrhcea while walking. Sulphur. Leucorrhcea smarting like salt. Leucorrhcea preceded by colic. Burning and painful leucorrhoea, making the vulva sore. Sulphuric acid. Leucorrhcea of sanguineous mucus, Avith a sensation as if the menses would appear. Milky or transparent leucorrhcea, without sensation. Very Aveak, Avith sensation of trembling all over; the weaker she feels the more she trembles. Tabacum. Leucorrhcea of serous liquid after the menses. Tart. em. Leucorrhcea consisting of watery blood, liable to occur in paroxysms; worse when sitting. Trillium. Leucorrhoea, "foetid, yellowish, of the consistency of cream ;" often excessive, and weakening the patient. Zinc. Leucorrhoea of bloody mucus after the menses, causing an itching. Cutting colic, succeeded by leucorrhoea. Leucorrhcea con- sisting of thick mucus for three days before and after the menses. Zizia. " Leucorrhcea, Avith retarded or suppressed menses ; it may be acrid or bland and profuse; the menses may set in for one day, then stop, and be followed by leucorrhcea, at first acrid and afterward bland and copious; chronic leucorrhcea, attended by irritation of the spine or brain." Metritis. True parenchymatous metritis, or inflammation of the deeper tissue and substance of the womb, is a disease comparatively rare. It must be distinguished from endometritis, or inflammation of the mucous coat of the womb, which has just been described, and also from peritoneal metritis, or more properly puerperal peritonitis, inflam- mation of the peritoneal or serous coat of the Avomb and peritoneum generally. This latter disorder usually arises subsequent to partu- rition, and has received attention in its proper place. Inflammation of the Avomb may be acute or chronic, and in either form may attack the uterus in each of the different conditions of METRITIS. 651 female life. It may be confined to the cervix uteri—as in fact it is in a great proportion of the cases, especially in the chronic form—or it may extend also to the fundus. It may be restricted to the proper tissue or substance of the uterus, or it may also involve either its serous covering or its mucous lining, or both. Acute inflammation of the uterus is seldom seen before puberty—never, perhaps, except as the consequence of mechanical injury. It very seldom appears in the virgin uterus, during pregnancy, or after the change of life. It is much more common in the married state and in connection with parturition. Rokitansky is of the opinion that in acute metritis the mucous lining is affected primarily, and that " this is scarcely ever the case with the uterine tissue, as far as can be demonstrated by the pathological anatomist, Avith the exception of the reaction following traumatic influences, especially of the vaginal portion." The causes of inflammation of the Avomb are similar in the acute and in the chronic form, and they are here enumerated in common to avoid repetition. Among the most frequent causes—especially those which influence unmarried Avomen—may be ranked exposure to cold while menstruating, and consequent sudden suppression of the men- strual Aoav, and exposure to cold soon after the monthly period, Avhen, although the menses have subsided, the womb still remains in a highly congested and excessively sensitive condition. Great physical exer- tion, such as walking, during the monthly period may result in inflammation of the womb; excessive or violent sexual intercourse; the use of cold water or astringent or irritating injections; the exten- sion of disease from the vagina or from the ovaries; wounds, violence or mechanical injuries of any kind; foreign bodies in the uterus; polypi, tumors or other adventitious growths may induce inflamma- tions of different degrees of violence in different constitutions and in the different conditions of female life. Exposure to cold and taking cold soon after child-bearing are the most common causes of acute metritis; and the inflammation Avhich results in such cases, especially if complicated with suppression of the lochial discharge, may prove rapidly fatal. This is a much more severe and dangerous complication than suppression of the menstrual flow, since it may lead directly to uterine phlebitis. Still another form of exposure to cold—or rather the taking cold in another variety of cases—deserves especial mention here, both from the frequency of the occurrence of such cases and from the almost invariably fatal nature of their termination. These are cases —lamentably frequent in these times—in which what is called " an 652 DISEASES AND DERANGEMENTS OF THE UTERUS. operation" has been performed in the early states of pregnancy for the purpose of inducing abortion. Here the violence offered to the parts, aggravated by exposure and over-exertion in traveling—often unavoidable in such cases—not unfrequently brings on inflammation, whose approach is marked by very severe chills, accompanied by intense anguish, excessive tenderness of the abdomen, rapidly in- creasing prostration, and followed by death, sometimes in seventy- two hours. In such cases the inflammation involves the serous coat of the womb, constituting a true peritoneal metritis of the most violent form, and of- a character very closely allied to traumatic ery- sipelas. Such are the formidable dangers which attend this violation of the laAA's of God and man. In her hour of extreme peril, in the midst of the most intense physical suffering and distress of mind, and in the immediate prospect of eternity, the dismayed female confesses her own crime and reveals the name of the person, often a practicing physician, but sometimes a male or female abortionist, Avho, under- taking to commit infanticide only, becomes involved in a double murder; for in the eye of the law whoever engages in a criminal act becomes responsible for all the consequences of his undertaking, how- eA^er little some of them may have been expected or desired. There are men who assume the sacred profession of physician, not to save but to destroy life, who, in defiance of all human and of all divine law, strew their pathway, not with living flowers, but with the withered blossoms, the shattered wrecks and crushed remains of em- bryonic life—monsters in human form, fiendish ghouls, who devour little children, Avho live by the slaughter of the innocents, and who qualify themselves for their future and eternal state by this lifelong destruction of such as are of the kingdom of Heaven. The mur- derer of a single individual we execute or seclude for life, but before such a murderer by wholesale and by profession, before such a de- stroyer of entire generations, human justice stands appalled, and, mournfully conscious of the utter insufficiency of all human means to arrest or to punish this gigantic social evil, sadly and sternly bids the unrepentant destroyer of "these little ones" fill up the measure of his crimes and await the dread summons of the Eternal Judge. Symptoms.—The first symptoms which indicate the accession of acute inflammation of the Avomb are similar to those of endometritis, but more severe. Thus Ave find rigors followed by feverishness, heat in the pelvic region, deep-seated pain in the vagina, paroxysms of pains in the back, Avhich dart through to the symphysis pubis, and METRITIS. 653 extend to the groins, and even down the thighs. The constant pain is less severe, but is aggraA^ated by coughing and sneezing, and is accompanied by a sensation of bearing down ; there is also usually a painful sense of weight in the pelvis. The pelvic pain is usually accom- panied by vesical and rectal tenesmus. These are the most prominent symptoms Avhere the cervix is principally affected. But where the inflammation extends to the fundus, there is also pain in the hypogastric region, Avhich is tender to the touch. In this case there is often a complication of the inflammation of the sub- stance of the womb with that of its outer or peritoneal coat. The hypogastrium is excessively sensitive, the painfulness is greatly aggra- vated by the least movement or pressure upon the parts, and the febrile condition is far more general and severe. The disorder extends by contiguity or sympathy to the neighboring organs, and there is tenesmus of the rectum and difficult and painful micturition. The pains are of that sharp, lancinating character, and aggravated by the least motion, which is so peculiar to inflammation of the serous tissues. The pulse is quick, full and hard; the skin hot and dry; the thirst may be extreme; the boAvels constipated; the stomach irritable; the tongue dry and furred; and there is often a disposition to faint, especially on sitting up. Headache may also be present, with redness of the cheeks and flushing of the face, disposition to delirium, twitching of the tendons, and alarming collapse of the vital forces. This accession of what is called the typhoid condition presents a formidable group of symptoms, which may appear in metritis occa- sioned by sudden and severe repression of the menstrual flux, with reabsorption, perhaps, of matters which should have been eliminated. In such cases the return of the menstrual Aoav indicates a favorable change in the condition of the patient. But the appearance of the menstrual flow in inflammation of the uterus from other causes, whether complicated with peritonitis or not, is not regarded as a favorable sign. The physical signs of acute metritis are—sensitiveness to pressure on the abdomen over the region of the womb; the cervix uteri is found, upon examination Avith the speculum or by vaginal touch, to be swollen and the os gaping; pressure upon the cervix or upon the body of the Avomb, Avhen made through the fornix vaginae, gives rise to excessive pain; the vagina is usually hot and dry, unless endome- tritis coexists, in which case the usual secretion consequent on that condition Avill be found to be present. Acute metritis may be con- founded with active congestion of the organ, or with pelvic peri- 654 DISEASES AND DERANGEMENTS OF THE UTERUS. tonitis, cellulitis or endometritis. It can only be diagnosed from the first named of these conditions by the progress of the case. It may be known from pelvic peritonitis, according to Dr. Thomas, by " mobility of the uterus, which would be fixed if it existed; by sensitiveness being confined to the uterus, and not existing over the pelvis, and by the enlargement and tenderness of the os and cervix." From cellulitis it may be known, according to the same authority, " by absence of a phlegmonous, tender mass in one broad ligament or near the uterus." If the case be one of endometritis, " it will be known by the fact that the uterus will not be found so markedly enlarged, nor so exquisitely sensitive upon pressure; the constitu- tional signs will not be so grave, and there will be the peculiar dis- charges marking this disease." The very great amount of nervous organization connected with the Avomb, and the intimate relation and profound sympathy of this organ with the great nervous centres, render inflammation of its substance a very grave disease. And the severe headache, vanishing of sight, and even diminution of hearing, nausea, vomiting, excessive debility, fainting turns and other important constitutional symptoms which may appear in such cases, indicate the serious nature of the affection itself and the extent of its influence over the entire system. In the advanced stages of the more severe forms we find tympanitis, hic- cough, low delirium, coldness of the extremities and discharge of offensive sanies from the vagina. These symptoms, especially if developed in spite of proper homoeopathic treatment, indicate approaching dissolution. Termination or Consequences.—I. Acute metritis may terminate in resolution or simple abatement of the symptoms, and this mode of termination is often seen under homoeopathic medication. The fever runs a rapid course, especially in its severer forms, and where its progress is not arrested by the appropriate treatment, it may destroy life in three days, or even in two, or in cases of less intense severity it may prove fatal at the end of one week or more. In these con- tinued uterine fevers the consequences of the fever may destroy life after the original disease has subsided. Intermediate between the prompt recovery and the fatal termination of the case from the sever- ity of the primary inflammation are various forms of disease, which may be regarded as the consequences of the original disorder, and which may either destroy life or establish themselves as varieties of chronic disease of the Avomb. It may also terminate in the forma- tion of abscess. METRITIS. 655 II. Hypertrophy, either with or Avithout induration, we find among the immediate consequences of acute inflammation. The hypertrophied womb usually attains to twice its natural size, or even more. This increase in size is of course accompanied Avith increased Aveight, and of course affects the position of the womb in the pelvis, and its relation with the other pelvic organs. This actual thickening of the substance of the walls of the uterus must not be confounded with physometra or uterine tympanitis. A certain amount of induration usually appears in connection with hypertrophy of the womb. This is the common result of inflamma- tion, particularly of the cervix, and especially where this part of the uterus has been subjected to frequent inflammatory attacks. Indura- tion is said to be simply the result of a bygone inflammation, but it is usually the consequent of such inflammatory action as is accompanied by hypertrophy or permanent thickening of the cervix, and so of those cases Avhich assume the chronic form of metritis. This condition is very rare in the young and unmarried, but not uncommon after mat- rimony. Induration may be, as aboA^e stated, the simple result of repeated inflammation, or it may be the primary stage of scirrhous hardening and cancerous ulceration. III. Softening of the walls of the Avomb, or ramollissement, is another and more grave sequence of inflammation. This is sometimes found to be the condition of the uterus in Avomen Avho have died of acute inflammation of this organ. The tissues of the uterus in such cases are found dark-red, swollen, softened and friable, with even disposition to gangrene from decomposition of the unhealthy (puru- lent) blood with which these tissues are engorged. IV. Gangrene is a more rare but necessarily fatal termination of acute metritis. This may result directly from violent inflamma- tion, and occurs at any period from the third or fourth to the seventh or eighth day. It may result from such inflammation as occurs in consequence of strangulation of the uterus in cases of procidentia, from the death and consequent decomposition of the foetus in utero, or finally it may appear in connection with phagedenic ulcers which oc- cupy the inner surface of the womb. Only the former of these three causes of gangrene concerns us at present, but it seems best to give a complete picture of this rare form of uterine disorganization AA'hile under consideration. This gangrene generally begins in the cervix, and is confined to it. According to the authorities, it is impossible to detect this form of disease before it terminates in death, since the ces- sation of the pain and of the foetid discharge from the vagina may 656 DISEASES AND DERANGEMENTS OF THE UTERUS. occur from other and independent causes. But a careful study of the symptoms present, and a faithful application of the corresponding homoeopathic remedies, will enable the physician to do all that human means can accomplish to arrest the mischief, even if he does not certainly knoAV that such disorganization is imminent. "The pulse is Ioav, quick, concentrated; the patients are seized with shiver- ings, startings, and even convulsive shakings of the body, without any apparent cause; and at the same time they cease to feel any pain in the uterus, or but a less degree; they fall into a state of oppression or extraordinary uneasiness, Avhich is but little short of fainting, and the extremities become so cold that scarcely any Avarmth can be detected in them." Such is the description, given from actual observation, of uterine gangrene. As the disease advances other and still graver symptoms appear, which threaten the speedy close of life if not promptly arrested: from the vagina is discharged a brownish liquid of exceedingly foetid odor, a cadaverous-smelling diarrhoea sets in, and cold, clammy perspiration appears over the Avhole body, or on some parts of it only, the features change, and the patient sinks into a prolonged coma, Avith or Avithout delirium. With symptoms so strongly marked the physician would have no difficulty in selecting the proper remedy. Whether this would prove sufficient to arrest the disorganization Avould depend upon hoAV much progress it had already attained and upon the constitutional strength of the patient. In some cases of gangrene of the uterus this organ has been known to become detached from the body, expelled through the vagina, and the patient nevertheless survive this terrible accident.* V. Pus may be infiltrated into the tissue of the uterus where the inflammation is very severe; and the reabsorption of this purulent formation, especially in cases of puerperal inflammation, gives rise to uterine phlebitis.^ In this case both the veins and the lymphatics become the receptacles of the puriform matter, which, lodging in them in different places, leads to the formation of fresh abscesses. V. Effusion of coagulable lymph is another consequence of acute metritis, especially in those cases in which the serous coat of the uterus is involved. The adhesions which result from the coagulation of this serous effusion, by confining the ovaries and especially the fim- briated extremities of the Fallopian tubes to the neighboring parts, may become the occasion of sterility or of extra-uterine pregnancy, preventing these extremities from embracing the o\Taries. Acute metritis, which occurs in pregnancy from Avhatever cause, * Jahr on Diseases of Females. f See Puerperal Peritonitis. AREOLAR HYPERPLASIA^-CHRONIC METRITIS. 657 will commonly result in the death of the fcetus, and the secondary inflammation of a very low form which is slowly developed in the womb in consequence of the retention of such blighted embryos may even lead to the death of the mother. So intimate and profound is the sympathy between the life of the mother and of the fcetus in utero, that while the death of the former almost necessarily leads to the destruction of the latter, the death of and subsequent putrefaction of the foetus, where it is not expelled from the Avomb, may result in fatal gangrene of that organ. A remarkable deathly look, sunken appearance of the eyes and dark discoloration of the lids, together with a peculiar deathly feeling—malaise—which pervades the entire system of the patient without any especial assignable cause, may be considered ground of suspicion of the death of the fcetus in utero. Cases have been knoAvn in Avhich the Avomb retained Avithin itself and preserved from decomposition a blighted foetus which had attained the age of three months before its death. In these cases the constitutional symptoms attracted attention to the examination of the case before any specific indications Avere given by uterine pains or vaginal dis- charge. In such cases the womb may seek to retain the product of conception till the full period, and then throw it off. Of course the farther advanced the ovum is before its vitality is lost, the more serious are the symptoms which ensue if it is retained in the womb. In many instances the product of conception, blighted in the first weeks, is entirely reabsorbed, or at any rate disposed of without being throAvn off externally. Areolar Hyperplasia—Chronic Metritis. Dr. T. Gaillard Thomas describes the condition known as chronic metritis under the title "Areolar Hyperplasia, or Diffuse Interstitial Hypertrophy of the Uterus." It is a disease of nutrition, he says, "which very frequently affects the uterus, and is characterized by congestion, hypergenesis of the connective tissue of the organ, and hyperesthesia of its nerves." This condition has been described by various authors as engorgement, infarct, irritable uterus, inflamma- tory hypertrophy, and by a variety of other titles. Either the entire womb may be involved, or, Avhich is the most common form, the dis- ease may be limited to the cervical portion; or, again, the body alone may be affected, while the cervix is nearly normal. The fact that this disease occurs most frequently in the cervix may be accounted for by this portion of the organ being more exposed to external influ- ences than is the body or fundus. It generally results from parturi- 42 658 diseases and derangements of the uterus. tion or abortion, and is most frequent in multipara?, nulliparous women being almost exempt, as Avell as virgins. The causes of chronic metritis, or hypertrophy of the connective tissue of the uterus, are predisposing and exciting. The first named are—constitutional taint; long-continued nervous or physical prostra- tion or general debility; childbirth, or imprudence during coin'ales- cence from childbirth; and puerperal peritonitis. The exciting causes are generally connected Avith parturition or abortion. The disease may result from the subsidence of an acute inflammatory attack of the lining membrane or parenchyma of the Avomb. The symptoms of this disease are multiform. They are not only due to the pathological condition of the uterus, per se, but very many of the most troublesome features of such cases are due to a sudden blazing up, as it Avere, of the smouldering inflammatory fire Avith which the course of the disease is occasionally marked; to displacements of the organ, to which its increased bulk and Aveight necessarily render it liable; to the pressure of the enlarged and heavy womb upon the pelvic viscera and nerves. Dr. Thomas gives the following enu- meration of these symptoms, all of Avhich, however, are not present in every case: " If the cervix alone be affected there are—pain in back and loins; pressure on bladder or rectum ; disordered menstrua- tion ; difficulty of locomotion; nervous disorder; pain on sexual in- tercourse; dyspepsia, headache and languor; leucorrhcea from sec- ondary endometritis, or granular degeneration of mucous membrane. If the disease be general or corporeal, the symptoms generally resem- ble very closely those of corporeal endometritis. The folloAving are especially indicative of the affection: A dull, heavy, dragging pain through the pelvis, much increased by locomotion ; pain on defecation and coition; dull pain, beginning several days before menstruation, and lasting during that process; pain in the mammae before and during menstruation; darkening of the areolae of the breasts; nausea and vom- iting ; great nervous disturbance; pressure on the rectum, Avith tenes- mus and haemorrhoids; pressure on the bladder, Avith vesical tenesmus." Vaginal touch will generally discover that the uterus, in conse- quence of its abnormal weight, has descended in the pelvis, and is perhaps lying upon the muscles of the perineum. The cervical por- tion will be found to be more or less enlarged and painful on pres- sure, while the os is usually gaping to the extent, perhaps, of admit- ting the tip of the finger. Pressure upon the cervix will give rise to considerable pain, and if the finger be passed high up into the rectum and pressure made upon the body of the womb, an extraordinary AREOLAR HYPERPLASIA—CHRONIC METRITIS. 659 degree of sensitiveness Avill be discovered ; the pain produced in some cases occasioning fainting. The womb is almost always displaced— usually retroverted. The use of the uterine probe will show Avith a sufficient degree of accuracy the extent to which the enlargement of the Avomb has progressed, as well as reveal the degree of sensitive- ness of the uterine walls. In some cases the cervix is enlarged to such an extent as to act as a foreign body in the pelvis, giving rise to great inconvenience of locomotion, constipation, and rectal tenesmus and vesical derangements of various kinds. It is important that this disease be distinguished from cancer in its earlier stages. A careful examination and comparison of all the symptoms, subjective and objective, will enable a differential diag- nosis to be made. The cancer cachexia is not manifest in chronic metritis; there is a tendency to amenorrhcea in this disease, while in cancer of the womb the tendency is to menorrhagia and uterine hsemorrhage; and again in chronic metritis the enlarged cervix feels like dense fibrous tissue, while in cancer (scirrhus) the cervical tissue feels like cartilage. On this point of differential diagnosis Dr. Lud- lam writes: " I have several times resorted to an expedient that has helped me to settle the diagnosis between them. You will do no harm by trying it. It is simply to use the cotton tampon saturated with pure glycerine. If the enlargement is due to plain, uncompli- cated cervicitis, the depletion by means of the glycerine will soon less- en the size of the uterine cervix very jierceptibly. If, hoAvever, the swollen state of the cervix arises from cancerous infiltration or from an interstitial fibroid, the glycerine will not sensibly diminish its bulk." * The prognosis of this disease is not very cheering. It may con- tinue for years, and be relieved at the cessation of the menstrual function, or it may even be cured spontaneously before the change of life sets in. On the other hand, a more serious form of organic disease may groAV out of it Avhen this period arrives. It may occasion serious cardiac, pulmonary or other forms of disease, under which the patient may sink. A proper attention to diet, position and other hygienic measures, and a careful selection of remedies, however, may in very many instances, and especially where there are but few or no serious complications, bring about a restoration of health. " It is quite as important to prescribe the proper posture for this class of patients as it is in cases of acute cervical metritis. Keep them in a horizontal or reclining posture, and off their feet, at the month especially. Shop- ping, A7isiting, party-going are as injurious as a journey by rail or an * Ludlam's Lectures, Clinical and Didactic, etc., p. 572. 660 DISEASES AND DERANGEMENTS OF THE UTERUS. excursion on horseback. Such a patient should let her sewing- machine rest and her servants take care of themselves."—Ludlam. Treatment of Acute and Chronic Metritis. In cases of acute metritis absolute rest in bed, upon the back, should be insisted upon. The patient should not be allowed to get up upon any pretext, not even for the purpose of evacuating the bladder or rectum. In chronic cases, as is remarked above, Avhile absolute continued recumbency is not necessary, it should be enjoined during the menstrual period, and comparative quietude should be ob- served at all other times. 1. Aeon., Apis, Bell., Bry., Canth., Cham., Coloc, Kali carb., Lach., Nux vom., Puis., Sabina, Sepia. 2. Ars., Carb an., Con., Hyos., Merc, sol., Lye, Rhus tox., Sulph. 3. Arn., Calc. carb., Carbo veg., Chin., Cocc, Coff., Creas., Crocus, Ferr., Graph., Hep., Ignat., Ipec, Jod., Magn. mur., Opium, Phos ac, Sec. corn., Stram. Aconite. This remedy is useful where there is a real synochal fever, hard, rapid pulse, hot, dry skin, intense thirst; sharp shooting pains in the whole abdomen, which is very tender to the touch. Apis mel. Stinging, thrusting pains, similar to those arising from the sting of a bee; Absence of thirst. Urine scanty. Dyspnoea. Arnica. In cases where the inflammation has been caused by a bruise or a concussion. Arsenicum. Burning, throbbing, lancinating pains; burning like fire. Great restlessness and anguish, with fear of death. She is sure she will die. Thirst for frequent sips of water, only a little at a time. Cold water aggravates her symptoms. She wants more cov- ering over her—Avants to be wrapped up. Belladonna. The pains are sudden, coming on quickly, and ceasing as quickly after continuing a longer or shorter time. Or there are clutching pains, as from clawing with the nails. Pressure as if all the parts Avould issue through the vulva. Throbbing headache, with heat, red face and eyes, and throbbing of the carotids. Involuntary floAV of urine. Furious delirium. The menstrual or lochial dis- charges suppressed or very offensive. The parts are very sensitive; she cannot bear the least touch or a jar of the bed even. Bryonia. The least motion aggravates her sufferings. Her head aches as if it would split open. Sitting up (as if in bed) causes nausea and fainting. Lips parched and dry; mouth dry, and very thirsty. Constipation, the stools being hard and dry as if burnt. treatment of acute and chronic metritis. 661 Calcarea carb. This remedy will often be found indicated in persons of leucophlegmatic constitution. The feet feel cold and damp. The head and upper part of the body are in a profuse perspiration; con- stant aching in the \Tagina. Thirst for cold Avater, worse at night. Pulse tremulous, or full and accelerated. Stitches in the neck of the uterus. The history of her case shows that her menses have been too profuse, and returned too often or too soon. Cantharis. Frequent and almost continual desire to urinate, in- effectual, or with cutting, burning pain, and passing a few drops only at a time, which are often mixed with blood. Burning in the uterine region. The urinary symptoms are of the greatest importance in de- termining upon the selection of this remedy. Carbo animal. In cases of chronic or subacute metritis. Inefficient urging to urinate, with painful pressure in the loins, groins and thighs. Great sense of soreness in the pit of the stomach. General sense of lassitude. Leucorrhcea, coloring the linen yelloAV. Carbo veg. Much soreness about the vulva, with aphthae. Aching or pinching in the iliac regions. Languor, weariness and physical depression toAvard noon, with faintness and hunger. Flatulence, momentary relief from eructations or downward emissions. She wants to be fanned. Chamomilla. In cases of inflammation which come on in connection with a fit of passion. Heat all over, with thirst and redness of the face; one side of the face red, the other being pale. Great impa- tience ; she can hardly restrain herself to patience and to treat people with civility. Urine abundant and light-colored. China. The inflammation has supervened upon great loss of blood. She suffers from distension and oppression of the abdomen, which is not relieved by eructations. Much ringing in the ears. The suffer- ings are increased by the least touch. Painless diarrhoea. Cocculus. Much paralytic pain in the back and paralysis of the lower extremities. Sensation as of sharp stones in the abdomen on motion. Head and face hot, feet cold. Pulse hard and small. Metallic taste in the mouth. Intense thirst or aversion to drink. Shivering over the mammas. Coffea. In cases Avhere the inflammation is induced by excessive joy; she is in a state of ecstasy, and is very sensitive to contact. Colocynth. Inflammation, Avhich comes on in consequence of violent indignation. Severe colicky pains, causing her to bend double, with great restlessness. Cutting as from knives in the boAvels, Avith great distress, distension of the abdomen; diarrhoea, Avhich is aggravated by 662 DISEASES AND DERANGEMENTS OF THE UTERUS. everything which is eaten or drunk. Feeling in the Avhole abdomen as if the intestines Avere being squeezed betAveen stones. Full, quick pulse; great thirst; bitter taste in the mouth. Conium. Burning, sore, aching sensation in the region of the uterus. The urine intermits in its Aoav. Much vertigo, particularly on turn- ing over Avhile lying doAvn. She usually has a bitter taste in her mouth, and thirst. The pulse is unequal. Some pulsations are smaller than others. The pulse is also irregular; sometimes it beats sloAver, sometimes faster. Creasote. Stitches in the vagina, proceeding from the abdomen, causing her to start at every pain. Putrid, acrid, corrosive leucor- rhcea. A low form of fever. Putrid fever. Crocus. Black, stringy discharge from the uterus, rolling and bound- ing in the abdomen as from a fcetus. Stitches in the abdomen arrest- ing the respiration. Ferrum. Fiery red face. The bowels feel sore on touching them, as if they had been bruised or Aveakened by cathartics. Leucorrhcea resembling watery milk. Graphites. Particularly when the ovaries are affected. Eruptions, tetters and excoriations on various parts of the body. A tendency to obesity. Hepar s. c. Particularly where there is evidence of a tendency to suppuration. Burning, throbbing pain; chilliness. Hyoscyamus. Especially if the inflammation be developed by emo- tional disturbances. If there appear spasmodic symptoms—-jerks of the extremities, face and eyelids, etc. In cases which fall into the typhoid state with delirium; the patient throws off the bed-clothes; she Avishes to be naked. Ignatia. Cramps with lancinations; the pains are aggravated or renewed, particularly on touching the parts. The woman is appar- ently full of suppressed grief. There is sorroAv and sighing. An empty feeling at the pit of the stomach. Ipecac. The patient suffers with a continual nausea; every move- ment is attended with a cutting pain almost constant, running from left to right. Pain about the umbilicus, extending toward the uterus. A continual discharge of bright-red bloQd from the uterus. Rapid pulse, with or Avithout thirst. Jodium. Acute pain in the mammse, developed by the inflammation of the uterus; the mammas also become very sore. There is a low, cachectic state of the system, with feeble pulse. Kali carb. Intense thirst morning, noon and night continually, TREATMENT OF THE ACUTE AND CHRONIC METRITIS. 663 and very rapid pulse. Distressing cutting, shooting, darting and stitching pain all over the abdomen, the stitching pains being in the ascendency; the more completely the stitching pains seem to predominate the more certainly will Kali carb. be the appropriate remedy. Lachesis. She cannot bear any pressure, not even of the clothes, upon the uterine region. She wishes frequently to lift them—not that the abdomen is so very tender, but that the clothes cause an uneasiness. A sensation as if the pains were ascending toward the chest. This remedy is especially indicated in cases where the inflam- mation is an attendant symptom of the critical age. The pain in the uterine region increases till relieved by a flow of blood from the vagina; not long afterward the same symptoms are repeated. Ex- acerbation of the sufferings after every sleep, whether by day or at night. Lycopodium. Cutting pains across the abdomen from right to left. Much rumbling and working in the abdomen, particularly in the left hypochondrium. Red sand in the urine. Much pain in the back previous to the flow of urine. Dryness in the vagina. Discharge of wind from the vagina. Magnesia mur. Hysterical complaints and spasmodic turns. Ute- rine spasms extending to the thighs. Constipation of large, difficult stools, which crumble as they pass the verge of the anus. Mercurius. Lancinating, boring or pressing pains. Much perspira- tion, Avhich, howeArer, affords no relief. Moist tongue, often accom- panied with intense thirst. She is worse throughout the night. Nux vom. This remedy is very frequently indicated. Pain as if bruised in the neck of the uterus; frequent desire to urinate, with pain. Scalding and burning. Frequent and ineffectual desire to defecate, or passing a small quantity of faeces at each attempt. Much pain in the small of the back, which is made worse by attempting to turn in bed. Heaviness and burning in the abdomen. \Much pain in the forehead above the eyes, and fainting spells. The symptoms are aggravated after four in the morning. She is despondent, sleep- less, or dreams frightful dreams. Opium. In cases originating in fright; the fear of the fright still remaining. Flushed face; delirium; soporous. In her lucid inter- vals she complains of the sheets being too hot for her. She is sleepy, but cannot sleep. Coldness of the extremities. Discharge of foetid matter from the uterus. Phosp. acid. In some cases of great debility, with great indiffer- 664 DISEASES AND DERANGEMENTS OF THE UTERUS. ence to all about her. Meteoristic distension of the uterus. SIoav fever. Platina. Particularly after confinement if there be excessive sexual excitement. Painful pressure in the region of the mons veneris and genital organs. Voluptuous tingling in the vulva and abdomen. Profuse discharge of thick black blood. Constipation, the stools adhering to the anus and rectum. Pulsatilla. In mild, yielding, tearful temperaments. Tension and contraction in the abdomen as if the menses Avould make their appear- ance, Avith nausea and sometimes vomiting of mucus. Semi-lateral headache; bad taste in the mouth ; nothing tastes good. Absence of thirst. Nightly diarrhoea and scanty urination. Rhus tox. Particularly after confinement. Worse at night, espe- cially after midnight. Restlessness; she cannot lie still, but must change her position, which affords a few moments' relief. Slow fever, dry tongue. Powerlessness of the lower limbs; she can hardly draw them up. Sabina. Especially after confinement or miscarriage. Metrorrhagia of clotted and fluid blood, with pain extending from the sacrum or lumbar region to the pubes. Severe stitching in the vagina from before backward. Frequent urging to stool; finally a liquid portion is discharged, folioAved by a hard portion. Secale c. Where there is a strong tendency to putrescence. The in- flammation seems to be caused by suppression of the lochia or menses. Discharge of thin black blood, a kind of sanies, with tingling in the legs and great debility. Sepia. Burning, shooting and stitching pains in the neck of the uterus. A constant sense of pressing into the vagina; she feels that she must cross her limbs to prevent a protrusion. A painful stiff- ness in the uterine region. Sense of weight in the anus. Putrid urine, depositing a clay-like sediment, which is difficult to remove. Icy coldness of the feet. A great sense of emptiness in the pit of the stomach. Stramonium. The face is bloated with blood. She awakens Avith a shrinking look, as if afraid of the first object she sees. She desires light and company. She is disposed to talk continually. Strange fancies; she imagines all sorts of absurd things—that the bed is full of creases, or that she is double and lying crossAvise, etc. The head Is often jerked from the pillow, and then falls back again. Sulphur. The vulva seems much inclined to become excoriated early in the attack. Frequent flushes of heat, passing off in a little IRRITABLE UTERUS—HYSTERALGIA. 665 moisture and faintness. Feet cold, or with burning soles, so that she Avishes to find a cold place for them or to put them out of bed. Sense of heat in the crown of the head. She feels suffocated; she wants the doors and Avindows open. Very light sleep; she awakens very frequently. Weak, fainty spells, occurring frequently during the day. After having improved under other remedies, she gets Avorse again until she receives a dose of Sulphur. She feels unusually faint, with strong craving for nourishment from eleven o'clock till twelve at noon. The remedies mentioned under the articles on Endometritis and Leucorrhcea may also be consulted with advantage, more especially those belonging to the category of " New Remedies." It should be borne in mind that in the treatment of a case of chronic metritis a remedy should be chosen with the utmost care, a due regard being paid to the totality of the symptoms, and its administration continued for some time, as no improvement can be perceptible at once, and the rapid changing of medicines might possibly lose to the patient a good chance of recovery. Irritable Uterus—Hysteralgia. The nervous disorders of the uterus, which in their various forms are included under the names of Hysteria, Hysteralgia, Irritable Uterus, Neuralgia of the Womb, etc., present a class of cases which, although neither structural nor directly functional, are no less im- portant, both from the severe sufferings in which they principally consist and from the complications to which they eventually give rise. Hysteria has already been treated of in full. We shall now call attention to that painful disorder which is knoAvn as Hysteralgia or Irritable Uterus, offering a few preliminary remarks, however, upon the subject of Nervous Irritation. The tAvo different nervous systems of the human body—the gan- glionic and the cerebro-spinal—although distributed to some consider- able extent to the same organic structures, possess entirely different functions and susceptibilities. Thus, the ganglionic nervous system is the one which supplies all the organic structures and sustains all the functions of the organic and inAroluntary life, while the cerebro- spinal nervous system supplies the same structures in their various degrees with the still higher powers of voluntary action, sensation, perception and sensibility. The former has exclusive relation to the 666 diseases and derangements of the uterus. phenomena of nutrition and reproduction, and so its filaments and ganglionic connections are distributed more or less palpably to all the substances and tissues of the body. The latter has more especial re- lation to sensation, volition, perception and sensibility; hence also its fibres are to be found in nearly all the structures of the body, even in those known as involuntary and not directly subject to the voluntary nervous system. Thus, Avhile the nerAres from each of these tAvo great vital centres are supplied alike to almost every structure or tissue in the body, those from each centre have their appropriate and readily distin- guishable functions. And the disorders Avhich may arise in connec- tion Avith the nerves from the ganglionic system are entirely different from those Avhich may arise in connection with the nerves from the voluntary or cerebro-spinal system. In the former case we have inflammation, congestion, engorgement in connection Avith the circula- tory apparatus, which is under the immediate and absolute control of the organic or involuntary nervous system. This inflammation may be active, and it is then usually considered to be more immediately dependent upon excitement of the arterial circulation; or it may be passive, and it is then supposed to be connected with arrest or stagna- tion of the venous circulation. Thus, organic nervous irritation gives rise to inflammatory congestion, both active and passive, acute and chronic. On the other hand, the cerebro-spinal irritation gives rise to a purely nervous congestion; that is, to one which corresponds in the nervous system to the inflammation of the circulation in organic irritation. Thus, in disorders which arise in connection Avith the cerebro-spinal nervous system we have irritation, irritability, in- creased and excessive sensibility; and the susceptibility to this painful irritability is augmented just in proportion to the extent of this form of nervous development in the particular structure. As where the tissues are most vascular there may be the most active inflammation, the most violent congestion, so Avhere the voluntary and sensitive nervous filaments are most abundant, there may be the most excessive irritability, the most distressing sensibility. Such is the case in the most remarkable manner in the uterus. In addition to its necessary relation to the ganglionic nervous system, the womb, although not immediately subject to the voluntary nervous system^ is alive with nervous filaments, and most intimately connected with the entire cerebro-spinal nervous system and sensitive sphere of the whole female body. The womb and ovaries are the seat of the highest vital NERVOUS IRRITATION. 667 action and functions of the female life; the highest and holiest joys and hopes are associated with the healthy condition of these organs and the proper performance of their functions; and the profoundest suffering and the most extensive and lifelong distress must neces- sarily result from the disorder of the nervous system connected with them and from the impairment of their functional action. Inflammation, whether acute or chronic, active or passive, involves some structural change, especially some more or less perceptible derangement of the arterial or venous circulation, and is essentially a disorder of the ganglionic nervous system of organic life. Irritation, whether existing in the condition of excessive irritability of the nerves or of positive pain, as in neuralgia, is essentially an affection of the cerebro-spinal nervous system, the nervous apparatus of animal life. And as inflammation may exist, even very extensively, without pain, so pain, or the disorder of the higher nervous system, may exist with- out inflammation. Inflammation necessarily involves a certain amount of structural change of tissue, as in congestion; but irritation does not involve change of tissue, except perhaps such modification of the substance of the nerve itself as is entirely beyond our minutest scrutiny. In inflammation the development of the disorder is always, perhaps, at the originally affected part, while in irritation the sensa- tion of pain or other evidence of nervous disorder may be at the sentient extremity of the affected nerve, or it may be in some other and remote part. Inflammatory congestion leads to effusion or to suppuration, according to the nature of the tissue Avhich becomes the seat of the morbid action and to the severity of the action itself. Irritation or nervous congestion may result in irritability, excessive sensibility, intense pain, cramps or spasms where the nerves dis- tributed to the muscles are affected, and finally in paralysis from exhaustion or collapse of the nerve-power itself. As too ready susceptibility to inflammation indicates a weakness of the organic nerA'Ous system, so excessive irritability indicates a cor- responding debility of the cerebro-spinal nervous system. The weaker the nerves the more sensitive they are, and the less can they bear of opposing influence Avithout being thrown into a state of excessive irritability or pure nervous erethism. But this form of nerA'ous de- bility, which leads to excessive suffering, does not seem incompatible Avith a most remarkable power of endurance of pain. Women of deli- cate constitution and exceedingly irritable nervous system are often seen to endure for days and nights such distressing neuralgias, Avith entire loss of sleep, as Avould seem capable of destroying a strong 668 DISEASES AND DERANGEMENTS OF THE UTERUS. man. Such pains are often seen to come on Avith suddenness, to con- tinue with most intense severity for many hours, and often finally to disappear with equal suddenness, and leave no mark or trace of their long-continued presence. But as in those forms of disease which have been referred to as con- nected with the organic nervous system pain may precede the acute inflammatory action, so in those forms of purely nervous disorder Avhich have been described as irritation the excessive sensibility and distressing irritability may precede such nervous derangement as Avould actually impair the functional action of the parts. Thus, Ave find in the first stage of a purely nervous irritation of the uterus no positive failure of its functions, but only an exceedingly great amount of pain in their performance. The menstrual function may be neither prevented nor impaired, otherwise than by an intense and agonizing pain preceding and accompanying it; so in coition, especially if the womb is touched; and so finally in pregnancy, the nervous irritation may not at first prevent the fulfillment of the functions of the uterus, only rendering them exceedingly painful. But such irritation cannot but cause all these functions to become more or less impaired in the course of time. These nervous affections may be transitory and evanescent, or they may be permanent and lifelong, in accordance Avith the nature of their causes. But as we have shown that the irritability of the nervous system is in proportion to its weakness, so it will pres- ently appear that debilitating influences are among the most fre- quent causes of this irritation of the uterus; thus complete recovery can only be possible in those cases in which the patients can alto- gether escape from these debilitating influences, and also have their dynamic effects entirely remedied and removed by suitable medication. Irritable Uterus—Hysteralgia—Neuralgia of the Womb. Irritable Uterus.—In irritable uterus the womb is in a painful and tender state, is morbidly sensitive and irritable, the least touch or pressure producing the most exquisite pain, and yet there is no appar- ent congestion, inflammation or induration. The principal symptoms which may indicate this condition are— deep-seated pain in the lower part of the abdomen, as if in the pelvis; aching pain in the back and loins, always present, but sometimes much more and sometimes less seA'ere. Upon examination by the touch, or even by the speculum Avhere this is practicable (which is seldom the case in this affection), the os and cervix uteri are found in their normal IRRITABLE UTERUS. 669 condition, except the remarkable sensitiveness to the touch; and, as remarked by Dr. Gooch, who first described this form of uterine dis- order as distinct from inflammation, this painful and tender state of the organ is neither attended by, nor tends to produce, change in its structure. Late writers on female diseases have inclined to consider irritable uterus a very rare form of disease. Thus, Tilt says: " Irritable ute- rus, as an essential disease independent of inflammation, can only be hysteralgia, a rare disease of which I have only seen two instances, and Scanzoni three." * But even if this irritable uterus is but rarely found as an original disorder, it is still so common, being an almost universal attendant upon displacements of the womb, and it exerts so important an influence upon the entire female economy, that there is little danger of attracting too much attention to it. And in fact under this general head are properly enumerated many conditions and symptoms which nosologists might designate by other names; but these conditions and symptoms are the very things which make up the case of the patient for whom we wish to prescribe, and not for some nosological disease by which she may be supposed to be affected. The pain is not confined to the sacral and pubic region; it is often felt in the sides of the abdomen, in the hips or in other parts of the body, or it may extend from the back completely around to the groins, the hypogastric region and down the thighs. In its nature the pain of irritable uterus is as various as is its seat. " It is most frequently described as a dull, aching, wrong feeling in the back, with more or less sense of pressure, weight, dead feeling, heaviness, fatigue or debility. Not unfrequently in the abdomen it is a sore pain, a sharp, needle-like, lancinating pain. With some it is mere soreness, and in very many, after the acute character has sub- sided, soreness remains often so great that the weight of the bed- clothes becomes troublesome. In the hips and down the limbs there is often the same Avrong and dull pain, with a sense of fatigue and an inability to move, but sometimes it is sharp, neuralgic and toothache- like, and occasionally excites spasmodic and painful action of the hips, thighs, etc. The sensations are often pulsatile, resembling those pre- ceding or accompanying the suppurative stage of inflammation. This beating, 'strumming,' vibrating pain is referred to the Avomb, vagina, bladder, rectum, etc., and is often very tormenting. A burning sen- sation, or feelings of moderate or severe degrees of heat, is not un- * Uterine and Ovarian Inflammation, London, 1862, p. 228. 670 DISEASES AND DERANGEMENTS OF THE UTERUS. common in the vagina, the vulva, urethra, sometimes in the sacral or hypogastric regions, over the Avhole lower part of the abdomen, and extending to all the anterior portions of the thighs. This is ATery dis- tressing, and sometimes so severe that patients have declared the burn- ing could not be greater were they to stand perfectly exposed before a hot fire or if coals of fire were placed within them." * In addition to pain, and very frequently where there is no pain whatever, there are numerous sensations more or less distressing, indicating an irritable state of the uterus and the adjacent organs. Some of these are very common, as sensations of weakness, debility, languor, often with feelings of fullness, pressure, weight; a bearing- down sensation in the back, vagina, rectum ; an open feeling, as if there Avere no support and all the pelvic contents must escape, or as if the patient would " fall in pieces " AA'hen in the erect position; a sense of pressure on the rectum, as if the bowels must be moved, or simulating the fullness and weight of hsemorrhoidal tumors. A great sensation of distress, of prostration, often exists after the bowels have been moved. Similar troubles are also experienced about the neck of the bladder and the urethra, especially at its orifice, with frequent, sometimes almost constant, inclination to urinate, and then a burning, scalding sensation. Such are some few of the multitude of sensations which arise from irritable uterus—sensations which vary in different cases, both in kind and in severity, some persons having some and other persons other symptoms, which may be so mild as hardly to be noticed, or so in- tensely painful as to be almost unendurable. These sensations are very severely aggravated by every kind of motion, such as walking, sneezing, coughing, vomiting, and by every effort or movement of the body which may cause pressure of the con- tents of the abdomen upon the irritable womb. They are also aggra- vated in the most remarkable manner by menstruation. It may be that a disorder of the ovaries was the original cause, in part at least, of the irritability of the uterus, and that such ovarian disease also tended to produce what is termed dysmenorrhcea. But even if this were so, the irritable uterus could not but render the function of men- struation still more intensely painful. When perfectly quiesceut and motionless, even the most irritable womb may be comparatively easy. But physiological stimulus, no less than mechanical violence, arouses its painful irritability; hence, both before and during menstruation in such cases the pain is intense and agonizing, and from whatever * Hodge, Diseases Peculiar to Women, p. 55. HYSTERALGIA. 671 cause the irritability of the uterus arises, dysmenorrhcea is an invari- able result. Leucorrhoea of some kind is also an almost invariable attendant upon irritable uterus. This discharge may be vicarious, as appearing in place of the menstrual flux, or it may appear as a temporary sub- stitute for the menses. As has been elsewhere shown, irritation of the organic nervous sys- tem leads to inflammatory congestion, while irritation of the cerebro- spinal nervous system leads to simple congestion, and to painful sensations or to spasmodic contractions, according to the sensory or motor nature of the nerve-filaments Avhich are principally im^olved. This irritability of the uterus, if it be supposed to involve each of the classes of nerves distributed to that organ and its appendages, be- comes the initial stage of a great variety of disorders of the sexual apparatus and of the entire organism of the female. And this gen- eral conclusion has been reached by some who certainly did not understand the reasons which support it. This is fully implied in the expression of a recent and able English author, where, speaking of irritable uterus, he calls it "that scapegoat of uterine pathologists in England." * The whole subject has been discussed in an extended manner and with remarkable clearness and ability by Professor Hodge, to Avhom, in the preparation of the present work and in common with the profession at large, we are greatly indebted, and to whose work f we Avould refer all those desirous of a more thorough exploration of this and kindred subjects. The various disorders of the female sexual system Dr. Hodge considers as the causes, the con- sequences or the complications.of irritable uterus. Hysteralgia, or Neuralgia of the Uterus, needs here to be considered as connected Avith irritable uterus, and yet, as to a certain extent, distinct from it. Irritable uterus is rather a negative condition of susceptibility or excitability from general nervous weakness in the organ, Avhile hysteralgia is a more positively painful condition which may be considered to be added to the irritable state by some special provoking cause. Thus, in cases of irritability of the uterus the patient may be comparatively easy when perfectly at rest, while any exertion, such as rising from the bed, walking, coition or menstrua- * Tilt, Uterine and Ovarian Inflammation, p. 334. f On Diseases Peculiar to Women, including Displacements of the Uterus. By H. L. Hodge, M. D., Professor of Obstetrics, etc. in the University of Pennsylvania. Philadelphia: Blanchard & Lea. 672 diseases and derangements of the uterus. tion, may develop the most painful sensations. " In dysmenorrhcea, or painful menstruation, the greater portion of the pain consists, I am conA'inced, of neuralgia; the deep lumbar pain is decidedly ovarian, and not uterine."—Tyler Smith. Here it is evident that both irritable uterus and hysteralgia may depend upon some primary morbid condi- tion of the ovaries. Symptoms.—" Neuralgia of the neck of the womb often exists in- dependently of any other lesion of this organ or of the body of the uterus: the patients complain of pains that are seated high up in the vagina, without any alteration being perceptible, even after the most minute investigation. Contact is ahvays painful, and sexual inter- course often produces such agonizing distress that the patients would rather bear any other torture."—Jahr. "In real uterine neuralgia the pain is situated in the uterus itself, to which it is referred by the patient throughout the attack, or in the uterus and ovaries simul- taneously. This pain, generally speaking, comes on suddenly, Avith- out being preceded by any premonitory symptom, unless it be slight numbness. A few minutes before and after the attack the patient may be perfectly well and free from pain, whereas during its ex- istence she is often rolling in agony on the bed or the ground. Real neuralgia is essentially intermitting in its character, returning for a limited time at stated intervals during the twenty-four hours. Some- times the attacks only occur once in the tAventy-four hours, sometimes oftener. They last from one hour or two to ten or twelve. An attack is composed of a series of paroxysms, each of which is fol- lowed by a period of comparative freedom of variable duration. During the attack pains are also felt in the lumbo-dorsal, ovarian and other uterine regions, and there may be exquisite cutaneous sen- sibility of the entire abdominal region. All these pains, hoAvever, disappear along with the uterine tormina, as soon as the attack ceases, merely leaving for a time numbness and soreness."—Bcnnet. " That affection which we shall designate acute hysteralgia is some- times the immediate consequence of marriage. The pains in such cases, sometimes of a burning nature, are more generally attended with a sensation of pinching and of forcible pressure in the hypo- gastrium and pelvic cavity, occasionally extending to the groins and loins. Like cramps and colics, they are intermittent, leaving, how- ever, in the intervals a tenderness and sensibility of the hypogas- trium which render them liable to be confounded with slight metritis. In chronic hysteralgia—the real uterine neuralgia—the paroxysms occur without assignable cause, and without anything of an inflam- TREATMENT OF HYSTERALGIA AND IRRITABLE UTERUS. 673 matory character. It appears in paroxysms, varying in frequency and regularity."—Boivin and Duges. The causes of hysteralgia, or uterine neuralgia, may be of two kinds: First, those influences, termed provoking, which may develop a positive neuralgic condition from an already existing negative state of uterine irritability or excitability. Second, those influences which are capable of developing a true uterine neuralgia where there was no pre-existing irritability. In the first class, as already mentioned, every bodily exertion, the orgasm of coition, or the molimen of men- struation, as in dysmenorrhcea, may easily induce the neuralgic suffer- ings. In the second class, patients of general nervous temperament, subject perhaps to what is termed " spinal irritation," may experience neuralgic paroxysms in various parts of the body upon every over- exertion. Fatigue, too severe and long-continued labor or any undue exercise in which such persons go beyond their strength, will invaria- bly produce neuralgia; and it requires only some special local or functional influence, such as excessive coition, over-exertion Avhile menstruating, to cause the neuralgia to be developed as an hysteralgia, rather than as a prosopalgia, a megrim or a tic douloureux. And in either class of patients there is no doubt that the local irritation un- avoidably arising from displacements of the uterus and its appendages may occasion constant or periodically recurring neuralgic sufferings, which may be felt in the womb itself, in its immediate vicinity, or developed in the epigastric or other region remote from the real and original seat of the disorder. Treatment.—For the treatment of the A^arious forms of the more painful nervous disorders of the Avomb and its appendages, irritable uterus, hysteralgia or uterine neuralgia and painful coition, study and compare the folloAving remedies: 1. Bell., Cham., Kali carb., Plat., Puis., Sab., Sep. 2. Carb. an., Con., Croc, Ferr., Gels., Nux vom., Op., Rhus tox., Sec. corn., Sulph. 3. Asaf., Asterias, Bry., Calc. carb., Chin., Cocc, Coff., Creas., Cypriped., Graph., Hyos., Ignat., Ipec, Lil. tig., Magn. m., Mosch., Natr. c, Natr. m., Nux mos., Phos. ac, Thuya, Veratr. a. Asafcetida. May be indicated in decidedly venous systems and ner- vous temperaments. Labor-like pains, with cuttings and bearing down. Menses too frequent and too scanty. Hysteria. Hypochon- driac, anxious, sadness and apprehension of dying; paroxysms of shuddering. Fits of great joy, Avith occasional bursts of laughter. Asterias rubens. General feeling of distress in the womb, as though 43 674 DISEASES AND DERANGEMENTS OF THE UTERUS. something were pushing out. TAvitching in the uterus. Feeling of extreme anxiety, as though some misfortune were impending—as though some bad neAvs were about to arrive. The menses are apt to delay. Aurum. Almost constant thought, more or less intense, of suicide. Bryonia. The uterine sufferings are increased from the least motion. Desire for things which cannot be had, or which are refused, or not wanted Avhen offered. Frequent nose-bleed. Calc. carb. Pale, leucophlegmatic, weakly, fearful persons. Fear of going crazy. Vertigo on going up stairs. Frequent spasms. Sense of Aveight and soreness in the uterus. Causticum. Pains in the abdomen, causing her to bend double. Fullness and pressure in the abdomen, as if she Avould burst. Con- stant but ineffectual desire to eructate. Violent increase of the pain after the least nourishment, or after tightening her clothes round her waist. Cham. The mental state of the patient leads to this remedy. In all her sufferings there is a vein of ill-humor; she can hardly speak pleasantly; feels like scolding about everything. She often gives vent to her ill-humor in spite of all restraint. China. Much singing in her ears. A sensation in the abdomen as if it Avere packed full, which is not in the least relieved by eructation. Worse every other day. Cocculus. Painful pressure in the uterus, with cramps in the chest and fainting nausea. Suppression of menses, or leucorrhcea in their stead. Feels too weak to talk loud. Coffea. This remedy also is chiefly indicated by the mental symp- toms. Ecstasy. Full of ideas. Quick to act; no sleep on this account. The physical system seems exalted and almost transported by the mental exaltation. Conium. Stitches extending from the abdomen to the right side of the chest. Vertigo when lying down or turning over. Intermission in the flow of the urine. Crocus. Sensation of rolling and tumbling in the abdomen. Great mental dejection. Menses suppressed, or dark and stringy. Ferrum. The patient is weak and nervous. She suffers much, hut has very red cheeks. Graphites. Itching blotches here and there over the body. Menses delay or are suppressed. The patient seems bloated and inclines to obesity. She is weak and irritable. Hyoscyamus. She inclines to that kind of insanity which leads to TREATMENT OF HYSTERALGIA AND IRRITABLE UTERUS. 675 nakedness—to throAV off her dress or the bed-clothes. Uninterrupted, loud laughing at the approach of the menses. She is very much in- clined to spasm. Uterine cramps, with pulling in the loins and small of the back. Ignatia. Uterine cramps, Avith cutting stitches. Great sense of sore- ness at the pit of the stomach. Full of grief and sighing. Brooding over imaginary troubles. Ipecac. Much pain about the umbilicus, extending toward the ute- rus. The most of the distress is about the navel, but it runs off into the uterus, the real seat of the disease. One continued nausea. Kali carb. Stitching pains about the tender uterus or all over the abdomen at times. Ahvays much distress in the abdomen an hour before stool. Magnesia mur. Sleeplessness, Avith difficult stools, which crumble as they escape the verge of the anus. Frequent hysterical spasms. Uterine cramps, with pains extending down the thighs. Natrum mur. Very sad and gloomy during the menses. Much pal- pitation of the heart and morning headache. Frequent dreams of robbers in the house, and on awakening will not believe to the con- trary till search is made. Great disgust for bread. Uterine cramps, with burning and cutting in the groins. Nux vom. Much sense of soreness in the neck of the uterus on rising up or sitting down. Wishes to urinate or to defecate very often, but little at a time, attended with pain. No sleep after three A. m. No appetite. Has indulged in high living, rich food, condi- ments, etc. Opium. She is nervous and irritable, and passes nothing but hard black balls from the bowels. Her bed feels so hot that she can hardly lie on it. She is sleepy, but cannot go to sleep. Phosphorus. Sensation of great Aveakness and emptiness in the abdomen. Sensation of great heat in the back, running up from the coccyx. Sharp cutting pains in the abdomen. Sexual desire almost irresistibly strong. Much flatulency. Phosphoric acid. The uterus is distended Avith gas. Pain, univer- sally, in the liver during the menses. She must often rise at night in order to pass large quantities of colorless urine. Is very weak, and indifferent to the affairs of life. Listless, apathetic. Platina. A voluptuous tingling in the genital organs and abdomen, Avith oppressive anxiety and palpitation of the heart. Frequent sen- sations as if the menses would appear. The mons veneris and vulva are extremely sensitive, feeling cold at the same time. Menses pro- 676 DISEASES AND DERANGEMENTS OF THE UTERUS. fuse, Avith black clotted blood. Much anguish; she feels as if she would lose her senses and die soon. Pulsatilla. With almost all her sufferings there are sure to be tears and cries. She weeps very easily about this or that; she can hardly give her symptoms for weeping. Menses suppressed or flowing inter- mittently. She has a bad taste in her mouth in the morning, and nothing tastes good. Rhus tox. In many cases following parturition. A vitiated dis- charge continues from the vagina, with shooting upAvard in the parts, and with a bursting sensation in the head. Much pain continues in the right limb, with numbness from the hips to the feet, for weeks after delivery. General unhappiness of temper. Sabina. The pain extends from the sacrum to the pubes. A slight sensation of motion in the abdomen, as if something were alive. Much irritability of temper. Music is intolerable to her. Secale corn. This remedy is often indicated in thin, scraAvny indi- viduals, and in those Avho are afflicted with melancholy, anguish, dread of death. A constant sensation of pressure or bearing doAvn in the uterus. Sepia. Great sense of emptiness at the pit of the stomach. The uterine region is tender to the touch. Little shooting, burning pains in the neck of the uterus. Sense of weight in the anus. Must cross her limbs, as if to keep the uterus from protruding. Very sad and fearful about her health; often weeps about it. Sulphur. Frequent flashes of heat, Avhich pass off in a slight per- spiration with weakness. Much sensation of heat in the crown of the head. She feels badly at the pit of the stomach from eleven till tAvelve in the forenoon; she is weak, empty at that time, can't wait for her dinner. Sleeps in very short naps, and is easily awakened. The most of the pain is in the left iliac region and in the left side generally. Much depression of spirits, or she is very happy and gay; everything is very beautiful to her. Thuya. Extremely scrupulous about the least thing. Walking or riding brings on such extreme suffering in the left inguinal and iliac region that she is obliged to go to bed. Zinc. The flow of the menses always relieves all her sufferings, but they return again soon after the cessation of the menses. A constant distressing boring pain in the left ovarium, only partially relieved by pressure or during menstruation, but returning again after the flow. ULCERATION. 677 CHAPTER XXXII. DISEASES OF THE UTERUS—CONTINUED. Ulceration. THE term ulceration as applied to the cervix uteri has given rise to many disputes amongst gynaecologists, Avhich have arisen in consequence of the various definitions of Avriters on the subject. Dr. Arthur Farre holds to the vieAV that the term ulceration should be applied only to cases in which there is a loss of substance, extending beyond the mere abrasion of the cervical surface and extending deeply into the tissues. If this be accepted as a true definition of ulceration of the uterus, then will such cases seldom be met with except in connection with syphilis or other specific disease. Bennet gives a broader definition, and regards ulceration as " a solution of continuity from which is secreted pus or a puriform, sanious or other matter." This of course takes in all forms of so-called ulceration, from simple epithelial abrasion to the malignant and deep ulceration, and for prac- tical purposes is perhaps the best that can be given. Ulcers of the uterus may be divided into the following distinct classes: Granular, Follicular, Inflammatory, Syphilitic, Corroding and Cancerous Ulcer. These will be considered in the order in Avhich they are named. It seems proper, however, to say a few words in advance regarding the methods of examination to be pursued in order to secure a correct diagnosis in such cases, as well as to refer to the general principles governing their treatment. In the forms of disease of the uterus hitherto treated of in the present Avork the touch has been deemed generally sufficient to enable the practitioner to determine with sufficient exactness the nature of the difficulty. And in fact the Avell-practiced touch is a surer guide to diagnosis in such explorations than is the speculum, which must necessarily interfere more or less Avith the position and appearance of the vagina. And the touch, Avhether per vaginam or per rectum, or both, is usually fully competent to determine the nature of the various forms of displacement. But in the examination of cases of suspected ulceration of the cervix, the speculum should be used to confirm the indications obtained by the touch, and to assist in decid- 678 DISEASES AND DERANGEMENTS OF THE UTERUS. ing as to the simple, malignant or cancerous nature of the ulceration itself. Still, from the very great reluctance of many Avomen to submit to such ocular examination, even when conducted in the most delicate manner possible, it seems better for the young physician to learn to depend as much as possible upon the touch in forming his diagnosis, and only to resort to the speculum in doubtful or difficult cases, or perhaps in the first examination of such as come under homoeopathic medication from allopathic hands. The finger may be as truly edu- cated to discriminate the different conditions of the uterine surface and substance as it may be to strike the strings of the harp or the keys of the piano. And it is a subject of no small gratulation to remember that not only the most eminent homoeopathic physicians, but also the entire body of respectable practitioners of our school, have set their faces against the disgusting and disgraceful resort to the speculum upon every possible pretence and occasion. HoAvever fashionable the use, or rather abuse, of the speculum was at one time— and we are glad to say it is uoav so no longer—such cultivation of morbid curiosity on the part of the physician, to give it no worse name, and such pandering to the prurient sensualism of some Avoman, and such unnecessary wounding of the delicate sensibilities of others, have never obtained currency in our school. And not only do all the soundest principles of medical exploration dissuade from the indis- criminate introduction of the speculum, but the Avhole tenor of our homoeopathic tberapia leads to a more excellent Avay, by substituting the subjective, the sensational, the constitutional and functional symp- toms for the pathological details of structural changes as the basis for medical treatment. Hence, Ave think that in most cases the touch alone Avill proA7e amply sufficient for the purposes of diagnosis, and far superior in cer- tainty to the speculum in the great majority of cases. In displace- ments of the womb and other organs it may be necessary to investi- gate by the touch the situation of the parts; and in some of these cases of malposition, as in retroversion of the uterus, manual assist- ance may be needed in order to restore the parts to their proper place. But in actual practice, so long as we do not give homoeopathic reme- dies for diseases by name, so long as we do not wish to confine our- selves merely to the removal or palliation of the consequences of the illness, so long as we make it our great aim, as skillful physicians, to restore our patients to health, and so long as Ave consider the disease removed only so far as we see such restoration to health, just so long ULCERATION. 679 shall Ave seek to find the remedy AA'hich shall correspond to all the symptoms of the case, and which shall especially represent the sub- jective and constitutional symptoms, instead of relying mainly upon the indications afforded by the speculum or the touch. And Ave believe that a careful and attentive study of these symp- toms and of the attendant conditions will enable the physician to make the right, the best possible prescription for his patient. For thus he regards the first elements, the dynamic causes, rather than the ultimate results of the morbid affection. And herein do we differ from the so-called physiological school, as Avell as from the patholog- ical and chemical schools. The method here inculcated is in strict accordance with pure homoeopathy, and it might perhaps be deemed the physiological method were not this term already appropriated as the designation of an entirely distinct system. This method, which we may perhaps be permitted to call our own, since Ave adopt and advocate it, may be termed the vital method. It is essentially the method of Hahnemann, of Bcenninghausen and others, Avhose learn- ing and skill have contributed to make homoeopathy an honor to the medical profession. In this method Ave realize that pains or subject- ive (sensational) symptoms come before the functional derangements, as these latter come before structural or organic changes, and that the tAvo latter forms of disease are but the extension and ultimate development of the morbific influences shadoAved forth in the former. So that if Ave pay strict attention to the subjective, the sensational, the constitu- tional symptoms, in addition to the local manifestations and to the attendant circumstances and conditions (Avhich are also constitutional symptoms, and so of the first importance), we shall come far nearer the mark, and be far more sure of healing the sick, than if we directed our principal attention to the more external and ultimate symptoms or forms of the disease. For purposes of diagnosis, and especially to satisfy the patient and her friends, the touch may be resorted to, and in some cases the speculum even. But for guides in the selection of the remedy, the indications afforded by the patient herself, those Avhich Ave have designated as subjectiA'e, sensational, constitutional and functional, afford us the greatest certainty and lead most directly to the happiest results. Granular Ulcer.—This form of ulceration has been likewise de- nominated, by A'arious Avriters, erosion, abrasion and granular degenera- tion of the cervix. It consists essentially of a changed condition of the 680 DISEASES AND DERANGEMENTS OF THE UTERUS. mucous surface of the cervix surrounding and immediately Avithin the os. It is of very frequent occurrence, but sometimes gives rise to but feAv and very slight constitutional disturbances. In other instances, however, various derangements of the system attract attention to the difficulty. It is usually accompanied Avith profuse leucorrhcea, which may be bloody or purulent; a A^ery annoying and fixed pain in the back and loins, of which the patient principally complains, especially when Avalking; disordered menstruation, the menses being generally too profuse; pain during coition and sore feeling afterward; a variety of nervous disorders and hysteroid symptoms. Upon resorting to the vaginal touch, the cervix will be felt to be deprived of its usual smooth surface, and a granular condition of the parts or a velvety feeling is imparted to the sense of touch. The speculum will shoAV the cervix, and more particularly that part lying adjacent to the os, and the entrance to the cervical canal itself, cov- ered Avith pus, which, upon being brushed aAvay, reveals a deeply red surface having a granular appearance, and resembling the inner sur- face of the eyelids in the disease knoAvn as " granular lids." The os is usually more or less patulous, and sometimes everted. There appears to be little or no destruction of tissue, and, on the other hand, there may even be the appearance of thickening of the epithe- lium and consequent elevation of the diseased part. In mild cases it may be difficult to ascertain whether the parts involved are not simply congested, or to perceive the limits of the ulceration when ascertained to exist. The most common causes of this form of ulceration are found in uterine displacements, in consequence of which there is almost con- stant friction of the cervix against the vaginal walls, or it may arise from injury to the cervix during sexual intercourse, by Avearing pes- saries or by parturition. It is commonly associated, in the Avorst cases especially, Avith endocervicitis, and may be produced by any- thing Avhich occasions hypertrophy of the uterus, or endometritis. Occasionally, these granulations in this form of ulceration become greatly enlarged, constituting what are knoAvn as coclcscomb granula- tions. These fungous excrescences spring up principally in the vicinity of the os uteri; they are sometimes found within the canal of the cervix, are of a livid red color and very vascular. They dis- charge an abundant purulent secretion, and are capable of giving rise to copious hsemorrhage from the least touch. Sometimes the ulcerated surface takes on an aphthous appearance, constituting Avhat is knoAvn as Aphthous Ulceration, or it may be the ULCERATION. 681 seat of diphtheritic deposit, and is then termed Diphtheritic Ulceration. Again, the parts involved may present numerous congested and varicosed veins, and under such circumstances the term Varicose Ulceration has been applied to it. Follicular Ulcer.—This variety of uterine disorder consists in inflammation and ulceration of certain mucous follicles of the cervix. Dr. Farre says of these that they are lined by epithelium and base- ment membrane, and that those upon or near the margin of the os may be sometimes observed to contain short papillae. The papillae of these follicles become enlarged, and present the appearance of red and elevated tubercules, AA'hich look as if ready to bleed at any time. This form of uterine ulceration is not so frequently met with as the granular ulcer, and indeed may be regarded as someAvhat rare. Inflammatory Ulcer.—Of the " true inflammatory ulcer " Dr. Thomas writes as follows: " In procidentia uteri of long standing it is seldom absent, and the deep excavationsj precipitous edges and in- flamed bases of the spots leave no room for difference of opinion as to their nature. This form of ulcer is very rarely met with, except as the result of direct injury, Avith coexisting parenchymatous congestion or inflammation. Thus it may arise from the injuries resulting from friction in procidentia and anteversion and retroversion, or from exces- sive coition, where the cervix is much enlarged and its parenchyma inflamed." Syphilitic Ulcer.—It seems to be a settled question that syphilis may attack the uterus both primarily and secondarily. It is not our purpose, hoAvever, to treat of this class of affections, further than to say that great care should be exercised in making up the diagnosis where syphilis is suspected, and that syphilis manifesting itself in this locality, whether primarily or secondarily, should be treated in the same manner as syphilis manifesting itself elsewhere. Corroding, Phagedenic or Malignant Ulcer.—This form of ulceration is fortunately uncommon, and its existence as distinct from cancerous ulceration has been positively denied. In its extent, malig- nancy, in the rapidity of its course, as well as in the usual fatality of its termination, it is no less formidable than cancer itself. Malignant, non-cancerous ulceration is more apt to happen to Avomen at the middle period of life or at a more advanced age, but it sometimes 682 DISEASES AND DERANGEMENTS OF THE UTERUS. occurs in Avomen Avho may still be said to be young. The ulcer gen- erally begins in the cervix uteri, and the uterus is at the same time sorueAvhat harder and larger than in the natural state. It docs not, hoAvever, grow to any considerable size. The ulcer spreads from the cervix to the fundus, and it is not unusual to see the greater part of the cervix destroyed by it, and the rest changed into a tattered, ulcer- ated mass. The ulceration is not always confined in its boundaries to the uterus, but it sometimes spreads into the neighboring parts, as the vagina, the bladder and the rectum, making communication be- tween them and producing dreadful havoc " This disease attacks females of the lymphatic temperament, and generally about the period of the cessation of the menses or soon after." Malignant ulceration of the womb is attended by heat and pain in the pelvis. But the first important symptom is the alarming hsemor- rhage to which it gives rise, and Avhich may be mistaken for a profuse menstruation. There is also a foetid discharge, Avhich varies from a light stravv color to dark brown. That portion of the uterus Avhich is not ulcerated is scarcely at all enlarged, and is free and movable, thus differing from the true cancerous ulceration. " In cancer uteri there is extensive deposition into the cellular membrane and glands between the vagina and rectum, as Avell as into the substance of the uterus itself, connecting them so as to form one large mass, and ren- dering the whole immovable; the finger on being introduced into the vagina finds very little space and no power of moving the parts with which it comes in contact; whereas in corroding ulcer, no deposition having taken place, the uterus can be moved by gentle pressure, and parts of the pelvic contents having been destroyed by ulceration there is more space than usual in the cavity." From simple ulceration of the cervix this malignant form is distinguished by the excessive fcetor of its discharge, by the more intense character of the pain and by the rapid extension of the ulcerative process. Corroding ulcer of the cervix, Avhich may also extend to the fundus of the womb, sloAvly eats away the uterine Avails, and in the allopathic practice is only hindered and delayed in its final and fatal termination. But in the homoeo- pathic practice Ave possess the very important double adA'antage of being enabled at the same time to give remedies which shall promote the healing of the local difficulty, and improve, instead of still further injuring, the general health. These cases cannot be cured unless by such means as shall eliminate from the system the dyscrasia which lies at the foundation of the ulceration, and at the same time remedy both the bad health which caused and that which folloAA'ed it. treatment of ulceration of the uterus. 683 Treatment of the above Varieties of Ulceration. These forms of ulceration never exist alone, and the ulceration cannot be made to heal permanently until the other morbid condi- tions of the womb are removed, and until the general health is more or less completely restored. Non-malignant ulcerations may heal spontaneously—that is, on the recovery of the general health and on the subsidence of the provoking cause or causes of the ulceration— but where the general health is neglected or grows worse, Avhere the ulcerations are left to themseh^es or aggravated by improper treat- ment, they may continue to spread and become so extenshre as to destroy life indirectly by undermining the constitution, or directly by the haemorrhages Avhich they may occasion. Simple ulceration of the Avomb is far more amenable to homoeo- pathic medication, and far more easily and safely treated by such gentle and yet constitutional means, than by the application of caustics, either liquid or solid. At the same time, the general health is restored by selecting remedies to suit all the constitutional indica- tions, and the patient is not only cured of her ulcer, but radically cured by the removal from her system of the dyscrasia which, com- bined Avith incidental local causes, produced the ulceration. Hygienic and dietetic measures are of great importance here as in other diseases. Nourishing food should be taken freely, but all stim- ulating food or drink should be avoided. The disordered diges- tion and Avant of appetite should be cared for. Plenty of fresh air and sunlight should be insisted upon for the patient, and a very moderate degree of exercise allowed where not contraindicated. It should be borne in mind that walking, or journeying by railway or any other method of rough riding, may be very injurious. Remedies. 1. Ars., Arg. nit., Asaf., Lach., Lye, Merc, sol., Nux vom., Puis., Sep., Sil., Sulph., Thuy. 2. Bell., Bry., Calc. carb., Carb. veg., Con., Hep., Phos., Phos. ac, Rhus tox., Staph. 3. Ant. cr., Arn., Aur., Carb. an., Caust., Cham., Chin., Creas., Graph., Hydrast., Mur. ac, Natr. carb., Ruta, Sab., Secale corn., Stann. Anti crud. Profuse discharge of acrid Avater, containing portions of pus. Gastric derangement Avith Avhite tongue is often present. The stools are often liquid, containing portions of solid matter. 684 diseases and derangements of the uterus. Argentum nit. Bleeding ulcers, the hsemorrhage being of short dura- tion. She seems dizzy and cloudy in her head; the headache is not severe, but dull and constant. The moral and nervous disturbances come on in quite regular paroxysms every night, in the morning, or at noon, more particularly after dinner. Great debility, particularly in the lower extremities. Much chilliness and nausea are often at- tendant in such cases. This remedy, in substance, is often useful in the old practice, because of its frequent homceopathicity to the case, but it is far more useful in our hands in the two-hundredth preparation, and for the same reason. Asafcetida. The menses are scanty; they are often too early, and last but a short time. The ulcer has high, hard edges, and easily bleeds. The ulcer is sensitive and painful. The discharge is profuse and greenish, thin and offensive. An hysterical condition is frequently attendant upon such cases. Hepar s. c. The ulcer has a bloody suppuration, smelling like old rotten cheese. Its edges are sensitive, and it often has a pulsative sensation. The discharge is also corroding. The ulcer itches very much. Hydrastis. For simple abrasion or other forms of ulceration, even malignant and cancerous. Much gastric disturbance, flatulence and constipation. Sinking or Aveak feeling in the epigastrium. Lycopodium. Red sand in the urine. Great rumbling and commo- tion in the abdomen. Pain in the back. Great depression of spirits. Muriatic acid. The ulcer has a putrid discharge, is sensitive and attended Avith a great sense of weakness. If the anus be very sensitive, either with or Avithout hsemorrhoids, Muriatic acid is sure to be the remedy. Phosph. acid. The ulcer has a copious, putrid, bloody discharge. There is an itching or corroding pain, or the ulcer is entirely destitute of feeling. The patient is apt to be quite indifferent to everything, even to those things which used to interest her most. Secale corn. The ulcer feels as though it had been burnt. It discharges a putrid bloody fluid, and is sometimes decidedly gan- grenous and painless. It is more frequent in thin and scraAvny individuals. Zinc The ulcer has a bloody, acrid discharge, but is of itself rather destitute of feeling. Her various sufferings, headache, etc., subside during the menses. An excessively violent and obstinate pain in the CANCER AND CANCROID. 685 brain sometimes accompanies this ulcer. This pain may even assume the form of an intermittent. For other ulcerations, Avhether thought to be malignant or not, see also the remedies recommended for cancer; since the same remedies may ansAver for either form of ulceration, the malignant as Avell as the non-malignant, the sensational and constitutional symptoms being of primary importance in making the prescription. For sensation of coldness, in the ulcers the folloAving remedies may be consulted, they being placed in the order of their importance in this respect: Bryonia, Arsenicum, Silicia, Mercurius, Rhus tox. Cancer and Cancroid. Cancer is an hereditary constitutional disease Avhich is character- ized by the peculiarity of its several forms, by the progressive nature of its development, by the intensity of its pain, and by its remarkable tendency to terminate fatally. The hereditary nature of the cancerous dyscrasia is proved, in part, by statistics, from a variety of sources, of cases in which the relatives of those subject to cancer have been known to have had the same dis- ease. Among the French authorities on this subject we may mention Velpeau, Avho states that in one-third of his cancer patients he could certainly trace an hereditary taint. Lebert's experience gives but one in twelve as thus constitutionally predisposed. Among English authors we find that Mr. Paget traces an hereditary predisposition in this man- ner in but one in four of the cancerous persons Avho have come under his notice. The statistics collected by Mr. Libbey, at the Middlesex Hospital, show an average of but 8f per cent, of the cases as thus proved to be hereditary cancer cases. In the Cancer Hospital the aggregate collection of the cases seen by the medical officers connected with the institution yields an average of one in seven who had rela- tions previously affected by this disease, while Mr. Cooke, from Avhose recent Avork * on this subject I have taken these details, states that one in four of the cancer cases Avhich have come under his observation give evidence of the hereditary nature of the disease in themselves. But it may be urged that these statistics do but indicate that a large proportion, still a minority, of the cases of cancer appear directly hereditary, as having relations who have suffered Avith the same disease; and that therefore the proof of the hereditariness—that is, of * On Cancer: its Allies and Counterfeits. By Thomas Weeden Cooke, Surgeon to the Cancer Hospital and to the Royal Free Hospital, etc. London, 1865. 686 DISEASES AND DERANGEMENTS OF THE UTERUS. the constitutionality of this disease—is very far from being conclu- sive ; and it may be affirmed that cancer may arise directly in persons who have no hereditary or constitutional predisposition to this form of disease. This conclusion we deem entirely incorrect. And we attach the more importance to a correct statement of the matter be- cause it involves some very interesting practical considerations rela- tive to Hahnemann's psoric theory on the one side, and to the inter- changeableness of different forms of ultimate disease on the other. Thus, in reply to the objection of the insufficient nature of the proof of the constitutionality of cancerous disease, it may be stated that even as individual cases of disease often require a long time to incu- bate before they develop themselves, so the cancerous affection mav have been increasing in intensity for several generations before it reached a sufficient amount of deAdation from the natural state to be able to ultimate itself in an actual cancerous growth. Again, it may be remarked that people do not always know the history of their families, and especially may oversights of this kind be considered probable Avhen Ave remember that the cancer, like other constitutional diseases, may skip o\7er an entire generation. But the main point to Avhich attention is invited in this direction is the fact that this latent dyscrasia, extending from one generation to another, may be developed in entirely different forms in different genera- tions, and in different individuals of the same generation. This fact, which has been in a great measure overlooked, we regard as of great practical interest and importance. It is found that there is another distinct disease, no less fatal, perhaps, and certainly no less surely progresshre in its course, Avhich appears to be the constitutional com- plement of cancer. And this disease is phthisis; which is, like cancer, an ultimate, organic, structural development of a constitutional dys- crasia—Avhich is, like cancer, a tuberculous affection—and Avhich, attacking principally a younger class of persons, destroys its victims in about the same average time that cancer does. These two forms of disease appear mutually interchangeable, since both their ultimate and fatal manifestations appear in different generations and branches of the same family, and in different individuals of the same genera- tion. Thus it happens that cases of cancer which cannot be traced to any cancerous affection in other members of the family may be referred to a strongly-pronounced hereditary predisposition to phthisis; and, con- versely, cases of phthisis are seen to grow out of dyscrasia Avhich in other relatives, branches and members of the same family have been developed as true, malignant, fatal cancer. CANCER AND CANCROID. 687 In the peculiarity of its principal forms cancer differs remarkably from all other organic diseases. These forms are three in number— scirrhous, hard or Fibrous Cancer; Encephaloid, soft or Medullary Cancer, and Colloid or Gelatinous Cancer. In addition to these varieties, Avhen cancerous disease attacks the epithelial surface of the womb—or, in other words, is superficial—it has been termed Cancroid or Epithelial Cancer, although its malignancy and tendency to de- struction and death are assured. The scirrhous seldom or never appears before puberty, is moderate in size and slow in its develop- ment. The encephaloid variety is the one which most frequently appears in infancy; it may occur in any part or tissue of the body; sometimes attains an enormous bulk; is the form which secondary cancerous deposits usually assume; is liable to very dangerous hsemor- rhage ; and Avhen once ulcerated runs a A^ery rapid course. The colloid cancer, itself firm and resisting, contains a peculiar jelly-like matter —occurs only in adults—most commonly in the abdominal cavity; may groAV rapidly and to an enormous size; rarely proceeds to ulcer- ation, and most commonly destroys life by encroaching upon some vital organ, and so permanently obstructing its functional action. The scirrhous form is the most frequently seen, and especially in the female breast and uterus, and is also the most difficult of cure. The en- cephaloid variety comes next in frequency. These different forms of cancer have been by some supposed to represent merely the different stages of the disease, its different states of development. It may indeed be true that particular cases of cancer may, in the course of their progressive development, successively rep- resent, and Avith more or less accuracy, all these various forms. But in general such a statement could hardly be supported by the facts. From the difference in the degree and intensity, if not also in the kind, of the cancer poison, as well as from the innate Arariety of the consti- tutions in Avhich it is developed, the cancer itself naturally assumes a variety of forms from the first. Thus Avhile scirrhous or hard cancer usually softens in its advanced stages, others, like medullary cancers, Avhich may occur in a wider range of human life, in the young as Avell as in the old, and Avhich are more malignant, as being more rapidly fatal, are soft from their very commencement. Still, there does not seem to appear in these different forms any essential difference in the elements Avhich may be deemed the radical constituents of cancer, or any other difference than that of proportion in the manner in A\diich they are combined. The disease is charac- terized by—1, proliferation of areolar tissue; 2, excessive generation 688 DISEASES AND DERANGEMENTS OF THE UTERUS. of cells; 3, tendency to molecular death, invasion of neighboring parts, and return if removed by surgical means, constitutional impli- cation usually progressing until the death of the person affected. All these characteristics belong to every form of cancer Ave have men- tioned. Without stopping here to enter minutely into the discussion of the question as to Avhether there exists a true characteristic cancer cell, histologically distinct from all other normal or abnormal forma- tions—a question once supposed to be settled in the affirmative, but rendered noAV more than doubtful by recent investigations—Ave merely indicate the general elements of cancer structure. These are the so- called nucleated cancer cell, a peculiar fibrous structure, among the meshes of which the cells are found, and a no less peculiar viscous fluid, Avith which the two former elements are more or less abun- dantly surrounded. The combination of these three elements con- stitutes the cancerous growth, and the relative proportion of these elementary ingredients may be considered to determine the form of the cancer itself. Thus, if the fibrous element predominate—as it does in the earlier stages of the great majority of cases—we have the scirrhous form. If the cells are more abundant, we have the en- cephaloma or soft cancer. If the viscous fluid be in the ascendant, there results the colloid or gelatinous cancer. Some cases are anomalous, presenting more the appearance of fungous growths, others again are more like bleeding tumors, hence termed bloody cancers; and it not unfrequently happens, notwith- standing the classification of these malignant affections, that a groAvth will be met Avith which cannot be classified under any of them, and which partakes of the nature of two, or even of all, varieties. But an attentive study of all the symptoms and conditions will enable the practitioner to decide as to the malignant nature of the disease. But such decision, independent of the data upon which it is founded, is of use rather with reference to diagnosis and prognosis itself than from any influence which it should be allowed to exert upon the selec- tion of the remedy. For the remedy must be selected at first hands— that is, from the symptoms themselves, AAdiich will guide aright—and not from our diagnosis of the case, which may be, and often is, wrong. As already implied, the cells which were supposed to be the abso- lute characteristics of cancer, and so called true cancer-cells, haATe more lately been deemed less positively determinate. Virchow,* the latest and highest authority in cellular pathology, considers the dry or juicy nature of the cells as much more decisively indicative of the benig- * Cellular Pathology, p. 530, et seq. CANCER AND CANCROID. 689 nant or malignant character than is their shape or form. "The forms which yield dry,juiceless masses are relathTely benignant; those which produce succulent tissues have always more or less of a malignant character." And in deciding upon the benignant or malignant nature of any growth, he says: " In the case of all these formations, every one of which corresponds more or less completely to a normal tissue, investigations ought not to be conducted Avith a view to determine whether they have a physiological type, or Avhether they bear a spe- cific stamp impressed upon them; our final decision depends upon the answer to the question whether they arise at a spot to which they belong or not, and whether they produce a fluid which, when brought into contact with the neighboring parts, may there exercise an unfavor- able contagious or irritative influence." We make this extract in order to show how modern science is finally compelled to pay tribute to the true spiritual doctrine, rather than to the more gross and external theory Avhich it had before re- ceived as a revelation from nature. The distinction of cancerous from other cells as a matter of external form is no longer deemed reliable, the form being, at least as often as otherAvise, homologous to the nat- ural and healthy cell-forms. The true distinction to which all must finally come is, that as the cancer-cell is itself the result of a morbid deviation, so it tends to perpetuate the same morbid influence im- planted Avithin it. It is a homologous growth as to form, and no less truly homologous in its vital activity, in perpetuating its own disor- dered vitality, exactly as if a ball projected into space in a curved line and meeting no obstruction Avould complete and continue on in the original circle. Thus, all the elements of cancer are positively homologous—that is, similar formations to other and healthy tissues. But they are heterologous in their composition—that is, in the propor- tions in Avhich they are combined to form a cancerous groAvth. In like manner different chemicals may be harmless or poisonous, accord- ing to the different proportions in which the same ingredients are arranged, or, as in the case of those called isomeric, according to the different manner in Avhich the same ingredients are arranged, even in exactly the same proportions. The scirrhous and encephaloid forms are the most common cancer- ous growths of the uterus, the former occurring much more frequently than the latter. But Avhatever may be the condition Avhich gives rise to cancerous formation, " it is certain that any form of the affection may arise from one and the same disorder. This is proved by the facts that several deposits of different varieties may coincidently exist, 44 690 DISEASES AND DERANGEMENTS OF THE UTERUS. that one form may change into another, and that one being removed by surgical means, a different one may replace it."—Thomas. The progressive nature of its development forms another and import- ant characteristic feature of cancer. All the different forms of cancer may sometimes be seen in a single case in its successiA'e stages; they appear to pass into and succeed each other, the indurated forms be- coming softer, but the soft neATer, so far as we are aware, becoming hard. The development may be sIoav, it may occupy years, and for a season appear entirely stationary, although this is scarcely ever the case in cancer of the uterus. Here the disease being usually found to seize primarily upon the vaginal portion of the cervix, the alteration of the tissue will extend from the os externum to the os internum, and from thence it will gradually extend over the interior surface of the body and fundus. At the same time, the softening and other degen- erations of tissue extend from within outward. But the progress of this fearful disease is not confined to the uterus alone. From the in- timate connection of this organ, through its peritoneal covering, with the bladder, the rectum and peritoneum, and directly Avith the Fallo- pian tubes and ovaries, the cancerous affection is in due time commu- nicated successively and in different degree to all these organs, and even to the peritoneum itself. In addition to the other and incidental sufferings which must follow such extension, the cancerous ulceration sometimes occasions vesico-vaginal and recto-vaginal fistulas, acci- dents which very greatly aggravate the pitiable condition of the patient. From the nature of the disease itself as possessing an essen- tially progressive character, it cannot but go on extending its ravages and increasing its tortures, unless arrested in its course by medical skill, until death closes the scene. For as there are forms of disease which are self-limited in their course, extent and duration, so this one of cancer (so named by the ancients from its large surrounding veins and general resemblance to the body and claws of a crab) is just the opposite. It seizes upon tissue after tissue and organ after organ, hardening, softening, wasting away all Avithin its reach, till the ex- hausted system can endure no more. The intensity of the pain forms another and characteristic feature of cancer. This is a sharp, lancinating or stabbing pain. It is similar to that which occurs in felon or Avhitlow, and it is no less acute. " It is not constant, or the patient could not live, but comes at uncertain intervals, and is so startling; as well as severe that it makes the sufferer bound from her chair or couch, not infrequently with a sharp cry of anguish. It is as though a dagger had been thrust into the tumor." This pain » CANCER AND CANCROID. 691 comes in paroxysms of varying duration, which are accompanied by an increased activity of the circulation, a turgescence of the enlarged veins which lead out from the cancer; and the paroxysm may often subside by a more or less profuse hsemorrhage, which seems to relieve the pain. Hence these paroxysms may be regarded as periodic (or irregular) aggravations or acute attacks, superadded to the constant chronic affection. These intense stabbing pains afford an almost infallible diagnostic indication, especially Avhen they thus recur in paroxysms. Such pains appear only (except in the case of felon already mentioned, where there could be no clanger of mistake) in cancer and in acute inflam- mation of the mammary gland. But in the latter cases the two ex- citing causes Avhich lead to mammary abscess—lactation and mechanical violence—will suffice to prevent the pains which attend such condi- tions from being mistaken for cancerous; and besides in these cases of abscess the pains come on much more rapidly, as in fact does the whole inflammation. The remarkable tendency to a fatal termination can never be over- looked in the consideration of cancer. In cancers of the breast and other exposed parts of the body the mischief may be apprehended, and effectual means taken by the exhibition of the appropriate homoe- opathic remedies to arrest its progress before it has too deeply seized upon the system. But cancer of the uterus may become A'ery firmly established before its presence is even suspected. Hence the inva- riably fatal termination of this form of cancer. Originating, as we have already shoAvn, in a constitutional dyscrasia, by its presence, by its derangement of the proper functions of the organ upon Avhich it seizes, and by the serious injury inflicted upon the system by the severity of its pain, it tends to reduce the vital strength, and thus render it more difficult to establish in the system a vital reaction of sufficient energy to throw off the incubus; and this physical depress- ing influence is greatly increased by the moral influence Avhich the knowledge of the terrible nature of her disease must exert upon the . patient herself. Causes.—These are either primary, predisposing, hereditary, consti- tutional influences, or secondary, exciting, provoking causes. Of the former we have already said all that was necessary. Of the latter Ave make brief mention here. And in the first place, it should be remarked, in this connection, that nearly if not quite all the secondary or provoking causes of cancer in the Avoman, Avith Avhich alone we have to do in the pres- 692 DISEASES AND DERANGEMENTS OF THE UTERUS. ent Avork, are directly or indirectly connected Avith her sexual system. Cancers of the womb and of the breast, Avhich form the great majority of all that attack Avomen, are evidently thus directly related, while those Avhich, hoAvever rarely, occur in other parts, either remote from the sexual organs or not in immediate physio- logical relation to them, may be seen to result from general depress- ing influences, which, as in the case of AvidoAvhood, or even of those Avho remain unmarried, have at least an indirect relation to the sexual condition. And in this connection it is interesting to observe the condition in life of a number of cases. Of one hundred and eight cases re- corded by Scanzoni, ninety-one were married, seventeen Avere maidens, thirty-six were sterile, seventy-two had had several labors. Excessive sexual excitation and immoderate coition form one of the most prominent causes of cancer of the womb. In connection with this, it must be remembered that constitutional predisposition plays a most important part. The insatiable desire known to be present in some of these cases, Avhich is of course the immediate cause of such sexual excesses, is itself a constitutional condition, existing before it develops itself in this voluptuous orgasm of the sexual apparatus. In like manner, disorders of the menstrual function, with leucor- rhcea, which, by the author already referred to, are set doAvn as the provoking causes of one-half of his cancer cases, must be deemed to be dependent upon or connected with a true cancerous dyscrasia. Otherwise, why have not the same disorders resulted in cancer in the thousands of other women who have suffered Avith them for years? The same thing again is true of the cases of cancer which are de- veloped under the influence of " emotions of grief, fretfulness, the cares of life, affliction after some bereavement, etc." All these poAverful depressing influences are capable of developing cancer only in those Avomen in Avhose systems are implanted the seeds of a true cancerous dyscrasia, or one which may be interchangeable with it, complementary to it. If we examine the age at which the great majority of cases of cancer occur, we shall find still further proof of their connection Avith the sexual system. The average age at which this disease makes its appearance is about the forty-eighth year. This of course brings the disease in immediate relation Avith the change of life. And in fact there is little reason to doubt that the various causes Avhich so afflict the female economy as to result in the development of this disease find their culminating point at this climacteric period. All CANCER OF THE UTERUS. 693 of the provoking influences already mentioned may concentrate their forces as it Avere at this period, and produce such cancerous disease at or soon after the cessation of the menses as they could not have done before. And this disease may be developed in the uterus or in the breast, or in some other part or organ, under the influence of other local provoking causes, or under the influence of what may be termed a reduplicated hereditary predisposition. For example, a Avoman of cancerous constitution Avhose mother had cancer of the womb will be so much the more likely to have this dyscrasia in her OAvn case developed in the same organ; and married women are much more likely to have cancer of the Avomb at this time than those who have remained single, although many cases of the latter sort are recorded. And in this country this form of disease is much more prevalent in the Southern than in the Northern States. It has been observed that at the South the same constitutional dyscrasia assumes the form of uterine cancer which at the North Avould, at an earlier period of life, have been developed iu the form of pulmonary phthisis. Cancer of the Uterus. The preceding discussion of cancer in general will obviate the necessity of any more than a very brief account of the particular forms and varieties of this disease as it attacks the uterus, breast or other organs. The most common form in which cancer appears in the uterus is the scirrhous. This form may be slow and insidious or very rapid in its development, according as it attacks the older or the younger females, and it is usually the least amenable to treatment. In fact, unless it can be diagnosed in its earlier stages, and properly treated from the very first, the prospect of doing any more than to relieve and prevent suffering, and so perhaps prolong life, is more than doubtful. Scirrhus of the Avomb passes through two general stages, and thus may appear to the physician on his first examination under either of its two forms. These are the primary form of indu- ration and the secondary form of ulceration. Indurated, Non-ulcerated Cancer of the Uterus.—This disease almost invariably attacks the cervix, but in some rare cases it is found primarily in the fundus or body of the uterus itself. From the view we haA-e taken of the nature of the cancerous affection it Avill be natural to conclude, as is taught by high authority on this subject, that the disease does not spring from a previous and different form of inflammation, with or Avithout induration, but that cancer is sui 694 DISEASES and derangements of the uterus. generis—that it arises as it Avere on a general constitutional foundation all its own, seated, built up and developed under the influences of special provoking causes. And from its remarkable tendency to a fatal termination it becomes most important to determine the exig- ence of the disease at the earliest possible moment, but this is no less difficult than it is desirable; for Avhere the indurated form of cancer attacks Avomen at the critical age or more advanced period of life, its onset is gradual and insidious, and it is liable to be confounded Avith the induration Avhich may result from benign inflammation; and Avhere it attacks younger Avomen it may develop itself in a much more rapid manner, and without any such seArere local symptoms as Avould lead to an examination of the affected organ. Disease of the uterus of much less importance than cancer may give rise to much more strongly marked symptoms. " I must again repeat that my own experience, as well as the analysis of that of others, leads me to the conclusion that cancerous growths of the uterus in the incipient or non-ulcerated stage of their development are always indolent, and give rise to no symptoms sufficiently decided to induce patients to complain or to seek advice. Thus we can explain how the disease in its incipient stage does not come under the notice of the conscientious practitioner, Avho never uses the speculum without serious reasons for so doing." Easy as it is, generally, to recognize cancer of the uterus in the advanced periods of the disease, it is often very difficult to distinguish it in the commencement from a simple induration of a benign character in the lower portion of the uterus. The diffused swelling of the affected part, with a considerable hard- ness and complete absence of sensibility, the appearance of the disease at the critical age, and the impossibility of referring the commence- ment of the affection to an anterior labor, may be regarded as charac- teristic signs of the commencement of cancer. And there is no doubt but that in many cases, especially of women who still menstruate, the cancer is ATery rapid in its groAvth and progress, and so may attain considerable size and present extensive induration and adhesion to the surrounding parts, before its existence is suspected; and eATen then the results of A7aginal exploration are said to be insufficient to distin- guish in a certain manner a chronic engorgement of the vaginal por- tion of the cervix uteri from scirrhous induration. A careful study of all the symptoms and conditions of the patient will be absolutely essential in order either to determine the nature of the disease or to decide upon the appropriate remedy. As it is of the utmost importance to distinguish cancer of the womb CANCER OF THE UTERUS. 695 at the earliest possible period, Ave gather from other writers the records and summary of symptoms which may appear before the cancer ad- vances to the ulcerated stage. Among the earliest symptoms are: "Leucorrhcea alone or combined with menorrhagia; aching in the back and sense of heaviness in the hypogastrium; dull pain in the top of the thighs, with bearing down; then there occurs darting, lan- cinating pain betAveen the pubes and the sacrum, or in the course of the vagina, with a sensation of glowing heat, more or less frequently experienced, and often attended with dysuria and mucous deposi- tion from the urine; itching of the vulva, which is affected Avith a kind of flabby swelling or with erysipelatous inflammation; pain in coitu; dyspeptic symptoms prevail, such as flatulence, heart-burn, sometimes vomiting, and sympathetic cutaneous eruptions." Or the appetite may at first be very greatly increased and the digestion ex- cellent, or with attacks of indigestion from over-eating. "In the course of the disease retention of urine frequently occurs, requiring the use of the catheter, or incontinence of urine may take place." The first symptoms generally are: menstrual irregularities; a tem- porary increase of the menstrual Aoav ; leucorrhcea, which is either continued or lasts for a short time only, white or yellowish,, some- times changing to a reddish color after intercourse or after any other local irritation; sense of weight at the hypogastrium, with pressure on the rectum or on the urinary organs; stool and emission of urine sometimes more painful, and ahvays more or less difficult; disagree- able sensation during intercourse; occasional transitory shooting stitches, especially at the period of the menses or after physical or moral excitement; transitory pullings in the loins or groin, and hysterical ailments; hsemorrhoidal distress; alternate distension and caving in of the abdomen, etc. Sometimes Ave discover even at this period slight swellings or indurations of the Avomb, occupying rather the neck than the body of the womb, with a sort of irregularity in the shape of the neck. These symptoms may remain unchanged for a long time, but as soon as cancer has openly set in, the neck, and even the body of the uterus, and likewise the lips of the os tincse, are swollen, hard, knotty, lobed and more or less red, but smooth and not sore, covered with bloody mucus or with pure blood, painful to pressure, and sometimes accompanied by engorgement of the ovaries. In some cases there is only a single clearly circumscribed tumor, the seat and extent of which may be discovered by an exam- ination through the rectum; in most cases there are several tumors. or even, if the entire uterus should be invaded, a group of several 696 DISEASES AND DERANGEMENTS OF THE UTERUS. rounded irregularities at the surface. These tumors might some- times be confounded Avith fibrous bodies if the other signs that accompany the cancer did not render such a mistake impossible. Besides, in its attacks upon the uterus, cancer but very rarely com- mences in the body or fundus, whilst these are the parts which are especially selected by the fibrous tumor. When cancer does involve the body of the uterus, it may be distinguished from fibrous tumor by its presenting a hard swelling of the whole uterus, and by the adhesions to the adjacent parts which attend such malignant in- durations. In attempting at the earliest possible period a diagnosis of a sup- posed cancerous affection of the uterus, Ave should consider— I. The portion of the womb affected, the vaginal portion of the cervix being the most likely to be attacked by scirrhus. II. The extreme hardness and general insensibility of the tumor. III. The period of life, the cancerous disease being most apt to occur at the cessation of the menses. IV. The gradual development of the tumor in such women, or its more sudden appearance in those Avho are younger. V. The severity, lancinating, stabbing and paroxysmal character of the pains. VI. The extension of the disease into the adjacent tissues, and con- sequent adhesion of the tumor to the surrounding parts. The Ulcerated Form of Cancer of the Uterus.—In its second or ulcerated stage cancer of the uterus is much more easily recognizable. The ulceration itself, in connection with the surround- ing induration and the peculiarly foetid nature of the discharge, very strongly marks the nature of the case; while, as the disease advances, the countenance assumes a no less peculiar straAV-colored complexion, which when once seen can almost ahvays be relied upon as an infalli- ble indication of the presence of cancerous affection. "As soon as the cancer has broken out, the pains, Avhich until recently had been tran- sitory, become more permanent, Avith acute lancinating pains, like needles or knives thrust through the part; the loss of blood becomes more frequent and sometimes habitual; a foetid serous or bloody leucorrhoea sets in, which becomes fouler the more the ulceration progresses, being sometimes mixed up Avith small flocks of putrid matter of a broAvnish color, and frequently having an excessively pungent (offensive) odor, or also with little coagula of blackish blood. If the menses have continued so far, they often increase to a flooding; in women where they have stopped they act as if cancer of the uterus. 697 they would reappear; others discharge constantly a profuse watery liquid without smell, or having an insipid sickening odor; at the menstrual period this liquid becomes rose-colored. This serous dis- charge generally indicates that the ulceration has either commenced or is imminent. Pain now succeeds pain; the loins, small of the back, hypogastrium, iliac region, even the nates dovra to the thighs, become the seat of contusive tearing or distensive pains, sometimes mingled Avith smarting pains or acute stitches in the neck of the uterus, and sometimes preventing sleep to such a degree that the patients dare not give themselves up to it." The mental functions remain unimpaired in spite of all these dis- tresses, and these cancerous diseases do not always prevent concep- tion, although the products of such conceptions seldom survive birth or the full term, and in most cases they perish at an earlier period. Neither is the cancerous disease communicable by contact, as is proved by the immunity of the husbands in such cases. As the disease advances in its course the ulceration becomes more extensive; the patient's strength is Avasted by the intense pain, Avhich is noAV almost constant, Avith dreadful paroxysmal aggravations; the loss of sleep and the repeated haemorrhages break down the system still farther; hectic fever makes its appearance daily, or even oftener, leaving the sufferer, after each accession, weaker than before; the ap- petite fails, the digestion becomes impaired, assimilation is impossible, and the life itself is finally exhausted by a chronic disease which orig- inates in its constitutional foundations, and which, while ultimating in a single organ, eventually involves every vital function Avithin its fatal influence. This disease may reach its termination in from five or six months to as many years; in its later stages it may be attended with most obstinate constipation or excessive diarrhoea, or both; the body may be reduced by gradual emaciation so as to resemble a skeleton, or the lower limbs may become infiltrated and the Avhole body bloated as Avith dropsy. In this latter case, especially in those advanced in life, colliquative diarrhoea sets in Avith putrid and dark-colored stools and horrible pains, Avhich reduce the patient to a state of collapse in a manner not unlike that of the Asiatic cholera. The diagnosis of the more frequently seen open or ulcerated can- cer is comparatively easy. Here, in addition to the constitutional symptoms and conditions already referred to under the diagno- sis of the non-ulcerated form of the disease, we have others, af- forded by the touch, the diagnosis being made more full and less 698 DISEASES AND DERANGEMENTS OF THE UTERUS. liable to be mistaken by the indications obtained from the use of the speculum. I. The ulcerated surface is hard and diversified by lobules, tuber- cles and ridges. II. The peculiar pale, straw-colored complexion is very character- istic of this stage of cancerous disease. III. The odor of the discharge from ulcerated cancer, so exceed- ingly offensive and so persistent on the finger after examination, and even in the Avhole room, is alone sufficient to determine the nature of the disease in the great majority of cases. Encephaloid or Medullary Cancer.—This, knoAvn also as hsematoid cancer, melanosis, encephaloid disease, is the most common, next to scirrhus, and may appear in the womb or in any part of the system. It runs a A7ery rapid course, but is more amenable to treat- ment than scirrhus. It is composed, in great measure, of a soft Avhite, pulpy substance, in color and consistence very closely resembling that of the healthy brain, whence its name, encephaloid. The fungus hcema- todes bears the same relation to the medullary cancer that the open ulceration does to scirrhus—it constitutes its secondary stage. When the medullary disease advances to ulceration, red, ragged, bleeding groAvths sprout rapidly from the open surface; hence their designa- tion as fungus hsematodes—bleeding fungus. The medullary cancer is far less liable to form adhesions with the contiguous parts than is the scirrhus. The Colloid or Gelatinous Cancer is much more rare than the eucepbaloid, and consists of a congeries of gelatinous cysts, gener- ally of the size of a hazel-nut, containing serous fluid, and having an investing envelope of delicate structure, which binds the cysts into a connected mass. "This form may exhibit the appearance of small portions of greenish-yellow transparent gum or jelly, arranged in regular cells; hence it is sometimes denominated alveolar cancer." The most common seat of this form of cancer is the abdominal cavity, although it has been known to occur elsewhere. It groAvs rapidly 3 often to a very great size, rarely proceeds to ulceration, but eventually proves fatal by encroaching upon organs whose healthy action is essen- tial to the prolongation of life. Mammary Cancer.—The female breast is even more frequently than the Avomb the seat of cancerous disease. In this situation it is CANCER OF THE UTERUS. 699 much more readily and much earlier detected, and thus an oppor- tunity is offered for administering the proper remedies at the very onset of the disease. The extreme stony hardness of a suspected tumor in the mammse, and the fact that it appears already adherent to the surrounding tissues, will greatly aid in deciding as to its malignant character. Some of these apparently scirrhous formations are developed in consequence of a bloAV upon the breast; many of these, whether they might have finally resulted in open cancer or not, are readily cured and caused to disappear entirely by the exhibition of Conium. (See the article on Mammary Cancer.) Cancroid or Epithelioma.—The special form of cancer known as cancroid or epithelioma differs from other varieties of cancerous disease chiefly in this, that there is less parenchymatous involvement, the disease being more superficial, and the systemic poisoning, usually so rapid in true cancer, being much more tardy of production. Dr. T. G. Thomas Avrites thus lucidly concerning it: "Cancer of the ute- rus, like the same disease in other parts of the body, has tAvo distinct stages—that of formation and that of destructive ulceration. In the first of these a generation of heterologous material takes place in the interstitial portions of the structure affected, and as the second period becomes established a connection is formed Avith the surface by ulcer- ation. In certain cases the morbid influence, instead of exciting in- terstitial deposit, is exerted upon the mucous membrane itself, affect- ing its production of epithelial cells. In such cases less deposit occurs in the tissue underlying the mucous membrane. To this class the names of epithelial cancer, corroding ulcer and cauliflower excrescence have been applied. As Mr. M. H. Collis remarks, its special name is unimportant, ' if its difference from cancer and its analogies to it be kept clearly in view.' " Cauliflower excrescence, as above remarked, is one of the terms em- ployed in designating epithelioma, or, more correctly, it is a special form of epithelioma. It appears at first in the form of a tubercle, Avhich increases in size Avith considerable rapidity, becomes fissured and branches out, forming a soft, irregular mass, Avhich, Avhen Avell advanced, bears some resemblance to a caulifloAver—a resemblance which is often Avanting. It gives forth a profuse and Avatery dis- charge, Avhich is not, however, usually so foetid as the discharge from medullary cancer. It sometimes becomes very large, filling the Avhole vagina, and is very vascular, giving rise to frequent profuse haemor- rhages. 700 DISEASES and derangements of the uterus. Volumes have been written in description of the forms of cancer, but we do not deem it necessary to give more minute accounts of these and the other less common varieties of this disease, since the symptoms themselves will inevitably lead the homoeopathic physician to select the most suitable remedy in each case. Treatment. Remedies for Cancer in general. 1. Ars., Bell., Carb. an., Con., Graph., Hydrastis, Creos., Sep. 2. Aur., Chin., Clem., Magn. mur., Merc, sol., Nitr. ac, Sep., Sil., Staph., Sulph. 3. Apis, Calc. c, Cocc, Jod., Lach., Lye, Murex p., Phos., Phytolac, Rhus tox., Sab., Thuya. Remedies for Scirrhus. 1. Bell., Carb. an., Con., Sep. 2. Aur., Chin., Magn. mur., Staph. 3. Clem., Cocc, Phos., Rhus tox. Arsenicum. Lancinating pain through the part. Terrible dartings and lancinatings, which burn like fire. The more like fire the burn- ing sensation is, the more strongly does it indicate Arsenicum. Acrid, corroding, burning discharges. The discharge may be thin or thick, brown or black. The discharge is often extremely offensive. The sufferings are usually Avorse after twelve at night. The patient is very easily fatigued. Aurum. The Avomb is discovered to be prolapsed and indurated. The pain is like that of a bruise, with shooting and drawing. The mind constantly dwells on suicide. Belladonna. The woman finds it difficult to stand, on account of a pressing down as if the internal organs would pass out. Occasional pains, Avhich come on suddenly and finally leave as suddenly. Flow of blood between the periods; the blood often feels hot. The blood often has a very bad smell, and Aoavs profusely. Violent pain in the back. The parts feel dry and hot internally. Calc. carb. Pale, leucophlegmatic temperament. The feet feel as if she had on cold, damp stockings. Vertigo on going up stairs. The menses flow too often and too abundantly. Sore, burning feeling in the internal genitals. A constant aching in the vagina. Very sensi- tive to the least cold air, Avhich goes right through her. Carbo an. Violent pressing in the loins, the small of the back and the thighs during the menses, Avith unsuccessful desire to eructate, TREATMENT OF CANCER OF THE UTERUS. 701 with chilliness and yawning. Great languor in the thighs before and during the menses. After the appearance of the menses she feels so tired she can hardly speak, accompanied by yawning and stretching. Weak, empty feeling at the pit of the stomach. China. This medicine will be useful when a profuse and long- continued hsemorrhage has seemed to produce the suffering. There is usually an ichorous leucorrhcea and dysmenorrhcea. The patient is Avorse every other day. Flatulency, which is not relieved by dis- charges of flatus. Clematis. For softened scirrhus, Avith corrosive leucorrhcea and lancinating pain, the other symptoms agreeing. Conium. There are burning stitches, stinging, nausea, Aromiting and sadness. The breasts are relaxed, except at the menstrual periods, when they often SAvell and become sore and painful. The urine in- termits in its Aoav. There is much vertigo, particularly on turning her head Avhen lying in a prostrate position. Creasote. Shooting stitches in the vagina; burning and swelling of the external and internal labia. Profuse discharge of dark coagu- lated blood, or of a pungent bloody ichor, preceded by pain in the back. Aggravation of the pains at night; fainting on rising from the bed. She always feels chilly at the menstrual period. Complexion livid; disposition sad, irritable. Graphites. In women inclining to obesity, and whose history reveals a disposition for the menses to delay; swelling of the feet; itching blotches in \7ari0us parts of the body, Avhich discharge a glutinous, Avatery fluid. Now that she has symptoms of cancer her skin is better. The ovaries are also affected. She has violent lan- cinating, stitching pains through the uterus doAvn to the lower ex- tremities. Heaviness in the abdomen, Avith exacerbation of the pains when standing. Jodium. Uterine hsemorrhage after every stool, with cutting in the abdomen and pains in the loins and small of the back. Great weak- ness during the menses, particularly on going up stairs. Long-lasting uterine haemorrhages. More particularly indicated in scrofulous per- sons. Dwindling and falling away of the mammse. Lachesis. More particularly if the cancerous affection be developed at the critical period or as a consequence of the change of life. The frequent haemorrhages at that period may indicate the approach of this disease. Sometimes the pain increases more and more, until re- lieved by a profuse discharge of blood; and after the lapse of a few hours or days the same phenomena are again exhibited, and so on. 702 DISEASES AND DERANGEMENTS OF THE UTERUS. At times the pain is as violent as if a knife were thrust through the abdomen, the pain itself resembling this sensation. Lycopodium. Pains passing through the vagina on stooping. Darting pain in the labia. Discharge of wind from the vagina. Much bor- borygmus and gurgling in the left hypochondrium. All her suffer- ings increase at about four p. m., and abate at about eight or nine in the evening. The urine deposits a red sand; it is often very frothy. Pain in the back before the flow of urine, Avhich is much delayed. Mag. m. If the peculiar constipation of this remedy be present; large, hard, difficult stools, which crumble as they come or to pass the verge of the anus. Let the action of the remedy be continued a long Avhile after the bowels become regular and comfortable, and the scir- rhus Avill also disappear. Mercurius. This remedy may be particularly indicated if there be prolapsed vagina. The inguinal glands sympathize with the cancer- ous affection. In cases in which there is syphilitic taint in the system, see the most characteristic indications for this remedy under Leucorrhcea and Prolapse of the Vagina. Murex pur. Has cured carcinoma uteri where very great depression of spirits, a sort of deep hypochondria, prevails as the characteristic symptom. Nitric acid. In cases Avhere the syphilitic taint is the basis of the affection. The urine is very offensive. The inguinal glands are sym- pathetically affected. The patient is Avorse after twelve at night. Violent cramp-like pains, as if the abdomen would burst, with con- stant eructations. Violent pressing, as if everything were coming out at the vuWa, Avith pain in the small of the back, through the hips, doAvn the thighs. Phosphorus. In tall, slim Avomen, with sense of emptiness in the abdomen; much heat up the back, and a narroAV, tough, dry stool, like a dog's. Cutting pains through the abdomen, sometimes with vomiting. Very sleepy, particularly after dinner. Belching up of an immense quantity of Avind after eating. Frequent and profuse hsemorrhages, pouring out freely, and then ceasing for some hours or days. Rhus t. Is particularly indicated where repeated drenching in the rain has deranged the uterine functions. The menstrual discharge causes a violent biting pain in the vulva. Vitiated discharge, with shooting upward in the vagina. Rheumatic pain and stiffness, re- lieved by motion. TREATMENT OF CANCER OF THE UTERUS. 703 Sepia. Lancinating pains from the uterus to the umbilicus. A putrid excoriating discharge from the vagina. A sense of weight and pressing doAvn, which causes her to cross her thighs lest the organ should escape. Sensation of weight in the anus, not relieved by an evacuation. Very cold feet and hands—icy cold. Great sense of weakness and emptiness at the pit of the stomach. YelloAvness of the face, particularly across the bridge of the nose, like a saddle. Shoot- ing stitches, with burning in the neck of the uterus. Silicia. Discharges of blood between the regular periods. Increased menses, Avith repeated paroxysms of icy coldness over the Avhole body. Attacks of melancholy; anguish in the pit of the stomach. She wishes to drown herself. Foetid, broAvnish, purulent, ichorous leu- corrhcea. Ahvays great costiveness immediately before and during the menses. Momentary attacks of sudden blindness. Staphysagria. Particularly indicated Avhere syphilis or mercurializa- tion acts as an exciting cause. Flow of blood from the genital organs occurring a long time after the critical age. Spasmodic pains in the vulva and vagina. The teeth turn black or shoAv dark streaks run- ning through them. Sulphur. This great polychrest will be found suitable in a large majority of cases if Ave are called early, and if we find a feAv of the following symptoms prominently developed: offensive, corrosive, ichorous leucorrhcea; sensation of heat in the crown of the head; coldness of the feet, or burning in the soles of the feet at night; flushes of heat, Avhich pass off in a perspiration, with faintness. The patient feels remarkably Aveak and hungry at the pit of the stomach from eleven in the morning till noon; she cannot wait for her dinner. She sleeps lightly at night, and aAvakens very frequently. Violent burning in the vagina, with painful soreness during sexual inter- course. Thuya. This remedy wall be particularly indicated if syphilis acts as an exciting cause of the disease. CaulifloAver excrescences, bleed- ing easily, having an offensive pungent odor. To be especially studied, and given in cauliflower excrescences if the other symptoms correspond. Warts, condylomata and other excrescences about the vulva or anus. Ulcers on the internal surface of the vulva. The vulva has a sore and smarting feeling. Pressing and contractive pain in the vulva Avhen sitting. Cramp-like pain in the vulva and peri- neum Avhen rising from a seat. Cramp pain in the vulva, extending as far as the abdomen. For other remedies and indications see Leucorrhcea, Amenorrhcea, 704 DISEASES AND DERANGEMENTS OF THE UTERUS. Dysmenorrhcea, Menorrhagia, Inflammation of the various organs, and compare and study the various remedies there recommended. Gangrene, Putrefaction or Ramollissement of the Uterus. These forms of degeneration of the Avomb arise only in consequence of other primary disorders, and require no particular description in this place. The following medicines should be carefully studied, and the remedy selected according to the individual characteristics of each case : Aconite. When the congestion and inflammation of the part are ex- treme. Great anguish and fear of death. Dry heat of the skin and intense thirst for cold water. When the pain has suddenly ceased, the characteristic discharges have taken place, and the febrile and mental symptoms continue, Aconite is unquestionably the remedy to be administered first and in repeated doses. Apis. Absence of thirst and scanty secretion of urine. Violent stinging, plunging pains. Great restlessness. Arsenicum. Rapid sinking; cold perspiration; extreme restlessness; great fear of death. Aggravation after twelve at night. Thirst for little A\*ater at a time and very often. Undigested food passes the bowels, with great distress and increase of prostration. Repeat the medicine frequently till better. Belladonna. The eyes are much congested with blood. She rather desires death than fears it. There is a strong sense of heat about the vagina; involuntary discharge of faeces and urine. The discharge is foetid. Carbo veg. The patient Avants more air—wants to be fanned all the time in the face. Eructates frequently, with momentary relief. China. Sensation of great distension in the abdomen, Avhich distresses her much. Frequent eructation, Avhich affords no relief. Ringing in the ears. The characteristic discharges of China. Creasote. There is very great fcetor; excoriation and prostration. The fcetor has a pungent effect. Secale corn. The patient is of a passive disposition, of a thin and scraAvny appearance, and subject to passive hsemorrhages. DROPSY OF THE UTERUS. 705 CHAPTER XXXIII. DISEASES OF THE UTERUS—CONTINUED. Dropsy of the Uterus. DROPSICAL accumulations in the uterus may consist of mucous or serous fluids. In the former case they appear to be simply the result of such closure of the orifice of the uterus as may prevent the discharge of its natural secretions. In the latter the fluids assume, in quality and in quantity, rather the character of ordinary dropsical effusions. Displacements of the uterus, by producing flexion of the cervix, and so bringing its walls in contact at the point of flexion, may occasion such an obstruction of its orifice as to cause the mucous accumulation. The same result may folloAV the pressure of a polypus or tumor, or other approximation of the Avails of the cervix; and as amenorrhoea is nearly ahvays associated Avith uterine dropsy, this mucous secretion appears sometimes to take the place of the menses. Cases have been recorded in which these mucous accumulations would occur from time to time in the absence of the menses, and then again disappear on the return of the proper menstrual flow. This mucous form of dropsy of the uterus may thus be called recur- rent, in contradistinction from the other, serous variety, which is more continuously persistent. Mucus from the accumulation sometimes appears to break away Avith more or less regularity, discharging itself and again re-forming. This variety appears in some instances to have relation to the menstrual nisus, aggravating about the time of the usual monthly periods. In many Avomen the cessation of the menstruation extinguishes the inflammatory affection of the Avomb, Avhich has been kept up by the menstrual molimen. But in some cases the deprivation of the monthly discharge increases the inflammation and renders chronic the conges- tion, which before had been but occasional and relieved by the men- strual Aoav. In such cases, while the body of the Avomb becomes the seat of a persistent morbid activity, its neck becomes atrophied, so as to impede more or less the exit of the fluids contained within the cavity of the uterus. The result is, that the womb becomes more and more dis- tended by a sero-sanguinolent, a muco-sanguinolent or a muco-puru- lent fluid. Severe uterine pains of an expulsive character may re- 45 706 DISEASES AND DERANGEMENTS OF THE UTERUS. peatedly occur, till at last the fluid is ejected and the patient is relieved. The same process of formation and expulsion of such accumulations may be reneAved again and again. But in the persistent form of uterine dropsy the fluid appears to be of a much more decidedly serous nature, and to be connected with a true dropsical diathesis. Reasoning fcom the analogy of similar disorders in other parts of the system, we may suppose that in this case there is considerable thinning of the mucous membrane of the uterine walls, and that this serous fluid is secreted from the sub- mucous cellular tissue, or rather from the vessels Avhich it con- tains. This is the idiopathic dropsy of the uterus, and the accumula- tion may go on for years, until relieved by art or terminated by death. Either of these forms of dropsy may be associated Avith hysteria or anaemia. And in those cases of dropsy of the uterus Avhich appear in consequence of structural disease of that organ the fluid is generally mixed with purulent matter or blood; while in certain conditions of the system the dropsical accumulations in the uterus, principally those of the mucous variety, become decomposed, and so give rise to volumes of gas, which may escape with a loud report. This is termed physo- metra; where both water and gas are contained in the Avomb, the term pneumo-hydrometra is descriptive of this anomalous and unusual condition. Dropsy of the uterus may be recognized by the enlargement of the uterus itself; by the sharp pains which may be present; by the sup- pression of the menses by which it is attended ; by the displacements, severe losses of blood, and other and perhaps malignant disorders of the womb which accompany or precede it; by the constant oozing or occasional gushing of fluid from the uterus, or, Avhere no such escape of the fluid occurs, by the long continuance and gradual increase of the enlargement of the uterus itself. Its diagnosis may be assured, hoAvever, by dilating the cervical canal by means of tents if not suffi- ciently dilated, and introducing an elastic catheter Avithin the cavity of the uterus. By a careful observation of all the attendant symptoms and circum- stances of the case uterine dropsy may be distinguished from preg- nancy, with which it is most apt to be confounded, and trom physometra, by the duller sound on percussion and greater gravity of the concom- itant symptoms. And in cases Avhere the catheter or uterine sound is introduced, the discharge, Avhether mucous, serous, purulent or bloody, will go far to determine both the existence of the dropsy and DROPSY OF THE UTERUS. 707 the nature of its cause. And Avhere flexion of the cervix, as in dis- placement, or total occlusion of its canal from organic disease, prevents the introduction of the sound, this circumstance will proA7e scarcely less certainly diagnostic In cases, especially recent ones, principally dependent on occlusion of the cervix resulting from flexion in displacement, the removal of the cause may at once relieve the complaint. The remedies should ahvays be selected after a careful comparison of all the symptoms and conditions, as Avell constitutional as organic and local. And in cases of more direct dropsical condition (idiopathic dropsy), or where the dropsy appears in connection with scirrhus or other malignant disease of the uterus or its appendages (symptomatic dropsy), the evacuation of the accumulated fluids may afford temporary relief, and give more time and better opportunity to remedy both the organic disease and its consequences. Those forms of dropsy Avhich occur in connection with pregnancy, whether the accumulation be formed betAveen the membranes of the ovum and the uterus, or consist in an excess of the liquor amnii itself, have been considered Avith the other disorders accompanying the pregnant state. Dropsy of the uterus, like that in all other organs of the human system, will cause a corresponding sympathetic affection of the Avhole body. Apis. Absence of thirst is very characteristic of Apis in uterine dropsy. Stinging pains, as of bee-stings. Abdomen very tender to the touch. Arsenicum. Very thirsty for small and often repeated portions of water. Water disagrees Avith her; it does not pass from the stomach, but seems to remain there and distress her. The lower limbs seem almost paralyzed. She can hardly walk. She is very Aveak, and easily wearied from exertion. She Avants to be in a warm place and to be Avrapped up warmer. Belladonna. The characteristic symptoms of pressure, as if all Avould pass out of the genital organs, particularly early in the morning. Urine dark and scanty; sometimes it is as yelloAV as gold. She is usually Avorse after three in the afternoon. The tenderness of the abdomen is aggravated by the least jar even of the bed or chair upon which she sits, and she is obliged to step with great care in walking for fear of a jar. Bryonia. The swelling increases during the day and diminishes 708 DISEASES AND DERANGEMENTS OF THE UTERUS. during the night. Her lips are dry; she Avishes to moisten them often. She is thirsty for cold water. The urine is dark and scanty, although discharged frequently, and it deposits a pinkish-colored stain. All her symptoms are aggravated by motion. Her stools are hard and dry, as if burnt. Calc. carb. In persons of a leucophlegmatic temperament. She has been menstruating too often and too profusely; she has some amenorrhoea and dropsy of the uterus and adjacent parts. She has vertigo on going up stairs; fluttering of the heart and faintness. Damp, cold feet. SAvelling at the pit of the stomach. She is very weakly in general. Camphor. Red urine, depositing a thick sediment, with much cold- ness of the external surface. The urine is emitted very slowly, the bladder being nearly paralyzed. The urine is sometimes green. Cantharis. More or less strangury. Tenesmus of the cervix vesicae. Bloody urine. Pains in the limbs; coryza. There is much SAvelling of the uterus, pain in the abdomen, vomiting and fever. China. The dropsy has been deAreloped by profuse hsemorrhages, or in aged women. Uncomfortable distension of the abdomen; she wishes to belch up wind frequently, which, however, affords no relief. Urine dark, scanty and sandy. Colchicum. The urine is very dark, very scanty, and discharged in drops, depositing a whitish sediment. Watery stools Avithout sen- sation. The dropsy had supervened upon the sudden suppression of the menses, Avhich had but just made their appearance. Much flatulency. Conium. The mammse sympathize very much; they enlarge, become hard and painful. The urine intermits. There is vertigo when lying in a recumbent position, especially on turning over. Digitalis. The heart sympathizes very much; the pulse is acceler- ated or intermittent. The stools are very light-colored. Dulcamara. This remedy will be indicated Avhen the dropsical affection makes its appearance after the suppression of perspiration by cold, damp air. Every cold change in the weather makes her worse. Ferrum. Dropsy of the uterus, with great debility and fiery red face. Helleborus. The secretion of urine is almost suppressed; the urine is very dark, and deposits a dark, coffee-ground sediment. Debility; coma somnolentum; piercing pains in the limbs; loose, gelatinous evacuations. PHYSOMETRA—UTERINE TYMPANITES. 709 Kali carb. Will often be found particularly indicated in aged women. Lactuca. ExcesshTe swelling of the abdomen, feet and eyelids. Ledum. Pains in all the limbs; the skin is dry; she feels very cold, and cannot keep Avarm. Worse from warmth. Lycopodium. There is much red sand in the urine. Borboryg- mus, particularly in the left hypochondrium. Sensation of fullness clear up to the throat on eating even a little. Constant sense of satiety. Mercurius. Much perspiration, affording no relief. Constant short and choking cough. Anguish. Phosphorus. (Edematous SAvelling of the hands, feet and face. Cough, shaking and exhausting, Avith shortness of breath. The urine contains quantities of gray sand. The boAvels are loose and stools whitish. Belching up of quantities of Avind after eating even a little. Rhus t. In cases of dropsy resulting from amenorrhcea caused by being drenched in the rain. Rheumatic stiffness. Restless at night; she must change her position frequently. Terrible cough, Avhich seems as if it Avould tear something out of her chest Sepia. Dropsy supervening upon a case of miscarriage. The urine is very putrid, or deposits a clay-like sediment which is difficult to remove from the vessel. She feels as if she must cross her limbs to hinder the escape of some of the internal parts through the vagina. Sulphur. In persons whose skin is full of pimples and eruptions. Heat upon the croAvn of the head, with coldness of the feet. Frequent hot flushes, with spells of faintness. She is unusually hungry before noon, cannot wait for her dinner. The soles of her feet are hot; she must put them out of bed or find a cool place for them. She Avalks all bent over forward. Physometra—Uterine Tympanites. Physometra or Uterine Tympanites consists in the formation and accumulation of gas in the uterus. This is generally the result of the decomposition of certain substances—such as shreds of the membranes, portions of a dead fcetus or of putrid coagula—Avhich may be retained Avithin the cavity of the uterus. It Avould seem, however, to be occasionally an idiopathic affection, in which the gas is generated Avithin the cavity of the uterus by the mucous lining of that organ, and produces considerable distension and discomfort. Dr. Gooch relates instances of this kind. In such cases it is possibly complicated with, and forms a part of, hysteria. 710 DISEASES AND DERANGEMENTS OF THE UTERUS. In the first variety the gas results from the decomposition of a fcetus, or of any extraneous substances remaining in the uterus after parturition; from the decomposition of the products of menstruation, where, by sudden suppression of the catamenia by cold, they may have been retained in the Avomb; or from the decomposition of leu- corrhoeal mucus or of cancerous discharges. All the effluvia from such putrefying processes are foetid and offensive, and many of them are inflammable. In these cases there may be serious constitutional symptoms, and even putrid fever. Symptoms.—The uterus distended with gas forms a round and more or less extended tumor in the hypogastric region; in the idiopathic variety of uterine tympanites there may be no constitutional symptoms, nothing to attract attention save the increase in size or occasional dis- charge of flatus per vaginam. In the symptomatic variety, which results from decomposition, there may be chills, a Ioav form of fever, with symptoms more or less grave, according to the quantity of the matter undergoing decomposition in the womb, and to the rapidity with which the process takes place. Diagnosis.—1. Idiopathic physometra may be distinguished from pregnancy by the resonance of the tumor, by the absence of ballotte- ment, of fcetal movement and of the signs afforded by auscultation, and by the occasional pain. 2. From hydrometra, or dropsy of the uterus, by the greater elas- ticity of the abdominal tumor, and by its resonance. 3. From ascites by the defined shape of the tumor, by its resonance and by the absence of fluctuation. 4. From scirrhous and steatomatous dispositions by the elasticity and resonance of the tumor.— Churchill. The objective symptoms, noisy discharges of flatus, and the cir- cumstances of the patient, as in those cases succeeding parturition, Avill greatly aid in determining the nature of the difficulty. "You can satisfy yourself that the accumulation has been in the Avomb by pass- ing a small canula or a male catheter through the os uteri. Then, by placing the outer extremity of the instrument under water, you can evacuate the tumor through it, and be assured of the escape of gas therefrom."—Ludlam. Treatment.—Idiopathic uterine tympanites may be radically cured by one or the other of the following named remedies, selected accord- ing to the indicating symptoms. The symptomatic variety, inasmuch as it depends upon the decomposition of foreign bodies remaining within the cavity of the womb, may require special attention to re- MOLES—HYDATIDS. 711 move these decaying substances if possible, and injections of warm Avater may be employed to cleanse away the peccant matters. By means of sponge tents the cervical canal may be kept open, thus allowing a free discharge of the noxious material as well as of the gas that is generated. Bromine. Loud emission of flatulence from the vagina. Aggravation of the symptoms from evening till midnight. Rest also aggravates, motion relieves. The left side is the most affected. Lycopodium. Discharge of wind from the vagina. Great sense of dryness in the vagina. The symptoms are worse or come on about four or five p. m., and abate four or five hours later. Much bor- borygmus in the abdomen and in the left hypochondrium. Red sand in the urine. Much pain before urinating. Phosphoric acid. Meteoristic distension of the uterus. She has always a pain in the liver during the menses. She passes large quantities of colorless urine at night. Indifference to all the duties and concerns of life. For other remedies consult those mentioned under Cancerous and Gangrenous Affections of the Uterus. Moles—Hydatids. The various shapeless bodies which are occasionally discharged from the vagina are termed Moles. These may consist of masses of squamous epithelium from the vagina itself, of the membranous pro- duct which is expelled in some cases of dysmenorrhcea, or of fibrinous collections from the cavity of the uterus. These constitute three varieties of what may be termed false or spurious moles, as occurring in the unimpregnated female. The flakes or tubular pieces of squamous epithelium exfoliated from the vagina are easily recognized. " The fibrinous masses ex- pelled from the uterus resemble an almond in size and shape, being to some extent casts of (the interior of) the uterus; they are smooth externally, and possess a very imperfect central cavity. The dys- menorrhoeal product consists of the uterine mucous membrane, exfoli- ated in a more or less perfect form. When entire it has the shape of the cavity of the body of the uterus, is rough externally and smooth within, having a distinct triangular cavity, with two openings aboATe and one beloAV, at the sites of the Fallopian tubes and the canal of the ceiwix uteri."—Smith. The true or genuine moles are all the result of impregnation, and 712 diseases and derangements of the uterus. their different varieties may be arranged under three classes—blighted ova, fleshy moles, vesicular moles or hydatids. In the blighted ova, which compose the first class of these moles, the embryo itself early perishes, Avhile the ovum, being retained, increases in size and solidity, not by the normal growth of regular pregnancy, nor even as in cases of tumor and polypus, but by the effusion of coagulable lymph from inflammation of the lining membrane. This forms successive layers OArer the surface of the dead ovum, giving it eventually a great degree of consolidation. Some of the masses, when cut into, have no cavity, but the chorion and amnion are demonstra- ble, although the enveloping membrane may be one or two inches in thickness. It seems somewhat surprising that the covering of the fcetus should be so carefully constructed Avhen there is no embryo. But such is the fact* In such cases the fcetus is undiscoverable, because it has been dissolved in the liquor amnii, but the remains of the umbilical cord may, however, be generally discerned attached to some part of the inner surface. In addition the membranes may be traced, Avith the placental development, on some portion of the periph- ery of the ovum. The influences which cause the death of the embryo transform the ovum from a perfectly normal development into a more or less dis- organized mass, Avhich is sooner or later expelled as a foreign body. The blighted ovum, if not expelled within tAvo or three months, degen- erates into a fleshy mole.f The influences which originally destroy the embryo are usually supposed to consist in certain already-men- tioned changes in the structure of the ovum itself. But we believe the reverse to be the case—that disorganization of the ovum and membranes results from embryonic death in the first instance. Whence then come the fatal forces ? That on the maternal side all is comparatively well is implied in the continuation of the original growth of the ovum considered externally. That the fatal element may have been inherent in the more interior constitution of the female ovum is indeed possible. But in most cases Ave believe it is originally contained in the seminal aura of the male, and thus im- parted to the ovum in fecundation. In many instances in Avhich the husband has been affected with syphilis Avhich has been treated allo- pathically, and so completely suppressed externally as to induce the belief of a radical cure, the offspring come into the Avorld Avrinkled as if with old age, prove entirely incapable of independent nutritioiij and constantly decrease in weight from the moment of birth till that "*Ashwell f Churchill. MOLES—HYDATIDS. 713 of their death. These received from the paternal side the element Avhich destroyed their vitality as soon as the support of the mother (in utero-gestation) was withdraAvn, and the stores laid up by her in the mass of the infant's body were consumed. Just so in those cases where a still more concentrated and active form of the fatal element is imparted by the male; by the time the supplies originally furnished by the ovum are exhausted, the embryo is blighted, destroyed, and the vital forces which should have formed the fcetal body are vitiated and perverted, till the mole is the only result. Fleshy Moles appear to be but the fuller development of the perverted process just described in connection with blighted ova. They remain three or four months, " until at length the degenerated ovum is expelled, consisting of the nest-like membranes and a small embryo of two or three Aveeks' growth, or in some instances the fcetus may ha\re disappeared, and traces only of the umbilical cord remain." They may either consist of a solid mass, or they may contain a central cavity possessing a distinct lining membrane, in Avhich there yet re- mains some of the liquor amnii. The solid moles are generally much larger than the holloav ones, and of a more irregular form. The larger ones are about the size of tAvo fists. If the texture be exam- ined, it Avill be found solid, but not very dense, spongy like the pla- centa, but more filamentous in some parts; in others consisting of fibrinous clots, and also portions of the fcetus, such as one or other extremity. The limbs of the foetuses have occasionally, though very rarely, been discovered.—Churchill. Hydatids, or Vesicular Moles, constitute Avhat are termed hydatiginous degenerations of the ova. They have also been termed " cystic degeneration of the chorion.'' " The hydatids themselves, in the recent state, are full of transparent fluid, and are either round, pyriform or oblong in shape, the size of the vesicles greatly varying. Some of them are borne upon pedicles, others are groAving from the larger hydatids. As a rule, the activity of the groAvth and the in- crease of the villi (Avhich degenerate into hydatids) are greatest in early pregnancy, and it is at this time that the hydatiginous degene- ration is most prone to occur." These hydatids bear a very close ex- ternal resemblance to polypi or pediculated tumors—so much so that some of the latter-named groAvths occurring in the virgin female have been considered to be hydatids. But it is now Avell settled that the name hydatids should be applied only to such formations as may arise 714 DISEASES AND DERANGEMENTS OF THE UTERUS. in connection Avith or subsequent to sexual intercourse and impreg- nation ; although here it must be remembered that the death of the embryo not being immediately folioAved by the expulsion of the ovum, the molar formation may be retained for months, and the hydatiginous variety for years, and then be discharged Avithout prej- udice to the character of the female, who may have become a widow in the mean time. The hsemorrhage which is apt to occur at the period of the expul- sion of the hydatids by successive installments renders them more dangerous than moles of other varieties. Molar pregnancy, Avhich results from the presence of the hydatid variety, is more strongly marked, since in this form the uterus at the fifth or sixth month may be as large as it should be at the end of pregnancy. It is not easy to determine the presence of this disease Avith absolute certainty, at least in the early months. But the dura- tion of the abdominal enlargement beyond the term of utero-gestation, the disproportion betAveen the size of the tumor and the period since it was first observed, together with the absence of quickening, of all fcetal movements and of the sounds of the fcetal heart, will conclusively prove that a regular pregnancy is not present. Then the greater weight of the abdomen and the absence of resonance will distinguish it from physometra. The absence of the sense of fluctuation will in like manner serve to distinguish molar pregnancy from hydrometra. The occasional hsemorrhages, and even the irregular discharge of a colorless, inodorous, aqueous fluid, are relied upon by some authors as unfailing diagnostic signs, but they are by no means sure to occur in every variety of molar pregnancy; and even when they are present they are far from being so characteristic of the existence of moles as to afford any positively reliable indication. The use of tents and the introduction of the uterine sound will enable the practitioner to dis- tinguish hydatids from uterine polypus, while from cancer it would be* known by the absence of the foetid discharge and the general con- stitutional disturbance. Treatment. A careful study of the symptoms of the patient will be necessary in order to determine the nature of the case and to make the proper prescription. As abnormal growths, the womb seeks to expel these moles sooner or later. This is effected by uterine contractions and pains similar to those of ordinary confinement, but more closely re- sembling such as occur in cases of miscarriage after the death of the UTERINE POLYPI. 715 fcetus. The large quantity of water and sanguineous discharges which may attend such efforts at expulsion sometimes render the case Arery serious; and it will be the object of the homoeopathic practitioner to promote this expulsion, and so remove the cause of the dangerous condition. But few special indications for the selection of remedies can at present be given. To promote the expulsion, Pulsatilla, Secale corn, or Caulophyllum may be given. The hsemorrhage which may follow such expulsion must be treated as are other hsemorrhages, according to the indicating symptoms. Calcarea carb. and Silicia have been recommended to remove a disposition to the formation of moles. Natrum carbonicum has been successfully administered in several cases. The following remedies have been recommended for particular study in these abnormities: Calcarea carb., Sulphur, Silicia, Mercurius, Aconite, Arsenicum, China, Ferrum, Graphites, Belladonna, Hyoscyamus, Kali carb., Lycopodium, Sabina, Sepia. And in general all the remedies mentioned in this Avork under the various heads of Cancer, Tumors, Polypi and Dropsy should be carefully studied and compared, for it is only by selecting the medicine in accordance Avith all the constitutional symptoms and con- ditions in such cases that we can hope either to promote the expul- sion of these morbid growths or to prevent their recurrence. Uterine Polypi. On page 607 reference has been made to Vaginal Polypi. We noAV come to treat of those peculiar and sometimes dangerous growths from the uterus known as Uterine Polypi. Polypi have been divided into three varieties, corresponding to their general differences of structure; these are the Glandular, the Cellular and the Fibrous. Glandular polypi consist in enlargements of the glandulse Nabothse in the canal of the cervix. They sometimes occur in clusters about the size of currants, and are suspended by very fine pedicles. Cellular, mucous, fibro-cellular, gelatinous or vesicular polypi are the least frequent, grow Avith the greatest rapidity, and may attain the most considerable size: these have already been sufficiently described under the head of Fibro-cellular Tumors or Soft Polypi. The Fibrous polypi constitute the most com- mon variety, and may occur at the same time in the uterus and in the nasal fossse. These morbid growths received the name polypus, or many-footed, 716 diseases and derangements of the uterus. partly from their fancied resemblance to the Polypus marinus (a sea animal), and in part from their being found in some cases to take their rise from more than one stem or foot. They are generally round oval or pyriform, but may assume other shapes in consequence of the pressure of the surrounding parts. The polypi are covered by the mucous membranes of the uterus or vagina, from which they arise; they may vary from the size of a filbert to that of a child's head; they are mostly insensible to the touch, but bleed from the least contact, as well as spontaneously. They are attached to their base by a pedicle of variable size, sometimes being connected by a slender stalk, like that of a leaf, at others by a fleshy attachment of con- siderable thickness. The glandular polypi are soft in texture, and may contain a small quantity of mucilaginous fluid. The cellular variety is soft, and in great measure composed of cells Avhich contain yellowish liquid. The fibrous polypi are more dense in structure, sometimes hollow, and either empty or containing blood, gelatinous or fatty matter, and hair. And whatever may be their structural consistence, hard or soft, vascular, mucous or fibrous, Avhatever their variety in size, and Avhatever the circumstances attending their de- velopment, all polypi have these two general characteristics: they take their origin from cavities or outlets of the body Avhich are lined by mucous membrane, and they are attached by a pedicle or stem. The polypi are made up of different constituents—Avascular structure, fibrous tissue and mucous membrane—and these different tissues are but the prolongations of the mucous and sub-mucous organs from which they spring; or they may be considered as hypertrophies of some of the minute glands or mucous follicles, attended by a corre- sponding hypertrophy of all the neighboring organic tissues, Avhether mucous, cellular or fibro-celLular. And according to the different proportions of these constituents and of the fluid infiltrations, the polypus itself becomes hard or soft, fibrous or vesicular, as is the case in the formation of hard or soft cancer. As regards their exact seat in the genitals, polypi occasionally arise from the vaginal walls, less often from the mucous membrane of the fundus, but more frequently from the interior of the cervix uteri, and even from the os. In addition to these three most general \^arieties of polypus, some authors enumerate also certain other morbid growths as polypoid, though Ave think Avith hardly sufficient reason. The causes of polypi are not very definitely ascertained. Any condition which tends to keep up a congested condition of the uterus may lead to hypergenesis of the constituents of the mucous mem- UTERINE POLYPI. 717 brane, which may take the shape of uterine polypus, but of the deter- mining cause nothing is positively known beyond this—that they may take their origin from a certain dyscrasia of the system which is less positively malignant than that which is developed in the form of cancer. As already stated in treating of the fibro-cellular tumors —which if pendulous are properly termed soft polypi—these growths sometimes appear in connection with actual cancerous disease. Polypous tumors may appear in single or married Avomen, mostly of the middle age; they do not necessarily prevent conception, but usually appear to destroy its product by abortion. The symptoms Avhich make their appearance in connection Avith polypi are very important. These groAvths are not themseh^es par- ticularly sensitive or painful, but a very severe form of inflammation is almost ahvays attendant upon their presence. This may arise from the same general influences Avhich develop the polypi themselves, or in consequence of the irritation which the morbid growths occasion in the lips of the os uteri and other parts Avith which they come in contact. Ulceration of these irritated and inflamed surfaces is not uncommon. The other most remarkable and constant symptom of polypus is the haemorrhage, Avhich is hardly ever wanting. Haemorrhages Avhich arise in connection with polypi are irregular as to their time and quantity, but constantly recurring, and by no means proportioned to the extent of the tumor. A small polypus may occasion as great a loss of blood as one much larger; and it is said that the very large polypi are less troublesome in this respect thaii those which are smaller. The reason of this liability to greater loss of blood where the polypi are small than where they are large will be found in the fact, now perhaps for the first time stated, that the hsemorrhage itself is not from the polypi at all, but from the inflamed, congested mucous sur- faces of the adjacent parts. The small polypi especially have no such vascular developments as would account for the alarming hsemorrhages which often appear in connection with them. The discharge which appears in connection with polypus is either mucous or muco-purulent. In other respects the constitutional symp- toms are very similar to those Avhich arise in cancerous cases, even to the sallowness of the complexion; only the intense, lancinating, stab- bing or burning pains, singly, successively or in paroxysms, Avhich are constantly the attendants of cancer, do not appear to result from polypus. Neither is the discharge so offensively foetid. As a general 718 diseases and derangements of the uterus. thing, the presence of uterine polypus is readily detected by touch or the speculum. But if the growth be small, and attached high up within the caAdty of the body, the use of the'probe will be necessary to make the exploration complete. In some cases it may be necessary before introducing the probe to dilate the cervical canal and internal os by means of tents. Treatment.—It occasionally happens that the womb of itself throws off a polypus, breaking its attachment and casting it out as a foreign body; or, again, that the groAvih becomes disorganized and broken up, and is washed aAvay gradually by the uterine secretions; but such terminations are not to be expected, and, as the drain upon the vital forces by frequently repeated and profuse hsemorrhages may produce very serious constitutional effects, Avhich may even result fatally, it may be fairly said that the sooner a polypus is removed after its pres- ence has been detected the better it will be for the patient. Where these groAvths do not give rise to any serious disturbances it will be well to attempt their removal by means strictly medical. In such a case the remedies laid down on pages 580, 581 and 608 may be consulted with great advantage. Again, there are many cases in which any mechanical means used to remove a polypus—especially if it be intra-corporeal, for instance—may result very disastrously; Avhereas by strict adherence to homoeopathic principles in the selec- tion of remedies to meet the symptoms and conditions of the patient, not only are sufferings mitigated, but the best means are being re- sorted to to bring about a spontaneous cure, either by a casting off of the morbid growth or by its absorption. When, however, the pres- ence of the polypus absolutely endangers life, and there is good reason to apprehend a speedily fatal result if it be not promptly removed, the removal may be accomplished either by excision, torsion, the ligature, ecrasement or the galvano-caustic wire. If the polypus be situated in the Angina, its removal is not difficult, or even if it be Avithin the cervical canal external to the os internum; but if its at- tachment be within the corporeal cavity, there may be considerable difficulty attending its removal. If it be necessary, the cervical canal and os internum must be dilated by means of appropriate tents, and the growth draAvn down as much as possible Avith a tenaculum fixed into it. If, from the situation of the tumor or the extent of its attachment, it cannot be safely removed entire, it may be taken away piecemeal, or freely incised, with the hope that its vitality Avill be thereby destroyed, and that it will then slough away and be dis- charged. uterine firroid tumors. 719 Uterine Fibroid Tumors. These morbid growths may be developed in any part of the uterus, but the body or fundus is most frequently their seat. They consist essen- tially of hypertrophied uterine tissue, to Avhich they are homologous. As a general thing, they consist of connective tissue and hypertrophied muscular texture, and they present under the microscope an appearance of " long, fine fibres, generally united in bundles; of fusiform fibre- cells analogous to fibro-pl^tic elements, and of round or elliptic granules of small size, the Avhole being bound together by fine inter- cellular substance." Sometimes these tumors are characterized by the formation of cysts within their substance, and Avhen this condition exists the groAvth is denominated a fibro-cystic tumor. These tumors vary greatly in size, in some instances being very diminutive, of the size of a pea, and in others attaining a groAvth of almost fabulous proportions. They haAre been divided into three varieties, according to their situation—viz., sub-peritoneal, sub-mucous and intramural or interstitial fibroids. The first variety has its growth from the surface of the peritoneum attached to the womb, and may be detected through the abdominal parietes as a somewhat loose tumor Avithin the pehdc cavity. The sub-mucous fibroid grows from the sub-mucous tissue of the Avomb, and either distends the mucous lining, pushing into the uterine cavity, or the muscular wall, pushing the tissues outward. The intramural variety grows Avithin the uterine Avails, enclosed in its proper capsule or envelope, and is generally very sIoav to increase in size. The causes which produce these tumors may be said to be un- knoAvn. They occur most frequently in Avomen of the negro face. It is highly probable that they are dependent, so far as a predis- posing cause is concerned, upon the scrofulous or some other systemic poisoning, excited into peculiar action by uterine functional derange- ments incidental to pregnancy, parturition or menstruation. Uterine fibroids are liable to various changes of structure, such as fatty, cartilaginous, or even calcareous degeneration. They are liable likeAvise to become inflamed and to suppurate, and sloughing likewise occasionally occurs. An cedematous condition of the tumor may occur by Avhich its bulk is greatly increased, and the subsidence of this may give rise to the opinion that the tumor itself is disappear- ing. A spontaneous disappearance is possible, however, and this is most apt to occur at the menopause, a retrograde metamorphosis of tissue occurring at that period as a consequence of the subsidence 720 DISEASES AND DERANGEMENTS OF THE UTERUS. of the menstrual function with its congestions and other accom- paniments. The symptoms developed by uterine fibroids are many and various, inasmuch as they embrace all those Avhich result from a variety of dis- orders Avhich they excite, such as uterine displacement, endometritis, cystic or rectal disturbances, pelvic peritonitis, etc. The most constant symptoms, howrever, are—excessive menstruation, or uterine hsemor- rhage not connected with menstruation; profuse leucorrhcea; more or less pain through the pelvic region, aijjl pain extending down the thighs from pressure on the crural nerves; dysmenorrhcea; irritability of the bladder and rectum. Most of these symptoms may be absent in some cases, and this is particularly true of the sub-peritoneal variety. Diagnosis Avill not be difficult if the tumor be large, but if it be small or of medium size, its detection may be a matter of greater difficulty. Abdominal palpation, rectal and vaginal touch, the speculum and the uterine probe may all be required in effecting a differential diagnosis. Impacted fseces, solid ovarian tumors, pelvic abscess or hsematocele, and displacements of the uterus may be confounded with this disease. Treatment.—Consult the remedies mentioned on pages 580, 581 and 608. Any remedy in the Materia Medica may be suitable in these cases. The violent procedures recommended by the gynaecologists of the old school have nothing to recommend them in the way of results, and the homoeopathic practitioner, by carefully choosing a remedy in strict accordance with the principle^ laid down by Hahnemann, may do much better, and cannot do worse in these cases, than the dominant school of medicine. The physician should enjoin upon his patient the necessity of leading a regular life, of abstaining, as much as possible, from coition and other sexual excitations, and of removing all obstruc- tion to free circulation by wearing her clothing loosely and supported from the shoulders. Properly directed hygienic and dietetic measures, in these cases as in all others, will be found to be great aids to the homoeopathic remedy. DISEASES OF THE OVARIES. 721 CHAPTER XXXIV. DISEASES OF THE OVARIES. THE nervous centre of the female organization has been described as residing in the sexual system, of Avhich the ovaries constitute the ultimate foci. Hence it might be expected that these organs would be subject to disorders, both nervous and inflammatory, similar to those which affect the uterus; and such in fact proves to be the case, notAvithstanding their great dissimilarity of structure. Thus, as the uterus is found subject to nervous irritability, neuralgia, acute and chronic inflammation, displacements, ulcerations both benign and malignant, dropsy, tumors and other forms of structural disorganiza- tion, so the ovaries are in like manner liable to nervous irritation, ovarialgia, inflammations, displacements, tumors, dropsies, and a great variety of organic degenerations. These disorders of the ovaries, even while presenting no apparent change of structure, exert a controlling influence upon the other por- tions of the sexual system, and so upon the entire constitution. Some of the most important of these disorders, being comparatively obscure, are liable to be overlooked in the consideration of more obvious de- rangements of Avhich they are still the efficient causes. By reason of their situation the ovaries are less exposed than the uterus to external injury, but from being as it Avere the centres of the entire sexual system, these structures are liable to have concentrated in them all the morbid influences arising from functional obstruction in the dependent organs. And the fact that the ovaries are thus exposed to disorders reflected from other parts of the generative apparatus, in addition to those Avhich may arise from their own functional derangement and structural disorganization, shoAvs the primary importance of a careful study of all ovarian disorders, not only by themselves, but still more especially in their connection Avith morbid conditions of other organs. In the ovaries are implanted the seeds of life and of death. And these latter may destroy the impregnated ova while yet contained in the Graafian vesicles; cause the product of conception to be blighted in the Avomb, resulting in a molar instead of a true pregnancy; produce abortion at three months, a still-born child at full term; or finally destroy life at any period short of the normal three score years and ten. 46 722 DISEASES OF THE OVARIES. Some of the forms of ovarian disorder are very common and im- portant, although not necessarily very obvious; these will be fully described. • Others, which are rare, Avill be briefly mentioned, so that they may be recognized when they do appear. In either case a care- ful study of all the attendant symptoms will be equally essential in order to make a proper prescription. Nor in many cases will the pathological details or diagnosis greatly aid in making such a pre- scription. But the homoeopathic physician needs to become familiar Avith the possible forms and terminations of such disorders, in order to knoAV how to examine such cases and to anticipate their natural course. And noAvhere is the superior advantage of the homoeopathic practice more obvious than in the anticipati\re treatment of forms of disease so obscure, so deep-seated and so formidable as are many of those to which the ovaries are liable. The single fact that ovarian tumors seldom or neArer appear in persons Avho have been brought up under homoeopathic treatment at once illustrates and confirms this statement. The Fallopian tubes no doubt Arery strongly sympathize Avith the uterus and the ovaries in their disordered conditions, but we have not deemed it necessary to make any particular mention of the various morbid conditions to which these organs are liable, partly from the difficulty of distinguishing any separate affections of these tubes, partly from the fact that those disorders which attack them from sympathetic connection with other organs will be most readily re- moved by treatment directed (in general) to the primary seat of dis- order, and partly from the fact that all the symptoms must in any event be considered in prescribing for these disorders. And this totality of the symptoms may be just as truly and completely arrived at in these cases whether we pay special attention to the Fallopian tubes or not. Ovarian Irritation. Ovarian irritation is the analogue of irritability of the uterus. By some authors this affection has been termed sub-acute ovaritis, but Ave think Avithout sufficient reason, since, as will be seen from the descrip- tion, the symptoms are not inflammatory, but purely nervous, and, as already intimated, ovarian irritation may be either the cause, the primary indication or the consequence of severe disorder of some other organ of the sexual system. It may appear in Avomen of all ages between the commencement and cessation of menstruation. Princi- pally an affection of the unimpregnated female, it is most frequent in OVARIAN IRRITATION. 723 those of a delicate nervous temperament, although by no means con- fined to them. Symptoms.—A certain sense of uneasiness, which may become a very severe pain, in one or both iliac or inguinal regions, but most frequently in the left, forms one of the chief characteristics of this disorder. This pain may be either a dull aching or a more acute sensation; it may appear in paroxysms, especially after fatigue or OArer-exertion; it may be aggravated by gentle pressure, but is some- times capable of being relieved by severe pressure, and may entirely disappear in a state of rest, leaving no evidence of its previous exist- ence. " The pain is much more severe than in chronic inflammation of the ovarian tissues. It is indeed often intense, comes on in paroxysms, is seldom aggravated, but is often moderated, by firm pressure from a hand, a bandage or abdominal supporters constantly worn. It extends to the groin, to the front and inside of the thigh, and sometimes is evidently connected Avith pain in the back. It is unaccompanied by any enlargement which can be discoATered by an external or internal examination. The patient has no fever (inflam- matory or hectic), is often not emaciated or anaemic, and frequently, as regards her organic life, is perfectly Avell, with plenty of rich blood, strength and physical development. The pain may be very persistent for days, months and years, Avithout any local or general change en- suing. In many patients brought to my care the antiphlogistic treatment had been perseveringly and repeatedly resorted to, in all its modifications, by rest, leeches, fomentations, by blisters and other revulsives, and had entirely failed to afford any permanent relief, but had rather aggravated the sufferings by debilitating the patient, and thus rendering her nerves more sensitive and her suffering greater."— Hodge. " When the irritation is great it may be extended to the bladder, giving rise to a desire to evacuate its contents frequently, and causing great pain in doing so. Hysterical paroxysms are by no means unfrequent. In two of the most violent cases of hysteria that I have seen for some time there Avas extreme tenderness of the region of the left ovary, and pressure there aggravated the hysterical paroxysms."—Churchill. These sufferings from ovarian irritation are unaccompanied by any sympathetic pain in the breasts or fever, as is the case in actual inflam- mation of the ovaries. " Should the skin on being lifted give great pain, it cannot depend on a deep-seated lesion; irregular variations and the complete subsidence of pain point to neuralgia (ovarialgia)."— Tilt. We have given these fragmentary descriptions of this affection 724 DISEASES OF THE OVARIES. from different authors in order to distinguish it from ovaritis (even sub-acute), and as containing pretty nearly all the symptoms by Avhich it is characterized. Various forms of disorder of the female organism appear in connec- tion Avith ovarian irritation, either as its causes or as its consequences. These Ave will indicate Avithout attempting to distinguish the former from the latter. Nor indeed Avould it be essential to make this dis- tinction, even if it were ahvays practicable, since avc must ahvays prescribe for the totality of the symptoms present. Causes and Connections.—Ovarian irritation scarcely ever appears entirely alone; usually it is accompanied by a corresponding irrita- bility of the uterus, or by some other morbid condition to which it either gives rise or by which it is itself caused. In many cases it is impossible to determine Avhat are the exact relations, as primary or secondary, which these various and concomitant affections bear to each other. Nor indeed is it essential, for on the one hand they are all alike caused no doubt by some profound constitutional dyscrasia, and on the other hand they are all alike to be taken into consideration in our prescriptions. And in either case the symptoms present, as in displacements of the ovaries, and the conditions of aggraAration, as Avorse from motion, will sufficiently indicate the requisite hygienic directions. A certain amount of ovarian irritation is frequently found in con- nection with amenorrhcea. The absence of the menses may be due to the same morbid condition of the ovaries that constitutes the irritability itself, or the irritation may be the result of a sudden sup- pression of the menstrual flux ; or other deep-seated and constitu- tional causes may at the same time occasion an irregularity or total absence of the menstrual discharge, and an irritable state of the ovaries and other sexual organs. The sudden suppression of the menses, as from cold, will almost necessarily result either in irritation or in acute inflammation of the ovaries. This condition is not very different from that in Avhich there is a deficiency of action from some latent dyscrasia or organic imperfection in the ovaries. Here the ovarian nisus is incapable of effecting its normal development, but only produces a» irritable condition of the ovaries themselves; for it must always be borne in mind that as organic inflammation is the result of congestions or obstructions of the arterial or venous blood- \Tessels, so nervous irritation is the result of suppressed, imperfect or excessive functional action. In dysmenorrhcea there is ahvays more or less irritation of the ovaries, and this general irritability will be OVARIAN IRRITATION. 725 found to be greatly aggravated at the period of the menstrual nisus. The importance of carefully observing the morbid conditions (irri- tation, " congestion ") of the ovaries, even in their incipient stage, on account of their strong disposition to lead to serious disorder, is well expressed by Dr. Duncan : " The propriety of attending seriously to the symptoms of congestion (irritation) of one or of both ovaries, as rendered evident by thrilling pain a little above the centre of Pou- part's ligament, accompanied by tenderness on pressure and increased by the erect posture, ought to be strongly insisted upon. Whether the pain be constant or intermittent, returning at or exacerbated during the monthly crisis, accompanied by menorrhagia or co-existing with amenorrhcea and chlorosis, it should receive our urgent consid- eration ; for when an organ has been congested for any length of time such a state is difficult of eradication; morbid changes rapidly occur and irremediable mischiefs result." Menorrhagia will sooner or later induce ovarian irritation, in con- sequence of the nervous Aveakness of the sexual organs and of the whole, system Avhich folloAvs such exhausting discharges. In all the abnormal varieties of menstruation—in profuse as AA^ell as in sup- pressed menstruation—the ovaries are often the organs most severely affected. And even where the profuse flow originates in a morbid condition of these organs, the reflex influence of such flow is capable of greatly aggravating the original morbid condition. In some in- stances ovarian irritation seems to be the result of erosion or conges- tion of the cervix uteri; in others the irritability appears only on the repression of such organic diseases by the barbarous surgical treat- ment of the allopathic school. The relation of amenorrhoea to ovarian irritation has already been explained; and in those forms of dysmenorrhcea which are due to im- perfect or difficult ovulation it is easy to see that the ovaries must be in an irritable condition. Thus, the entire absence of sexual inter- course, its imperfect performance, or excessh'e indulgence in coition may, in different Avays, lead to the same state of ovarian irritation; and in many cases of sterility the only assignable cause will be found in a similar irritability of the ovaries. Hysteria is a no less invari- able attendant upon this form of irritation, but it must be regarded rather as the consequence than as the cause of the irritability, since, as already stated in a previous chapter, hysterical paroxysms may sometimes be immediately produced by pressure of the fingers upon the ovaries. For treatment of Ovarian Irritation see remedies for Inflammation of the Ovaries. 726 DISEASES OF THE OVARIES. Acute Ovaritis. Acute ovaritis may be idiopathic or puerperal, according as it arises directly from local or constitutional influences peculiar to the ovaries, or results from peritoneal inflammation succeeding to abortion or parturition. Description and Symptoms.—Idiopathic ovaritis is comparatively rare, except where it is the consequence of external injury. It is most apt to occur just previous to, during, or immediately after the menses. The ovaries themselves swell to three or four times their natural size, and their peritoneal covering usually becomes tender and inflamed. Scattered through the substance of the inflamed ova- ries will be found purulent matter, contained in cysts Avhich have been supposed to be the Graafian cells filled Avith pus of their own secreting. The patient suffers with severe, deep-seated pain in the pelvic cavity; the pain is accompanied by a burning sensation, and is made much Avorse by. motion. If the peritoneal covering becomes involved, the pain is rendered much more acute and lancinating, aggravated by pressure and by sud- denly assuming the upright position, AA'hile the former tenderness on pressure, instead of being confined to the ovarian regions, will be found to have extended OA7er the whole surface of the abdomen. In the severer forms of ovaritis the feATer and other symptoms will greatly resemble those constituting peritonitis; " the skin is hot, the pulse quick and concentrated, the stomach becomes disordered, and nausea and vomiting occur." The inflammation usually does thus extend more or less over the adjacent peritoneal membranes, causing dysuria and ATery frequent and painful micturitiou, or the inflamma- tion may be directed more posteriorly, and the rectum rather than the bladder become principally affected. In this latter case there may be frequent and ineffectual calls to evacuate the bowel, even with distress- ing tenesmus. " In the earlier stages of idiopathic ovaritis, nausea, sickness, and sometimes constipation, are frequent accompaniments, depending at first on the irritation of the visceral peritoneum and on the temporary paralysis of the muscular coat of the intestines. When the tumor has increased and rests on the rectum, the patient is troubled by a more constant constipation and by tenesmus. The pressure on the rectum is sometimes so great that the faeces are moulded into the form of a ribbon. Sometimes constipation is so great that the case is said to be one of ileus."—Tilt. Acute ovaritis may give rise to nymphomania; " the mind is more ACUTE OVARITIS. 727 evidently affected in the sanguine, the irritable and the plethoric; the desires are inordinately excited, so as almost to amount to utero- mania." But this exaltation of the sexual feeling can only arise in the earlier stages of the ovarian inflammation; and on the other hand "inflammation of the.ovary decidedly occurs not only Avithout the slightest approach to nymphomania, but it is frequently attended by a directly opposite state of feeling on the part of the patient."— Lbwenardt. Diagnosis.—In inflammation and in irritation of the ovaries an ex- amination per rectum may be found requisite. " Without the aid of an examination per rectum it Avould be exceedingly difficult to form a certain diagnosis; the finger per anum easily reaches to the side of the uterus, where the swollen and generally painful ovary may be dis- tinctly felt. Examination per vaginam leads to little or no certain results." And by such exploration per anum ovaritis may be dis- tinguished from all other affections, because in no other affection is the ovary necessarily enlarged. A careful study of all the symp- toms and conditions will remove any remaining obscurity in these cases. The history of the case, the previous condition of the patient, the nature of the pain, as sharp, lancinating, aggravated by motion, will all aid to determine the origin and extent of the o\rarian affec- tion. This must also be distinguished from simple ovarian irritation by that symptom of aggravation on pressure which is common in acute inflammation, but not in nervous or neuralgic conditions. Termination.—The natural course of ovaritis, like that of other acute inflammations, is to terminate in suppuration unless its progress is arrested. In the latter case, Avhether the result be brought about by art or by unaided nature, the termination is in resolution. This is but another name for the subsidence of the inflammation itself. But a partial resolution or subsidence of the more violent inflammatory symptoms may be supposed to haA^e taken place where the chronic ovaritis replaces the acute. Here Ave haAre the commencement of an ovarian tumor, for the enlargement of the OArary which appeared under the acute form of inflammation may not only continue, but even increase more and more under the chronic form. Where suppuration occurs as the result of acute ovaritis, the pus is generally diffused throughout the substance of the ovary. This pus— whose formation may be indicated by rigors, softness of the pulse and mitigation of the general symptoms, Avith an increased sense of local weight and throbbing—may be reabsorbed into the system, and thus a form of resolution may succeed even after suppuration; or the 728 DISEASES OF THE OVARIES. abscess may burst and discharge its contents, either externally through the vagina, into the intestine, into the bladder or into the cavity of the peritoneum. The discharge of the matter through the vagina is the most favorable of all, Avhether it be transmitted through the Fal- lopian tubes and uterus, or, as is more frequently the case, directly into the ATagina itself. The discharge of the product of ovarian sup- puration through an intestinal or a vesical opening may result favor- ably or unfavorably, according to the other circumstances of the case. But the effusion of ovarian pus in quantity, as of any other purulent matters, into the peritoneum, is almost necessarily fatal. In many milder cases of ovaritis, in which no structural disorganization, as suppuration or tumor, appears, the organ may none the less effectually become incapable of ovulation by the condensation of its tissues, or adhesions may occur which may indirectly, but no less certainly, occasion sterility. Ca,uses.—Idiopathic ovaritis may result from external injury, and it has been known to follow sudden suppression of the menstruation. It has also supervened on the suppression of gonorrhoea by astringent injections, and it has occasionally occurred in connection Avith \7ariola and in pneumonia. " A cold taken during menstruation, the suppres- sion of the courses, coitus during or immediately after this epoch, the use of violent emenagogues, pediluvia or hot baths at the same period, are the principal causes likely to produce ovaritis in the absence of the gravid or puerperal state."—Scanzoni. Puerperal Ovaritis is much more common, and is often merely an extension of inflammation from the uterus or broad ligaments to the ovaries. As this is rather the consequence of another morbid condi- tion, of which it forms a complication, we refer the reader to Puerperal Peritonitis for a fuller description. Chronic Ovaritis. Chronic ovaritis, as already explained, is often but the continuation of the acute in a less active form. In other instances it is the result of a corresponding inflammation of the uterus and its appendages, or it may arise, as it Avere, originally and spontaneously in the indi- vidual follicles. In either case there is more or less enlargement of these organs, their contour becomes irregular, their surface roughened and their entire substance indurated. This enlargement and indura- tion usually affect but one of the ovaries in the first instance, the other retaining its natural size, or only becoming affected subsequently. The enlarged ovary remains within the pelvis, either freely movable CHRONIC OVARITIS. 729 or adherent, until its increasing size causes it (if movable) to pass into the abdomen entirely, or to extend its growth in the same direc- tion, Avhere, from the formation of false membranes, adhesions have bound the original tumor Avithin the pelvic caA'ity. Having risen up into the abdomen, the enlarged ovary may still remain freely movable, or become fixed by means of adhesions to the adjoining viscera, or by completely occupying the cavity of the abdomen itself. In this general manner do Avhat are called ovarian tumors spring from chronic inflammation of the ovaries. The symptoms of chronic inflammation of the ovaries, except in those cases Avhich follow the acute form, are not very strongly marked. The pain, which in acute ovaritis had been very severe, gives place to a sensation rather disagreeable than painful. There are a variety of sufferings Avithin the pelvic region Avhich, in default of any other cause, may be safely attributed to chronic ovaritis. Such are " frequent need of urinating, painful constrictions of the A'agina, uterine colics, a very painful tenesmus, together Avith the formation of hsemorrhoidal tumors." The patient complains of an inconvenient weight in the diseased spot, which increases Avhen touched, when walking, by re- maining too long standing, by coitus, and especially at the menstrual period. Frequently we meet Avith various disorders in connection Avith the menstruation, without our being able always to comprehend Avhy the courses are sometimes nearly or quite suppressed, while at other times they are much too abundant; as the disease very often affects one ovary alone, the courses are not necessarily accompanied every time by dysmenorrhceal phenomena ; Ave even see the catamenial Aoav occur two or three times without particularly painful sensations, Avhich sug- gests the inference that the matured ovum at these periods belongs to the healthy ovary. At other times each menstrual period is accom- panied by a violent dysmenorrhcea, and then either both ovaries are diseased or the ovulation affects in a high degree the diseased o rgan.—Scanzoni. The pain, which is either limited to the region of the ovaries or radiates from thence, which has continued for some time, and Avhich is aggravated either before or during the menstrual period, will lead to the belief that there may be chronic inflammation of one or both ovaries; and this belief will be strengthened if we find the vaginal cul-de-sac painful to the touch on the affected side. Chronic ovaritis, Avhether it folloAV acute inflammation of the ovaries or become imperceptibly developed from some external in- jury, constitutional dyscrasia, or even from excesses in sexual inter- 730 DISEASES OF THE OVARIES. course or abuse of the sexual organs—as in females Avho lead vicious lives or indulge in secret vice—is at the same time accompanied Avith enlargement, and naturally tends to induration, softening or other structural degeneration. Treatment of Irritation and Inflammation of the Ovaries. In acute and in chronic ovaritis rest is of great importance, and is especially demanded during the menstrual period. Severe exercise or fatiguing occupations should be avoided, and all influences calculated to depress the patient, either mentally or physically, should be re- moved. Remedies which act especially upon the Ovaries. 1. Apis, Canth., Staph., Thuya. 2 Asaf., Aur., Bry., Carb. an., Chin., Lach., Lye, Plat., Ran. bulb., Sec. corn., Sep., Zinc. 3. Aeon., Ambra., Ant. cr., Ars., Bell., Carb. veg., Chel., Coloc, Con., Graph., Hep., Ignat., Merc, sol., Mez., Nitr. ac, Nux vom., Ran. seel., Sulph. Aconite. Will be indicated where the patient has been exposed to dry, cold air, and has been so chilled through as to develop a real synochal fever, or in cases in which this inflammation has resulted from a fright. Ambra g. Stitches in the ovarian region Avhen drawing in the ab- domen or pressing upon it. Discharge of bluish-white menses from the vagina. During urination there is a burning, smarting itching and titillation of the vulva and urethra. Antim. crud. Nausea and vomiting; Avhite tongue; tenderness over the ovarian region. Apis m. Stinging pains in the ovaries. Aggravation after sexual intercourse. Enlargement of the right ovary, and pain in the left pectoral region, with cough. There is evidently a mutual sympathy betAveen the ovaries and the lungs. Especially for the right ovary. Arsen. a. Intense burning or tensive pain in the ovary, with great restlessness, some relief being afforded by constantly moving the feet. Thirst, Avith drinking little and very often. Aurum. Much depression of spirits. Her mind dAvells constantly on suicide. Belladonna. The right ovary is much enlarged, and Avith every menstrual period the pressure doAvmvard was so great, as if every- thing would be forced out of the vulva, that she was compelled to treatment of irritation and inflammation. 731 keep her bed for several days. This case Avas entirely cured in the course of a year Avith but three doses of Belladonna. Bryonia. Stitching pains in the ovaries on taking a deep inspiration. The pains are made Avorse by motion. She can hardly bear the least touch on the affected parts. Cantharis. Much tenderness and burning in the ovarian regions. Dysuria; cutting burning in passing only a drop or two, which is often bloody, or complete strangury. This remedy is very often in- dicated in this complaint. China. In cases Avhere profuse hsemorrhages or too frequent sexual intercourse have produced the attack of inflammation. She can hardly bear the least touch upon the affected parts. Cimicifuga. Inflammation of the ovaries, with irritable uterus ; hys- terical symptoms and rheumatism; also with suppressed, painful or profuse menstruation ; distress and dullness of the head; trembling ; sinking at the stomach ; frequent calls to urinate. Colocynth. Intense boring or tensive pain in the ovary, causing her to draAv up double, Avith great restlessness. Conium. Induration and enlargement of the ovary, attended with nausea, vomiting, eructations of wind and expectoration of phlegm; lancinating pains; acrid, Avhite and slimy leucorrhcea; labor-like con- tractions ; pains in the iliac regions. Graphites. The inflammation is aggravated by every cold she takes, or from getting her feet damp. Her menses delay. Morning sickness during the menses. Itching blotches on the skin here and there, oozing a glutinous fluid. Hepar. When suppuration is feared, and other remedies have failed, Hepar may prove to be the medicine, if no other is more strongly indicated. Ignatia. In cases Avhere the disease has seemed to be developed from disappointed affection. There is involuntary sighing, great despondency, and Aveak, empty feeling at the pit of the stomach. Lachesis. If pus has already formed, Lachesis may be the most appropriate remedy to promote its escape externally. The right ovary is affected. Lycopodium. Cutting or shooting pain, extending from the right to the left, across the ovary ; Avorse after four P. M., better after eight or nine in the evening. Nux vom. When the disease appears to haA^e been occasioned by rich living, highly seasoned food, stimulating drinks, or by a too sedentary life. 732 DISEASES OF THE OVARIES. Palladium. The right ovary is SAvollen and sore on pressure, with bearing-doAvn pains; heavy Aveight in the pelvis—worse Avhen stand- ing, better when lying on the left side. Platina. In cases Avhere the sexual passion is altogether too strong, as an attendant condition. The pain in the region of the ovary is of a burning character, occurring in paroxysms, Avith stitches in the fore- head. Hysterical condition strongly marked. Has proved curative after the pus has been discharged under Lachesis. Ranun. bulb. In chronic cases Avhere rough, Avindy Aveather excites the symptoms. Staphysagria. In many cases, particularly where the mind has been dAvelling too much on sexual subjects as an exciting cause. Very sensitive to mental and physical expressions. Very sharp shooting pains in the ovary, Avhich is exquisitely sensitive to pressure. Pains extending down into the crural region and thighs. Thuya OC. In cases Avhere the left ovary is more particularly affected. The sufferings are much increased at every menstrual period ; they even become almost intolerable. The pain extends all through the left iliac region into the groin, and sometimes into the left leg; the pain is sometimes burning. Sometimes the pain is ex- cited by walking or riding, and becomes so severe that she must lie doAvn. Zinc. In chronic cases; boring pain in the left ovary, causing her to press on the part continually; but the pain is entirely relieved only during the Aoav of the menses, and it returns with the same violence at the expiration of the menstrual period. Ovarian Tumors. Ovarian tumors are by no means uncommon, and may be divided into three general classes—viz., Fluid Tumors, Solid Tumors and Com- posite Tumors. Solid Ovarian Tumors. Solid tumors comprise those the structure of which is solid, there being little or no fluid matter in their composition. They are of several varieties, and are either external and attached to the ovary, or im- bedded Avdthin its substance. They are similar in situation, structure and variety to tumors of the uterus, and often occur in the ovaries at the same time that they do in the Avomb, but are less intensely painful. The solid ovrarian tumors of a non-malignant character are comparatively rare; they may be quite small, or vary from the size OVARIAN TUMORS. 733 of a goose's egg to that of a man's head. One of this kind, mentioned by Scanzoni—which, however, gave some traces of a cancerous nature—Avas found to Aveigh nineteen pounds, the patient having died of Bright's disease. In their general appearance these tumors are correctly described in the Avords of Dr. Baillie: " The ovarium is much enlarged in size, and consists of a very solid substance, intersected by membranes Avhich run in various directions. It resembles in its texture the tumors which groAv from the outside of the uterus, and I believe has very little tendency to inflame or suppurate." In many instances the induration partakes of the nature of an en- chondroma, in Avhich the sub-peritoneal fibrous membrane of the ovary itself assumes an osseous or cartilaginous hardness. Thus, in two ex- amples mentioned by KiAvisch : " Once these cartilaginous concretions surrounded the ovary in the form of numerous plates or of rounded protuberances, more or less large, which gave to the entire organ an aspect altogether tuberous. At another time the right ovary Avas en- tirely transformed into a tumor of the size of the fist, surrounded Avith numerous false membranes, Avhose exterior layers contained large, hard, cartilaginous nodules, while the interior of the tumor resem- bled a cartilaginous hyaline mass of very great hardness." Very rarely the induration partakes of the calcareous or cretaceous nature, or from the presence of a peculiar dyscrasia in the system, which may be termed tuberculous, tubercles may be deposited in the substance of the enlarged, hardened and inflamed ovary, as in pul- monary tuberculosis. In such cases the adjacent organs Avill also show traces of similar tuberculous deposits. And thus, by almost insensible gradations, the non-malignant may be seen to run into the malignant form of ovarian induration. The reciprocal relation of the constitutional dyscrasia Avhich produces tubercles to that Avhich results in genuine cancer has already been explained in a previous chapter, on Cancer of the Uterus, to which the reader is here re- ferred. The diagnosis of these solid tumors of the ovary will be assisted by examination per rectum, by Avhich such a tumor can be distinguished from tumor of the uterus, and by the consideration of the general health of the patient, and the less poignant and lancinating character of the pains, by which such a tumor may be distinguished from cancer of the ovary. But this is of consequence rather for the comfort and encouragement of the patient than for our own guidance in prescrib- ing, since the medicine must ahvays be selected from a careful study 734 DISEASES OF THE OVARIES. of the totality of the symptoms and conditions, never from our patho- logical theories or conclusions. The symptoms will surely lead uw right, Avhile our pathological theories, by persuading us to generalize instead of individualizing, will assuredly preclude us from the success we might attain. Composite Tumors of the Ovary. In this class of ovarian tumors are included all those the make up of Avhich is both solid and fluid. In some of these cases there is a preponderance of either the fluid or solid element, which makes it dif- ficult to draw a line of distinction. Thomas describes four varieties of these groAvths—viz., Cysto-adenoma, Cysto-fibroma, Cysto-sarcoma and Cysto-carcinoma. These names are a key as it were to the quality and composition of the tumors themselves. The most common Avay in which tumors of the composite class are produced is by a solid tumor forming cysts within its substance or by undergoing cystic degeneration. Cysto-sarcoma is the form of composite tumor most frequently met with. "By cysto-sarcomata," says Lucke, "those large tumors are especially meant which consist of solid masses, papillary proliferations and numerous closed and open cavities, such as are found in the mammse, ovary and testicle."—Thomas. Fluid Tumors of the Ovary—Ovarian Dropsy. The greater number of ovarian tumors are fluid in their nature. And although in all cases the contained fluids are encysted, not dif- fused, there are several distinct forms of such tumors. Thus, there are simple serous cysts, Avhich are merely attached to the surface of the ovary; tumors Avhich consist in dilatations and dropsies of the Fallo- pian tubes ; dropsies of the ovaries, Avhich consist of unilocular, multi- locular or multiple cysts. It is Avell to understand these various forms, although it may not always be necessary or possible to distinguish them in the living subject, and also to knoAV that they may be com- plicated with more malignant forms of disease. The unilocular tumor consists of a single cyst developed within the ovaryT, which may be- come of enormous size. It does not usually form adhesions to the abdominal viscera, and is for that and other reasons more amenable to treatment than are the other varieties. Multilocular tumors consist of several sacs, Avhich maybe developed from a unilocular cyst. These various sacs do not communicate with each other except in case of rupture of their AAralls. Multiple tumors consist of a number of inde- OVARIAN TUMORS. 735 pendently developed cysts, growing side by side, contained Avithin one envelope and constituting but one tumor. The encysted dropsy of the ovary, either consisting of a single greatly enlarged cyst or of several smaller ones, is by far the most common form of ovarian tumor. " This consists of an enlargement of one or more of the vesicles of De Graaf, the coats of which are thickened, greatly dilated, and become filled with a fluid, while the intermediate structure becomes atrophied as the vesicle or vesicles enlarge, until the fibrous tunic of the ovarium, covered by the peri- toneum, forms the boundary of the tumor. When the principal cyst is formed of the entire ovarium, it often happens that the vesicles, having partaken of the morbid disposition, form a series of smaller cysts or cells, Avhich are developed within the parent cyst, and occa- sionally communicate Avith each other by considerable openings, the tumor attaining an immense size, so as to occupy almost the whole abdomen. The thickness of the parietes of the cysts differs much; they are often as thin as a bladder, but at other times of a substance as thick as the hand."—Leadam. " If there be a great variety in the size of ovarian tumors, in the density of their external coverings and in the nature of their contents, there is scarcely less diversity in the number of the cells and in the thickness of the septa Avhich separate them. In most of these compound ovarian dropsies the number of cysts is very considerable, as the larger cells Imve series of smaller ones developed and in the course of groAvth on their internal surface, so that Avhen the disease has attained great bulk this creation of sub- ordinate cysts is almost interminable."—Ashwell. These tumors may vary from the size of a fist to that of a mass weighing a hundred pounds. " The fluid secreted Avithin the cysts may be serous, like that of ordinary dropsy, or mixed Avith slimy matter, or it may be a thick, ropy fluid or gelatinous; different cysts in the same tumor will sometimes contain different sorts of fluid. Pus is occasionally found in one or more of the cysts, mingled with the other fluid, a consequence of inflammation having occurred in the cyst." The fluid contained in multilocular and multiple ovrarian tumors is not generally so clear as that of the simple or unilocular variety. It is often as tenacious as honey or white of egg—so thick, indeed, that it will not Aoav through a large canula, and may assume very dark hues. At times it is colored by cholesterine, blood or pus, and is broAvn, red or like coffee-grounds. The multiple cysts, as in multilocular cystic dropsy, are said by a late authority to depend on a particular specific alteration of the tissue 736 DISEASES OF THE OVARIES. Avhich constitutes the normal parenchyma of the ovary. Some of them are filled Avith similar, some Avith different, substances. Thus there may be a purely serous liquid, or one mingled Avith blood, resulting from the rupture of interior vessels. In Avhat are called composite cysts, in some rare cases, but usually in a few isolated cavities only, we find a mass of fat, of hairs, of cartilage, bones or teeth. Ovarian dropsies occur more frequently in single than in married Avomen, and in the sterile rather than in the parturient of the latter class. This form of disease never appears before puberty; it is most apt to occur in the middle age, Avhen the generative organs are in full activity. Usually but one ovary is at first or at all affected, even in cases in Avhich the tumor occupies the entire cavity of the abdomen. The other ovary may have become atrophied by compression or the superior influence of the morbid processes going on around it. The right ovary is more frequently affected than the left. Symptoms.—During the first feAv months, or Avhile the dropsical tumor continues in the cavity of the pelvis, the symptoms and sensa- tions are not to be distinguished from those occasioned by a more solid ovarian tumor. Its weight and size occasion uneasy, dragging, bearing-doAvn sensations in the pelvis, or more or less positively painful affections of the bladder and rectum. Upon vaginal examina- tion the tumor may be discovered betAveen the vagina and rectum, and if the parietes be thin fluctuations may be detected. A similar exploration per rectum may be requisite fully to determine the nature and relations of the tumor, and to distinguish it from retroversion of the Avomb. After the tumor has passed up from Avithin the pelvic cavity, the bearing-down sensation, the pressure upon the rectum and bladder, and consequent retention of faeces and urine, will be re- lieved. The disturbance of the organic action of the system will be shoAvn higher up. The position and free movement of the intestines, stomach, diaphragm and other organs will be so interfered Avith, as the tumor increases in size, as to cause a great variety of nervous sufferings and functional derangements, such as palpitation of the heart, dyspnoea, dyspepsia, heartburn, etc. The gradual but con- stant advance of the tumor, its sIoav but steady growth, even when apparently the normal quantity of urine is discharged, indicate the nature of the case, independent of the fluctuation, Avhich if present is of course a positive indication, Avhile its absence may arise from the excessive thickness both of the external parietes of the tumor and of the intermediate septa. There may be considerable fever, espe- OVARIAN TUMORS. 737 cially in the evening, Avith much thirst, or both fever and thirst may be comparatively slight. "In the course of the disease the patient may have pains in the belly, with fever, indicating inflammation of part of the tumor, Avhich may terminate in suppuration and produce hectic fever; or the attack may be more acute, causing vomiting, ten- derness of the belly and high fever, proving fatal in a short time; or there may be severe pain, lasting for a shorter period, Avith or without temporary exhaustion, and these paroxysms may be frequently re- peated ; but in many cases these acute symptoms are absent, and little distress is felt until the tumor acquires a size so great as to obstruct respiration and cause a painful sense of distension. By this time the constitution becomes broken, and dropsical effusions are (elsewhere) produced. Then the abdominal coverings are sometimes so tender that they cannot bear pressure, and the emaciated patient, worn out Avith restless nights, feverishness and Avant of appetite, pain and dyspnoea, expires."—Burns. The causes of ovarian dropsy are not so very definitely stated, except that they may arise from a great variety of influences in per- sons of a general dropsical diathesis. These are stated by Leadam to be injury during parturition, blows, falls, strains, frights, sudden ap- plications of cold, undue excitement, etc. Hence in general, next to a careful consideration of the constitution, symptoms and indications, it may be important to bear in mind those things which may have resulted in such abnormal developments; for so powerful is the in- fluence of the mind over the body that, even in structural disorders Avhich have thus resulted from such influences as terror and fright, but little progress will be made toward a cure so long as we neglect to take such circumstances into consideration. Ovarian dropsies may also arise in connection with suppression of the menses, as is the case with all forms of ovarian tumors. And in the former, as in the latter case, it may not always be possible to de- termine Avhich is the primary and Avhich the secondary affection, at least where both ovaries are at the same time affected, which, however, is not common. In ordinary instances one ovary Avill become diseased, and the other still perform its function of ovulation, and conception itself may result. This may be the case until the larger size of the 0A7arian tumor interferes with the proper action of the other 0Arary. Complications.—Dropsies of the ovaries are very often complicated with malignant disease, either of the scirrhous or of the medullary or colloid variety, and during life it is sometimes impossible to distinr 47 738 DISEASES OF THE OVARIES. guish between those Avhich are simple and those which are thus seriously complicated. In some such obscure cases nothing but a careful attention to the constitutional indications and symptoms Avill guide the physician aright. He may know of no remedies capable of curing the form of dropsical tumor before him, but he may be able to select remedies which shall greatly benefit, and even finally cure, his patient. Ascites, or even hydrothorax and general anasarca, may become complications of ovarian dropsy, especially in its advanced stages, thus greatly aggravating the sufferings of the patient, and hastening the fatal result. Inflammation may arise in the dropsical tumor, which may lead to suppuration and a fatal termination, espe- cially after the operation of paracentesis has been performed. Diagnosis.—It is important, though not ahvays easy, to be able to distinguish dropsical from other OA'arian tumors, particularly Avith reference to prognosis. From pregnancy inter-pelvic OATarian dropsy may be distinguished by internal examination, by means of which this tumor may be sepa- rately felt apart from the fundus uteri. And in a similar manner, by examination per rectum, as well as per ATaginam, this dropsy, while yet Avithin the pelvic cavity, may be distinguished from dropsy of the Fallopian tubes. From retroversion of the uterus it may be distin- guished by its slow groAvth, as compared with the frequent suddenly formed tumor Avhich arises from this displacement of the uterus, by the greater mildness of the symptoms, the bowel not being at once affected, and by examination per rectum. After the dropsical tumor has so increased in size as to have ascended into the abdomen, it may be distinguished from pregnancy by auscultation ; by its being one-sided sometimes; by examination per rectum and per vaginam showing the uterus not to be enlarged. In those instances in which pregnancy does exist in connection Avith ovarian dropsy, it may not be possible to determine the facts of the case until the ear can catch the sound of the foetal circulation, and even then there may be some obscurity. Still, even here the consti- tutional affections, the sensational symptoms, will lead infallibly to the right remedies, and thus the A7ery best that can be done will be done. From ascites ovarian dropsy may be distinguished by the\Arell-defined form of the tumor; by its original or permanent inclination to one side; by its maintaining its situation even Avhile the patient is in the recumbent position; by the more obscure fluctuations; by examina- tions per rectum and per ATaginam, Avhich will also enable it to be dis- tinguished from dropsy of the uterus; and by the absence of oedema TREATMENT OF OVARIAN TUMORS. 739 of the feet and ankles, Avhich almost invariably attends ascites, but which is less apt to accompany encysted dropsy, except in the last stages. The constitutional symptoms are less strongly marked in this encysted form of dropsy than in ascites. From solid ovarian tumors ovarian dropsies are to be distinguished by the fluctuation and by their more rapid groAvth. It must be borne in mind, however, that there are cases of true ovarian dropsy Avhich come on very slowly, which may remain dormant and stationary for a number of years. The prognosis in a case of ovarian dropsy will be favorable or the reverse according to the rapidity of its growth, the severity of the attendant symptoms, the period of life, and the conclusion Ave can form as to the mild or malignant character of the affection itself. In almost all cases of confirmed encysted dropsy, even if uncomplicated with scirrhus, it is merely a question of time. But that time may not neces- sarily be short, for cases haATe been recorded, even under old school treatment, in Avhich the patients have lived for many years with OAra- rian dropsy of considerable size without being tapped, while under the homoeopathic regime there is reason to hope that the progress of the disease may be entirely arrested in many cases, and the patient may be considered cured even if the enlargement remain. But those dropsies Avhich occur toAvard the change of life, Avhich are accompanied by total loss of menstruation, which appear to give rise to severe constitutional symptoms, to great debility or to a general cachectic condition, may Avell occasion serious anxiety. Treatment of Ovarian Tumors. Under this head may be considered both the internal medication and operative interference. The latter may be more readily disposed of first. Operations for ovarian tumors are of two kinds—those which are intended to entirely remove the disease by extirpation of the tumor itself, and those Avhich attempt merely to relieve the patient by draw- ing off the accumulated fluids. Tapping and Drainage.—Tapping is resorted to in some cases of ovarian cystic tu mor for relief of the patient, but not with the expecta- tion of obtaining a radical cure of the disease. It is especially indi- cated in unilocular cysts in Avhich fluctuation can be distinctly felt, and in Avhich the patient experiences a great deal of suffering in locomo- tion and respiration from the large quantity of Avater accumulated in the tumor. "It should not, as a general rule, be performed so long as the patient is comparatively comfortable, experience having shown 740 DISEASES of the ovaries. that Avhen it has once been done it will usually have to be done soon again." Although comparatively simple, this operation should only be un- dertaken with the proper precautions. The bladder should previously be evacuated, in order as much as possible to avoid the danger of puncturing this organ. The patient may be placed on her side near the edge of the bed, or more conveniently, in some cases Avhere it is possible, sitting on the edge of the bed. The abdomen should be supported by a bandage broad enough to cover the space betAveen the superior border of the mons veneris and the inferior margin of the epigastrium, but not too broad, since it might thus impede the respira- tion. The bandage should be divided at each end, to within a few inches of its centre, into three or four strips, which are to be interlaced as they cross each other behind. An assistant is to be placed on each side of the patient—the one on the left side holding in his hands the extremities of the bandage which are passed from the right side (behind) to the left; the one on the right side holding in his hands the extrem- ities Avhich are passed from the left side (behind) to the right. In this manner firm and uniform pressure may be exerted upon the abdomen, which will at the same time promote the discharge of the fluid and sustain the patient, preventing the feeling of faintness Avhich Avould otherwise folloAV from the sudden deprivation of the accustomed pres- sure of the tumor on the internal organs. Preparation having thus been made to protect and sustain the patient, a couple of basins should be at hand to receive the fluid as it flows from the opening, and buckets, or even a tub, should be placed conve- nient for emptying the basins. It Avill be found best to have two basins, one to replace the other as it is being emptied. A third assist- ant will be useful to attend to these. Should the patient show signs of faintness or dyspnoea, the Aoav may be checked by placing the finger upon the canula until she feels better. AH things being ready, the exact point for introducing the instru- ment is determined and marked by a slit in the bandage. The instru- ment is the trocar. " Holding this firmly in the right hand, with the thumb and index finger resting upon the canula, the surgeon plunges it into the linea alba, about three inches above the pubis, and by a steady forcible pressure pushes it through the abdominal Avails." " When the tumor occupies the side of the abdomen, care must be taken to puncture it external to the course of the epigastric artery, othenvise this vessel might be Avounded and the patient die of haemor- rhage. When the tapping is performed in the multilocular variety of treatment of ovarian tumors. 741 dropsy, the puncture should be made in the most prominent and fluc- tuating part of the tumor. If one cyst does not yield the requisite supply, another is opened, an eye being always had to the situation of the epigastric artery."—Gross. It is Avell to introduce the trocar Avith the handle a little depressed and the point looking upward ; thus the superior integument will form a sort of valvular covering over the Avound and tend to prevent the intrusion of air. The subsequent treatment requires that the patient remain quiet to prevent peritoneal inflammation, the abdomen being firmly com- pressed by means of a thickly-folded cloth and a broad bandage. Some cases are reported in which this operation has been repeat- edly performed, on each occasion drawing off as much of the fluid as would readily Aoav, sometimes three or four pails full, and this during a course of years. But this constant drain upon the system sooner or later Avears it out, and the patient finally perishes of exhaustion. Ovariotomy.—The operation for the removal of ovarian tumors has of late years been very successfully performed by many men who have become famous for skill as ovariotomists. The results warrant a resort to the operation Avhere other measures have failed. For a description of this operation and the method of performing it, to- gether with a more perfect and complete account of the various forms of ovarian tumors, Ave refer the reader to the recently published works of Atlee, Peaslee, Thomas and Wells. The following remedies are recommended in the treatment of ova- rian tumors. The practitioner should select his remedy with the greatest care in these cases, keeping before him ahvays the possibility of effecting a cure by medicinal means alone, and leaving operative interference as a dernier ressort. Apis mel. Stinging pains, like bee-stings; sometimes lancinating pains. Absence of thirst. Scanty urine. The dropsical effusion may be trifling and merely local, or the patient may be completely anasarcous and enormously SAvollen; the skin is usually Avhite and almost transparent. The boAvels are often very costive, with large, hard, difficult passages, which Apis also cures. Arnica m. If developed from a bruise, the Arnica symptoms remain- ing, a sore, bruised sensation. Arsenicum alb. The tumor may be large or small, and is accom- panied with a general anasarcous condition and pale, wax-like skin. 742 diseases of the ovaries. Burning pains in the tumor. Water lies heavily and cold upon the stomach Avhen drunk. Belladonna. The pains coming and going suddenly. Downward pressure, as if all would issue through the genital organs. China. If the tumor can be traced as a consequence of loss of animal fluids. Conium. Much nausea and vomiting. Vertigo whilst in a recum- bent position, particularly on attempting to turn over. The urine in- termits in its flow. Graphites. She has itching blotches here and there over her person. Getting her feet a little damp aggravates her sufferings. Obstinate constipation of large, knotty faeces, with varices. Iodium. In women of decidedly scrofulous diathesis. Leucorrhcea, Avhich excoriates the flesh, and even corrodes the patient's clothing. Lachesis. Especially in cases where the left ovary Avas first affected, Avith tendency toward the right. Worse after sleeping. The pain is often relieved by a discharge of blood from the vagina. Lycopodium. The right ovary is first affected, and inclines to the left. Aggravation after four o'clock P. M. Much borborygmus, par- ticularly in the left hypochondrium. An abundance of red sand in the urine. Much pain in the back before urinating, which is relieved as soon as the urine Aoavs. Zinc. The sufferings are entirely relieved during the catamenial Aoav. A sensation as of boring in the tumor, which requires pressure and shaking of the part for relief. Study also Apocynum cann., Eupatorium purp., Hydrastis and Sepia, and the remedies mentioned under Cancer of the Ovaries. Cancer of the Ovaries. The malignant and the non-malignant may be stated to com- prehend all the varieties of solid ovarian tumors; of these the latter—principally fibrous tumors—have just been described; the various forms of scirrhus, cancer and fungus hsematodes make up the former. Fibrous cancer, or true scirrhus, more properly belongs to the class of solid tumors of the ovaries. This form of ovarian cancer is usually very moderate in size, very slow in its growth and develop- ment, and as a primary affection comparatively rare in its occurrence. The more frequent form of cancer of the ovaries, hoAvever, is not the scirrhous, but the cerebriform variety, the cysto-carcinoma which appears in connection with encysted rather than with solid ovarian CANCER OF THE OVARIES. 743 tumors. Both varieties, for the sake of simplicity and conciseness, will be considered in the present section. Cancer of the ovaries is less common than that of the breasts, and not nearly as frequent as cancer of the uterus. It appears to attack principally unmarried Avomen at the middle period of life, while cancer of the uterus more frequently occurs in those of a more ad- vanced age. Scirrhus of the ovary presents the characteristic stony hardness of this affection in general; it is uneven in its surface and nearly homo- geneous in its substance. Its coexistence Avith cancer of other organs, especially in the breast, greatly aids in determining the nature of the difficulty. In other respects the reader is referred to the symptoms as described under cancer of the uterus. The examination per rectum will enable the tumor to be distinguished from that of the uterus. The more common form of ovarian cancer is the cerebriform, which is also much more rapid in its groAvth. " We have the ovaries or Graafian vesicles SAvelled out into cysts Avhose walls are like scirrhus, or Ave have them converted into those bags of gelatiniform substance Avhich have obtained the name of colloid. We see also here those proliferous cystic groAvths classed by some authors among the non- malignant tumors, but Avhich are, I believe, true cancer. It appears from the results of operation that the diagnosis of these tumors from the simple cystic formations is very difficult, and also that very un- favorable results have ensued Avhenever the ovarian tumor which has been removed proved to be cancerous."—Cooke. It is desirable, Iioav- ever, as above stated, to be able to distinguish at as early a period as possible scirrhus from an ordinary and comparatively innocuous induration; and so also to distinguish a fibrous from a cerebriform or colloid cancer of the ovary, since, Avhile the former may occupy years in its development, and even then attain to but a moderate size, the latter runs a very rapid course, and may acquire an enormous volume in a feAv months. As fibrous cancer of the ovary may become a softened, ulcerated cancer, so these two forms of the cancerous affection either present at different periods of their development great differences of consistence, or they combine in one and the same tumor, and at the same time, the most opposite constituents. An ovarian tumor Avas dissected by Veter Aveighing fifty-six pounds, and of a consistence almost cartilaginous; in three parts, however, it was softened, and resembled the substance of the brain. The encephaloid substance Avas more distinctly charac- terized in a case of enormous cancer of seventy-five pounds Aveight, 744 diseases of the ovaries. which occupied the left ovarium, and contained Avithin a fibrous and a fleshy mass and a fatty tissue. It is this encephaloid disease which has been termed cephaloma wdien it is Avhitish, and hcematoma Avhen it is vesicular and saturated Avith blood; the same that by others has been denominated malignant or fungoid tumor of the ovarium.* A similar fungous or cancerous cauliflower excrescence has been described, in Avhich, in connection with dropsy, both ovaries Avere changed into a mass infinitely ramified Avith vessels in its substance and granulous at its surface. Many forms of encysted dropsy of the ovaries are attended with cancerous affections; here Ave find colloid cancer, medullary cancer, and Avhat, for more exact definition, are termed cysto-sarcomata. For a more thorough and complete vieAV of the various structural disorders of these organs the reader is referred to the works of modern gynae- cologists. Symptoms.—Ovarian cancers are less painful than the uterine, but the pain is of the same lancinating character; menstruation may con- tinue so long as the disease is confined to one ovary, but it will neces- sarily fail when both organs become involved. Conception has been knoAvn to take place in persons laboring under malignant disease of one ovary. From their situation in connection with the rectum and bladder, the enlarged ovaries must of course occasion more or less irritation and disturbance of both these organs. And in fact the most painful symptoms Avhich arise in connection Avith ovarian cancer are those which occur either from its thus involving other and more sen- sitive organs, or from its escape into the abdomen and subsequent softening, hwolving all the surrounding peritoneal membranes in this distressing inflammation. " These diseases frequently lead to a rapidly fatal termination, and are accompanied by that extreme sense of de- bility and bloodless appearance of the body so characteristic of malig- nant disease." " The malignant form of the disease may be recognized, during life, by the Avant of nutrition, the broken health of the patient, the unceasing and rapid groAvth of the tumor, the simultaneous en- largement of glands in other parts of the body, and the occasional recurrence of lancinating pains in the parts. The latter symptom is not constant. The pulse is quick and feeble, and as the disease pro- ceeds there is hectic fever, and often aphthae in the mouth, Avith an inexpressible sense of debility."—Boivin and Duges. Diagnosis.—" From ovarian dropsy both scirrhus and encephaloid may be distinguished by their greater hardness and compactness, by * Boivin and Duges, page 479. MAMMARY CANCER—CANCER OF THE BREAST. 745 the absence of fluctuation generally, and by their lobulated, tuberous surface. " From pregnancy, by the hard, lobulated surface, and by the absence of the audible signs of pregnancy. " From fibrous tumors of the uterus, by their greater size; by their not being pediculated, but more movable, at least during the early stages, and in an adA7anced stage by the lancinating pain and con- stitutional distress. "Scirrhus is of sIoav growth, gives rise to mechanical symptoms, and to disturbance or irregularity of the catamenia, but to no pain or constitutional suffering. Encephaloid disease, or fungus hsematodes, on the contrary, gives rise to fever, emaciation, and other constitu- tional symptoms."—Churchill. For other constitutional symptoms and affections see Cancer of the Uterus, since cancer either in the uterus or in the ovary must affect the system in a very similar manner. Treatment.—For the treatment of cancer of the ovary consult the treatment under Ovarian Tumors and Cancer of the Uterus. Mammary Cancer—Cancer of the Breast. There are many forms of tumors occurring in the mammse, some of Avhich are mild or innocuous, some malignant, apparently from their outset, and some, after remaining stationary and harmless for a long course of years, are capable of suddenly assuming a malignant form and character. This latter circumstance is OAving no doubt to the fact that in such cases the tumor becomes the representative of a more depraved or of a cachectic condition of the system. And as in a former chapter we have seen the reciprocal relation of the tubercu- lous to the cancerous diathesis in different members of the same family, so here Ave see Iioav at different stages of the same life the constitu- tional miasm may assume a more malignant form. Of the actual cancerous affections of the female system the breast becomes the seat of development of by far the larger number. And the cancers of the breast—either those originally so appearing or those subsequently so becoming—are almost all of the scirrhous variety, and they all occur after the accession of the period of puberty. But before proceeding to the description of mammary can- cers it Avill be proper to mention two or three forms of tumor which resemble such cancers, especially in their initial stages. These are glandular engorgements, " Avhich have received the name of adenoid tumors or adenocelc. Commencing as a small almond- 746 MAMMARY CANCER—CANCER OF THE BREAST. shaped tumor very loosely attached to the surrounding tissue, and gliding Avith great freedom under the skin Avhen pressed by the fin- gers, it may groAV to the size of a duck's egg or even larger. It is seldom solitary, never attaches itself to the skin, and Avithin my ex- perience never suppurates so long as it remains simply an adenocele. This tumor is observed more generally in the mammse of unmarried females."—Cooke. These tumors, or glandular enlargements and indurations, are supposed to be of a scrofulous (tuberculous) nature, an external development of Avhat might have become pulmonary tuberculosis. Some cases of tumors of this form are believed to depend upon uterine irritation or sexual excitement, and to be only capable of being removed by the removal of the exciting cause. Other cases of adenoid tumors of the mammse are those which may remain for many years painless and innocent, and finally assume a cancerous form. " It need not be denied that cancerous growths may occur in tumors that Avere previously of an innocent kind."—Paget. This is to be accounted for from the fact that phthisical parents beget cancerous offspring, and cancerous parents have phthisical children— hence tumors of long standing, having none of the characteristics per- taining to cancer, may suddenly assume an active cancerous condition. These statements are made particularly to show the importance of being guided in all our prescriptions for such tumors not by our diag- nosis as to their being cancerous or otherAvise, but by the symptoms present. Still another class of tumors of the female breast is to be found in those Avhich arise from external injury. "A blow upon the soft tissues of the female breast may result in a diffused hypertrophy of the gland and neighboring structures, or in a circumscribed tumor which obtains considerable hardness, and is attended with great pain, or in the development of cancer," the result in either case being deter- mined by the internal condition of the various systems, which are all alike externally affected by the same exciting cause. Thus, unless one has in her constitution either the cancerous dyscrasia itself or its complement, the tuberculous diathesis, no cancer can result from an external injury, hoAvever severe. The various forms of non-malignant tumors of the mammae hith- erto mentioned are indurated, solid. But there are others, which may become cancerous or not, which are properly termed cysts in the mammae,. These arise from the distension of one of the lactiferous tubes of which the gland is composed. " When fully developed this cystic tumor is so tense as to give rise to some doubt whether it be a solid MAMMARY CANCER—CANCER OF THE BREAST. 747 or a fluid body." They may occur singly or in numerous clusters. In the former case, they are declared by Cooke to be innocent and curable; in the latter, they may be either innocent or malignant. The cancers of the female breast have already been stated to be almost entirely of the scirrhous variety. The medullary form of mammary cancer is so rare that it is sufficient to state that it some- times does occur. Scirrhus of the breast has been divided into three general classes: I. Scirrhus proper: a hard tumor Avhich is felt beneath the skin, generally movable, but in an advanced stage attached to the pectoral muscle as well as to the skin, very heavy and incompressible, and attended Avith severe stabbing pain. These tumors may be reab- sorbed or become open ulcerated cancers. II. Scirrhus with cysts—cysto-scirrhus: a cancerous tumor having an indurated base, in Avhich cysts have been developed. This variety in some instances appears to be but a further development of the former. III. Cuirass-form scirrhus: tegumentary scirrhus, Avhich involves both the skin and the gland, binding the Avhole down by a hard, brawny, almost iron clasp, to the ribs themselves. This peculiar indu- ration of the skin frequently extends over the thorax, creeping grad- ually round to the back, and anteriorly across the sternum to the other breast. It is the least manageable of all the forms of scirrhus, and never at any time admits of operation Avith the slightest prospect of delaying its progress. It is in this form of scirrhus principally that Ave have those nodules or tubercles which are sometimes seen upon the surface of the breast, and indicate generally the hopeless nature of the case; but these tubercles do also appear in the advanced stages of the other forms of scirrhus, and especially when the disease returns after an operation.— Cooke. The history of the case, the relation of the tumor to the adjacent parts as first movable, then fixed, the extreme, stony hardness of the tumor itself, and the stabbing, lancinating character of the pains, will enable the physician to give a qualified, guarded diagnosis, even in the earlier stages of the disease, and to express the hope that the tumor may be prevented from assuming the form of ulcerated cancer; and that, if it is not entirely dissipated by the exhibition of the appro- priate remedy homoeopathic to the Avhole case, it may at least be arrested in its progress, and its further development finally prevented. With regard to the operation for the removal of cancer, we may noAv state that the results of surgery go far to confirm the principles 748 MAMMARY CANCER—CANCER OF THE BREAST. adopted in this book and which are common to the homoeopathic school. The extirpation of the tumor, so far from removing the disease, does but result in most cases in its more rapidly fatal devel- opment. All those cases in which the surgeon Avould dare to operate afford still greater prospect of a radical cure from the use of the homoeopathic remedies. And finally, if these remedies fail to arrest the progress of the disease entirely, they can greatly retard its ad- vance, and at the same time do much toward relieving the intense pains Avhich characterize almost every form of cancerous affection. Treatment.—Study the folloAving remedies, and also the others men- tioned under Uterine Cancer and Ovarian Tumors. Apis m. Indurations. Scirrhus or open cancers, attended Avith " stinging burning " pains. Arnica m. Should be employed immediately after a contusion, or, should this not be found sufficient, Conium will most probably be found to be the remedy. Arsen. a. Burning like fire. Putrid exhalations. Waxy paleness, and great debility from the cancerous affection. Great loss of flesh. The pains are relieved by motion. Asterias rubens. Cures cancers, particularly of the left breast. "Feeling as if the left breast were drawn inward." "DraAving pain in the breast." " SAvelling and distension of the breasts, as if before the menses." Belladonna. Red streaks, like radii, extend from the scirrhous in- duration or ulcer. The pains come on suddenly, and finally disap- pear with equal suddenness. They are aggravated by motion or the least jar. Bryonia. Where there is a tensive burning and tearing pain, aggra- vated by moving the limb of the affected side. She feels generally better on keeping still. Calcarea carb. In leucophlegmatic constitutions. The cancer is very sensitive and painful to the touch. Calcarea oxalata. Cancer of the left breast, with intense agonizing pain. Carbo an. Burning and tearing pains; dyspnoea and anxiety; low- spirited and desponding. Faint, empty sensation at the pit of the stomach. Cham. Induration, Avith draAving tearing; painful to the touch— she feels as though she could not possibly bear the least touch. She becomes almost furious about the pain; she cannot bear her clothes MAMMARY CANCER—CANCER OF THE BREAST. 749 to touch the part affected. The pains are aggravated in the open air and at night. Clematis e. Cancer in the mammse, painful only on being touched. Colocynth. Will be found indicated in some cases of very painful cancer. Conium m. Is particularly indicated in cases developed by means of an injury, or if aggravated at every menstrual period. Pricking, stinging pains. She is roused from her sleep Avith pain. Creasote. The Avhole mammary gland is hard, bluish-red and cov- ered with little scurfy protuberances, from which blood oozes out whenever the scurf is removed. Graphites. If developed from old cicatrices formed from repeated abscesses in the mammse. Hepar s. C. Cancer of the breast, Avith stinging, burning of the edges, and smell of old cheese. Little pimples or smooth ulcers surround- ing the scirrhus or principal ulceration. Lachesis. The cancer has a bluish or dark-red base, interspersed with black streaks of coagulated or decomposed blood. Lycopodium. Hard, burning nodosities in the mammse. Study the constitutional symptoms of this important remedy. Mercurius. The cancer has a sore pain, a sort of raAV feeling. Nitric acid. Hard knots in the mammse, particularly of mercurialized Avomen. Phosphorus. Inflamed indurations, very painful, much aggravated by exposure to the air. Stitching pains striking through the part affected. Tall, slim, phthisical females. Pulsatilla. May be indicated in all lumps occurring in the breasts of young girls. They are sometimes very painful, and often affect the arm of the corresponding side. Sepia. Is a poAverful remedy in these affections. The urine is putrid, and deposits a sediment like clay burnt on the chamber. Painful sen- sation of emptiness in the pit of the stomach; yelloAV spots in the face; burning pain in the cancer. Sulphur. The constitutional symptoms are strong in this direction; flushes of heat; burning in the soles of the feet; heat on the crown of the head; weak, faint spells. Weak and unusually hungry from eleven to tAvelve a. m. Hydrastis, Phytolacca, Galium aper., Hamamelis, Chima- phila, Cistus can., and the Iodides of Arsenic and Lime, have likewise been recommended. 750 diseases of infants and children. CHAPTEK XXXV. DISEASES OF INFANTS AND CHILDREN. Physiology and Lesions of Infantile Nutrition. THE most remarkable circumstance connected Avith the young infant is its rapid growth. In comparison Avith the very great activity of its nutrition in a state of health, most of its other func- tions seem nearly dormant. And it follows that most of the dis- orders of infancy are either direct lesions of nutrition or the conse- quences of such lesions. A brief notice of the normal physiological growth and develop- ment of the infant will prepare the way for a more intelligible account of the disorders which are but deviations from such growth, and at the same time afford opportunity for explaining the causes of such deviations. Just after the birth of her child, and before the secretion and floAV of milk sufficient to nourish the babe, the mother is in a condition of temporary rest. The same is true of the corresponding period in the life of the babe. Before birth it had been nourished directly through the sanguineous circulation of the mother. After its birth comes that brief interval of repose in which its system may be supposed to consume all the last remaining elements supplied through the mother's veins. To this succeeds a state of hunger, in Avhich the system becomes prepared to receive its necessary food in a form entirely new and by means of an organization equally different and distinct. The mother's milk is the simplest and most nourishing form of food, and one that requires to undergo the least possible change in order to be capable of assimilation by the child. The milk contains all the elements Avhich enter into the composition of the blood, and of course into the construction of the body. " It is very interesting to observe that milk contains the three classes of principles which are required for human food—the albuminous, the oleaginous and the saccharine; and it is the only secreted fluid in which all these exist to any considerable amount. It is therefore the food most perfectly adapted for the young animal, and is the only single article supplied by nature in which such a combination exists."—Carpenter. In ma- ternal lactation the milk is freshly prepared as needed, and imparted to the babe from time to time in small quantities, and under the beneficent influence of physical and moral circumstances Avhich in a INFANTILE nutrition. 751 remarkable manner tend to promote its kindly reception into the infant's system, its grateful assimilation, and the consequent exceed- ingly rapid growth and development of the infant itself. For the animal heat of the mother's body imparted to the babe in her arms is not more necessary and more grateful to the infant's physical sys- tem than is the moral influence of the cherishing kindness and tender affection of the mother's love essential to the Avhole spiritual, intel- lectual and physical groAvth of her offspring. The grosser material life of the babe is indeed sustained by the abundant supply of milk Avhich it receives from the maternal fountain; yet even this material supply Avill be found to have been deprived of a large part of its effi- cient vitalizing force Avhen it loses the indAvelling spirit of the mother's love, of which it naturally forms the material body, and of which in great part it constitutes the medium of communication between the mother and her child. This in some measure accounts for the great mortality of those who are attempted to be brought up by hand in- stead of being nursed by their OAvn mothers, as intended by nature. " The infant whose mother refuses to perform toward it a mother's part, or Avho by accident, disease or death is depriA^ed of the food that nature destined for it, too often languishes and dies. Such chil- dren you may often see with no fat to give plumpness to their limbs, no red particles in their blood to impart a healthy hue to their skin, their face Avearing in infancy the lineaments of age, their voice a con- stant AATail, their whole aspect an embodiment of woe. But give to such children the food that nature destined for them, and if the remedy do not come all too late to save them the mournful cry will cease, the face will assume a look of content, by degrees the features of infancy will disclose themselves, the limbs will grow round, the skin pure red and white; and when at length we hear the merry laugh of babyhood, it seems almost as if the little sufferer of some weeks before must have been a changeling, and this the real child brought back from fairy-land." * The mortality of infants in foundling hospitals is vastly greater than that of those Avho, although deprived of their natural mothers, are still brought up in private families. And yet these extreme cases will serve all the more plainly to shoAV the mischievous results pro- duced by a violation of the laAvs of nature in this most important respect. The following statement of the course pursued and results obtained in the three principal foundling hospitals of France, com- pared with the subsequent statement of the almost universal mortality * West, Diseases of Children. 752 DISEASES OF INFANTS AND CHILDREN. in the largest foundling hospital in America, will fully explain itself. At Lyons each infant on its reception is given into the charge of a wet-nurse, and its stay in the hospital does not exceed a very few days, after which it is sent to be nursed in the country. At Rheims the stay of the infant in the hospital is equally short, but neither Avhile there nor afterward when at nurse in the country is it brought up at the breast. At Paris the stay of the children in the hospital is often very much longer, but they are usually, though not invariably, suckled by wet-nurses. The mortality under one year of the children admitted into these institutions is, at Lyons, 33.7 per cent.; at Paris, 50.3 per cent.; at Rheims, 63.9 per cent. At the Foundling Hospital on Blackwell's Island, New York, the pastor in charge states " that of the five hundred motherless infants that he had baptized Avithin the tAvo years preceding January, 1867, only about twenty-five Avere living, most of the balance having been returned dead within about twenty days after their admission. Their food was cow's milk only. On the first of November the same reverend gentleman informed me that he had baptized one hundred and sixty since the first of March, of Avhom only six remained living, the most of them havdng died Avithin twenty days after arriving at the hospital." * These children were fed upon milk obtained from coavs kept and fed upon the island. Other unfavorable influences—of the sea air, the cold and damp east Avinds, in addition to the usual unhealthy circumstances insepa- rable from extensive hospital establishments—must have contributed very largely to the production of this almost universal and unprece- dented mortality. Still, the remarkable and very early fatality itself, after making all clue alloAvance, deserves attention in part from its relation to the comparative viability of infants brought up at the breast and by hand, and in part from its relation to the quality of the food best adapted to support life in these little ones when they can- not be nursed. And the question becomes a very practical and im- portant one in many cases in which the poor health or the unsound constitution of the mother gives reason to conclude that if the child's life can be preserved in its tender months by other means, its Avhole constitution and future health may be very much benefited by the same method. But this will be again considered subsequently; and yet it may be proper to remark here that, even in those cases in Avhich it may be impossible or inexpedient for the mother to nurse her child entirely, it is still very important for her to suckle her child for a Avhile, however short the time in Avhich she may be able to do so, and * Ilahnemannian Monthly, vol. ii., p. 357. INFANTILE NUTRITION. 753 that her OAvn milk should be the babe's only food during this period. Although this is contrary to the opinion commonly entertained among the people, the young infant will thus obtain a start in life in the right direction, and be better able to be nourished by other food should that subsequently become inevitable. Just as the mother's milk is found to adapt itself to the changing condition of the babe as it becomes older and stronger, so during the first feAv days after the infant's birth the colostrum possesses peculiar qualities, and not merely abounds in fatty, saccharine and albuminous material, but pre- sents its caseine in a more easily assimilable form than subsequently. So delicate and peculiar are the digestive organs of the young infant, and so especially adapted is the mother's milk to their comparatively feeble digestion, that it becomes no easy task to provide a substitute which shall in like manner be constantly suited to the varying con- ditions and wants of the infant's daily growth. But since there will ahvays be cases, owing to the sickness or death of the mother, or to her inability to nurse her children from other causes, in which it will also be impossible to procure a Avet-nurse, and in which, therefore, it becomes necessary to provide the next best sub- stitute, particular directions for this purpose will now be given. The milk of coavs is the most accessible, and in many instances forms the only substitute Avhich can be procured.* But since the proportion of caseine or cheesy matter is larger in this, Avhile there is less sugar and generally less fatty matter than in breast milk, it becomes necessary to alter this in order to adapt it to the stomachs of infants, especially of those quite recently born. For this purpose should be chosen the milk of a perfectly healthy coav, one that is fed upon her natural diet of hay or grass and pure water alone; a " new milch cow " is best. * The following table, from the most reliable authorities, will show the composition of several kinds of milk: Constituents. Cow. Ass. Goat. Ewe. Woman. 86.28 4.38 5.27 3.80 0.27 91.65 0.11 6.08 1.82 0.34 86.50 3.32 5.28 4.32 0.58 85.62 4.20 5.00 4.50 0.68 89.20 2.60 Sugar of Milk............................. 6.00 2.00 0.20 Total..................................... 100.00 100.00 100.00 100.00 100.00 As the mean of eighty-nine analyses of human milk, MM. Vernois and Becquerel obtained the following result: Water, 889.08 ; solid matters, 110.92. These solid con- stituents are composed of—sugar, 43.64; caseine and extractive matter, 39.24; butter, 26.66; incombustible salts, 1.38; total, 110.92. 48 754 DISEASES OF INFANTS AND CHILDREN. This milk should be alloAved to stand from tAvo to four hours after being draAvn from the coav ; then the top part only, being the richest in fatty matter, should be dipped off and diluted with an equal part of pure Avarm water; the whole to be sweetened Avith pure white sugar, or sugar of milk* till its taste in this respect resembles mother's milk. By this process the proportion of cheesy matter is diminished, the butter and saccharine qualities increased, and a very excellent imi- tation of human milk obtained. Care should ahvays be taken to present the infant's food at the proper temperature; this should be as nearly as possible the same as that of the mother's milk; and a ther- mometer Avill be found very useful in enabling the food to be given ahvays at a uniform and healthy temperature. No less important is it to prepare the food often enough to secure it from becoming soured in the least, either before or after it is consumed, for rancid milk is even more destructhre to these little ones than is putrefying food to adults. And if the sugar of milk be employed to SAveeten the infant food instead of common cane-sugar, it will be very much less capable of becoming sour in the child's stomach, and of thus inducing serious gastric and intestinal irritation. The utmost care is requisite in order to keep the nursing bottle and other utensils used in artificial nursing in a perfectly sweet and cleanly condition. The life of the infant may depend upon this apparently trivial matter. As the child grows older the proportion of Avater may be gradually diminished. As the child becomes still older and the teeth become more developed, some portion of good, well-risen domestic bread may be added to the milk. By carefully pursuing the course here pointed out, the new-born babe may be fed without fatally deranging its digestive organs before it has acquired any strength of its OAvn for assimilating suitable food; and its food can be made gradually more hearty in order to comply Avith the increasing demands of its daily groAvth, and thus prevent it from becoming atrophied by starvation or diseased from Avant of nutriment of the proper kind. For these reasons also it becomes ahvays the first duty of the nursing mother to take care of herself, in order that she may maintain her OAvn system in a state suitable for sustaining the young and tender life which is dependent upon her. This, indeed, unassisted nature teaches in general; our art simply requires that we see to it that such persons live on a plain, nutritious * Every homoeopathic physician should furnish to his friends this invaluable article, and persuade them always to employ it in preparing food for infants, since, from being far less likely to become rancid, it is found to be immeasurably superior. ANTIPSORIC PROPHYLACTIC TREATMENT. 755 diet, make use of no unsuitable or highly-seasoned food, and in all other respects observe all the hygienic rules which belong to the period of lactation. Infants at the breast require food sufficient in quantity, as well as to receive it at short interArals. When the milk is secreted very abundantly, as is often the case, the child overloads its stomach; the excess is rejected by vomiting, or rather by regurgitation, with little effort and no distress. But if the flow of milk is scanty, the child Avorries the breast in vain, and is ahvays unsatisfied. The milk also varies in quality in different women, as Avell as in quantity, and in the same mother under different circumstances and conditions. Some slight modification of the healthy standard of the milk can be borne, for a Avhile at least, without any immediate and apparent alteration in the child's health. But let this change be more strongly marked, and the child's health will begin to fail at once; its life may be exhausted in a feAV hours by convulsions, or almost instantly destroyed by nervous "shock," as in cases of sudden and violent emotion on the part of the mother. These violent emotions, which sometimes prove so suddenly fatal to the infant at the breast, are evidently conveyed into its delicate system with all their deadly force through the milk which passes so rapidly into its circulation and poisons its blood. Antipsoric Prophylactic Treatment. From the treatise of Dr. Leadam we quote the following excellent remarks on the antipsoric prophylactic treatment of infants: " Dr. Gastier of Paris has entered largely into the subject of the prophy- lactic treatment of children, Avith the viewT of preventing the heredi- tary dyscrasia Avhich come under the denomination of psora. He has also declared that the vaccine virus does not usually take effect in those subjects Avhose constitutions have been acted upon by this treat- ment, and that they are, a fortiori, unsusceptible of the small-pox. (With the greatest respect for the prophylactic treatment here recom- mended, we still doubt whether it can be depended upon to do all that Dr. Gastier here claims for it.) This may be- open to dispute, but experience alone can decide the question. If observation should con- firm it, it Avill evidence a renovating and conseiwative power in the homoeopathic remedies which Hahnemann himself could scarcely have dreamt of. "The plan recommended by those Avho have paid particular atten- tion to the subject is to administer to the infant, soon after birth, two globules of a high dynamization of Sulphur200, by placing them on 756 DISEASES OF INFANTS AND CHILDREN. the tongue, and to repeat the same dose at the end of four or five Aveeks if no morbid symptoms demand any other medicine. After this, at about the third month, a similar dose of Calcarea is to be given, AAdiich has the advantage of facilitating in a surpassing man- ner the development of the teeth. Under this treatment the infant expands and thrives with a physical and moral energy which indicates health, AA'hile the root of much bitterness has been destroyed by the prophylactic treatment above-named." In addition to the recommen- dation of Sulphur by Dr. Gastier, or rather in place of it, in certain cases we advise to use a high preparation of the remedy Avhich is the exact homoeopathic simile to the psoric miasm of the parent Avhere any particular indication of this kind can be derh^ed from either parent. And this Ave think can be done in many instances; Calcarea in some cases, in others Arsenicum, in others Graphites, will be found in affinity Avith the constitution of the parent, and a single dose of the very highest preparation of the remedy, given to the infant, will exert a beneficial influence in rendering much less violent and dan- gerous all the subsequent illnesses to which children and youth are necessarily exposed. Atrophy of Infants—Marasmus. The atrophy of infants is the very opposite to their healthy nutri- tion, and consists in a general marasmus or wasting aAvay of the entire system. This condition may result either from the unhealthy or un- suitable character of the food with Avhich they are supplied, or from their own inability to assimilate it on account of some inherent hereditary disease. In reference to each case, therefore, it is very important to distinguish as to which of these tAvo classes it belongs. In the previous section on nutrition full directions Avere given re- specting the mother's and nurse's milk, and their substitutes when the natural sources failed; and in the present section our remarks will principally apply to those cases in Avhich infants become gradually atrophied from actual inability to digest and assimilate the most suitable food that can be provided for them, whether this be that furnished by their OAvn mothers, by nurses, or, in default of both of these, such artificially prepared food as has previously been recom- mended. The nature of the difficulty Avill be best understood by reference to some extreme cases, such as have already been referred to. lu- fants are sometimes born into the Avorld in a remarkably wrinkled, Avithered and shriveled condition, in Avhom the process of atrophic ATROPHY OF INFANTS—MARASMUS. 757 degeneration, even before their birth, seems already to have become far adAranced. Such babes never increase in Aveight, but rather con- stantly decrease till they die—in the course of from tAvo or three days to as many months. Some—it might perhaps be safely said, all—these cases are the victims of a profound scrofulous, syphilitic or other malignant dyscrasia, A\Thich so materially affects the organism that the function of the assimilation of food is never developed into activity. These helpless beings pine' in wretchedness as long as their meagre bodies can supply the substance for their own support, and then they perish, as many others do even before birth, from congenital lesion of nutrition. In other cases the atrophy, infantile marasmus or \vasting away appears after the child has begun to thrive. In these the symptoms are various; sometimes the food is rejected as soon as swallowed, or presently after; sometimes it passes from the bowels in an undigested condition; and sometimes there is diarrhoea Avith whitish-colored stools, indicating deficient action of the liver. But in all cases of infantile atrophy the child is restless, peevish, fretful, crying, as if continually distressed, and always groAving thinner and thinner, whatever the other symptoms may be. In some instances the mischief may be occasioned by the severe derangement of the digestive apparatus incidental to dentition. Here the loss of sleep and the exhaustion of the nervous forces inseparable from difficult and painful dentition cannot but weaken the stomach. Thus," the food is in part rejected; in part it becomes sour and cur- dled, and thus by its very presence and influence adds to the original gastric irritation ; and finally, in an imperfectly prepared condition it is transferred to the intestines, only to extend the same distressing irritability throughout their entire tract. The indigestion, thus com- menced in the stomach and continued through the intestines, becomes in the next stage of physiological disorder a non-assimilation, and confirmed atrophy is the necessary consequence. In other cases the seat of the difficulty may be an original disorder in some portion of the digestive apparatus, such, for example, as enlargement and indu- ration of the mesenteric glands. This is the most common form of atrophy in scrofulous children. And even where this constitutional miasm is not present in sufficient force to develop such disease of its own accord, the irritation occasioned by diarrhoea from indigestion, or by Avorms, or by the destructive effects of calomel, may combine to give rise to such tuberculous affection of these glands as shall become an actual phthisis intestinalis, or fatal consumption of the boAvels. 758 DISEASES OF INFANTS AND CHILDREN. The folloAving are giA^en by Leadam as the principal symptoms which precede or accompany atrophy: " Frequent belly-ache, with irregular bowels, the motions being too frequent and variegated, or clay-colored and watery; acid odor, not only of the evacuations, but also of the breath and perspiration; fickle appetite and much thirst; the urine often turbid and white; the child is fretful or quite sullen and indifferent, less playful than usual, and cries peevishly. The countenance changes color frequently, and the tongue is creamy or morbidly clean and red. There is SAvelKng and hardness of the belly, with emaciation; sometimes irregular small tumors are to be felt through the parietes of the abdomen; the skin becomes shriveled, the complexion earthy, the appetite voracious; diarrhoea supervenes, if it has not existed throughout; there is sloA\r, continued or remittent fever, augmenting toAvard evening, with flushing of the cheeks, a hot, dry skin and incessant cough, extreme restlessness, increasing debility, and finally hectic. In this form of scrofulosis the boAvels and the secretions poured into them require to be regulated, not by purgatives, hoAvever, but by remedies which are consonant with the general state of the patient." The irritation occasioned by dentition is peculiarly apt to develop the morbid enlargement of the glands just described, in Avhich the little sufferer emaciates just in proportion as its abdomen groAvs larger and its appetite more voracious. This affection, usually termed tabes mesentcrica, is indeed hardly ever fully developed in the first few months of infant life; still, the foundation is early laid for it in the profound debility resulting from insufficient food, and still more from injudicious nourishment, from the close, foul air so common in the sleeping rooms in cities, and even in the country, and from the depri- vation of light. " Children confined in badly-lighted and ill-ven- tilated apartments are uniformly unhealthy; so those brought up by hand in a city seldom do Avell; in the country their chance of living and thriving is much greater, because the purity of the air renders their digestive powers more vigorous." * , Treatment.—In the treatment of cases of atrophy or failure of nutrition the very first indication will of course be to seek the special cause of the difficulty; and if there is anything about the diet, regimen and care of the child itself, or anything in its habitation and surroundings, AA-hich seems capable of exerting an injurious influence, this must be amended first of all. Thus removing, so far as possible, all the external causes of the marasmus, Ave shall the more readily * Warren, On Scrofula. ATROPHY OF INFANTS—MARASMUS. 759 succeed in promoting that recovery of the little patient Avhich might othenvise defy all our skill. Where the cause of the malady appears in the quality of the food—Avhether it be that of the mother, of the nurse, or some artificial substitute and preparation of cow's milk— such change should be advised as will secure the most healthy nour- ishment possible in the circumstances. Sometimes the mother's milk is unwholesome, the milk of a particular cow may disagree, or the milk served by the milkmen in the large towns may be, and indeed often is, adulterated Avith lime or soda. The long-continued use of any of these unhealthy articles of food cannot fail to develop, sooner or later, Avhat may easily become fatal disorder of the digestive appa- ratus. Nor is the artificial food at all improved by mixing lime- AA'ater in the diet, as is sometimes done in hospitals for foundling infants, for wherever this course is long pursued the little ones will all die. In fact, observation shows in this case just Avhat the ho- moeopath Avould predict—that these calcareous additions to the food, while they may indeed render the stomachs of the infants more tolerant of it, do but cause still severer disorders in the bowels—just such disorders as the homoeopath is accustomed to cure with the dynamized preparation of the same drug. Finally, therefore, as a most essential adjunct to the appropriate remedy in these cases—ahvays serious, often apparently hopeless—the utmost care should be exercised to give the little patient every pos- sible advantage in the Avay of light, fresh air, suitable food, and, what is often entirely overlooked, sufficient quiet to enable it to take its natural and necessary rest undisturbed. Then the remedy should be selected Avith the most particular reference to all the symptoms and conditions of the child, and even with regard also to the peculiar form of psoric or scrofulous dyscrasia Avhich it may be possible to discover in the constitution of its parents. JEthusa cynapium. The child throAA'S up its milk soon after nursing, with great force, suddenly, then falls asleep as if from exhaustion, to aAvaken for a fresh supply. Milk seems to not agree with the child, which is shoAvn by colic, diarrhoea or constipation; it does not thrive. Aphthous condition of the mouth and throat. Aloes. The child passes substances looking like jelly-cakes, some- times small, at other times large, but they adhere together like con- gealed mucus; they may be green-colored or transparent, Alumina. The child strains greatly to evacuate even a soft stool; soreness of the anus; colic; the child wastes aAvay. 760 • DISEASES OF INFANTS AND CHILDREN. Antimonium cr. Violent and persistent vomiting, with Avhite-coated tongue and absence of thirst. Apis mel. Violent shrieking or screaming spells at longer or shorter intervals; no appetite; emaciation; Avhite and wax-like skin; scanty urine; SAvelling of the feet and ankles, of transparent Avhiteness. Argentum nit. Diarrhoea of green foetid mucus, passing off with much flatulency. Arnica. The infant has had a severe shock from a fall, and has not been Avell since; it becomes feeble and emaciated; does not sleep Avell, is restless, has no appetite, and is in great distress after eating. Arsenicum. The stools are painful, offensive, and contain quantities of undigested food; there is much debility and a pale, Avaxy look. The child is restless, especially after midnight; it seems to be cold and chilled. Baptisia. The infant has almost constant diarrhoea; chokes on attempting to SAvallow anything not very fluid; it can swallow nothing but fluids. Belladonna. Especially suitable for precocious children having blue eyes and fair hair. The child does not sleep much, though appearing to be drowsy; it lies half sleeping and half Avaking; moaning; jerk- ing of the muscles. Benzoic acid. The urine has a strong ammoniacal odor, and leaves a dark stain on the diaper; the diarrhoeic stools have an odor similar to that of the urine. Borax. The child dreads a downA\Tard motion; is easily startled by the slightest noise ; aphthae; sleeps badly, and awakens Avith screams as if in affright, and clings to something as if afraid of falling. Bryonia. The food is vomited immediately after being taken; con- stipation ; the lips are dry and parched, and the Avhole mouth is dry; the child Avishes to be kept at rest, and prefers the recumbent posture; it becomes worse at every hot spell. Calcarea c. Clay-like evacuations; dry and flabby skin; enlarge- ment and induration of the mesenteric glands. Large, open fon- tanelles ; much perspiration about the head in large drops, Avhich wets the pilloAv far around when the child is sleeping. Cough, with rattling of mucus in the bronchia. Leucophlegmatic temperament. Chamomilla. The child must be carried all the time, for it is quiet only then. Diarrhoea, green and Avatery and slimy, or like chopped eggs and spinach. Odor like decayed eggs. One cheek red, the other pale. ATROPHY OF INFANTS—MARASMUS. 761 China. Offensive, painless, undigested stools, Avith flatulency; abdo- men distended Avith flatulency; the child cries Avhen it is touched. Cina. The child picks its nose very much; is very restless, cries and is. very unamiable; it is hungry and wants food all the time; it wants to be in constant motion—to be rocked all the time when sleeping, and Avill not sleep Avithout it. Nothing pleases the child for a moment. Conium. Hardness and distension of the abdomen, Avith frequent sour evacuations; is worse during the night and better by day. Creasote. Foetid evacuations and excoriation of the mucous surfaces generally ; restless and sleepless at night; the skin is Avrinkled. Ferrum. Frequent vomiting of food ; stools undigested; redness of the face; the child is very pale and delicate in appearance. Graphites. The child has moist blotches on its skin that exude a transparent glutinous fluid; chafing back of the ears; diarrhoea or constipation. Hepar. The child has a sour smell, and Avhite, foetid evacuations; undigested stools; seems to be better after feeding; does not incline to play or to amuse itself in any Avay; does not laugh. Iodine. A broAvn color of the face, and copious and papescent stools; seems to be better after eating:. • Ipecacuanha. Nausea is the most predominant symptom, Avith fre- quent vomiting; fermented stools. Lycopodium. Much commotion, rolling and rumbling in the abdomen. The child is worse after four P. M., and gets better at eight or nine in the evening. Red stain or red sand on the diaper. Magnesia C Green, Avatery, very sour-smelling diarrhoea, and great emaciation; stools of green slime, like the scum from a frog-pond. Mercurius. Much straining at stool, Avhich is slimy, often bloody. The child is never so well during damp weather. Enlarged glands; night-SAveats. Nux V. Constipation of large, difficult stools; no appetite; does not sleep after three or four in the morning. Oleander. The food passes off unchanged in a remarkable degree, and very easily and almost unconsciously. Petroleum. Emaciation, Avith diarrhoea by day, and none at night. Phosphorus. Copious stools, pouring away like water from a hydrant, followed by exhaustion. Phosph. acid. Stools yellowish and very offensive, and the child is very listless—wants nothing and cares for nothing. 762 DISEASES OF INFANTS AND CHILDREN. Podophyllum p. Emaciation; many stools daily, all of which are natural. Diarrhoea in the morning. Pulsatilla. The diarrhoea is Avorse at night; no tAvo stools alike, they are so changeable. For a time the child seems much-better, then it gets Avorse again Avithout any appreciable cause. The appear- ance of the child changes in this manner several times during the same day, but it is usually worse toward evening, and always seems better in the open air. Rhus t. The child ahvays gets particularly worse after twelve o'clock at night; it has then more colic, more diarrhoea, more rest- lessness. Stannum. The child is always relieved in its abdominal sufferings by pressing hard upon the abdomen, leaning upon something. Sulphur. The child frequently awakens from sleep Avith screaming; great voracity; Avishes to put into its mouth everything it sees; watches eagerly for everything—cups, tumblers, vessels of food; it wants to SAvallow everything it sees. Its passages excoriate the anus. The child jumps and starts and screams fearfully. Indigestion. Sour Stomach—Vomiting—Colic.—The infant, equally with the adult, is subject to attacks of indigestion, and the disorder in the one case bears a certain general similarity to that in the other, even as the same general cause is common to both. Stated in the simplest terms, this cause consists in a want of harmony between the food and the digestive force. In an infant whose stomach is perfectly healthy thisfaut de rapport may folloAV the introduction into it of food either too abundant in quantity or unsuitable in quality; or, on the other hand, the disorder may arise, in spite of the utmost hygienic care, from some innate pathogenetic influence Avhich finds an easy form of development through the high physiological excitement of the diges- tive apparatus. Should neither of these two conditions—of digestion primarily deranged or of original dyscrasia finding vent through a digestive apparatus healthy indeed, but highly excited—be present in force, the indigestion will prove symptomatic of some other malady. The vomiting Avhich precedes an attack of scarlatina affords an excel- lent illustration of this. When the stomach is simply overloaded, or rather overfilled, it relieves itself of the excess by vomiting, and this act takes place Avith little effort and no suffering, the process of digestion of the still remaining food going on undisturbed. But if, on the contrary, the INDIGESTION. 763 indigestion arises from the unsuitable quality of the food, Avhether this be due to the unhealthy character of the milk of the mother or nurse, or to the imperfection of its substitutes, the mischief is not so soon arrested. In this case the food passes from the stomach into the intestines in an imperfectly prepared condition, and occasions there a still greater irritation; an intestinal indigestion always succeeds to that of the stomach. In some rare cases, but especially in the first three months, this may give rise to constipation, but diarrhoeas of dif- ferent kinds and of greater or less severity more commonly folloAV. Where the indigestion is not due to excess in nursing, and Avhere nothing indicates an original disorder of the stomach itself, it is necessary to understand that there is something in the milk of the mother or nurse, or in the substituted food, which disagrees with the child. And besides this, it is often observed that change in the accus- tomed diet on the part of the mother, violent mental excitement or dis- tressing moral emotions, the return of the menses or other temporary causes, very greatly disturbs the character of the milk and results in the sudden and severe indigestion of the babe. For such cases, arising from influences usually unforeseen and not ahvays obArious, the physician should be on his guard ; nor, whate\Ter conclusions he may arrive at as the result of inquiries more or less direct, will it always be proper or safe to avoAv them. The knowledge that the child Avas suf- fering from a severe fit of anger or other passion of the mother will enable the physician to give directly to the babe—and perhaps, on some pretence of soothing her nervousness, to the mother also—such remedies as will do good. But the simple consciousness on the part of the mother that the doctor knows the exact cause of the illness of her babe Avill sometimes complicate the excitement, and render the case of both patients still more difficult to treat in the most successful manner. The physician must always hear and see and act Avith the greatest cir- cumspection, but sometimes the less he says the greater will be the satisfaction of the parties more immediately concerned, and the more gratifying his own professional success. When the babe is thus suffering from unusual external influences conveyed through the medium of the milk from the mother's disturbed nervous system, every effort should of course be made to remove the cause as rapidly as possible, and at the same time alleviate the morbid symptoms induced in the babe itself. While in any state of undue excitement the mother should refrain from nursing her babe. Prominent causes of infantile colic are found in improper attention to cleanliness and exposure of the infant to cold. It cannot be urged Avith too great 764 DISEASES OF INFANTS ANI) CHILDREN. force upon mothers that if they Avish to have their babes in good health they must be kept most scrupulously clean ; they should be en- joined to frequently look to the child's diaper, and to change it at once when soiled. A babe should never be laid down to sleep with a soiled diaper upon it, and mothers should have the importance of keeping their babies Avarm properly impressed upon their minds. There is no point in the hygiene of infancy more important or more neglected than this. And a proper attention to cleanliness and Avarinth Avill reduce the frequency of occurrence of infantile colic very greatly. When indigestion, colic, constipation or diarrhoea arises from im- proper food in babies raised by hand—that is, from food Avhich evi- dently does not agree Avith the child's stomach—or even from uiiAvholesome maternal milk, the physician will frequently have to encounter many difficulties before he can select a suitable article of food that will agree Avith the delicate digestive apparatus of the babe. He should endeavor to make a good choice of food; and if, having done so, he find his choice to have been a mistake, he should try again, not despairingly, but remembering ahvays that what is one baby's food may be another baby's poison. Treatment.—Aconite. The infant has a dry, hot skin, is sleepless, restless, cries much, bites its fists, and suffers from green and Avatery diarrhoea. A dose or two of Aconite cures all these difficulties in a feAv days. JEthusa. See the indications for this remedy under the head of Atrophy. Arsenicum. The food passes undigested, the stools are offensive; much crying during and after nursing, or as soon as the child begins to take food. Emaciation; restlessness. Baryta c. Useful in colic of dwarfish children, those Avho do not groAV. Belladonna. The child cries out suddenly, and after a AAThile it ceases crying as suddenly as it began, and appears as if nothing had been the matter. Starting, Avith jerking of muscles; the child whines and cries a great deal. Borax V. The child cannot bear a doAvmvard motion, not even during sleep. It cannot be put doAvn out of the nurse's arms; it aAvakens and cries on the attempt being made. It has much colic and indigestion. Bryonia. The child must evidently be kept very still in order to relieve INDIGESTION. 765 its colic and other sufferings. The stools are dark, dry and hard, as if burnt. Calcarea c. In children of leucophlegmatic temperament, Avith large fontanelles. Profuse perspiration of the head; white chalk-like stools. Long and continued crying. Inguinal hernia seems to be the cause, which Calc. c. will remove. Chamomilla. Very irritable and fretful—must be carried. Distress after nursing. Sleepless; starting and jerking while asleep. Stools smell like rotten eggs, and are green, chopped, or consist of Avhite and yellow mucus. China. Colic comes on at a certain hour every afternoon. Cina. The child is ahvays cross and troublesome Avhen aAvake. It Avill not sleep unless it is kept in constant motion. It is seldom still and quiet, Avhether sleeping or aAvake. Coffea. Great restlessness and wakefulness, Avith nen^ous excitability; much crying; hot skin. Colocynth. The child Avrithes in every possible direction, doubles itself up, and seems in great distress; it cries very hard. Dulcamara. When the child gets worse at every cool change of the weather. Hepar. Colic, Avith dry, rough, pimply eruptions, that itch very much. Ignatia. When the trouble seems to arise on account of grief of the mother or nurse. Ipecacuanha. There is much sickness of the stomach; the more con- stant the nausea the more certainly will Ipecac, be indicated. Fer- mented stools. Iris versicolor. Protracted nausea and frequent vomiting of sour water, the vomiting being accompanied Avith pain; belching up of wind from the stomach with considerable force, or profuse emission of flatulence; colic and diarrhoea, Avith bilious stools and sick stomach. Jalapa. When the child is "good" all day, but screams and is rest- less all night. Lycopodium. The child ahvays cries and screams before passing water, and is relieved immediately afterward. Red sand is found in the diapers. Much rumbling and rattling in the abdomen. Magnesia C Very much colic, Avhich is finally relieved by a green liquid stool. This occurs very many times day and night. Mercurius. Much colic, which is relieved by a slimy, bloody stool, with straining. Nux V. Much colic, Avith constipation. The child cries much, 766 DISEASES OF INFANTS AND CHILDREN. draws its feet up, and then kicks them out again, etc. Its mother lives on highly-seasoned and stimulating food. Opium. The Avhole trouble seems to have arisen from fright of the nurse. Podophyllum p. An attack of colic at daylight every morning. Severe colic, causing an absolute retraction of the abdominal muscles. Pulsatilla. The child always gets worse toAvard evening, and remains so till toAvard morning. Rheum. Much colic, with very sour stools. Senna. The child cries terribly, and seems full of incarcerated flatus; it even turns blue all OArer during its cries. Sometimes it has frequent and bloody stools. Silicia. Colic, with difficult stools; they slip back into the rectum Avhen nearly evacuated. Stannum. The child's colic is relieved by pressing firmly upon its abdomen. When it is crying with colic, relief is at once obtained by carrying it Avith its abdomen resting upon the point of the nurse's shoulder. Staphysagria. The child seems to be suffering from a fit of chagrin or indisposition of the nurse. Indicated in the sufferings of pot- bellied children, Avith much colic and humid scald-head. Sulphur. The child has a tendency to excoriations wherever the skin is folded upon itself. Pimply eruptions filled Avith pus. Red- ness about the anus after an eAracuation. This remedy very often cures the colic and derangement of the stomach of infants. Veratrum. Terrible colic, Avith coldness of the forehead. Very cold feet Avith the colic. The sufferings cause a cold sweat to stand upon the surface, particularly upon the forehead. Dentition. The development of the teeth in their regular order, although a perfectly natural process, is often attended Avith much suffering. When dentition is sIoav, retarded and difficult it not only becomes of itself a serious disorder, but it iiwolves also a long train of morbid symptoms and actual diseases, Avhich may exhaust the patient's strength and finally destroy its life. The primary difficulty in such eases is in the nutrition ; and as we often see in older children a remark- able backAvardness in the development of the osseous system in general, so Ave often find in earlier periods of infantile life a corresponding sIoav- ness in the development of the teeth. And both these forms of imper- fect development, occurring, as they often do, successively in the same DENTITION. 767 children, are to be attributed to some profound constitutional dyscrasia which affects the nutrition. Even Avhen the teeth are grown and cut through in the easiest and most natural manner, there is usually some constitutional excitement, which may variously manifest itself in the forms of fretfulness, worry- ing, restlessness, inflammation of the gums, heat about the head, and more or less general fever. Where dentition is difficult and retarded there is prolongation of all the constitutional disturbance, great aggravation of the symptoms already mentioned, and the addition to them of others still more severe, such as vomiting and diarrhoea. The still increasing debility of the system, resulting from the nervous exhaustion inseparable from so much suffering and from such de- rangement of the digestive function, cannot but augment the original constitutional lesion of nutrition. And unless the mischief is arrested by suitable medication the patient may sink from inanition, from colliquative diarrhoea, from hydrocephaloid, or from convulsions. And perhaps in no other morbid condition of the human system is the homoeopathic practice more evidently superior than in this, Avhere the medicines may relieA^e much of the nervous suffering, and prevent the injurious effects ordinarily resulting from disorders of the diges- tive apparatus, at the same time that they promote the groAvth and development of the teeth by remedying the primary and constitu- tional lesions of nutrition. In order that the physician may judge of the degree of deviation from the normal standard of dentition in any given instance, Ave pro- ceed to state here the mode and order of the appearance of the teeth in health. It should first be observed, hoAvever, that there are anom- alous cases of dentition, but, as Avas previously observed Avith regard to the non-appearance of the menses in young women at the usual time, delay in the appearance of the teeth should not be regarded as requiring active interference unless other morbid symptoms are also present. The non-appearance of the teeth at the usual time, unless accompanied by symptoms indicative of constitutional disturbance, really furnishes less occasion for apprehension than their premature appearance Avould. Even in the condition of apparently perfect health, some infants begin to cut their teeth very early, even by the third month, while in others this process commences at a very much later period. In the early months the infant's mouth is naturally dry; this dry- ness is relieved by frequent nursing. But usually about the fourth or fifth month a very considerable change takes place in this respect; 768 DISEASES OF INFANTS AND CHILDREN. the mouth is noAV found constantly full of saliva, and the child is constantly driveling—or drooling, as it is vulgarly termed—" but no other indication appears of the approach of the teeth to the surface, except that the edge of the gums becomes broader than it was before. No further change may take place for many Aveeks, and it is generally near the end of the seventh month, oftener later than earlier, before the first teeth make their appearance. The middle incisors of the loAver jaw are generally the first to pierce the gum; next in order appear the middle incisors of the upper jaw; then the lateral incisors of the lower. The first molars next succeed, and often Avithout any very definite order as to Avhether those of the upper or of the loAver jaAv are first visible, though in the majority of cases the lower molars are the first to appear. The four canine teeth succeed, and lastly the four posterior molars—making in all the number of twenty deciduous teeth." There are, however, intervals of rest betAveen the successive ir- ruptions of teeth; thus, a period of six or eight Aveeks generally inter- venes betAveen the loAver and the upper central incisors; the lower lateral incisors come very soon after. But a pause of three or four months may occur before the first molar teeth make their appearance; another of equal length may occur previous to the appearance of the canine teeth; and still another before the first dentition is completed by the irruption of the last molars. In some few cases the teeth come through so readily as scarcely to disturb the infant; but more frequently indeed the mouth becomes hot and the gums look tumid, tense and shining, Avhile the exact position of each tooth is marked some time before its appearance by the prominence of the gum ; or the irruption of the teeth is preceded or accompanied by a somewhat different condition of the mouth, in which there is much heat and intense redness of the mucous mem- brane, an extremely copious flow of saliva, and a disposition to the formation of small aphthous ulcerations on the tongue, at the outer surface of the alveola? or at the duplicature of the lips, though the gums themselves may not be particularly SAvollen and painful. Either of these states is usually attended Avith some degree of febrile dis- turbance, and apparently with considerable suffering to the infant, who is constantly fretful and peevish, or cries out occasionally as if in pain. A third morbid condition of the mouth is sometimes seen, Avhich is usually ushered in or attended by very considerable fever and disorder of the chylopoetic viscera. The gums then become extremely hot and SAvollen, and unusually tender, especially over some tooth or other in particular; and in that situation we find the gum DENTITION. 769 swollen up into a kind of little tumor. Small, unhealthy ulcerations, with a sloughy appearance, often form upon the summit of the gum, and especially around any tooth which has partially pierced through it. To this affection, which is often very painful and difficult of cure, the name of odontitis infantum has been applied.— West. As if from a common centre, almost all the various disorders peculiar to infancy and early childhood may be seen to spring from difficult dentition. Especially is this true of those lesions of nutrition already described under the head of Indigestion, Vomiting, Diarrhoea, and of some of the diseases presently to be mentioned, such as Aphthae, Convulsions and Hydrocephalus. Thus, sooner or later, all cases of protracted dentition requiring medical assistance will be found com- plicated Avith some one or more of these forms of disease. In treating such cases, therefore, regard must be had to these consequences of the original disorder as of the one grand cause of all. All these troubles are developed in a successive series, and at Avhatever point of the series Ave are called in, then we must begin and try back, as it Avere, and by thus carefully attending to all the successive developments, of vomiting, diarrhoea, aphthae, etc., seek to find the one remedy Avhich shall remove the Avhole train of symptoms by reaching its original and primary cause in constitutional lesion of nutrition, and its secondary cause in the protracted and difficult dentition. And Avith these vieAA'S it will be seen to be requisite to consult and compare the remedies advised under Diarrhoea, where that condition obtains, and those mentioned under Vomiting, Aphth&e, etc., Avhere these conditions appear, as well as those more especially recommended at the close of this article. A single Avord with reference to lancing the gums. This operation is in almost all cases unnecessarily performed, and in many it proves positively injurious. And yet it sometimes affords the most import- ant and immediate relief. Where the gums are red and inflamed, in our opinion they never need to be lanced, but only when in their very sIoav groAvth they have changed to a dense, firm and unyielding car- tilaginous formation, thick and of a Avhitish color, through Avhich the teeth vainly attempt to make their Avay, and the irritation of the child's system threatens to destroy its life by sheer exhaustion or by inducing fatal convulsions. Before proceeding to indicate the remedies to be employed in dis- orders of dentition, Ave remark that the tooth does not mechanically cut its Avay out of the gum, but its groAvth causes slight pressure by the crown of the tooth—a pressure Avhich excites the absorbents to 49 770 DISEASES OF INFANTS AND CHILDREN. remove the impediment. In this manner the absorbents do absolutely, when the infant is in a perfectly healthy condition, open up the Avay for the tooth to escape without pain or suffering. Noav, the duty of the physician is so to direct the course of events that the evolution of the teeth shall become as painless as any other process of develop- ment. All the laAvs of health should be rigidly enforced and every prescription most carefully made, and finally, when the period of dentition fairly commences, if suffering is experienced or difficulty arises, the folloAving remedies should be carefully and particularly studied and administered, or others whose strong characteristics present the picture of the opposite of an orderly and painless process of dentition. The subjoined indications for the use of remedies for the disorders of dentition are taken from my paper on that subject, read before the Philadelphia County Homoeopathic Medical Society, and printed in the Hahnemannian Monthly: Aconite. Constant restlessness, as from distress which no change of posture or circumstance seems to relieve. The child gnaws at its fingers or fists or something else; cries, whines or frets much of the time. Its sleep is very much broken, and there are usually much heat about the head, and a dry skin, sometimes with cold hands and feet. Soon after, or Avhilst awaking from sleep, its cries of discomfort recom- mence. Accompanying this state of things, sometimes there is con- stipation, when the stools are hard and difficult to evacuate; more commonly there is diarrhoea, when the stools are Avatery and dark- colored or bloody and slimy. The child is usually very thirsty, and seems to be relieved very much by holding on to the cup containing cold water with its mouth, apparently for the purpose of cooling its gums. Antimonium crud. When the stomach so sympathizes as to present prominent symptoms. Tongue white; much vomiting; no thirst. Stools composed of hard lumps and watery secretions, passing together. Apis meL Child screams out suddenly and sharply during sleep, more usually occurring at night. If now the child can talk, and is asked what is the matter or what hurts it, the reply generally is, "Nothing." The urine is mostly scanty, but sometimes very profuse. Sometimes there is prolonged constipation, more frequently diarrhoea. Red spots scattered here and there over the skin, often causing itching and restlessness; Avorse at night. The gum covering the developing DENTITION. 771 teeth sometimes has the appearance of a AAratery infusion or of a sac containing Avater. Arsenicum alb. The child has undigested, foetid stools, and is ema- ciated; dry and shriveled skin; particularly restless after twelve at night. It has paroxysms of anguish day and night, during which it often strikes its face or head Avith its little hand, as though that afforded relief. It often vomits all fluids soon after swalloAving them, particularly water. It will only take a sip or two of Avater at a time, but very often. The gum over the advancing tooth sometimes ap- pears to be blistered, or to be filled with a dark, watery fluid. The Avhole scalp is occasionally covered with a dry, scaly, milk-crust, and the stools are of very light color. Sometimes the child has a very pale and Avaxy look, and is very Aveak. If constipation exists, it does not positively contraindicate Arsenicum. Belladonna. The child moans a great deal, as though the moaning caused partial relief of suffering. Violent starting or jumping of parts or of the Avhole body Avhilst sleeping or waking. If the start- ings occur during its waking hours it seems frightened at them, or it awakens from its sleep frightened with one of these starts. Convul- sions, folloAved by a very sound sleep. Face and eyes red, often with dilated pupils and heat of head. AAvakens from sleep Avith fright and staring eyes. The skin is often very hot, so as to leave a sensa- tion of burning to the palm of the hand Avhen removed from its sur- face. Aggravation every afternoon. Very hot fever at night, often lasting all night, Avith delirium. The stools are often composed of thin, green mucus of sour odor, and the child is often seen to shudder during stool. Sometimes the same kind of stool is involuntary. The gums are sometimes marked by numerous turgid arteries. Borax. The child is evidently afraid of a doAvmvard motion, even during sleep. If the nurse attempts to loAver it from her arms in a sleeping state it is sure to cry out and to throw up its hands as from fear. It is very sensitive to the least noise, such as the rumpling of paper, of a silk dress, or the click of a door-latch, etc. Whilst sleep- ing it will sometimes start, cry out and hold on to things—its nurse, for instance, or the sides of the cradle or crib—as though it were afraid of falling. Stools watery, yellow, green or brown. Aphthous condi- tion of the gums, and so sensitive as to shrink from the least touch, even of the nipple when hungry, in many cases. Bryonia alb. Dry, parched lips; dry mouth and constipation, the stools being dark and dry, as if burnt. The child wishes to be kept very quiet, and seems to dread to be moved. If it be raised to the 772 DISEASES OF INFANTS AND CHILDREN. perpendicular it often vomits, seems faint, and Avishes to lie back again. Vomits its nourishment soon after taking it, unchanged. It seems eager for cold Avater, Avhich seems to be preferred to its usual aliment. The SAvollen gums are hot and dry, though pale or light red. Calcarea carb. The child has large, open fontanelles. The head perspires during sleep, so as to wet its pilloAv far around. Stools large, hard and of a chalky appearance, or thin and whitish. The gums are often pale and shiny when the tooth is a long time in coming through. The child's feet are often cold and clamp. The abdomen is, in some cases, large, and cold tumors are found about the neck. Loose, rattling cough; soft and flabby muscles. Hydro- cephalus sometimes threatens. Calcarea phos. Peevish and fretful children. Often screaming and grasping with the hands. Fontanelles still open, or had closed and reopened; most in the vertex. Cold SAveat on the face; body cold. They cannot hold the head up; move it from place to place; head totters. Squinting, as it Avere from pressure; eyeballs seem dis- tended ; they protrude somewhat. Coryza, running in a cool room, stopped in warm air and out of doors. Ears cold; point of the nose cold. Swollen under lip; face pale, salloAV, yelloAvish; gets hot, with other complaints. During dentition, diarrhoea with much Avind. Greenish, thin stools. Children refuse the mother's breast; the milk has a saltish taste. Children lose flesh ; Avill not stand any more; do not learn to walk. Backward in teething, also in closing of fon- tanelles. Skull soft, thin; crackling noise, like paper; crepitation when pressed, most on the occiput.—Hering. Causticum. Children with delicate skin, when, during the evolution of a group of teeth, intertrigo makes its appearance, Avith occasional convulsions. Prolonged constipation; stools tough, covered with mucus, and shine like grease. The child has a yellowish, sickly- looking face; raA^enons hunger, and takes its food in a hurried man- ner ; frequent gulping up of the Avatery portion of its nourishment; "pot belly." The swollen gum sometimes suppurates. Cicuta virosa. " Grinding of the teeth (Avhen any are through the gums), Avith pressing of the jaAA'S together, like lockjaAV. Convul- sions, Avith limbs relaxed and hanging down, or unnaturally stiffened and extended."— Williamson. Cina. The child rubs its nose much, and is unusually hungry. Very restless in its sleep; must be kept in motion nearly all the time by rocking or othenvise. Hacking cough, folloAved immediately by DENTITION. 773 an effort to SAvalloAv something. Diarrhoea; stools occurring imme- diately after drinking. Child Avants many things, which are rejected immediately or Arery soon after being offered them. Even its most choice playthings or articles of food are repelled with violence. It does not like to be looked at, spoken to, or even touched; in fact, it is a very peeAnsh child. Its urine, when it can be preserved in a vessel or when seen in a puddle on the floor, soon turns white like milk. Restless at night; frequent crying out as from colicky pains, and calling for water. Chamomilla. The child starts and jumps during sleep. When awake it must be carried all the time, in order to soothe its sufferings. Sometimes it will sleep only whilst being carried in the arms. One red cheek, the other pale. Diarrhoea, Avatery and slimy, or like chopped eggs and spinach. Stools the odor of decayed eggs. Dry, hacking cough. Very thirsty; likes to hold its mouth in cold water a long time Avhen drinking. The appetite not so good as usual, and there is frequent vomiting of thin, sour milk. Gums red and tender; much sleeplessness. Coffea cruda. The child is very excitable and sleepless; it seems as if it could not sleep. It frets and worries in an innocent manner; is not cross, but sleepless. It laughs one moment and cries the next; is feverish for Avant of sleep, which it cannot obtain. Colocynthis. When the bowels sympathize particularly; much colic, forcing one to double up, with writhing and twisting. Stools watery, frothy or bloody, with pain, Avhich seems to contract or double up. Sometimes the pain is relieved by pressing hard upon the abdomen. Creasote. In this we have an invaluable remedy in difficult denti- tion. Very painful dentition. The sufferings are usually aggravated at six p. m., and continue till near six A. m. During all this time, by rubbing, and patting, and tossing, and worrying with the child, a very feAv short naps are obtained. It is a little more comfortable during the day, but the same scene is enacted the following night. The protruding gum seems infiltrated Avith a dark, watery fluid. Such teeth as are through the gums are dark and show specks of decay down to the gums. Constipation is more frequent; stools hard and dry. When there is diarrhoea the stools are dark-broAvn, watery, and very offensive; odor rather cadaverous. The stools seem to be exhausting; they excoriate, and sometimes contain portions of undi- gested food. In such cases Ave need not despair of so changing the morbid condition of the system as that other teeth shall not turn 774 DISEASES OF INFANTS AND CHILDREN. black and decay; and even the affected teeth will improve in their appearance. Cuprum acet. or met. " Dryness of the mouth, Avith colicky pains in the boAvels. Green, bloody, painful stools, and efforts to vomit. Convulsions, beginning Avith cramps in the loAver extremities, anil drawing in of the fingers and toes, Avith much throAving about of the limbs, frothing at the mouth, and choking in the throat."—William- son. Spasms preceded by violent vomiting of mucus. After one spasm the child screams, turns and tAvists till another spasm occurs. All trouble seems inclined to be translated to the brain, threatening that organ with paralysis or dropsy. Dulcamara. The aggravations of dentition are all increased by every damp, cold change of weather. Not so much that the child takes cold then, but that the morbid condition of the child is such as to be so influenced by that atmospherical change, upon the same principle as that the pains of Rhododendron are all aggravated by a storm of wind, although the patient be warm and in bed. If the child be inclined to salivation, diarrhoea, eruptions upon the skin. Fernim. When a persistent diarrhoea is the result of morbid den- tition. Stools composed of mucus and undigested food; sometimes excoriating and exhausting, though painless. The face is often flushed, or has a red spot on each side. Often vomits its nourishment soon after taking it. Dentition advances sIoavIv. Graphites. When the scalp, face, behind the ears or other portions of the surface become the seat of an eruption which oozes a clear, glutinous, watery fluid. Sometimes the whole scalp, face, behind the ears or such other parts as may be affected become one complete raAV surface, constantly pouring out this peculiar fluid. At the evolution of each group of teeth this condition becomes aggra\Tated. Often a severe constipation of large, difficult stools attends the above condi- tion. Sometimes the affected parts itch severely. Helleborus niger. When brain symptoms are being developed. Dilated pupils, drowsiness, particularly when the stools are white and jelly-like. Hepar is the remedy when a dry herpetic eruption is developed on some parts of the skin. It often appears in the bend of the forearm, upon the arm, in the popliteal spaces, upon the face or scalp. The itching is very troublesome. A whitish, sour-smelling diarrhoea often attends. Aggravations occur at the approach of every fresh group of teeth. The gums are sometimes ulcerated, very tender and appa- rently very painful. DENTITION. 775 Hyoscyamus. "Pressing of the gums together, with putting the hands to the jaAvs, putting the fingers into the mouth, and other indi- cations of pain in the jaAvs. Difficulty in SAvalloAving. Convulsions, beginning with twitching of the muscles of the face, especially about the eyes. Dilatation of the pupils. Dark-colored, bloated appear- ance of the countenance, and deep sleep after the spasms go off."— Williamson. Ignatia amara. The child awakens from sleep with piercing cries, and trembles all over. Convulsive jerks of single parts. Frequent flushes of heat, Avith perspiration. Spasms return at the same hour daily, with trembling all over. Spasms, with cries or involuntary laughter. Stools usually of mucus or of bloody mucus, often attended Avith undue exer- tion and prolapsus of rectum. Sometimes there is tenesmus and pro- lapse of rectum Avithout stool. The child has much sighing, sobbing and crying; sighing and sobbing continue long after the crying. • Ipecacuanha. Continual nausea, with occasional vomiting. Diarrhoea. Stools fermented and of many colors, or green as grass. Face pale, with blueness about the eyes. More frequently useful if, to the above, a variety of catarrhal symptoms are added by cold. Lachesis. The child awakens in an unhappy mood, and often in a distressed condition. At times convulsions Avill occur so sure as the child goes to sleep. If we watch such children attentively, we will perceive the breathing to cease just prior to the convulsion, or just before it awakens in distress Avithout the convulsion. The protruding gum is sometimes found to be dark purple. Lycopodium. The child sleeps Avith its eyes partly open, throwing its head from side to side, Avith moaning. It cries and screams just previous to passing water. Red sand or a reddish stain is perceived on its diaper after passing water. Much rumbling, rattling and com- motion in the abdomen. If it passes flatus it is very offensive. Aggravations occur at four P. m., and relief at eight or nine. Often very restless all night, like a Rhus restlessness. It takes but a small portion of food at a time, and does not care much for that. Magnesia carb. The teeth do not come through. A green and sour- smelling diarrhoea has continued a long time. Emaciation. Some- times the stool has the appearance of scum on a frog-pond. Frequent vomiting of sour substances. Sometimes there is loss of appetite and sour breath, Avith constipation, and frequent urging to evacuate a natural-looking stool. Magnesia mur. Slow dentition, Avith distension of the abdomen and constipation. The region of the liver is enlarged and hard, and the 776 DISEASES OF INFANTS AND CHILDREN. nurse or mother says "the child is liver-groAvn." The stool is often large and hard, and crumbles as it leaves the verge of the anus. Some- times the stool is green and pap-like. Mercurius sol. Copious salivation, and sometimes little blisters are seen on the tongue, gums and cheeks. Quite large ulcers sometimes are seen on the protruding gum. With the above conditions the nights are usually very troublesome. Noav it occasionally happens that the child takes cold and the salivation becomes arrested; theo convulsions occur. The diaper is often stained Avith a yellowish, strong-smelling urine. Abdomen often hard and distended. Stools usually slimy, bloody, green and accompanied Avith tenesmus. A single dose of Merc, is often sufficient. Nux vomica. For teething children being raised by artificial or mixed feeding, or whose mothers or nurses indulge constantly in highly-seasoned food, wines, etc. Aggravations occur at about four in the morning. Appetite becomes impaired, thirst increases and the child becomes peevish and fretful. Constipation, Avith large, difficult stools, occurs, or the stools become small, frequent, lumpy or fluid. Bloody saliva often stains their pilloAVS when sleeping. The mouth sometimes becomes sore and the breath very offensh'e. Nux moschata. Particularly Avhen the stools are very thin and yel- 1oaat, soaking into the diaper as it were. They are very exhausting, and the child is very sleepy. Podophyllum. Grinding of such teeth as are already cut, with cry- ing and worrying, often Avith painful diarrhoea. Rolling of the head from side to side, with green stools. Whitish, chalk-like stools, very offensive, with frequent gagging and thirst. Morning diarrhoea. Frothy, undigested stools. Prolapse of the rectum Avith every stool. Sometimes the stools are very frequent all day, all of Avhich are natural. Very worrying and sleepless all the early part of the night, apparently from nervous irritability. Voracious appetite, Avith other bad symptoms. Diarrhoea immediately after eating or drinking. Food sours soon after eating, Avhen it is rejected. " Gagging, and the discharge of foetid, carrion-like smelling stools. The motion of gag- ging is made Avith the mouth, and not accompanied with the effort in the stomach seen in retching."— Williamson. Psorinum. These cases, at first vieAV, resemble Sulphur. On exam- ining more carefully, if Ave find a dark fluid stool having the smell of decayed eggs, and eructations, or the child's breath having a similar odor, Ave may feel very sure that Psorinum is the remedy. Rheum. Is particularly indicated Avhen a very sour-smelling diar- DENTITION. 777 rhcea is developed, with much pain in the abdomen during stool. The diarrhoea is aggravated by moving about. Sepia. Dry ring-Avorms make their appearance, or seem to brighten up at the evolution of every fresh group of teeth. Bad smell from the mouth. Aggravation of diarrhoea after taking boiled milk. The diarrhoea appears to be very exhaustive. Silicia. In scrofulous children having worms, with profuse saliva- tion. Frequent pulling at the gums. Fever toward evening and all night, with heat in the head. Difficult stools. The mother or nurse declares, from observation, that the stool frequently recedes before the child can effect its passage. The feet smell badly, notwithstanding every effort to prevent it. Profuse sour-smelling perspiration upon the head in the evening. The fontanelles are large, and the head is larger in proportion than the rest of the body. The protruding gum seems blistered, and is very sensitive. Stools, Avhen very loose, are usually very dark, and sometimes very offensive. Stannum. In some cases Avhere it seems as if Cina should cure and it does not. Particularly if the child is more comfortable by lying with its abdomen across some hard substance—the shoulder or knee, for instance. Epileptiform convulsions, Avith clenching of its thumbs. If hernia should protrude, Avith Stann. symptoms, this circumstance Avould strengthen its indication. Staphysagria. The child is very sensitive to the least impression, Avhether mental or physical. It winces and shrinks from every Avry look or harsh Avord, and cries from the least pain. The gums have a pale Avhite appearance, and are very tender to the touch. Pot-bellied children. Frequent desire for stool, not relieved even by a free evacu- ation. Such teeth as are cut have a dark look or dark streaks run through them. Moist scald head, Avith yelloAV scabs, and very offensive. Stramonium. When the child's brain seems so affected as to cause it to cease making its Avants knoAvn except by motions. Violent grinding of such teeth as are cut. It seems to shrink from the sight of objects when first presented as if afraid. The approach of a bright light causes spasms. Blackish, thin stools, having a cadaverous odor. A very dry mouth or profuse sanation. "Grinding of the teeth. Moving of the fingers in sleep, as if searching for something. Dis- position to stammer and try to talk. Often there is a desire for more light, and at other times light brings on an aggravation, and even convulsions. Convulsions, Avith cries as if from being fright- ened by the sight of hideous objects. Much throwing about of the 778 DISEASES OF INFANTS AND CHILDREN. limbs, especially of the arms and hands, Avith motions of the fingers. The motions are most violent in the upper portions of the body."— Williamson. Sulphur. White, sour diarrhoea, with redness about the anus. Green or bloody stools, with crying and Avorrying, and rawness about the anus. Frequent vomiting of nourishment. Papulous eruptions on the skin, with much itching. The child does not like to be Avashed any more. Very tender and red about the anus after every stool. It takes no more long and refreshing sleeps. Frequent Avaking; Avide aAvake. Jumps in its sleep. Seems to have frequent weak and faint spells. Sulphuric acid. The mouth and gums are in an aphthous condition, and seem very painful. The child is very irritable, restless, and cries much of the time. The stools are peculiar, the appearance being like chopped mucus of a saffron color. Even if there is not aphthae, the stools are sufficiently characteristic, and may be regarded as the key- note when present. Veratrum a. Vomiting, with severe retching, and severe retching without vomiting. Cold sweat on the forehead. Vomiting renewed by the least motion. Diarrhoea. Each stool followed by great pros- tration. Cold, damp feeling of the extremities in spite of all cover- ing and wrapping. Very weak, faint pulse. The above condition simulates cholera infantum, but difficult dentition may be the cause. APHTHiE—TH RUSH. As described by Leadam, the thrush often attacks the infant in the second Aveek, and is characterized by the mouth and tongue being covered with minute Avhitish blisters, which are rubbed off by the action of sucking; a succession of these vesicles is constantly taking place so long as the disease lasts, Avhich is sometimes five or six Aveeks. It is often preceded by a granular appearance of the tip of the tongue a few days after birth, Avhich is caused by enlargement of the papilla?. The thrush often runs in families, and is a disease of debility; but it is generally caused by irritating secretions in the ali- mentary canal, from bad digestion or improper food, or by the acidity of the food in the stomach, as Avell as of that remaining in the infant's mouth. This affection generally traverses the whole length of the digestive tract, and develops a redness and excoriation at the anus corresponding to that originally appearing in the mouth. Thrush may constitute a temporary and comparatively trivial dis- order, apparently unconnected with any constitutional disturbance. APHTHiE—THRUSH. 779 But more often it appears as one of the first of a long train of symp- toms indicative of severe gastro-intestinal disorder. And finally, in the last stage of such disorder, toward the close of life, the tongue, the inner surface of the cheeks, and even the margin of the lips and corners of the mouth, may be covered by a Avhitish, paste-like forma- tion, Avhich being forcibly removed discloses a surface red or raw. Thrush is most commonly met Avith amongst the children of the poor. It consists essentially in the growth of a fungus (oidium albicans) upon the buccal mucous membrane, and seldom involves the tissues lying beneath. In public institutions for children, such as children's hospitals, it is very common, and generally appears under such cir- cumstances in grave and even malignant form. Microscopical research has demonstrated its fungous origin. In all except the very mildest forms of thrush the disorder ren- ders nursing a painful operation to the child; but as it usually appears in connection Avith, or in consequence of, serious derangements of the stomach and boAvels, such as vomiting and diarrhoea, the proper remedy will be found among those indicated for such conditions. It should always be borne in mind, however, that if the child is kept constantly clean, and if it is not dressed too warmly, it Avill seldom or never be troubled Avith the thrush. But where the thrush ap- pears by itself, and is unattended as yet by other morbid symptoms, it may be removed, and the still deeper mischief to Avhich it Avould lead anticipated by the exhibition of Calcarea, Chamomilla, Borax, Bryonia, Mercurius, Sulphuric acid, Arsenicum or Muriatic acid, accord- ing to the character of the accompanying condition and to the partic- ular appearance of the infant's mouth. We give indications for a feAv remedies: iEthusa. The aphthous condition causes great distress. Profuse salivation or dryness of the mouth. Vomiting of milk or of a sub- stance resembling milk. Diarrhoea or constipation; sometimes undi- gested stools. Much crying, as if from colic. Arsenicum. When the aphthse assume a livid or bluish appearance, attended with great weakness and diarrhoea. Baptisia. Profuse salivation. Offensive stools. The child can swallow nothing but fluids; even a small lump of thickened milk Avill occasion gagging. Borax V. The child frequently lets go the nipple, shoAving signs of pain in the mouth from nursing. Bryonia. The mouth is unusually dry, with thirst; dry lips, rough 780 DISEASES OF INFANTS AND CHILDREN. and cracking; the child does not like to take hold of the breast, but AAmen once its mouth is moistened, and it is fairly at Avork, it nurses well. Carbo veg. The mouth is very hot, the tongue almost immovable, and a sanguineous salhTa escapes occasionally. Chamomilla. When the child exhibits much uneasiness, and must be carried all the time. Mercurius sol. Much saliAction, or more than usual moisture in the mouth. There is inflammation in the Avhole buccal cavity. Ulcers upon the gums. Staphysagria. When the aphthous patches seem to bleed easily and the gums are spongy. Sulphur. The child does not take its usually long sleep; it aAvakens often. The general appearance of the child indicates Sulphur. Sulphuric acid. The mouth appears very painful, and the child is very Aveak. Ecchymosed spots form on the skin. Pure molasses, applied by means of a piece of muslin or linen, or by the finger, constitutes the best (healing) Avash Avhere one seems to be needed. Consult the indications furnished under the head of Disordered Dentition and Indigestion. Constipation. Even very young infants are sometimes affected Avith constipation; in fact, during the first two months of infantile life constipation is frequent, while diarrhoea is comparatively rare. This may be occa- sioned by some hereditary predisposition, and be maintained by the constantly imparted influence of a costive habit on the part of the nursing mother. In most cases of infantile constipation the difficulty consists, so far as the child is concerned, in an inactive state of the boAvel. Some mothers are in the habit of relieving this by the stimulating irritation of a roll of paper or other small object anointed Avith lard and intro- duced Avithin the rectum. The employment of purgatives of any kind, as indeed in all other forms of constipation, is worse than useless. In some cases the constipation may be due to functional derangement of the liver, as in children affected with jaundice, where the stools may be hard, dry and clay-colored, shoAving a deficiency in the secretion of the bile. There are also cases of complete inaction of the boAvel and reten- tion of the faxes from birth, Avhich are due to imperfect development or actual malformation of the intestine. In these cases the rectum CONSTIPATION. 781 may be perfect, but Avith its canal closed by a false membrane, which obstructs it either at its orifice or higher up in the intestine, or the canal of the rectum may be obliterated for a greater or less extent by the adhesion of its opposite sides. These cases may be relieved by a very simple incision where the hard and protruding accumulation of faeces furnishes a sure guide to the operator.* But there are other and more complicated varieties of malformation, such as those in which the natural aperture of the boAvel is absent, and the intestine terminates by opening into the urethra, bladder or vagina, or those in which the intestinal canal is not only malformed, but altogether absent for an extent more or less considerable. All such cases require in their treatment no small amount of surgical skill, and the particu- lar directions for the operations they inA^olve will be found in the best Avorks on practical surgery, or better still in West's recent and elabo- rate Treatise on Diseases of Children. In the medical treatment of the constipation of infants recourse must always be had to the cause. If this is found in the nursing mother, the proper remedies should first be administered to her. Should there be anything in her diet—such as the use of coffee— which may be capable of rendering either herself or her babe consti- pated, this also should be attended to. With scarcely a single excep- tion cases of costiveness in nursing infants will be found dependent upon the influence of diet, hereditary and constitutional weakness and inaction of the boAvel, or actual derangement of the liver. The remedy should, hoAvever, be selected in accordance Avith all the symp- toms, a single dose administered, and alloAved entirely to exhaust itself before either repeating it or making a new prescription. Aconite. Much heat about the child's head ; it is feverish, sleepless, restless, gnaws its fist, and its stools are hard and difficult. -ffithusa. Constipation, with vomiting of the milk and other symp- toms of this remedy. Milk seems to disagree with the child. Alumina. There seems to be a want of action in the rectum; the child has to make a very great effort, even for a soft stool. Apis m. The child is restless, screams out in its sleep, and has bright red pimples on its skin. Bryonia. The stools are very dry, as if burnt, and of a dark color; dry lips and mouth. Alternation of constipation with diarrhoea. Calcarea c. Hard, undigested stools of a light color. *See cases of this kind reported in the American Journal of Homoeopathy for 1854, p. 16, vol. viii. 782 DISEASES OF INFANTS AND CHILDREN. Graphites. The stools are of an uncommon size, A'ery large, and the child has more or less humid eruption over its body, behind its ears, on its face, on the chin, in its groins. This eruption exudes a Avatery transparent, gelatinous fluid. Lycopodium. Tied, sandy urine, the sand is seen in the diaper; much flatulence; difficult stools, Avhich it is almost impossible to evacuate. Mercurius. When the general symptoms of mercury are present; salivation, sore throat, glandular swellings, frequent efforts to evacuate; all these symptoms become more prominent every time the child takes cold. Nitric acid. This remedy cures many cases where the pain of evacu- ating is great during and after the passage, as though the little sufferer had fissures of the anus. Nux V. Stools large and difficult, or small, frequent and painful, with much colic. When the nurse takes much coffee or highly- seasoned food. The child is quite sleepless and restless. Opium. The stools occur in hard, round black balls. Platina. The stools adhere to the rectum and anus like soft clay, so that it is difficult to discharge them. Plumbum. The stools are composed of conglomerate balls, like sheep's manure. Sepia. The stools are very difficult to discharge; they seem to re- main in the loAver part of the rectum, and to require the assistance of the nurse in order to facilitate their discharge. Silicia. The stools are with difficulty forced to the verge of the anus, Avhen they slip back again. Sulphur. The child has intertrigo, pimply eruptions, swelling of its skin, soreness of the anus, so that it screams with every attempt to evacuate the boAvel; it seems to have piles. Veratrum. There seems to be a paralyzed condition of the rec- tum, requiring much straining, when a cold SAveat appears on the forehead. Collinsonia, Hydrastis and Phytolacca should likewise be consulted, especially for habitual constipation. See also the treatment of Constipation of Pregnancy. DlARRHCEA. Infantile diarrhoea constitutes one of the most frequent and serious of all the diseases that occur in infancy and childhood. Of itself alone, diarrhoea does not often prove directly fatal, but its long con- tinuance seriously weakens the patient and endangers the health; and DIARRHCEA. 783 it constitutes, moreover, a very grave complication of other forms of disease. Diarrhoea may appear without fever or other constitutional dis- order; this is usually termed by medical Avriters simple or catarrhal diarrhoea. Or it may be accompanied by more or less fever, and is then properly termed inflammatory diarrhoea; this may become an actual dysentery or inflammation of the boAvels. In its mildest forms infantile diarrhoea corresponds exactly to the easy and painless vomiting already described as the means by which the overloaded stomach relieves itself. This may be either a lienteria, in Avhich the food passes undigested, or a diarrhasa crapulosa, in which the excess of food mixed Avith fseces is passed in large and frequent quantities. Or again, as is still oftener the case, the diarrhoea may be of a purely mucous character, a condition Avhich results from disordered (excess- ive) action of the gastro-intestinal muciparous glands and follicles. In this latter form the mucus designed to facilitate the digestive pro- cess is secreted in such abundant quantity and in such altered quality that it exerts an influence entirely different; for this primary derange- ment of the muciparous glands by sympathy affects all the neigh- boring organs of the gastro-intestinal tract, Avhose secretions are intended to promote the accomplishment of the function of digestion. In some instances this mucous diarrhoea seems to become a real blen- norrhcea, or catarrh of the bowel. This form may arise from cold and dampness, from careless exposure and from want of sufficient covering over the abdomen. The causes of the principal forms of diarrhoea may be arranged under three general heads : I. Those which are connected with the organism itself; II. Those Avhich depend upon the quantity and quality of the food; III. Those connected Avith atmospheric in- fluences and changes in the weather. I. The diarrhoeas which spring from interior causes are such as those just described as catarrhal, arising from excessi\Te action of the muciparous glands. To this form of diarrhoea many children are so remarkably predisposed that the slightest change of Aveather or per- sonal exposure renders them subject to it. The extraordinary activity of the Avhole digestive apparatus in young babes renders the access of diarrhoea of some kind the almost inevitable result of the irritability induced by the process of dentition. And in addition to these it should be borne in mind that the changes taking place in all parts of the alimentary canal and of its dependencies, in order to fit them for the proper reception of the varied food upon which the infant will soon 784 DISEASES OF INFANTS AND CHILDREN. have to subsist, cannot but render these organs still more susceptible to this form of disorder. The change Avhich takes place in the mouth during the period of lactation is exactly equaled by a corresponding change in all the organs of digestion and assimilation. Hence it happens that very feAv children entirely escape the attack of diarrhoea during their first dentition, while one-third suffer from it severely. II. The manner in AA'hich food too abundant in quantity or un- suitable in quality occasions diarrhoea has already been explained under the head of Indigestion. In many of its forms, at least, diar- rhoea itself is little other than a symptom or consequence of intestinal indigestion; and of course those external accidents of food too pro- fuse in quantity or disagreeable in quality but serve to aggravate the pre-existing disposition to diarrhoea arising from the before-mentioned internal or constitutional conditions. We have already referred to the subject in the opening remarks on the Lesions of Infantile Nutrition and in other parts of this work. But the frightful mortality of infants and children arising from bowel complaints excuses us for quoting the folloAving Aveighty paragraph from Meigs's and Pepper's Treatise on Diseases of Children : "The system of indiscriminate diet allowed to children in this country is, it seems to us, a fruitful cause of gastric and intestinal complaints. We believe that, as a general rule, children over tAvo and three years of age are allowed amongst us to eat of the food prepared for the older members of the family. Now, any one who will reflect upon the variety of dishes habitually placed upon an American table, ought not to be surprised to see children permitted a choice amidst such profusion, pale, thin, delicate, exposed to frequent indigestions, attacks of diarrhoea and entero-colitis, to gastric fevers and the host of minor ills attendant upon feeble digestive powers.....It has been stated that simple diarrhoea sometimes folloAvs as a consequence of indigestion. We have known such a result to occur in children previously in fine health, and to continue for several Aveeks or months. In these instances the disorder appears to depend in good measure on the loss of the digestive poAver of the stomach. This seems proved by the great influence Avhich the character of the food has upon the malady, Avhich is always aggravated by the use of any articles except those universally acknoAvledged to be the most digestible, and also by the frequent coexistence of lientery Avhen the food is not of the lightest kind." III. As to the third class of diarrhoea, that dependent upon climatic or atmospheric conditions, it will be sufficient to recall the immense DIARRHCEA. 785 proportion of cases of this disorder which occur in particular seasons in order to realize how largely even young infants are subject to such influences. Thus, on a comparison of the results of eight years' ob- servation at the Children's Infirmary in London, Dr. West found that in the six winter months, from November to April inclusive, diarrhoea formed seventeen and three-tenths per cent, of all the cases of disease, while in the six summer months, from May to October inclusive, diarrhoea formed thirty-eight and three-tenths per cent, of the cases of disease.* Exposure to the night air will often occasion an attack of diarrhoea in young infants. And dysentery, or actual inflammation of the boAvels, so notably depends upon certain conditions of the weather—either magnetic or atmospheric—that when they recur, especially in the autumn, this disorder prevails as an epidemic throughout the Avhole district. Symptoms.—The different appearances of the stools in diarrhoea deserve careful attention, since in many instances they greatly aid in the selection of the appropriate remedy. Thus, at the onset of the disorder the discharges are at first purely fsecal -r presently they may assume a bright-yelloAV color, like that of the yolk of an egg; often they are intermixed Avith slime; and in other cases they present a frothy appearance. Under exposure to the air the bright-yellow color of the evacuations often, though by no means ahvays, changes to green. In other cases the green and yellow colors appear inter- mingled in the eAracuations, Avhile the presence of the small Avhite specks, the caseine of the undigested milk, shoAArs that the function of the stomach is disturbed by the same cause that produces the over- action of the boA\rels. From the admixture of the Avhite and yellow in these cases the stools ha\Te the appearance of chopped-up eggs. As the disorder advances the stools become more frequent, and they are attended Avith much more distress, each motion being evidently pre- ceded or accompanied by griping or other pains. The symptoms of simple diarrhoea are, hoAvever, very variable in their character, as well as in their intensity. Sometimes there is much suffering; sometimes very little, even in severe cases. In many instances the child does not seem, for a while at least, to be much Aveakened by the disorder; in others it very rapidly runs doAvn. But these latter are rather cases of the severe or inflammatory form of diarrhoea, into Avhich the simpler variety is very often apt to run if continued more than a few days. In the inflammatory diarrhoea, so called, Ave find all the symptoms of true inflammation of the boAvels, and sometimes also of the stomach, * West, On Diseases of Children, Phila., 1866, p. 508. 50 786 DISEASES OF INFANTS AND CHILDREN. in different degrees of violence; there are fever, thirst, tenesmus; colic; abdominal tenderness and heat; frequent, painful, slimy, bloody, or OA^en offensive discharges; great and rapidly increasing exhaustion; and evident tendency to hydrocephaloid, coma or con- vulsions. Either the severity of the pain and fever, the putridity of the stools or the occurrence of tympanitis will indicate very great danger. When the attack comes on suddenly it often commences with vomiting, and sometimes the irritability of the stomach becomes and continues so extreme that the least drop of fluid is immediately rejected, and frequent and distressing efforts to A^omit occur when the stomach is entirely empty. Almost simultaneously Avith the vomiting occurs the relaxation of the bowels, and the child may have twenty or thirty, or even more evacuations in the course of the tAventy-four hours. These may be slimy and streaked Avith blood, or greenish and watery, or serous, or they may consist of intestinal mucus inter- mixed Avith faeces and more or less streaked with blood. Where the stools are scanty there is usually much tenesmus, folloAved by the dis- charge of a little mucus or a few drops of blood. With all these se\rere local symptoms the constitutional disorder is no less distress- ing ; the pulse is quick, the skin hot and dry, and the child is either fretful and irritable when disturbed, or lies sleeping, apparently, with half-open eyes. " The tongue at first is moist, coated slightly with mucous fur; its papillae are often of a bright red, as are also its tip and edges, while if the disease continues the redness becomes more general, and the tongue groAvs dry, though it is not often much coated. The thirst is generally intense, the child craving for cold Avater, and crying out for more the moment the cup is taken from its lips; and the thirst is quite as urgent even in those eases where the stomach is so irritable that it immediately rejects Avhatever is SAvalloAved."—West. Aconite. The skin is hot and dry; restlessness and much excita- bility ; stools Avatery and often of a dark color. After the fever has subsided, we have but to wait and the diarrhoea will also disappear without the use of another remedy. ^Ithusa. See the indications for iEthusa under Dentition and In- digestion. Antimonium c. White-coated tongue, some nausea and watery evacuations; sometimes hard lumps of faeces Avith the water. Absence of thirst. Argentum nit. Much loud flatus passing with the stool. Arsenicum. Much exhaustion and rapid emaciation; stools undi- DIARRHCEA. 787 gested ; offensive and painful stools immediately after taking nourish- ment. Stool and vomiting at the same time. Belladonna. The child is very drowsy, half sleeping and half Avaking; much moaning. Bryonia. Diarrhoea from hot weather, or it is aggravated by the return of every hot spell of Aveather. Calcarea c. In children av!io have large heads and open fontanelles. The head perspires much, so as to wet the pillow far around. Mus- cles soft and flabby. The child aAvakens at three a. m. Carbo veg. If Bryonia does not cure Avhen indicated. Chamomilla. Stools watery or greenish, or like eggs beaten up. The child must be carried; it is very feverish and cross. The stool has the odor of rotten eggs. China. Painless and undigested, putrid stool; very copious stool, worse every other day, Colocynth. The passages are small and frequent, with very much pain, causing the child to Avrithe and twist as if in great distress, and to draw itself double. Croton t. Colic and diarrhoea immediately after nursing. The stool escapes suddenly, as if with an expulsive spasm. Dulcamara. Every cool change of the Aveather excites the diarrhoea; it is excited also by exposure in cold, damp places. Ferrum. Undigested stools, with easy vomiting of ingesta, often Avith a very red face. Graphites. Very frequent and small stools, with eruptions on the skin, from Avhich oozes a gelatinous fluid. The stool is often sour, and excoriates the external anus. Hepar. Foetid stools, the child itself smelling sour. Ipecacuanha. Much nausea or vomiting; almost constant nausea. Fermented stools, particularly indicated at the period of weaning, Avhen food disagrees. Ms. Brown and very offensive diarrhoea, Avith cutting colicky pains, nausea and vomiting; emission of very foetid flatus. Lachesis. Excessively offensive stools ; the child always awakens in distress. Magnesia c. Stools resembling the scum of a frog-pond. Stools green and slimy, or watery and sour. Mercurius sol. Much pain before the stool; great relief immedi- ately after. Stools frothy, slimy, bloody or dark green, with much straining. The child's thighs and legs are cold and clammy, partic- ularly at night. 788 DISEASES OF INFANTS AND CHILDREN. Nux V. Alternate constipation and diarrhoea. Indigestible food has been the cause of the diarrhoea; the passages are small and frequent and painful; much fretfulness. Worse at four A. m. Opium. Diarrhoea from fright. Phosphoric acid. The diarrhoea does not seem to debilitate much, although of long continuance, and the mother Avonders that the child remains so strong with it all. Podophyllum p. Morning diarrhoea, green or watery, or the stools may be quite natural, only too frequent. Prolapsus ani and diarrhoea. Pulsatilla. The stools are very changeable, no tAvo alike; much Avorse at night. Rheum. Very sour-smelling stools, attended Avith much pain. Very sour smell of the child, Avhich cannot be removed by any amount of Avashing and care in keeping it clean. Rhus t. Worse particularly after twelve at night; very restless after that hour. Sepia. There is an almost constant oozing from the bowels. Sulphur. Particularly in children of delicate parents. Much red- ness around the anus, or excoriation between the thighs and upon the parts adjacent.. Eruption of pimples upon the skin, or if the child, after getting better under other remedies, ahvays gets worse again. Veratrum a. Much exhaustion after every passage, with cold sweat upon the forehead and upon the skin in general. Dysentery—Colitis. Inflammation of the large intestines seldom occurs except in con- nection more or less obvious Math that of the small intestines; and the latter, especially in infants and little children, is usually connected with a greater or less amount of gastro-enteric inflammation. Thus, dysentery, or colitis, as it is sometimes termed, may come on as a consequence of the extension of inflammation, AAdiich, commencing in the stomach, involves the entire digestive tract in its course. There are, hoAvever, many instances of pure idiopathic dysentery which are directly traceable to exposure of the child to the cool, damp air, espe- cially at night, Avith its abdomen and limbs insufficiently clothed. According to Dr.. Condie, " Colitis Avould appear in the majority of cases to be the result of sudden transitions of atmospherical tempera- ture, particularly the sudden change from warm and dry to cold and damp weather. It is most prevalent during the latter part of sum- mer or the commencement of autumn, when the days are hot, but DYSENTERY—COLITIS. 789 the nights chilly and damp. It is apt to prove endemic in unhealthy localities, especially those favorable to the production of intermittent and remittent fevers, and often prevails epidemically with fevers of a catarrhal character. A feAv days of cool, rainy weather occurring in the summer will often cause the prevailing bowel complaints of children to assume a dysenteric character." Except Avhen the result of such endemic or epidemic influences, aggravated perhaps by personal exposure, dysentery is seldom met with in children before dentition has commenced. In these latter cases it evidently arises in consequence or in continuation of the gastro- enteric inflammation Avhich so frequently attends difficult den- tition. Symptoms.—Dysentery sometimes commences as diarrhoea. It is usually attended Avith considerable fever, with evening aggravation and thirst; there may be vomiting, especially of the copious drinks or other ingesta, but usually the development of colitis tends to relieve in some degree the previously existing gastric irritation. The abdo- men is tense and tender to the touch, especially along the course of the descending colon. But the most characteristic symptoms of this disorder are the painful discharges per anum, Avhich are very frequent, but very small in quantity, and either composed of bloody mucus, pure blood or mucus alone, and the tenesmus Avhich precedes, attends or folloAvs the discharges, or which may very frequently compel an abortive and exceedingly distressing effort at stool. In some cases the irritation is kept up by the presence in the boAvel of retained faeces, the usual peristaltic action of the intestine having been suspended by the influence of sudden change in the temperature. Such cases are marked by incessant calls to stool and almost constant tenesmus, Avhich are either totally ineffectual, or result in the evacuation of minute portions of faecal matter, Avith much slime tinged Avith blood. But the symptoms of dysentery are so evident that there is no necessity for enumerating them more at length. The anatomical lesions are very grave, especially in severe cases. They are generally confined to the large intestine. "The mucous membrane is commonly found thickened, SAvelled, red and softened; the submucous tissue sometimes presents ecchymosed points; the follicles are often diseased, their orifices being enlarged and ulcerated. In grave cases, especially those occurring under an epidemic influence, there are usually more or less extensive ulcerations, Avhich may impli- cate only the raucous, or extend to the muscular or eAren peritoneal. coat. In such instances pseudo-membranous exudations are often 790 DISEASES OF INFANTS AND CHILDREN. formed, sometimes in large quantity, and often covering the ulcera- tions. The intestine contains sanguinolent mucus, or at times a brownish or greenish material, Avhich is evidently the result of a gangrenous condition of the mucous membrane, pus, and lastly false membrane. In some rare cases perforation has been knoAvn to take place."—Meigs and Pepper. Treatment.—Select that one of the folloAving named remedies, or any other, Avhich most exactly corresponds to the condition of the patient, and be particularly careful of exposure to the night air, not only during the continuance of the disorder, but even after convalescence has set in, for the relapse which Avould otherAvise be sure to folloAV might prove more intractable than the original disorder. Aconite. Much fever; dry heat; restless distress; an irritable or inflammatory state of the system. This remedy is often the specific for the entire case. Aloes. Stools in consistence like jelly-cakes; a quantity of clear jelly, which may be green or Avhite. Sometimes there is very severe pain, Avith straining and tenesmus. Alumina. Has to strain at stool in order to pass water; can pass Avater only while so doing. Apis. Frequent bloody stools, without pain. No thirst; restlessness; sleepless, especially during the latter part of the night. Screaming spells. Arnica. Frequent stools of clear mucus, with tenesmus. Bloody stools, or dark and bloody mucus, with sore pain. Arsenicum. Signs of great exhaustion; after any effort, such as turning over, having its diaper changed, etc., the little sufferer almost sinks from exhaustion. Stools very frequent, of dark-green mucus, or very dark and Avatery stools, looking like watered bile. Stools very offensive, sometimes corr-osive; drinks little but often ; great restlessness, turning and tossing, Avith exhaustion. Aggravation from eating or drinking. Great and rapid emaciation. Often vomits Avater as soon as taken. Baptisia. Stools preceded by terrible colicky pains, Avhen bloody mucus passes off, folloAved by great relief. Sometimes the stools are dark-brown, and apparently faecal. Belladonna. Much tenderness about the abdomen, so that even a little jar is painful. Flushed face, red *eyes; much bearing-down pain. Moaning, jerking of the limbs while asleep or awake; bright, DYSENTERY—COLITIS, 791 bloody mucus, then green mucus, smelling sour; tenesmus during and after stool. Bryonia. When caused by cold drinks or by, very hot weather. The stools are thin and bloody; the child Avishes to lie down and be quiet; when sitting up there is nausea and disposition to faint; thirst, with desire for large draughts at a time. Vomiting of food soon after taking it. Parched lips and dry mouth. Cantharis. The discharges are apparently the scrapings from the mucous membrane, streaked Avith blood; the urine is burning and very scanty, often passed in drops, and Avith much pain. Sometimes there is complete suppression of urine, with great distress. Carbo veg. In very advanced cases; coldness of the breath; heat about the head; desire to be fanned; putrid eA'acuations; great de- bility ; a venous condition is gaining the ascendency. Chamomilla. One cheek red, the other being pale; very cross and fretful; thirsty; bloody and mucous stools. The child Avants to be carried all the time. The difficulty has been caused by checked per- spiration. Often vomiting of bile in the morning. China. The child is worse eArery other day; much flatulency and distension of the abdomen, particularly in the afternoon. Stools dark- colored, and having a cadaverous odor Avhich is terribly offensive. Great exhaustion, especially after stool. Colchicum. Autumnal dysentery; passages like transparent mucus, or like jelly, or of bloody mucus. Sometimes the pain in the rectum and anus after stool is perfectly agonizing, and lasts a long while, causing screams and crying. Colocynth. The crampy pains are very severe, causing the child to double up Avith every stool. There is little or no straining. The stools consist of pure mucus or of bloody mucus. Dulcamara. If the dysentery is caused by exposure to cold and damp, or if it becomes worse as the weather grows cooler. . Ipecacuanha. Much nausea and vomiting, or constant nausea. Dysentery from eating sour substances or unripe fruit or vegetables. Loathing of all food; loaded tongue. Slimy, bloody and offensive stools, Avorse in the evening. Tenesmus during or after stools, or both. Autumnal dysentery. Lachesis. Dark-colored stools of a cadaverous odor. Abdomen very hot; tongue red and cracked at the tip, or broAvn and.bloody. The child aAvakes apparently much Avorse and as if in great distress. Mercurius cor. Very much pure blood is passed Avith the stool, with much tenesmus. 792 DISEASES OF INFANTS AND CHILDREN. Mercurius sol. Not so much blood, more bloody mucus, with tenes- mus before and after stool. Much relief immediately after stool. Moist tongue and great thirst. Cold feeling in the abdomen, some- times extending doAvn the thighs and legs. Cool perspiration. Some- times the child Avill sit on the commode for a long Avhile after stool, as if it had not quite finished or did not Avish to leave. Nux v. A small portion of natural faeces is passed with every evac- uation of blood and mucus; no appetite; sleepless toward morning. Stools frequent but small. Ineffectual urging. Phosphorus. Green and bloody passages, the anus remaining con- stantly open. If able to talk, the child Avill complain of a weak, empty feeling across the abdomen. Podophyllum p. Evacuations of bloody and green mucus, with toss- ing of the head from side to side. (Worse in the forenoon.) Pulsatilla. Mucus streaked Avith blood; Avorse in the evening and through the night; no thirst. Great changeableness of the stools, so that no two are quite alike. The child is restless, and wants to be in the open air; seems to be smothered in the house. Rhus t. Is almost, if not quite, a specific where the pain runs in streaks down the limbs with every evacuation. Useful in cases with typhoid type. The child is generally Avorse after midnight. Sulphur. The passages make the perineum red all around the anus. In scrofulous patients, and in those Avith eruptions more or less numer- ous upon the body. Frequent relapses; the child seems to be doing well, AArhen, Avithout any apparent cause, it gets worse. Veratrum a. Great prostration after every evacuation, with cold sweat upon the forehead. Cholera Infantum. Much of what has already been said under the head of Diarrhoea Avill apply to Cholera Infantum. This disease very often proves fatal, even under the best of treatment, since it appears usually in the latter part of the summer, when the young infant's system is already someAvhat exhausted by the previous heat, when the air is impure and the Aveather sultry, or Avarm and damp, and since it seems to spring up as an epidemic from some atmospheric miasm which is little less than malignant. In this Avorst form of infantile diarrhoea all the symptoms seem to vie Avith each other in intensity, and the disorder runs a very rapid course. This course, however, is not always marked by a steady uniformity; sometimes the violence of the gastric symptoms will temporarily abate, and the diarrhoea CHOLERA infantum. 793 continue in intensity ; at other times the diarrhoea appears to become less frequent and painful, and the stomach more severely affected in proportion; and sometimes also a similar lull may be observed in the force of the whole disease, and the poor Avorn-out mother can hardly realize that her child is not out of clanger—can scarcely un- derstand the physician Avho sadly explains to her that the improve- ment should come in a gradual decline, and not in a sudden subsi- dence of the symptoms. The former condition affords ground for hope, but the latter, in some distressing cases that have come under my observation, but preceded the onset of fatal convulsions. The causes of cholera infantum are predisposing and exciting. Of the former, the chief cause consists in an hereditary or acquired Aveak- liness of constitution, Avhich leaves the child open to the attacks of various diseases. Of the latter, Ave may enumerate summer heat, im- proper food, exposure to an impure or poisonous atmosphere, and the irritability of system consequent on dentition. The intense heat of summer appears to exert a poAverful influence in promoting the dis- ease. In the tabular statement prepared from the records of the Board of Health of Philadelphia by Dr. Pemberton Dudley, and pub- lished in volume seven of the Hahnemannian Monthly, the disease appeared year after year about the middle of June, and disappeared about the-middle of September, rising to its height during the hottest days, and the mortality being apparently regulated day by day by the temperature. Vomiting and diarrhoea form the most remarkable symptoms. The stomach is so irritable that it rejects immediately, and sometimes Avith violence, everything Avhich it receives. At first the vomited matter consists of the ordinary contents of the stomach, but this does not continue long, and soon the characteristic Avatery, sero-mucous material is poured forth in greater or less quantity and frequency, and Avith greater or less violence. Sometimes the matter vomited is tinged Avith bile and presents a greenish hue. In the advanced stages of the dis- order the vomiting becomes spontaneous, and the fluids ejected resemble those thrown off from the boAvels. The discharges from the bowels are ordinarily composed entirely of a perfectly colorless and inodorless fluid, often containing minute mucous flocculi. In other cases they are still Arery watery, but the fluid is yelloAvish or brownish in color, con- tains rather a larger amount of thin feculent matter, and has a most offensive odor—an odor Avhich is peculiar for its extreme fcetidity, a foetidity so great that Ave have knoAvn it to cause Amounting in those exposed to it, and so adhesive as to render it necessary to change at 794 diseases of infants and children. once all the clothing and bed-linen of the child, and even then the fcetor may cling to the body of the patient after repeated washings. These stools are discharged without the least effort, sometimes uncon- sciously, and they are generally large in quantity, soaking not only through the child's diaper and clothing, but the bed upon Avhich it lies. In some cases, however, they are very small in quantity, and are squirted from the anus as if from a syringe. In such cases there is usually more or less tormina and tenesmus. Eight, ten, twelve, twenty, or even more stools may occur within tAventy-four hours. It frequently happens that two or three movements will occur within a few minutes of each other, followed by a cessation for an hour or so, during Avhich interval the child lies perfectly inanimate, as if completely exhausted. Sometimes the stomach seems to lose its irri- tability, and to alloAV Avhatever food or drink is taken in to pass through both it and the intestines unchanged, and to be immediately throAvn off from the boAvel in the same condition. But the extreme languor and prostration and rapid emaciation are as characteristic of this affection in infants and very young children as of the corre- sponding Asiatic cholera in adults. As the disease advances the discharge becomes still more frequent, involuntary, " profuse, dark-colored like dirty Avater or the washings of stale meat, and very offensive. The emaciation of the patient becomes extreme; his eyes are languid, hollow and glassy; his coun- tenance pale and shrunken; his nose sharp and pointed; and the lips dry, thin and shriveled. The surface of the body becomes cool and clammy, of a dirty broAvnish hue, and often covered with petechiae. The tongue is dark-colored, smooth and shining, or covered, as Avell as the parietes of the mouth, with aphthae. In many cases the child lies constantly in an imperfect doze, Avith half- closed eyes, and so insensible to external impressions that flies will frequently light upon the half-covered eyeballs Avithout the patient exhibiting the least consciousness of their presence. The abdomen becomes more or less tympanitic, and the hands and feet of a leaden hue or pallid and cedematous. The fauces becoming dry, causes a sense of uneasiness, which often induces the patient to thrust the hand deep in the mouth, as if to remove some offending substance. (Bella- donna.) The patient, unless relieATed from his sufferings by a judicious treatment, becomes daily more and more exhausted, rolls his head about Avhen aAvake, and utters constantly short, plaintive, scarcely audible cries. He falls at length into a state of complete coma, death being frequently preceded by a convulsive attack. Not unfre- CHOLERA INFANTUM. 795 quently, at an early period of the disease, the brain becomes affected, and the child dies with all the symptoms of acute meningitis."— Watson. The child has no desire for food in many cases, but the thirst appears to be extreme, and cold fluids are taken Avith avidity, even though discharged from the stomach Avithin a few minutes afterward. The pulse rises rapidly in frequency as the disease advances, gradually becoming more and more feeble and thread-like; Avhile the tempera- ture of the body rises gradually, and in some instances the little patient becomes exceedingly hot. Respiration becomes shortened and anxious, Avhich may even amount to dyspnoea in bad cases. The urine becomes more and more scanty as the quantity of fluid voided by the stomach and boAvels increases, and may even be entirely sup- pressed. The tongue, as the disease progresses, loses its moisture and becomes dry and pasty, and in some instances cold. The abdomen does not appear to be tender of pressure, but is sunken, doughy and inelastic, and the skin of the abdomen may be pinched into folds in Avhich it Avill remain for some time. If the disease is not checked collapse will set in. It usually runs a very rapid course, and will terminate fatally in one, tAvo, three or four days, or gradual restoration to health will occur. The prognosis of cholera infantum depends upon the violence of the attack, the ability of the patient to Avithstand it, and the skill of the physician in encountering the disease and combating its unfa- vorable conditions. In some instances, when cholera infantum attacks an infant, the physician feels that the case is a hopeless one, from his knoAvledge of the weakly constitution of his little charge; Avhile in others he has the comforting assurance of considerable in- herent strength to resist, and a consequent hopefulness as to the final result. As a general thing, it may be stated the prognosis will depend upon the severity of the symptoms. " When the discharges consist merely of serous fluid, and are copious and frequent; Avhen they consist of small quantities of deep-green matter mixed with much mucus or Avith blood; Avhen accompanied by straining; Avhen they number from fifteen to tAventy-five in the day; Avhen they are very foetid; and when, Avith these symptoms, the abdomen is tense and tympanitic, the countenance pinched, the expression languid, the extremities cool, the pulse rapid and small, and the child irritable and restless, or, on the other hand, very still and subdued,"—then, according to very high old-school authority, the prognosis is exceed- ingly bad. And the truth of this statement is in general terms ad- 796 diseases of infants and children. mitted, Avith some qualifying circumstances to modify it, such as the previous good condition of the child, both hereditary and acquired, the absence at the time of the attack of the irritation of dentition, the fact that the child is nourished at the maternal fount, and has favorable atmospheric surroundings, together Avith the Avonderful efficiency of homoeopathic medication. Favorable symptoms are—an abatement of the fever and the gradual restoration of an even temperature, with increased volume and decreased frequency of pulse; cessation of vom- iting, and decrease in the number of the evacuations, Avith a gradual return of the stools to a more natural condition and appearance; natural and peaceful sleep; desire for food; and a general improve- ment in the appearance of the child, together with a return of play- fulness, etc. Treatment.—Cholera infantum is almost peculiar to large cities and to summer heat, and a child having an attack of simple diarrhoea is peculiarly susceptible to the producing influence of this dread disease. It is obvious, therefore, that it is of great importance to remove the simple diarrhoea; and one of the best methods of securing that, and of otherwise affording comparative immunity from cholera infantum, is to send the little one away into the country to some salubrious situation, Avhere pure air may be breathed plentifully. Should this be impossible from any cause, then the physician should enjoin upon the parents the importance of keeping the child as much as possible in the open air, taking it into the parks or public squares, and making short excursions with it upon the rivers and into the country places adjacent, taking great care not to fatigue or Avorry the child, and not to expose it to the hot sun. Fresh and pure air has saved the lives of many little ones. The physician should see to it, likeAvise, that the child under his care is properly clothed and fed; many of the com- monest and most obvious laAvs of hygiene and dietetics Avill otherwise be violated by parents, even in their anxiety to do the' best they can for their children. And the physician, in case he is called to a child suffering from a diarrhoea in summer, and especially if the stools become copious and Avatery, should select his remedies Avith the utmost care and Avateh the case with great solicitude, lest it slip into cholera infantum, and the child, having its strength taken aAvay by the pro- dromic diarrhoea, dies Avhen its life might othenvise have been saved. Consult the folloAving remedies and their indications, as well as those given under the headings Atrophy, Diarrhoea and Dysentery: iEthusa. The child lies stretched out and in an unconscious condi- CHOLERA INFANTUM. 797 tion, Avith pupils dilated and a fixed and staring look. Linea nasalis. Face sometimes red and sometimes pale; mouth either moist or dry; vomiting of Avhite, frothy matter. Vomiting and diarrhoea, with great prostration. Pulse sometimes imperceptible. Convulsions, Avith clenching of the thumbs and turning doAvnward of the eyes. Pro- fuse vomiting of the milk, which is thrown off as soon as it is taken. Milk in any form does not agree with the child, and excites vomiting. Constant thirst and great prostration. Vomiting of coagulated milk. Antimonium c. White coating on the tongue; nausea, retching, coughing; vomiting and watery diarrhoea; absence of thirst. The child is fretful and peevish, turns itself aAvay and cries when looked at or touched. Arsenicum. The child is very AAreak, and the slightest effort, such as vomiting, etc., seems to exhaust it. Intense thirst, Avith vomiting immediately after drinking. Although the child constantly Avishes to drink, it takes but a sip at a time. Simultaneous vomiting and purg- ing. Coldness of the extremities. The face is pale and cadaveric, and the skin is dry and shriveled. The child is very restless, con- stantly tossing to and fro. All the symptoms are aggravated after midnight. Belladonna. Great heat of the head and dryness of the mouth and lips. Tongue coated Avhite, Avith red margins. The child wakes from sleep Avith a start, and is delirious, or is A^ery sleepy and yet cannot sleep. Sudden darting and twitching of muscles during sleep. Benzoic acid. "Foetid, Avatery, Avhite stools, very copious and ex- hausting. During stool much pressing or straining. Strong-smelling- urine, mostly dark-colored. Troublesome dry hacking cough. Tongue coated Avith Avhite mucus or ulcerated." Bryonia. When hot \veather seems to develop the attack. The child vomits its ingesta immediately. Lumpy diarrhoea; colic, Avith much thirst and desire for a large quantity at a time; lips dry and parched. Calcarea c. In leucophlegmatic children during teething. Swelling and hardness of the abdomen; flabby muscles; skin dry and shriveled; hair dry, looking like toAV. Profuse sweat of the head Avhen sleeping. Stools Avhitish, watery and undigested. Camphor. The skin is cold as marble, yet the child will not remain covered; much prostration and diarrhoea. Sometimes these cold spells only come on at night and pass off in the morning. Occa- sionally there is neither vomiting nor purging, but coldness and great prostration. Carbo veg. Similar to Bryonia; may be used when that remedy 798 DISEASES OF INFANTS AND CHILDREN. appears to be indicated, but fails to cure. InA7oluntary stools, Avhich are very offensive; emissions of large quantities of flatus, either foetid or inodorous. China. Very flatulent diarrhoea, containing portions of the ingcsta; stools foetid, and occurring immediately after eating. Partaking of fruit may haA7e been the cause of the attack. Great Aveakness and inclination to SAveat or great prostration after a stool. Croton t. The stool occurs suddenly—one gush and it is finished. The lips are dry and parched. Great prostration after a passage. Dulcamara. EArery cool change in the Aveather or an unusually cool night causes a relapse, or such condition of the weather appears to cause the attack at its first onset. Gratiola. Violent vomiting and purging of yelloAV substances, and much flatulency. Ipecacuanha. Much nausea and vomiting, or almost constant nausea; these symptoms predominate. Watery diarrhoea, or green, or, still more, particularly, fermented stools. Laurocerasus. Pulse very sIoav and irregular or imperceptible. When the child drinks the fluid gurgles Avhen passing through the oesophagus like the noise made by pouring fluid into an empty barrel. Mercurius sol. The child has colic, slimy and sometimes- bloody stools, Avith tenesmus, the colic being relieved immediately after the stool. There is often much perspiration, particularly upon the thighs, where it is cold and clammy. The child is Avorse in the early part of the night, and is very weak. Nux V. In cases Avhere some marked error in diet has caused indi- gestion ; or we may think of Nux after Ipecac, has failed. Phosphorus. The child vomits its drink as soon as it gets AA^arm in the stomach. The stools are very watery, and contain little lumps Avhich look like tallow. Phosphoric acid. Great exhaustion; sunken eyes, with blue margins; stools are generally painless. Podophyllum p. Exceedingly offensive stools, which are most fre- quent in the morning. Prolapsus ani with stools. Moaning during sleep, Avith half-closed eyes, and rolling the head from side to side. Gagging or ineffectual retching. Secale c. Great debility, vomiting and diarrhoea; much thirst; pale face, sunken eyes, dry heat, quick pulse, restlessness and sleeplessness. Involuntary stools. Great aversion to heat or to being covered. Sulphur. When there are repeated relapses, or when the case seems to linger, with excoriations, redness about the anus; eruptious; Aveak VOMITING. 799 spells; sleeps with frequent Avaking. Worse in the early part of the morning. Veratrum. The least motion increases the nausea. Cold SAveat on the forehead, from vomiting, with great prostration. Pulse almost imperceptible. The least quantity of liquid excites vomiting, which is followed by cold sweat on the forehead. Prostration, Avith cold sweat and cold breath. Stools consist of greenish water with flakes. Vio- lent thirst for cold Avater. Vomiting. Vomiting in infants and little children constitutes one of the most obvious symptoms of indigestion. This, as already stated, may be merely an effort of nature to relieve the overloaded stomach. But in a large number of cases the vomiting, Avhile it forms but a single one with other symptoms, indicates a still more serious disorder of the stomach; and from the explanation already gh^en of the nature and progress of indigestion, it will be seen why vomiting should often be accompanied Avith diarrhoea. In the more severe forms of gastro- intestinal disease this is ahvays the case; and this connection was especially sIioavii in the consideration of Cholera Infantum in the pre- ceding section, Avhere these tAvo characteristic symptoms Avere dis- cussed together. Vomiting differs in different cases, in accordance with the nature and extent of the morbid influence upon Avhich it depends. Thus, Ave may note several kinds of vomiting Avhich may occur in infants: First. That simple regurgitation of food taken in excess already sufficiently described. Second. Acrid and sour-smelling vomiting, vomiting from indiges- tion, and such as appears to result from gastric or general fever. Third. Bilious vomiting—vomiting of greenish or bitter fluids, either separately or mingled Avith food. This form may imply functional disturbance of the liver, or it may simply result from gastric irritation and straining to vomit, Avhich causes an actual regurgitation of the bile. Fourth. The vomiting Avhich accompanies severe forms of diar- rhoea, as in cholera infantum, inflammatory vomiting and diarrhoea; the discbarges from the stomach may be Avatery. Fifth. Vomiting of blood, a rare form of disease in very young infants, occurring within a few days, sometimes Avithin a few hours, after birth, and accompanied by purging of blood. This seems to result from engorgement of the liver and abdominal A'eins, and may 800 DISEASES OF INFANTS AND CHILDREN. arise from interruption of the circulation by external compression in difficult labor.— West. Sixth. Faecal Amounting, indicative of obstruction of the boAvels, as in cases of most obstinate constipation, of intussusception and of strangulated hernia. Seventh. Vomiting Avhich occurs as symptomatic of other diseases. Of these we mention that Avhich appears as one of the most import- ant symptoms of incipient cerebral disease: " Nausea and Aromiting are seldom absent. I am not acquainted Avith any one symptom Avhich should so immediately direct your attention to the brain as the occurrence of causeless vomiting, and especially its continuance. At first, perhaps, the child vomits only Avhen it has taken its food; but before long the stomach Avill reject even the blandest fluid, and then the efforts of vomiting Avill come on when the stomach is empty, a little greenish mucus being ejected Avith no relief, the retching and vomiting soon returning." This may continue for several days before any other indication of cerebral disease is discovered; and in this connection the boAvels are usually, although not invariably, con- stipated. The persistence of intractable vomiting, in the absence of any other cause, either in the quality of the food or in the state of the digestive apparatus, Avill occasion a very strong suspicion of deep- seated dyscrasia, powerfully affecting the organic nervous system, and threatening to develop itself in the form of hydrocephalus, either acute or chronic. The vomiting which so constantly precedes the attack of scarlatina is well known; and in this case, as in that first mentioned of incipient cerebral disease, the severity and persistence of the symptomatic vomiting bear some proportion to the gravity of the subsequent disorder. For further consideration of this subject see the article on Hydrocephalus. Treatment.—In the treatment of vomiting, careful attention must be given to all the accompanying symptoms and conditions, eAren to the observation of the state of the pupil of the eye, to the scrutiny of the discharges themsel\res, and to the absence or presence of known causes and attendant circumstances. When there is vomiting of blood, first be sure that the blood does not come from the nipple; if it does, a little pressure upon the neck of this organ Avill cause it to appear. For the several kinds of vomiting study the folloAving remedies: Vomiting of blood: Arnica. May be needed if the child has been injured. LESIONS OF THE RESPIRATORY MUCOUS MEMBRANE. 801 Arsenicum. The child seems weak and much exhausted. Ipecacuanha. Persistent nausea, Avith vomiting of blood. Nux vomica. Constipation. Violent vomiting of bright-red blood. Regurgitation or vomiting of milk : iEthusa, Bryonia, Calcarea c, Cina, Jodium, Ipecacuanha, Lycopo- dium, Nux vomica, Silicia, Sulphur. Vomiting of ingesta: Calcarea c, Cham., China, Ipecacuanha, Iris, Lycopodium, Nux vomica, Phosphorus, Pulsatilla, Sulphur, Silicia. Bilious vomiting: Arsenicum, Bryonia, Cham., China, Ipecacuanha, Mercurius, Nux vomica, Pulsatilla, Sepia, Veratrum. Faecal vomiting: Belladonna, Nux vomica, Opium, Plumbum. CHAPTER XXXVI. DISEASES OF CHILDREN—CONTINUED. Lesions of the Respiratory Mucous Membrane. THE great majority of the disorders incident to infants and young children consists in affections of the gastro-intestinal and res- piratory mucous membranes. The latter organs especially are so exceedingly delicate as to offer but inefficient resistance to the many noxious influences inseparable from atmospheric vicissitudes, and at the same time they form the seat of development for various consti- tutional dyscrasia, and actively sympathize Avith morbid processes in other organs. It is stated on the authority of Professor Jorg of Leipsic that the great sensibility of the lining membrane of the respiratory apparatus does not exist in the same degree in the first month or tAvo of infantile life that it does afterward. " The exposure of an infant two or three weeks old to a Ioav temperature or to a vitiated air will be followed by disturbance of the functions of the liver and the occurrence of jaundice, or perhaps by such depression of the muscular power as to render the child incapable of taking a full inspiration, so that its lungs collapse, and it dies from disease of the respiratory organs, but without the cough or bronchitic symptoms, 51 802 DISEASES OF INFANTS AND CHILDREN. Avhich Avould not fail, if it Avere a little older, to announce the irrita- tion of the mucous membrane of the air-tubes." To this remark, hoAvever, coryza forms an exception, since this affection is often seen to prove very annoying at an early period of infantile life. Catarrh, Bronchitis and Pneumonia seem to follow in order, in unison Avith the development of the child's physical system, and each disorder pre- pares the way for that Avhich may folloAV, the last form seeming in some cases to be but the extension and development of the first. Coryza. Coryza, snuffles or cold in the head is one of the earliest and most common affections of the young infant. It consists in inflammation of the mucous lining of the nasal passages. Sometimes the first that is known of it is that the infant's nose is stopped up, so as to hinder its respiration while at the breast. The swelling of the mucous mem- brane of the nares, and especially the accumulation of the secreted mucus, not only hinder the little sufferer from breathing through its nose, as is its wont in nursing, but occasion also during its sleep the peculiar snuffling sound—similar to snoring in adults—which gives to this disorder its popular name. In some cases there is a considerable flow of mucus, and all the symptoms resemble those seen in the epi- demic influenza of older children. Here the Euphrasia deserves attention, in addition to the remedies commonly used, since it will often be found to correspond in a remarkable manner Avith the totality of the symptoms. In other cases there appears to be "something more than a simple inflammation of the Schneiderian membrane, since it either secretes a very tenacious mucus in extreme abundance or becomes coated Avith a false membrane, Avhich sometimes extends even to the tonsils and palate. Cases of this kind are usually associated with extreme de- pression of the vital powers, and have received on this account the name of Coryza maligna. I have no doubt of their identity with diphtheria, of which they constitute the form known as nasal diph- theria."— West. In addition to the Kali bi., those two more recently proved remedies, Cubebs and Arum triphyllum* will be suggested to the homoeopathic practitioner, to Avhoni the totality of the symptoms of each case is everything, while the name by A\diich the disease may be designated is of small account. Where the coryza tends to become chronic, and to maintain itself in spite of the indicated remedies, we must look still deeper into the * Hahnemannian Monthly, vol. ii., pp. 213 and 459. CORYZA. 803 nature of the case, if not before, since this very disposition to per- sistence evidences some constitutional taint—either scrofulous or worse—which had not otherwise been discoverable. Indeed, chronic coryza, fully deA-eloped and established, wants only the intolerably offensive odor of the discharge to become a veritable ozcena. This latter will of course consist in an ulcerated state of the mucous mem- brane of the nares, and may be purely scrofulous in its origin, or dependent upon some more or less remote syphilitic taint in the sys- tem. The history of the case and the attendant symptoms will usually show the nature of the affection, and in his diagnosis the physician may sometimes be assisted by observing in spots the minute traces of a characteristic copper-colored eruption. By thus adapting his reme- dies to all the conditions and symptoms of the case, he may well hope in a short space of time to remoA'e the primary affection of the nasal mucous membrane of the young infant, which if not thus early eradi- cated Avill presently extend itself to the adjacent mucous surfaces, and become a much more formidable and intractable kind of disease. Aconitum. This remedy is frequently introduced at first when there are febrile indications. It will often cut short an attack of catarrh when promptly administered. Allium cepa. The discharge from the nose is profuse, watery and excoriating, and there is corresponding lachrymation. Violent cough accompanies the coryza. Ammonium c. Dry coryza, with stoppage of the nose, especially at night, and lachrymation. Arum triphyllum. Profuse coryza, the fluid discharged being burn- ing and ichorous, making the nostrils and lips sore; feverishness and hot, dry skin. Calcarea c. This medicine may be appropriately given after Cham- omilla Avhen that remedy seems indicated, but fails. Carbo veg. If the coryza return in the evening. Chamomilla. When there is a watery or mucous discharge. The child is quieted, and in fact relieved, by carrying it up and down the room. One cheek red, Avhile the other is pale. Dulcamara. The child gets Avorse at every cold change in the weather or from exposure to cold air. Dry cough. Euphrasia. Profuse fluent coryza and acrid lachrymation; the eyes are much invohred. Ulceration of the margins of the eyelids. Kali bi. An invaluable remedy Avhen the discharge from the nose is tough and stringy; sometimes it seems to extend to the throat, and to cause choking. 804 DISEASES OF INFANTS AND CHILDREN. Mercurius. The nostrils are reel, raAV and ulcerated. Frequent sneezing and profuse fluent coryza. Nux V. The catarrh is worse at night, particularly toward morning or in the morning. Through the night the nose is very dry. Pulsatilla. Coryza much Avorse every evening, better every morning. Discharge of yellowish-green, thick and sometimes foetid coryza. Worse toAvard evening. Sambucus n. The nose seems perfectly c?n/and completely obstructed. Very frequently indicated Avhen the child " snuffles " constantly. Sticta p. There is a constant irritation in the nose to bloAV it, but no discharge. Sulphur. Fluent coryza, like clear water, and very profuse. Tartar em. Obstruction of the nose, and at the same time much rattling in the bronchia. Bronchitis. The term Bronchitis is employed to express an inflammation of the bronchial mucous membrane. It is also knoAvn as Catarrh, Catarrhal Fever and Bronchial Catarrh, and is a disease of very common occur- rence among infants and older children, especially during the spring and winter months. The acute form of bronchial inflammation, that which is generally understood by bronchitis, is confined to the larger bronchial tubes, and displays at first considerable fever, upon the subsidence of which the catarrhal secretion may make its appearance as a critical discharge. This form of disease is the one which oftener attacks children appa- rently robust, and in some—Avhose constitutions are far from being so good as they seem—the disorder runs a very rapid course, and is suc- ceeded by a mucous secretion, dangerous in proportion to its abun- dance, and abundant in proportion to the plumpness and apparent heartiness (and real Aveakness) of the child. The disease results from exposure to a low or damp temperature, or from a sudden transition from heat to cold or from cold to heat; sometimes it appears to prevail epidemically. The style of dress adopted by mothers for their children is likeAvise a fruitful cause of bronchitis. It is distressing, and at the same time absurd, to see the tender infant exposed to cold and inclement weather clad in such insufficient garments as to render it liable to "take cold" at any moment—garments Avhich its parents Avould consider entirely insuffi- cient if they Avould take the trouble to compare them with their own ample and comfortable clothing. Sometimes also it appears as a com- BRONCHITIS. 805 plication of epidemic eruptive fevers, especially measles. It com- mences Avith the ordinary symptoms of cold in the head, such as sneezing, running at the eyes and nose, hoarseness, cough, dry, hot skin and accelerated pulse. In fact, a severe attack of bronchitis usually consists in an extension into the air-passages of inflammation originally commencing in the form of influenza. The child cries when it is put to the breast or attempts to SAvallow; it is disturbed by frequent fits of coughing, Avhich is at first short and dry, but soon becomes wheezing and rattling; and it appears oppressed with tight- ness of breathing. In mild cases slight mucous rales are heard, which increase Avith the extension of the inflammation. As the inflamma- tion extends more and more through the ramifications of the bronchia, assuming then the form of capillary bronchitis, the febrile symptoms become more developed and the skin burning, hot and dry; the pulse is rapid; there is considerable restlessness, panting of the breath, tossing of the head about from one side to the other, flushing of one or both cheeks, the cough being constant Avith little or no expectora- \ tion, and on putting the ear to the chest sibilant or whistling with harsh mucous or sub-crepitant rales are heard at different parts, proving the extension of the inflammation throughout the whole chest. The symptoms are aggravated toward evening, the child having been com- paratively comfortable during the day. This evening exacerbation is due, according to Handfield Jones, "to a lowering of the nerve-poAver, the vaso-motor nerves partaking of the general debility, and thus allowing dilatation of the arteries, and causing increased hyperamaia of the affected parts, with more abundant exudation." As the disease subsides, the respiration becomes more free and the cough loose and easy, the sound of the cough itself being the only guide in this respect in young children, since, the phlegm is ahvays SAvallowed. When the disease occurs in the most acute form, the catarrhal symptoms are fre- quently absent and the attack sudden; on the other hand, a low form of sub-acute bronchitis, Avhich has originated in a slight catarrh or influenza, often constitutes a protracted and dangerous variety of the disease. Bronchitis arising from an extreme and sympathetic irritability of the mucous lining membrane of the air-passages constitutes a very distressing complication in measles. In such cases, Avhere the cough is dry and almost spasmodic, incessant, accompanying evrery breath, Avith imminent danger of congestion, Ipecacuanha has given imme- diate relief. In the severer forms of acute bronchitis the subsidence of the primary fever is succeeded by a profuse secretion of (tenacious) 806 DISEASES OF INFANTS AND CHILDREN. mucus, which chokes the bronchial tubes and effectually excludes the air from a considerable portion of the air-cells and blood-vessels. The little sufferer is in great danger of perishing in such cases from sIoav suffocation. The countenance becomes livid, the extremities cold and lead-colored, droAVsiness supervenes, Avhich may be folloAved by coma, convulsions, and finally by fatal asphyxia. To the above description of bronchitis—draAvn principally from Leadam—it may be sufficient to add that this disorder in its initial stages may be dis- tinguished from pneumonia by the external catarrhal symptoms, subsequently by the distressing and paroxysmal nature of the dry and almost spasmodic cough, by the wheezing and Avhistling sounds, and finally by the very copious, sometimes stringy and suffocative secretion of mucus, Avhich in the third stage of the disorder either concludes it by a favorable resolution, or destroys the patient's life by suffocation. Capillary bronchitis—the acute suffocative catarrh and congestive catarrhal fever of some writers—may occur either as an independent disease, or may result from the extension of the primary inflammation of the larger bronchia to the smaller ramifications of the air-tubes. The symptoms are more violent and dangerous than in the ordinary form of the disease. The respiration becomes greatly hurried, and the pulse rises to 150, or even higher; there is an anxious expression of countenance, great restlessness; the cough is very troublesome, and evidently gives rise to pain. " The resonance on percussion is not modified. Auscultation reveals at first sibilant rales, mixed Avith some mucous rhonchus; but soon a fine sub-crepitant rale is heard over all the lower parts of both lungs behind, and approaching some- times over the bases of the lungs, the character of crepitus. After a time the sub-crepitant rale is heard over the whole, or nearly the whole, dorsum of the chest, and to a greater or less extent, though not so well marked as behind, over the anterior regions of the thorax. This rale is audible at first both in inspiration and expiration, and is very dis- tinct, but at a later period it is heard only in the inspiration, or there is substituted for it the mucous rale, Avhile the sub-crepitant rale is noAV heard only in the forced inspirations during coughing or crying. These rales are fugitive and irregular, disappearing or changing from one to the other after fits of coughing."—Meigs and Pepper. This form of the disease usually runs a very rapid course, lasting from five to eight days, although it may terminate in death or restora- tion to a better condition in a much shorter time. Favorable symptoms are—less frequent and easier respiration, a return of the natural respi- ratory murmur in parts of the chest, a subsidence of the sub-crepitant BRONCHITIS. 807 rales, and a diminished frequency in the beats of the pulse. Should the breathing become more and more oppressed and exceedingly rapid, 80 to 90 per minute, Avith fan-like motion of the alse nasi, and an in- creased frequency of pulse, which is small, thread-like and irregular, the case may be regarded as very grave and a fatal termination may be apprehended. As death approaches in fatal cases "the respiration is uneven, irregular, stertorous, and often slower than before; the cough is smothered and less frequent; the restlessness generally diminishes, and the child sinks into quiet, and often becomes comatose; the paroxysms of suffocation are less frequently renewed and less violent, and death occurs in a state of quiet insensibility, or is pre- ceded by partial or general convulsive movements." Sub-acute and chronic bronchitis usually result from the subsidence of an acute attack. The symptoms vary in seArerity in different cases, but are usually a mild type of those presented above, the most con- stant and distressing being the cough and expectoration. And chil- dren suffering from these forms of bronchitis are liable, upon any exposure to unfavorable atmospheric influences, to a rousing up of the inflammatory process, which results in an aggravation of all the symp- toms, or, in fact, to an acute bronchitis, either simple or inflammatory. Such aggravations, it is claimed, likewise frequently occur in children who are teething at the irruption of eATery tooth. Treatment.—It is important that the child be kept in a well- ventilated room, of equable temperature, and free from exposure to draughts and cold. The folloAving remedies should be consulted: Aconite. When the fever runs very high; hot skin ; much distress and great restlessness. When these symptoms are present at the com- mencement of an attack of bronchitis, Aconite will sometimes cut it short. Arnica. The child cries every time it coughs, or even before cough- ing, as though it dreaded it. Arsenicum. When there is great prostration; restlessness after twehTe at night; it drinks little and often; suffocative attacks. Belladonna. The mucous rales are large and crepitous, hoarse cough; much moaning; moaning at every breath; starting and jerking of the muscles. Bryonia. Respiration much oppressed; dry, cracked lips; cough worse after drinking; constipation of dry, black, burnt-like looking stools. The child seems to desire rest; every motion seemingly aggra- vates the suffering. 808 DISEASES OF INFANTS AND CHILDREN. Calcarea C. Much mucus in the chest. In leuco-phlegmatic children ; large and open fontanelles; much perspiration on the head, so that the pillow is Avet far around. Chamomilla. The child is very cross and fretful; one cheek red, the other pale; must be carried to be appeased. Cina. Vermiculous symptoms prevail, such as picking the nose; nothing satisfies the child; it is always hungry. Drosera. The fever and the cough—which is very hoarse—are worse after tAA'elve at night. Dulcamara. The disease has been induced by cold damp air. Hepar. The child seems croupy, decidedly so, and the phlegm is loose and choking. It chokes in the cough. Ipecacuanha. Much nausea and vomiting of mucus; the cough is strangling and suffocating, so much mucus seems to be accumulated in the bronchial tubes; it turns blue in the face. Lycopodium. There is much oppression of the chest, and the aim nasi are seen to dilate or spread out wide, like the large end of a trumpet, and then to contract, alternately. Nux v. The child is ahvays Avorse after four o'clock in the morning. Constipation ; loss of appetite; the cough is very tight and dry, and is sometimes relieved by expectoration of a small quantity of mucus after much coughing. Phosphorus. Severe and exhausting cough, which the child dreads and avoids as long as possible. The case becomes worse in the even- ing, and continues so during the night. The fever is often very high and the pulse very rapid. Pulsatilla. The cough is very loose, and with all the fever there is but little or no thirst. The child gets Avorse toward evening, and it has more difficulty of breathing when it lies on its side. Silicia. In children who have large bellies; perspiration about the head; of a scrofulous constitution. Sulphur. The child has papular eruptions upon its skin; rather inclined to excoriation; much rattling of mucus in the chest; sleeps in very short naps, frequently awaking. Tartar em. Much thirst; wishes to drink little and often. When the child coughs there appears to be a large collection of mucus in the bronchial tubes, and it seems as if much Avould be expectorated, but nothing comes up. Pneumonia—Lung Fever. As an idiopathic disease, inflammation of the lungs is compara- tively rare in infants, never occurring, it may be affirmed, except in PNEUMONIA. 809 those who have a decided constitutional predisposition to such affec- tions. Such predisposition may be traced in little children whose parents, one or both, have suffered with pulmonary phthisis. Infants born from such parents, one of Avhom may have recently died Avith consumption, when but a few months old have been observed to fall victims to pneumonia, developed in a very rapid manner and under the influence of scarcely noticeable external causes. It is not always easy to determine, at the first and with any degree of positiveness, Avhether an infant is suffering Avith pneumonia or with bronchitis; nor in fact is it absolutely necessary for the homoeo- pathic treatment, since we carefully select the remedy which is the exact simile of the existing symptoms and conditions; nor will the prescription be properly influenced by our pathological interpretation of these symptoms. And indeed in many cases both forms of in- flammation, that of the parenchyma of the lungs and that of the mucous lining membrane of the air-passages, run into each other, and the pneumonia of infants is as apt to be asssociated Avith bronchitis, constituting broncho-pneumonia, as that of adults to be complicated Avith pleurisy. The sputa, alike characteristic in bronchitis and in pneumonia, afford no aid where the patient is either an infant or a very young child, since these little folks never expectorate. The ex- istence of the mucous rale, distinctly confined to one lobe of the lung, and a circumscribed redness in the cheek of the same side, Avould afford strong presumption of pneumonia. In this latter disease, also, the cough is less violent, though frequent and short, and it is not so much attended Avith rattling of mucus; there is often a circumscribed redness of the cheek of the same side with that of the inflamed lung, and the child evidently prefers lying on the affected side. Where the pneumonia invades both lobes of the lungs—Avhich, hoAvever, may be a successive development—there will be still more evidence of conges- tion ; flushing of the face and hurried and short respiration, and rapidly increasing exhaustion. The history of the case, and its rela- tion to hooping-cough, to influenza or to measles, either of which may remarkably tend to develop such phenomena, Avill greatly aid in the diagnosis; and the same is true of the previous history of the patient and of his hereditary proclivities. In pneumonia, at its first stage, or stage of engorgement, as in bron- chitis, the fever comes first, Avith dry cough; then the fever abates someAvhat as the cough becomes more loose and catarrhal. But in no stage of the disease does the cough assume the paroxysmal and almost spasmodic form so often seen in bronchitis, and Avhich results from 810 DISEASES OF INFANTS AND CHILDREN. the tenacious nature of much of the secretion in this latter disease, and the consequent difficulty of starting it from the bronchia. The first stage of pneumonia is characterized by nervousness, fretfulness and restless- ness; constipation of the boAvels and sometimes vomiting; redness of the tip of the tongue, the latter coated Avhite in the middle; the child breathes through the open mouth, instead of through the nose; or there is an unusual alternate contraction and expansion of the nos- trils—a symptom which should ahvays attract attention to the respira- tory organs when seen in young children. He sucks by starts, because he cannot breathe as usual through the nose Avhile nursing; he " seizes the breast eagerly, sucks for a moment Avith greediness, then suddenly drops the nipple, and in many instances begins to cry." In the second stage, or that of red hepatization, the little patient becomes languid, sometimes droAvsy ; the respiration is more evidently hurried, " the ake nasi are dilated Avith each inspiration, the abdominal muscles are brought into play to assist in its performance, and any change of posture renders the breathing more labored and more hur- ried. The cough becomes much more frequent; it is still hard, some- times evidently painful, so that the child cries at each cough; at other times it is an almost constant short hack." As the disease still advances the bright flush of the face and the florid tint of the lips subside; the body remains \Tery hot, while the extremities may become cool; the face may appear pale and the lips assume a livid hue Avhere the pneumonia is very extensiA^e. The babe becomes still weaker, vomits the food, Avhich it takes greedily from the severe thirst; and finally, through the hurried nature of the respiration, becomes incapable of nursing at all. Percussion reveals a dullness over the seat of the dis- ease, Avhile there is evident diminution of elasticity of the thoracic Avails. Auscultation reveals fine sub-crepitant rales, with well-marked bronchial respiration. Death may suddenly occur in this stage from exhaustion or from collapse of the lung. In the third stage, or that of gray hepatization, the respiration be- comes more labored and irregular, though less frequent. The little sufferer loses its voice, or becomes very hoarse and almost entirely incapable of coughing. The face is sunken, the extremities cold, the pulse extremely small, and so frequent as to be almost impossible to count. The child is restless at intervals, or lies in a state of half-consciousness, and suffers very much from dyspnoea on being moved. The face and nails exhibit a livid hue if the disease ad- vances unchecked, and coma and compulsions close the sad scene. Abscesses sometimes form in this stage of the disease, and if they PNEUMONIA. 811 should discharge into the pleural sac, pneumo-thorax would be the result. During dentition, under the attack of measles and the prevalence of influenza, infants are especially liable to become subject to pneu- monia; at such times, therefore, the physician Avill most carefully scrutinize eA^ery symptom Avhich might indicate the onset of a disease that is alike insidious and fatal in the aged and in the very young. The only other form of disease for which infantile pneumonia might be mistaken is incipient hydrocephalus; to this error the vomiting, the feArer, restlessness and constipation—which are alike common to both diseases—might easily lead those not on their guard. And this the more especially since, according to Dr. West, to whose Avork we are much indebted in the above description, the cough in some cases of pneumonia is at first so slight as scarcely to be noticed, and even Avhere it is more strongly marked it might easily be mistaken for the sympathetic cough Avhich is sometimes present in the early stages of hydrocephalus. Treatment.—The following remedies will generally be found suffi- cient for the treatment of cases of pneumonia, which usually termi- nate favorably, especially in children over tAvo or three years old. Consult also the medicines mentioned under the head of Bronchitis. Aconite. If the child has a truly synochal fever, is very restless, Avith much oppression of the chest and anxiety. It can scarcely cough, the suffering is so intense. Short and rattling breathing; constant cough; almost constant crying, with anxious countenance and great un- easiness. Belladonna. Face very red and eyes injected. The child moans with every breath. Its skin imparts a burning sensation to the hand. Jerking and twitching of the muscles. Bryonia. The child cannot bear to be moved, the least movement so greatly increases its sufferings. Dry and parched lips; mouth dry; constipation; faeces hard and dry as if burnt, usually of a dark color. The cough is aggravated by drinking, but the child nevertheless Avishes to drink large quantities of fluids. Lycopodium. Decided flapping or fan-like motion of the alse nasi; they dilate widely and extremely, and then contract, alternately. Mercurius. Much fever; thirst; salivation; a profuse perspiration which affords no relief; a great deal of coughing, with great distress. Phosphorus. Particularly in tall and slender children; cough violent, sounding dry or loose; panting respiration; hoarse toward evening. 812 DISEASES OF INFANTS AND CHILDREN. Sulphur. In cases attended with pustular eruptions; skin rough and scaly, and other indications for this remedy. Calcarea and Hepar should also be studied, the former in very fat children especially. Croup. Croup is an especial disease of little children, and it by no means spares young infants. Strictly speaking, it is an inflammatory affec- tion of the mucous membrane, first of the larynx, and subsequently of the trachea also. Under the general name of croup are popularly included two distinct forms of disease—one, the inflammatory or true croup; the other, the spasmodic or spurious croup. The inflamma- tory or membranous croup is gradual in its onset and insidious in its character, and unless arrested by the appropriate medication it is pretty certain to terminate fatally. The spasmodic or false croup is not attended Avith formation of false membrane, and, though much more sudden and violent in its onset, it is far less dangerous in its nature. The true membranous croup has an element of persistence, and the great hoarseness may remain for a long time unabated, as Avell as the other symptoms, and give the physician much anxiety about the ulti- mate result, even when improArement is actually taking place as rapidly and favorably as possible. And in no other disease is the triumph of homoeopathy over allopathic practice more evident or more grateful than in this. Three-fourths of the cases of membranous croup con- fessedly perish under allopathic treatment, and no small proportion of those of the spasmodic variety; while those who survive, especially an attack of true croup, have been so barbarously treated Avith blisters, cups, leeches, purgatives, emetics, et id omne genus, that they remain for a long time enfeebled. In the homoeopathic practice, on the contrary, a case of croup is very seldom lost, even of the mem- branous variety, and never, we think, sa\re from want of attention and care on the part of the nurse, failure to call in the physician before the disease has too far advanced, or failure on the part of the physician himself to administer the remedy required by the exigencies of the individual ease. Etiology.—Croup is developed in constitutions predisposed to this disorder by a variety of causes Avhich in other persons might have resulted in simple catarrh or pneumonia. The most frequent cause, however, is exposure to cold and damp. We remember an exceed- ingly obstinate case of croup occurring in a little boy in consequence of his sitting playing in the damp snow. It has been remarked by CROUP. 813 the physicians of Edinburgh that the croup occurs among the poorer classes in that city most commonly on a Sunday or Monday, and the^ account for it by the fact that the cottage floors are usually Avashed on Saturday afternoon, and remain very damp. We remember a re- markable case of croup Avhich resulted from a leak in the roof, by means of which the moisture penetrated the ceiling of the child's sleeping chamber after a heavy rain in Avinter, and rendered damp the papering of the Avails in the comer where his bed Avas placed. Particular states of the atmosphere and Avind sometimes seem to favor an epidemic development of croup, and this may be in dry, cold air, as Avell as in the wet. Membranous Croup may begin with simple hoarseness, folloAved by an occasional hoarse cough, Avhich to uneducated ears has no par- ticular significance, but Avhich to the initiated announces the prelimi- nary stage of this much-dreaded disease. In some cases related by allopathic Avriters the children thus affected Avere stated to be already past all hope of recovery while yet able to play about the room! This hoarseness may continue, and the hoarse cough become more frequent, for tAvo or three days before the illness of the child becomes so obvious as to seriously alarm the parent. But usually toward evening these cases become very much Avorse, yet the next day the child seems so much better the fond mother allows herself to think the clanger is past. But the second and third night soon undeceive her, Avhen, if unarrested by the homoeopathic remedy, the gradual but sure de- velopment of the false membrane threatens to destroy her child Avith slow suffocation. In many cases of true membranous croup, hoAvever, the symptoms are much more severe from the first. " The child, after retiring to rest, suddenly aAvakes from his sleep Avith difficult and Avheezing respiration and frequent paroxysms of loud, ringing cough; his skin is intensely hot, his face flushed, and his voice hoarse and indistinct. In general, these symptoms after a short period gradually abate; the respiration becomes more free, the patient falls asleep again, and on aAvaking in the morning, Avith the exception of some degree of hoarse- ness and a slight cough, presents no symptoms of any serious disease; the pulse, however, Avill, in general, be found to be more frequent than natural, the cough more hoarse and resonant. " On the ensuing evening the respiration becomes again suddenly difficult, loud and Avheezing, and the cough convulsive and ringing, the patient experiences a sensation of impending suffocation, and 814 DISEASES OF INFANTS AND CHILDREN. carries his hand to his throat, as if to remoATe the cause of his suffer- ing. His face becomes SAvollen and flushed, his pulse hard and frequent, and his voice hoarse and almost inaudible." These symp- toms become more and more intense, unless the progress of the disease is arrested by appropriate medication, Avhile the remissions become shorter and less distinct. The cough loses its acute ringing sound, Avhile the loud ringing respiration of the patient is heard beyond the apartment he occupies. The dyspnoea becomes excessive; the patient is in a constant state of agitation; his face is swollen and livid, his lips purple, and his forehead covered with large drops of perspiration. The skin becomes cool, the pulse small, feeble and extremely rapid ; the thirst is often intense. By the cough, assisted sometimes by vomiting, a quantity of thick, ropy mucus, and even fragments of the false membrane, are expelled. If a tubular portion of the false membrane is thrown off, great relief may result. Spasmodic or Non-membranous Croup.—In this form of croup the symptoms from the first are much more violent, and the onset of the disease is correspondingly sudden. The patient, Avho retired to bed apparently in perfect health, is suddenly awakened from sleep Avith a violent fit of loud, ringing cough; his respiration is loud, Avheezing and oppressed, and attended with a feeling of immediate suffocation. As in the former variety, the difficulty of breathing and the cough occur in paroxysms, Avhich as the disease advances become more and more frequent, until there is no longer any remission. While the attack, by its suddenness and violence, announces no small degree of danger, still it gives some reason to hope the case is rather one of the spas- modic than of the membranous form of croup. In the more advanced stages of croup the evidences of the formation of the false membrane become too positive to be denied. Still, the same great symptoms of hoarseness, peculiar ringing cough, and loud wheezing or sibilant (hissing) inspiration, and dyspnoea appear in both varieties of croup, in different degrees of intensity according to the severity and more or less advanced stage of the case. A brief recapitulation of the symptoms of croup—that is, of those common to both forms—will enable the physician the better to recog- nize the disease and select the simile for each case. The hoaiseness, Avhich comes on gradually in the membranous croup, and more suddenly in the inflammatory variety, in either form remains during the remission. The alteration of the A'oice gives Avhat is recognized as the croupy tone, but this sounds very differ- CROUP. 815 ently in different cases. Sometimes it .resembles the croAving of a cock or the barking of a dog; in some cases it is holloAv and deep, in others screeching, lisping or wheezing; iu others again the voice is entirely suppressed as the disease advances, and in some rare instances from the very first. The cough also has various sounds; it may be violent, short, shrill, hacking, afterward crowing, hollow and harsh ; it may be simply hoarse, or sound as if the child were coughing into an empty pot or metallic tube. In general the cough is dry, and it is folloAved by the peculiar sonorous, loud-sounding or hissing inspiration. As the dis- ease advances the cough acquires a husky or even muffled sound, which would indicate the effusion of coagulable lymph. The respiration becomes short and difficult, in paroxysms, Avith loud and wheezing, hissing and saAving inspirations. As the disease advances the paroxysms become more severe, the dyspnoea more terrible; " the little patients raise themselves up, Avant to leave their beds, grasp at the larynx in order to remove the obstacle from the throat; they put out their tongues, throw their heads back, and breathe in this Avay Avith the windpipe pushed forAvard; there is an evident endeavor to elongate the neck, and to stretch it upAvard and backward. According to Heim, this is a sign of membranous exu- dation having taken place."—Hartman. After these violent parox- ysms of orthopncea, the sufferers fall back exhausted, and sometimes sleep. The later stages of the disease are marked by the blue or livid color of the skin, the result of deficient oxygenation of the blood; swelling of the face and neck from obstructed circulation; and drowsiness, etc. The fever, Avhich from the first is strongly marked, becomes still more intense as the disease advances; there is great thirst, and little or no difficulty of SAvallowing; while the pulse becomes irregular and rapid in the paroxysms, and more and more faint Avith the rapidly increasing debility. There are numerous other symptoms, either common to croup or peculiar to individual cases, which it is impossible, and indeed un- necessary, to enumerate here or among the indications for the various remedies. But the most remarkable and characteristic have been mentioned in either case; so that the practitioner, hoAvever inexpe- rienced, need be at no loss to know on the one hand Avhat he has to contend with, or to determine the appropriate remedy on the other. It should be remembered that croup is one of the feAv diseases in which it may be necessary to aAvaken the patient in order to give the 816 DISEASES OF INFANTS AND CHILDREN. medicine regularly, for if alloAved to sleep too long at a time the disease makes very great progress. This is, hoAvever, principally to be observed by those who use the lower homoeopathic preparations. In badly-treated cases there may be noticed sometimes a strong dis- position to the development of bronchitis, or even of pneumonia, as the successor of croup, but this will very seldom occur under the homoeopathic regime. Treatment.—Aconite. This remedy should always be given at the first; it Avill often prove to be the only one needed, if given right, unless some other remedy is strongly, in fact I might say perfectly, indicated. Aconite will be especially called for if there is a high fever, skin dry, much restlessness and distress. " Cough and loud breathing during expiration, but not during inspiration. Every ex- piration ends with a coarse hacking cough." * Arsenicum is ahvays to be thought of when there is great exhaus- tion ; the least effort seems to overcome the patient; the child is cold and Avants to be coA7ered. The cough is very exhausting, and becomes Avorse after midnight. The cough is also worse after drinking; is generally dry, but sometimes accompanied with expectoration of frothy mucus. The croup attack is accompanied with nettle-rash. . Belladonna. If the cough is hoarse, causing the face to flush and the eyes to become red. Is a very useful remedy in croup when these symptoms are present. Bromine. Spasm of the larynx; suffocative cough; hoarse, whist- ling, croupy sound, Avith great effort; rattling, Avheezing, gasping; impeded respiration; heat of the face; formation of a false membrane in the larynx and trachea ; much rattling in the larynx when cough- ing. If this last symptom be present more especially, even in des- perate cases, Bromine will cure if a cure be possible. It should be given every hour or two, and continued for some time. Chamomilla. With this unusual remedy I once cured a very bad case of croup, when all other medicines had failed to afford relief and I despaired of the child's life, from observing very strongly marked in this case that characteristic symptom of Chamomilla—the child must be carried up and doAvn the room for relief. I Avas led to give this remedy, Avhich, much to my delight, was followed by speedy recovery. Hepar. If there is a rattling, choking cough, becoming Avorse par- ticularly in the morning part of the night. The croup comes on or *Dr. W. E. Payne, U. S. Journal of Homoeopathy, vol. ii., p. 521. HOOPING-COUGH—PERTUSSIS. 817 gets worse during the after part of the night or early morning. The child chokes Avith every coughing spell. Iodine. Always indicated Avhen there is pain in the chest and larynx. Membranous croup, with wheezing and sawing respiration. If the child is too young to express its feelings, it will grasp these parts Avith the hand. The child is pale. Coldness of the face in very fleshy chil- dren. The voice has a deep, hoarse, rough sound. Kali bi. Croup, Avith expectoration of tough, stringy mucus. Mem- branous croup. Especially suitable for light-haired, plump and fat children. The air sounds as though it Avere passing through a metallic tube. The croup comes on insidiously. Kaolin. Promises to be a valuable remedy for croup. Cough accom- panied by suffocative attacks; the child is very hoarse and breathes with difficulty. It may be tried when other remedies have failed. Lachesis. This remedy has cured very far advanced and apparently hopeless cases of croup, indicated particularly by very distressing aggravation after sleeping, as if the child were dying. Or the child, as it were, sleeps into the croup and awakens Avith an attack. So long as the child is awake it does very well, but on sleeping the attack comes on or gets worse, and it arouses with a paroxysm of choking, almost loses its breath, and sometimes goes into- convulsions. Phosphorus. When a hoarseness remains after croup, and Avhen there is a tendency to relapse. Spongia. The cough is dry and sibilant, or it sounds like a saw driven through a pine board, each cough corresponding to a thrust of the saw. Spongia is particularly indicated when there is no mucous rattle with the croup. The cough is dry and hoarse, and causes pain in the throat. Tartar e. When there is a sound as if a large quantity of mucus were in the bronchial tubes, while none is expectorated, and there is apparent danger of suffocation. This symptom, as if a quantity of mucus Avere rattling in the larynx at every coughing spell, Avhile so little is expectorated, is characteristic of Tarter Emetic. Hooping-Cough—Pertussis. Hooping-cough is a contagious and frequently epidemic disease, which at its first onset appears as catarrhal, then becomes nervous, paroxysmal, spasmodic and convulsive, and. then again catarrhal. It particularly attacks little children, and seldom occurs twice in the same individual. Adults are not ahvays exempt Avhen exposed to its influence for the first time, and it constitutes one of the most dan- 52 818 diseases of infants and children. gerous forms of disease to Avhich young infants are liable. At its first appearance this affection is scarcely to be distinguished from a common cold, but Avhen fully developed it is characterized by a convulsive cough in which the attacks, occurring at longer or shorter intervals, are composed of sudden, jerking and noisy expira- tions, and folloAved by inspirations anxious, protracted and still more sonorous. When left to itself and uncomplicated, hooping-cough runs a regu- lar and progressive course, occupying about six weeks in each of its successive stages of development, persistence and decline. But the disorder in each case proves more or less severe in intensity and various in manifestation according to the nature of the individual constitution in which it is implanted. In some instances it takes no very severe hold upon the system, in others it seems to develop organic pulmonary or bronchial disease. In others, again, it more poAArerfully affects the cerebro-spinal nervous system, and terminates in convulsions, which, arising in consequence of nervous exhaustion, soon destroy Avhat little strength remains. Like the asthma of adults and the laryngismus stridulus of children, hooping-cough appears to be primarily a nervous affection, which con- sists in an irritation of certain of those motor filaments of the pneu- mogastric which supply the organs of voice and respiration. And the profuse catarrhal secretion which appears in its more advanced stage forms a similar crisis in this disorder and in asthma. That this affection is an irritation of the motor filaments, corresponding to neuralgia of the sensitive filaments, and not an actual inflammation of the nerve, may be seen from the severe functional disorders of the parts supplied by this nerve on the one hand, and on the other from the almost constant absence of organic lesion, as proved by numerous post-mortem examinations. And, as Avill appear in the following de- scription of the phenomena of hooping-cough, the nervous affection may at the same time produce, by spasmodic contraction, a temporary occlusion of the smaller bronchial ramifications,* and a still more severe contraction of the rima glottidis. In spasmodic cough spasm of the glottis forms a constituent part of the affection. At the onset of the attack " there is a feeling of con- traction and oppression of the chest, during which the patient generally seizes hold of some firm object; at times there is nausea, and then attacks of cough supervene, the expiration occurring in jerks, and in a more or less rapid succession, introduced or interrupted by a sudden * Laennec, Diseases of the Chest, p. 101. HOOPING-COUGH—PERTUSSIS. 819 inspiration Avith a lengthened sound. The respiratory muscles act tumultuously, the abdominal muscles are drawn in and rigid, the trunk is bent forward. At times there are convulsive movements of the extremities and startings of the Avhole body. Suffocating attacks are more violent and threatening the less the patient exhales. The impeded transmission of the air shows itself in the absence of the vesicular murmur, as well as in the phenomena attending a disturbed state of the circulation—viz., lividity of the tumid face, congestion of the eyes, and ecchymosis between the conjunctiva and the sclerotic, haemorrhage from the nose, the cavity of the mouth and the bronchia. The cough is dry, and a little viscid mucus is expectorated with diffi- culty. After a duration of from tA\-o to five minutes the paroxysm, which often consists of two fits divided by an interval, ceases; it generally terminates Avith vomiting of bronchial mucus and of the contents of the stomach, and at times with syncopic exhaustion. After this comes a period of great repose."—Romberg. As the disease adATances the paroxysms become more protracted, severe and exhausting; the infant becomes black in the face, and seems to lose its breath entirely; and the characteristic whooping sound with which the attack commences, which appears so frightful to strangers, seems to call the attention of the mother or nurse if the child is for the moment out of her arms. In the decline of the disease the symptoms may become less violently spasmodic and more prominently catarrhal, the catarrh becoming in some cases so profuse as to threaten suffocation. In other cases, from hereditary disposition to such disease, the hooping-cough seems to become complicated with, or to run into, pneumonia. In these cases, instead of intervals of per- fect rest and natural respiration betAveen the paroxysms, Ave find a permanent acceleration of breathing, shortness of breath and dyspnoea, the characteristic symptoms presented by auscultation or percussion, a livid hue of the lips and cheeks, incapacity for exercise or exertion, and loss of strength. Hooping-cough is not a dangerous disease per se, but it is liable to become complicated with certain other affections Avhich may add to its severity, and indeed lead to a fatal termination, and this is particu- larlv true Avhen the cough occurs in Aveakly and cachectic children. The chief of these complications of hooping-cough are—convul- sions, collapse of the tissue of the lungs, bronchitis, pneumonia and emphysema, while tuberculosis is a not infrequent sequent of the disease, leaving the little patients in miserable health, early to fall victims to consumption. Hence, hooping-cough is a disease requiring 820 DISEASES OF INFANTS AND CHILDREN. nice and discriminating treatment. Unfortunately, the AAant of suc- cess of the allopathic school in cutting short the disease has led the people to regard hooping-cough as an evil that must be endured with- out remedy, except that afforded by time, and hence too many cases are neglected. In children Avho are naturally predisposed to cerebral disease the tendency of the hooping-cough may be to assume a still more strongly marked convulsive form. According to Watson, "Avhen the disease occurs within the first tAvo years of life it is usually attended by con- vulsions, and many more die within those periods than afterward." And it is in this direction especially that the homoeopathic treatment will be found remarkably valuable. The remedies greatly moderate the violence of the disdrder, even if they do not at once remove it, and by thus shortening its paroxysms, and rendering them less frequent and severe, the little patient's strength is saved. And the remedies carefully selected to meet the particular indications of each individual case,, at the same time that they preserve the strength as much as possible, and prevent the disease from assuming its most violent form in general,, hinder also its particular development and complication in neAv forms of pulmonary or cerebral disorder. In the treatment of this affection, therefore, the homoeopathic physician should not expect to find in any remedy, howler highly lauded, a complete specific. Still less should he seek to compel the disorder to succumb to the massive doses of any such remedy. Let him be satisfied to prescribe for his patient, and adapt as accurately as possible the remedy to the existing conditions. A little extra pains taken in this direction in the first visit in ascertaining the totality of the symptoms, and in finding the true simdlimum for them in each case, will save him a Avorld of trouble in the end. In some epidemics of hooping-cough the remedy Avhich is thus found suited to the genus epidemicus in one instance may also apply in other cases, but not absolutely in all, since ahvays and in every instance the medicine must be made to suit the indi- vidual patient rather than the general form of the prevailing epidemic disorder. Aconite. If a constant febrile condition seems to prevail, or if the patient grasp at his throat with every cough, as if he were in pain. Arnica. Every coughing spell is announced with crying; the child not only cries during the coughing spell, but before its accession, as if in dread of it. Bloody expectoration. HOOPING-COUGH—PERTUSSIS. 821 Arsenicum. When there is great prostration, with waxy paleness and coldness of the skin. Expectoration of frothy mucus, often accom- panied Avith suffocative spells. The cough is excited by drinking. Belladonna. The child gets very red in its face with every coughing spell, or the cough has produced such congestion as to cause the sclerotic to appear extremely reddened. Bryonia. Cough worse after eating or drinking, with vomiting of the ingesta; cough excited by the slightest motion. Lips are dry and parched, and the child Avishes to drink large quantities of Avater. Carbo veg. Great exhaustion after every coughing spell, with blue- ness of the skin, hot head and face. Causticum. A dry cough remains a long time; it does not get en- tirely well. Especially adapted to feeble, delicate children. Chamomilla. The cough is dry; the child is very fretful; must be carried in order to appease it; one red cheek. Chelidonium. When a very loose, rattling cough remains a long time, and does not improve any more. Cina. The child picks its nose much, or gets perfectly rigid in every coughing spell; ravenous hunger. Coccus cacti. Every coughing spell is terminated by spitting of large quantities of ropy mucus. Conium. When violent fits of coughing occur, mostly through the night; the cough is ahvays Avorse during night. Coralium rub. In some forms of violent spasmodic cough. " Firing minute guns of short, barking cough, all day, and for half an hour or so toward evening increasing to a violent spasmodic paroxysm." * Cuprum ac. With every paroxysm, the child coughs itself into a cataleptic fit; it appears as if it were really dead. Much mucous rattling. Long-continued paroxysms of suffocative cough. The child wishes cold water after every coughing spell, and seems to be relieved by drinking the Avater. Drosera. When the child is worse, particularly after twelve at night, with high fever ; cough in violent spasmodic spells as if it would suffocate ; sometimes bleeding at the nose and mouth. Dulcamara. The child is made Avorse by the changes of the weather from Avarm to cold, or by exposure to cold, damp air. Ferrum. Vomiting of the ingesta after every cough; not so pro- fusely as in a Bryonia case, neither is there the parched lips and thirst, but there is more pallor and weakness. Hepar. When the cough seems complicated with croup; worse * Dr. Kichard Hughes, Brit. Jour, of Horn., No. ci., p. 501. 822 DISEASES OF INFANTS AND CHILDREN. toAvard morning; the cough sounds croupy, and it seems as if the patient Avould choke Avith the cough; or choking cough Avithout having a croupy sound. Hyoscyamus. The cough is ahvays worse as soon as the child lies doAvn, and is relieved by sitting up. Ipecacuanha. Strangling Avith the cough till blue in the face. Much mucus in the chest. Nausea and vomiting with the parox- ysms. Kali bi. Choking cough and spitting out tough, stringy mucus, which sticks to the throat, mouth and lips, and hangs doAvn in strings from the lips. Kali c. Sacculated SAvelling over the eyes in light-haired children. Lachesis. The child always awakens in a coughing fit; it seems very faint and weak. Mephitis p. In some forms of spasmodic cough this remedy is a specific. Mercurius. The child sweats very much at night, and bleeds at the nose and mouth Avith every coughing spell. Either by day only, or by night only, it has always double coughing spells, which are separated by an interval of perfect rest. Nux V. Hard dry cough, Avith constipation; worse after four o'clock A. m. The child becomes blue in the face, and bleeds at the nose and mouth. Phosphorus. Much hoarseness; almost total loss of voice from the effects of the cough. Pulsatilla. Cough very loose, with vomiting of mucus; diarrhoea; Avorse at night. Sepia. The cough is always much worse in the morning, when it is loose, and terminates in an effort to vomit or in real vomiting. This termination of a paroxysm is characteristic of Sepia. Silicia. May be useful in vermiculous subjects, in whom Cina does not answer. Sulphur. There are frequent relapses without any known cause, or where the cause consists in exposure to cold in scrofulous subjects. Sulphur is a specific in a sort of suppressed cough—dry, suppressed and choking, Avithout the cough being pronounced. Squilla. During the cough the child sneezes, waters at the eyes and nose; the child constantly rubs its eyes, nose and face with its fista during the cough. Veratrum. After every fit of coughing the child falls over ex- hausted, with cold SAveat on its forehead. LARYNGISMUS STRIDULUS. 823 Laryngismus Stridulus—Asthma of Millar. Under the names of Asthma of Millar, Thymic Asthma of Kopp, Laryngismus stridulus, Child-crowing, Spasm of the Glottis, Spas- modic Croup and False Croup, different authors have described an affection peculiar to infants and very young children, Avhich is not indeed very common, but which for this reason, from its apparent resemblance, is apt to be confounded with croup. The difficulty consists essentially in spasm of the glottis, which impedes respiration and occasions sonorous dyspnoea. " Spasm of the glottis occurs in paroxysms of varying intensity, according as the glottis is partially or entirely closed. The milder attacks are charac- terized by a short attack of dyspnoea, difficult and often sonorous inspiration, as in apnoea, accompanied by restlessness and anxious expression of the face; such attacks are at first often unnoticed, as the health of the child does not appear affected in the intervals. A trifling mucous rattle in the larynx sometimes precedes. In the more violent paroxysms the apnoea approaches to suffocation, and the respiration is interrupted for seconds, and even for one or tAvo min- utes. The eyes are Avide open and staring, the face becomes livid and cadaverous, the alse nasi and the muscles of the neck act violently, the arms are stretched out and rigid, asphyxia appears unavoidable, when at last the air penetrates Avith jerks and with a sonorous tone, and the paroxysm closes with a fit of crying and sobbing." * These attacks may terminate with a loud sonorous inspiration, or by a long, deep-drawn inspiration, with a crowing noise. This particular mode of termination will be seen to be characteristic, and diagnostic of this affection from croup, in Avhich no such distinct remission of the dyspnoea can be recognized, at least not in true membranous croup. Dr. Ley, in his very able treatise on this disorder,f gives the fol- lowing still fuller resume of its symptoms: "The essential symp- toms, then, of laryngismus stridulus are, sudden attacks of breath- lessness from partial or total obstruction to the admission of air into the windpipe, varying according to the degree of closing of the glottis, and commonly succeeded, or at all events attended, by a sono- rous inspiration. Where the closure of this chink is not perfect the child struggles for its breath, the respiration is hurried, the countenance generally bluish or livid, the eyes staring, and each inspiration is attended with a crowing noise; where it is more complete—and this *Komberg, Diseases of the Nervous System, i., p. 331. fAn Essay on Laryngismus Stridulus, by Hugh Ley, M. D., London, 1836. 824 diseases of infants and children. state at the commencement of the paroxysm, according to my obser- vation, is much more frequent—the function of respiration is entirely suspended for a Avhile; there is an effectual obstacle to the admission of air, the child makes vehement struggles, by some termed convul- sive, to recover its breath; at varied intervals, from a feAv seconds up to a minute, or, upon some occasions, nearly tAvo minutes, air is at length admitted through the glottis, now partially open, and this rush of air, passing through a very narrow chink, produces the pecu- liar sound. To these symptoms not unfrequently succeeds a fit of coughing or crying, which terminates the scene; or, if the glottis be not even thus partially open, the child, at the end of from two to three minutes, at the utmost, will die of asphyxia; pallid and ex- hausted, it falls lifeless upon the nurse's arm, and it is then that the child is generally said to have died in a fit. " In the violent struggles for the recovery of the breath to which I haA7e alluded all the muscles supplied by the respiratory system of nerves are throAvn into violent action; the eyes are often involuntarily rolled upAvard by the agency of the trochlearis; the muscles of the face are expressive of agony, or occasionally convulsed; the head is thrown back by the muscles supplied by the spinal accessory nerve; the serratus magnus is in violent action; the diaphragm and abdomi- nal muscles contract vehemently, and even the extremities are rigid. With all this, however, the face is commonly pallid, and has that lurid tinge denominated cadaverous, and the external veins, tinged with highly carbonized blood, form long streaks upon the forehead and temples, which continue long after the cessation of the paroxysms." The cause of this terrible malady was long but imperfectly under- stood. Dr. Ley, whose description of "child-crowing" Ave have already quoted, published his very learned and able monograph in 1836. In this he attributes the malady to pressure exerted by enlarged bronchial glands upon the pneumogastric and recurrent nerves. This opinion he founded upon actual post-mortem examinations, and he illustrated it by five lithographic engravings from these morbid specimens, which show the nerves thus flattened and compressed by such enlarged glands. Dr. F. Barrier of France, Avriting in 1844, attributes the disorder to pressure exerted directly upon the air- passages.* Laennec, writing in 1808, says inflammation of the bron- * " Bien que nous partagion 1'opinion de 31. Blache, qui attribute au spasme de la glotte la dyspne"e decrite par des auteurs Anglois et AUemands sous le nora d'asthme t thymique, nous dirons plustard qu'il nous repugnerait point de placer la cause de cet asthme dans la compression exerce"e par le thymus hypertrophic" sur les voies aeri- ennes."—Traite Pratique des Maladies de L'Enfance, par F. Barrier, D. M., Paris, 1845. laryngismus stridulus. 825 chial glands is very little knoAvn, and appears to be very rare. He speaks of tuberculous affection of these glands, particularly in scrofu- lous children. Louis, in 1843, says of the bronchial glands, "These bodies very frequently undergo tuberculous transformation, not only in children in whom all accurate observers coincide in regarding the transformation of these organs as even more frequent than that of the lungs." And he states that the compression of the trachea and bronchi, causing difficulty of breathing and SAvalloAving, impeded circulation, and even fatal haemorrhage, is far from being a rare effect of their enlargement.* Dr. Marshall Hall states that the disease may arise from affections of the centre of the excito-motory system. He regards it as " an affection of the excito-motory or true spinal system of nerves, produ- cing in mild cases partial closing of the glottis and difficult inspira- tions, Avhile in more severe cases the spasmodic disposition extends to other parts of the body—to the eyeballs and to the flexors of the fingers and toes." From a careful study of the different descriptions of the disorder under consideration, Avhich has indeed a great variety of designations, but which is commonly called laryngismus stridulus, it will appear that on the one hand the symptoms are so various that they are almost capable of being distinguished into tAvo or three different diseases, and on the other it Avill appear also that the causes are no less various in their seat and mode of action. Thus, again, Ave have on the one hand the paralysis of the trunk of the vagus and its branches, resulting from the SAvelling and induration of the parts exerting pressure upon them: " its conducting poAver is frequently impaired by scrofulous affections of the cervical and thoracic glands, and especially of the bronchial glands;" and on the other hand spasm of the glottis, Avhich has very similar, results, although under someAvhat different conditions. That is, it is more apt to occur in early infancy ; the attacks of spasm of the glottis more frequently appear at night, on awaking from sleep, or from any sudden movement or exertion; they may often be traced to hereditary predisposition. This form of disease is more frequent in the city than in the country; in those Avho are brought up by hand or prematurely Aveaned, instead of being nursed; and in many cases it may be seen to result, in some way, from the influence of the first dentition. In a note to one of his lectures Dr. West thus speaks of this disorder: "There is a form of spasmodic affection of the larynx which, under the name of thymic asthma, has attracted considerable * Researches in Phthisis, Syd. ed., pp. 91 and 92. 826 diseases of infants and children. attention among continental Avriters. The spasm of the glottis, Avhich is the most prominent symptom in this affection, is supposed to be due to the pressure of the hypertrophied thymus upon the larynx, and the consequent irritation of its nerves." There can be no doubt that the several forms of dyspnoea more or less variously described under the different names above given are due to pressure exerted by the cervical glands, by the thymus gland, or by the bronchial glands, in a morbidly enlarged and indurated condition, either upon the nerves, upon the bronchia, or directly upon the larynx. But Avhether in any particular case they act by producing direct spasm of the glottis, through pressure upon the bronchus or larynx, irritating the peripheral extremities of their nerATes, or Avhether they cause paralysis, by pressing directly upon the vagus or one of its branches, the physician must determine for himself from the study of the symptoms present. Sufficient has been here stated to lead him to a careful study of his case; to realize that he may have to contend, not so much with a temporary or accidental affection, as Avith a disorder of a most important function—a disorder resulting from some deep-seated, even hereditary dyscrasia, which may haATe been developing itself in those obscure glandular structures, and Avhich only reveals itself to his observation in its secondary con- sequences. Hypertrophy of the thymus gland is no doubt the most frequent in earliest infancy, and this morbid condition may have originated even before birth. The corresponding enlargement of the thyroid gland occurs later in life, and constitutes the disorder known as goitre or bronchocele. Arsenicum. If there is much thirst and restlessness. Belladonna. The face and eyes are very red; the head is very. hot. Gelseminum. Sudden and severe attacks of dyspnoea, Avith crowing noise, profuse perspiration and darkly flushed face. Ipecacuanha. If much nausea prevails, or there is much strangling as if from mucus. Lachesis. The paroxysms recur as often as the child gets into a sound sleep. Laurocerasus. If the spells seem to be excited by some abnormal condition of the heart. Moschus. In cases similar to the above, but not so violent. Phosphorus. This remedy may be called for in some cases of very tall, slim children. atelectasis pulmonum. 827 Sambucus n. The child suddenly aAvakens, nearly suffocated; sits up in bed and turns blue; gasps for breath, Avhich it finally gets; the spell passes off; it lies down again in bed, but to be aroused sooner or later in the same manner. Stramonium. If the child seems quite delirious, does not know where it is; as soon as it can speak it constantly calls for papa and mamma, although they may be at the same time present and trying to console the child. In chronic cases, such as may be supposed to arise from enlarge- ment of the cervical or bronchial glands, study Calcarea c, Jodium, Iodide of Mercury and Spongia. Atelectasis Pulmonum. The term atelectasis—derived from the Greek arekqz, imperfect, and eyxaan;, expansion—is used to express a condition of the lungs occasionally met Avith in infants, in Avhich portions of them remain in the foetal condition, having never, from some cause or other, been penetrated by air. This condition may be due to the circumstances attending the infant's birth, such as exposure to cold or to a \Titiated atmosphere; the casting off of the placenta before the establishment of the respiratory act, and a consequent lowering of the vital forces, etc. But the disease is usually congenital, and may be due to debility of the infant in consequence of imperfect nutrition in utero, or to the dis- eased and debilitated condition of the mother during her pregnancy from phthisis, typhoid fever or other exhausting disease, or from dis- ease of the father, such as syphilis, Avhich is calculated to impress itself upon the child in the form of imperfect cell-development. The following are amongst the most constantly present of the symptoms that indicate the presence of atelectasis pulmonum : " The child comes into the Avorld feeble and weak, and instead of crying vigorously and loudly the moment or very soon after it is born, it fails to cry at all, or the cry is low and Aveak, or it is whimpering or wailing; the color, instead of being brick-red or dark red, is pale and whitish, leaden or livid; the muscular movements, Avhich in healthy children are strong and vigorous, are in these languid and sIoav, or there are none or scarcely any, the limbs being relaxed and motion- less. If the breathing is observed, it is found to be short, high and imperfect, and it is evident that the thorax is but imperfectly dilated at each movement of respiration. When these symptoms exist in a very marked degree, the infant either dies soon in a state of asphyxia, or, the muscular force slowly increasing, the respiration gradually im- 828 DISEASES OF INFANTS AND CHILDREN. proves, and the child is, after a longer or shorter time, either out of danger, or it falls into the same state as that of one in whom the symptoms have been from the first less severe. Under the latter cir- cumstances the infant continues feeble and Aveak. It breathes shortly, rapidly and imperfectly, but often Avithout any appearance of labor. The cry is rare, and Avhen heard is low and feeble, or there is a con- stant plaintive moan, which is very characteristic and strongly ex- pressive of exhaustion, with each respiration. The color continues pale and whitish, or it is bluish, and the temperature of the extremi- ties is lower than natural. The child sleeps the greater part of the time, and is unable to nurse or nurses very feebly, but can SAvallow when food is poured into its mouth." In favorable cases and under proper hygienic and medicinal meas- ures these symptoms, after lasting a few days or a few weeks, begin to improve, and the child assumes a more natural hue, breathes more freely and Avith less difficulty, and begins to nurse. In unfavorable cases the respiration becomes quicker and more imperfect, the evi- dences of insufficient oxygenation of the blood become more marked, it ceases to SAvallow, muscular twitchings set in, and the child either dies in convulsions or sinks into a condition of syncope, and thus ends its life. Dr. Kees of London, in an essay on atelectasis, calls attention to the peculiar movement of the ribs during respiration, and regards it as a characteristic symptom of the condition of the lungs: " During the inspiratory effort the ribs are seen to move inward to- ward the mesial line of the trunk, instead of outward as in ordinary respiration, thus diminishing instead of expanding the transverse diameter of the thorax. The explanation of the altered movement is as follows : When the diaphragm descends the lung ought to expand in such a way as to fill up the increased space produced in the thoracic cavity by the descent of that great muscle. Instead of this being the case, however, the lung is collapsed and inexpansive, and cannot en- large sufficiently to fill up the spaee alluded to, so that there would remain a vacuum in the chest were it not that the thoracic walls are driven inward by the pressure of the atmosphere upon their outer surface." Treatment.—In treating a case of atelectasis very much will depend, in securing a successful result, upon hygienic measures. Everything should be done that will have a tendency to improve the general health of the infant and to increase its ability to breathe. The room in which the infant is should be at all times of a temperature of about 75°, thoroughly ventilated, and the child should be Avarmly clothed and ATELECTASIS PULMONUM. 829 covered. Perfect rest or at most very gentle motion is very important. It has been recommended that the infant should lie upon its right side, with the head and shoulders elevated at an angle of 45°. The nour- ishment of the child is of great importance. If breast-milk of good quality can be obtained, and the child is too Aveak to suck, the milk should be draAvn by means of a pump and given to the babe, fre- quently and in small quantities at a time. This failing, diluted coav's milk—one part milk to two parts of water—may be used. Consult the folloAving remedies: Aeon. Great difficulty in inspiring; very restless and distressed; easier with its head and shoulders raised to a sitting posture. Bell. Face bluish-red, or alternating with a very pale face; eyes seem injected; respiration seems painful; much whining and crying; the child seems afraid to breathe. Bry. Color of the face is of a bluish-red ; great difficulty in inspiring, seemingly as if the lungs could not expand, and the child is evidently easier Avhen lying down and Avhen kept very quiet. Camph. Bluish color of face; the child's surface feels very cold; rather more difficulty in making an inspiration; very great debility; better when lying down. China. Face very pale; the trouble all seems to be from the loss of blood. Cuprum. Color of the face bluish; difficulty of respiration; much rattling of mucus, and rather inclined to spasms, which are first seen in the fingers and toes and extremities. Hyos. Bluish color of face; great difficulty in inspiring; must be raised up; all the muscles of the body and face incline to jerk and twitch. Phosph. Color of face is very changeable; the child is hoarse; long and slender in its figure. Spong. Face reddish; croAving respiration; no mucous rattle; must be raised up. Tart. emet. Very pale face; more difficulty in expiration; head hot and sweaty; rattling of mucus, more in the throat-pit. Verat. Face bluish; much exhaustion; cold perspiration on fore- head or other parts of the body; almost pulseless. Consult also remedies for Apparent Death, Laryngismus stridulus, Croup, Catarrh, Bronchitis and Pneumonia. 830 DISEASES OF INFANTS AND CHILDREN. CHAPTER XXXVII. DISEASES OF CHILDREN—CONTINUED. Scarlatina—Scarlet Fever. SCARLATINA is an epidemic and contagious exanthemata, cha- racterized by a high degree of continued fever, a scarlet rash, and inflammation of the tonsils and mucous membrane of the mouth and pharynx. It forms the most terrible and fatal scourge of infancy and childhood. Its highest mortality is said to occur during the third year of life, and under the old-school treatment entire families of children have been SAvept away. The homoeopathic treatment of this much-dreaded disease renders it far less fatal. In fact, from all but the more malignant forms of scarlet fever the danger of a fatal termination seems almost Avholly removed. Still, the cases of this latter variety, and even others of less original severity, require for their successful treatment the utmost patience and skill on the part of both physician and nurse. This is due in part to the unsteady and even treacherous nature of the disease itself in the severer cases, and to the serious complications which may arise during its progress, and in part to the sequelse which may change an apparently favorable convalescence, even in milder cases, to a neAv and still more dangerous form of disease. Scarlet fever has usually been divided into three varieties—Scarla- tina simplex, Scarlatina anginosa and Scarlatina maligna. But this difference in degree of the severity of the disease, whether confined to particular cases or extended to epidemics, is of little practical value. A more simple classification consists in a twofold division—viz., Scarlatina Sydenhami and Scarlatina milia,ris. Perhaps the best classification of all would be into mild and grave cases, according to the degree of severity of the attack and the character and extent of its concomitants and complications. The scarlet fever of Sydenham, the true Belladonna scarlet fever of Hahnemann, is noAV comparatively rare. But it is important to distinguish it Avhen it does appear from the more common scarlet fever, if for no other reason than because the prophylactic use of Belladonna, so strongly recommended by Hahnemann and proved so Avonderfully efficacious in the former variety, is of no avail in the latter form. The true scarlet fever of Sydenham, the Scarlatina SCARLATINA—SCARLET FEVER. 831 kevigata, or smooth scarlet fever of some authors, runs a compara- tively regular course, and is much less disposed to strike in and occasion dangerous metastases than is the other variety. This latter and more common form of scarlet feA^er is at once more insidious, more treacherous and vastly more dangerous than the former. In its severer forms it is ahvays impossible to tell hoAv much more of the malignant element may yet remain behind and waiting for the favorable moment—of convalescence even—for development; and in the milder cases Ave knoAv not what an hour may bring forth; the eruption, apparently well out, may suddenly recede Avithout apparent cause, and the most critical and alarming symptoms replace a con- dition which had been encouraging and satisfactory. Scarlet fever is the popular name of a disease which is developed from an epidemic and infectious poison. Children who have not had the disorder will rarely escape taking it from visiting a house Avhere it prevails, or even Avhere it has recently prevailed ; and children in houses miles aAvay from any others, with no direct communication, are stricken doAvn with the disease, the infection being conveyed by the wind for long distances across the country. This disease con- sists, then, in the development of a peculiar poisonous miasm, princi- pally upon the skin, where the eruption forms a salutary crisis of the fever. With this deA'elopment upon the skin there may also be a development upon the mucous membrane, Avhich becomes more or less deeply and extensively involved in proportion to the malignancy of the morbid influence by which it is caused; and finally, failing this sufficient development upon the skin, in the fauces, nostrils, etc., or deserting the skin, the disease may attack the meninges of the brain, producing convulsions necessarily fatal unless relieved with the utmost promptitude. As a consequence of the ravages made by this disorder in the system—ravages Avhich are dreadful just in pro- portion to the amount of pre-existing psoric dyscrasia which the scarlatina poison finds and Avith Avhich it unites itself—all the latent psoric miasm in the system is developed, and there results a post- scarlatina dropsy or some form of "scrofulous" disease. Symptoms.— Vomiting or nausea is very frequently the first symp- tom Avhich indicates the onset of either variety of scarlet fever; and Ave think a malignant form of the disease, and especially of the scar- latina miliaris, may be apprehended when the vomiting is very severe and persistent. In other respects, the more generally the eruption is developed over the entire surface of the skin the less apt is the throat to become seriously affected; for in all but the worst cases the disease 832 DISEASES OF INFANTS AND CHILDREN. thus seems in a measure to expend itself upon the exterior surface; Avhile the mucous surface, the throat and nostrils are apt to become the seat of the development of the disease in proportion as it fails to be sufficiently developed upon the skin. And yet in the malignant forms of the disease the eruption involves the entire surface, and in the Avorst cases assumes a livid hue, Avhile the fauces and nostrils are affected to the extent of ulceration, putrid exudations, gangrene, and sloughing of the swollen and compressed portions of the tonsils, etc. This is the old scarlet fever and canker-rash, or Cynanche maligna. The fever Avhich forms the continued crisis of the eruption is cha- racterized by being steady and almost uninterrupted in its course, gradually increasing till the eruption is Avell out; continuing with little or no abatement during its continuance, and in favorable cases gradually subsiding as the eruption itself gradually fades away. The pulse also maintains a corresponding uniform height, showing scarcely any of the decline and aggra\ration, day and night, which is common to true synochal fever. Many of the other symptoms, as the nervous restlessness, may be relieved by the accession of the eruption; but the fever itself holds on its steady course of intensity, until at the full term the appearance and continuance of the efflorescence gives place to its decline. And even then, in badly managed cases, instead of sensibly abating, the fever may take a fresh start under the typhoid form. The eruption in the smooth \rariety is a mere blush of efflorescence, a redness of the skin Avhich, beginning about the face and neck, grad- ually spreads over the whole surface of the body and of the extremi- ties. This full development of the eruption is only arrived at by the third day, and a similar redness may be seen in the mouth and fauces, and even in the nostrils. The eruption in Scarlatina miliaris— the more common form of the disease—ghres a perceptible- rough- ness of the skin, and a sensation as if its surface were covered with minute granules. This is caused by an enlargement of the cutaneous papillae, and is more evident on the extremities and front of the body. On the fourth day the eruption is at its height; and even after the rash has extended pretty generally over the surface of the skin, it Avill come out much more fully and assume more and more the boiled- lobster appearance, both in color and in the sensation of roughness Avhich it imparts to the applied hand. On the fifth, sixth and seventh days the eruption declines, first remaining stationary a clay or so, or commencing very gradually to fade away. In favorable cases the SCARLATINA—SCARLET FEVER. 833 decline corresponds to its original mode of appearance, but in the reverse order, gradually disappearing in a uniform manner, and from the extremities first. Next succeeds desquamation of the cuticle, a process which often occupies many days before it is completed. It generally commences about the seventh day, though it may begin either earlier or later. It usually occupies ten or twelve days, but may be greatly prolonged. During the stage of desquamation the urine becomes more abundant, pale, and has a faintly acid reaction. Albuminuria is also frequently observed during desquamation—more frequently in fact than during the eruption. Scarlet fever is a very uncertain and treacherous disorder. All may be going on Avell when at once some untoAvard change, some unlooked-for and dangerous symptoms may arise. Sudden fading aAvay of the eruption in different parts of the body, its partial recession, its premature decline or in- creasing lividity—symptoms which may occur in apparently fiworable cases, but which are more apt to appear in the malignant forms of the disease—Avill necessarily awaken the greatest anxiety, and the remedy should be at once most carefully selected to meet the imminent danger. The tongue affords some very characteristic indications in scarlet fever of either variety, since, as will subsequently appear also in the fauces, the mucous membrane develops an appearance corresponding to that of the external skin. We give Dr. Watson's concise descrip- tion of what, in different degrees of intensity, may be always seen in this disorder: "The appearances of the tongue in scarlet fever are also peculiar and characteristic. In the scarlatina simplex and an- ginosa it is often covered at the outset Avith a thick white, cream-like fur, through which are seen projecting the red and exaggerated papilla?, the edges of the tongue being likewise of a bright-red color. The red points gradually multiply, and the white fur clears aAvay, and at length the whole surface of the tongue becomes preternaturally red and clean and raAV-looking, and after becoming thus clean, as Avell as red and rough, and like a strawberry, it will sometimes, Avhen the disease goes on unpromisingly, get dry and hard and broAvn, as you know it is apt to be in certain species and stages of continued fever." In the milder as well as in the severer cases of the disease the tongue and fauces should always be inspected at each visit. The fauces present a still more striking resemblance to the eruption on the external surface. If able to speak, the patient will complain of soreness of the throat, and upon examination will be found a greater or less amount of SAvelling, Avith redness of the tonsils, uvula and 53 834 DISEASES OF INFANTS AND CHILDREN. palate, either smooth and bright red, corresponding to a similar erup- tion on the skin, or rough and granular, of a darker color or dusky hue, corresponding to the accompanying external scarlet rash. After the first day or two the tonsils and uvula may be seen to be covered Avith a whitish exudation, or gray, aphthous formations, like false membranes, which, being removed, leave an ulcerated or sloughy sur- face. The tonsils, UAmla and palate are very much inflamed and SAvollen, but the aphthous or false-membrane-like formation which covers them, although it may extend to the nares, and even in some measure involve the oesophagus, does not affect the larynx; in this important respect differing from the more firmly organized exudations of croup and diphtheria. Frequently, as an accompaniment of bad cases, we have inflammation and swelling of the submaxillary glands and considerable oedema of the surrounding cellular tissue. This en- largement sometimes becomes very great, and of course adds to the already existing difficult deglutition, and, in such cases, where the pressure is great, to difficulty of breathing. The skin becomes dry and hot in proportion to the intensity of the fever; the pulse is quick and hard, varying from one hundred to one hundred and fifty7 per minute, according to the severity of the case and the age of the patient. The thirst is not remarkable; the appetite is of course lost, and the bowels are usually bound up, or, if they are opened, the stools are observed to be of a much darker color than is natural. The temperature in scarlet fever is not nearly so high as might be supposed, ranging betAAreen 100° and 106°. " In thirty cases reported by Ringer (Med. Times and Gaz., Feb. 15, 1862) the temperature remained at the same point throughout the day in the more severe attacks; in slighter ones it fell in the morning and rose during the day, being most frequently at its highest point betAveen tAvo and eight P. M. When the morning remission was marked, it indicated the ap- proach of a favorable termination. The first decided fall of tempera- ture, coinciding Avith a diminution of the eruption, occurred in the majority of cases on the fifth day, or if not on the fifth day it usually was deferred until the tenth or fifteenth. In these latter cases, how- ever, a fall of varying extent had occurred on the preceding fifth days. After the marked fall on the fifth, tenth or fifteenth day the tempera- ture remains from 99° to 101° for a variable time, coinciding Avhen persistent with continuance of the angina or some one of the other lesions of the disease. If at any time after the complete fall of the temperature there is any considerable elevation again, it indicates the SCARLATINA—SCARLET FEVER. 835 development of some sequel, either an affection of the kidneys, throat or one of the serous membranes. It is thus seen that the temperature in scarlatina tends to form arcs or cycles, usually of five days' duration." The preceding account of the natural history and principal and most characteristic symptoms of scarlet fever has reference rather to those cases of the ordinary severity. In those Avhich run a regular course and terminate favorably, the eruption consumes three or four days in reaching its height, remains apparently stationary a day or two, and then in the course of three or four days more gradually fades away, so that by the eighth or ninth day the period of desquamation Avill have been reached, and this may consume an equal or still greater amount of time in proportion to the severity of the case. And until this process is entirely completed, and the old cuticle, destroyed by the intense cutaneous inflammation, is replaced by neAv skin, it will be absolutely essential to have the patient very carefully watched over to guard him from any exposure, which even in comparatively mild cases might be rapidly followed by a new and still more dangerous disease in the form of some one of the various sequelae of scarlet fever. In that condition of the disease Avhich has been designated Scar- latina anginosa the principal force seems to be expended in the throat. Hence all the throat symptoms are rendered much more intense and painfully severe than in the simpler and more common form of scarlet fever. The general fever, and especially the eruption upon the skin, are much less strongly marked. "Almost from the commencement of the attack soreness of the throat is experienced, attended with difficulty of deglutition, and often Avith considerable stiffness of the neck, and pain and difficulty in moving the lower jaAV, due in part to the swelling of the submaxillary glands. On examin- ing the throat, it is seen to be intensely red, and the tonsils are red and SAvollen. The SAvelling of the tonsils increases rapidly, until they almost block up the entrance of the pharynx, and thereby render the attempt to swallow so difficult that fluids are often returned by the nose. An adhesive mucus collects about the back of the throat, and often seems to cause great annoyance to the patient, and specks or patches of lymph form upon the tonsils, and look like sloughs cover- ino- ulcers. In some of the severest cases a very troublesome coryza comes on and an adhesive yelloAvish matter is secreted in abundance by the mucous membrane of the nares, Avhence it runs down upon the upper lip, excoriating the skin over Avhich it passes, and causing still 836 DISEASES OF INFANTS AND CHILDREN. more serious suffering by the obstacle that it presents to free respira- tion."— West. In addition to these symptoms the ears also become affected from the extension of the severe inflammation along the course of the Eustachian tubes; there is very great deafness, followed by copious and acrid discharge from the external meatus. Even the mastoid process of the temporal bone becomes carious. When the throat thus becomes the principal seat of the disease the eruption does not appear so regularly or so seasonably upon the ex- ternal surface. It is often delayed till the third or fourth day, and generally comes out in scattered patches on the chest and arms. In some cases it is wholly confined to the back of the hands and wrists, and sometimes entirely vanishes the day after its appearance, and re- appears partially and at uncertain times. About the fifth or sixth day it begins to decline, folloAving the same order in its decline which it had previously observed in its appearance, subsiding first on those parts which it had primarily occupied. Desquamation of the cuticle follows the disappearance of the rash, unless the latter has been Arery slight; and the fever and inflammation of the throat begin to abate Avith the fading of the eruptioi*» though sometimes the sore throat and some degree of fever continue for a week or ten days after the rash has entirely disappeared. All these symptoms, in their severity and persistence, are capable of being very much modified by the use of the appropriate remedy. Our object here is simply to portray the natural order and the progress of the disease when not interfered Avith, and yet it must be remembered that they naturally present a very great variety, in different persons, as regards their severity and their mode of combination. In Scarlatina maligna all the symptoms may be said in general terms to be simply much more severe than in the milder forms of the disease, the principal distinction being rather of degree than of kind. Still, a brief account of such cases may be useful. The rash is ex- tremely irregular, both in the time of its appearance and in its duration, and also in its extent. It often comes out at a later period of the dis- ease, disappears after a few hours, or suddenly vanishes, to be again and again renewed in the course of the disorder. Its color may be paler than in milder cases, or in irregular patches it may assume a livid hue; in the course of the disease in its worst varieties petechias may also appear on the skin. Soon after its first onset " the fever assumes a typhoid form, the heat of the skin is less intense, and there is great disorder of the functions of the sensorium, with small, fre- SCARLATINA—SCARLET FEVER. 837 quent and often irregular pulse. There is at the same time a dull redness of the eyes, with a dark-red flush on the cheeks ; the patient is restless, fretful, and at times delirious; the delirium is sometimes violent, but more generally it is of a low, muttering kind. The tongue quickly becomes dry and brown, or red, dry and glazed, and often so tender and chapped that a slight touch causes it to bleed; the teeth and lips are covered with sordes, and the odor of the breath is extremely foetid. The throat has a dusky-red appearance; there is not much SAvelling, but dark incrustations form on the velum, uvula and tonsils, which are not, as has been generally supposed, sloughs, but merely exudations of lymph or false membranes. In some cases, hoAvever, there is a gangrenous inflammation of these parts, which are destroyed by the sloughing which succeeds. There is at the same time acrid, excoriating discharge from the nostrils, and a viscid secre- tion from the fauces, impeding respiration and producing a rattling noise. In severe cases the inflammation extends to the posterior pharynx, Avhich, though not much swollen, is so irritable that on attempting to SAvalloAV fluids they are rejected through the nostrils. The inside of the lips and cheeks is frequently covered with aphthae, and the cervical and submaxillary glands become inflamed, abscesses occasionally forming in them and in the surrounding cellular tissue." In many cases of this malignant form a fatal termination comes on the third or fourth day, the little sufferers appearing to sink under the general malignant influence. Scarlet fever without the eruption, in Avhich the entire force of the disorder is expended upon the mouth and fauces, is of no uncommon occurrence; some instances haATe been knoAvn in which those Avho have thus had the throat affection Avithout the eruption have subsequently had the scarlet feA^er eruption without the throat affection, the same poisonous influence appearing capable of developing either the one or the other affection exclusively or both together, according to the state of the patient's system. But in this, as in the other forms or varieties of this disorder, the true phy- sician Avill seek to adapt the individual remedy to the particular condi- tion of each individual patient. Treatment.—Select the remedy to meet the condition of each indi- vidual patient according to the indications given beloAV, and com- pare also the medicines subsequently indicated under the Various Sequelae. Aconite. When there is much distress, restlessness, heat, thirst and sleeplessness; the rash is not smooth. Aconite relieves the excitement 838 DISEASES OF INFANTS AND CHILDREN. of the system, both nerATous and sanguineous, and at the same time promotes the development of the eruption. Miliary rash, of a dark- ish hue; there is e\ddence or expression of fear. The patient does not wish to be alone; red face, which turns pale on rising. Ailanthus gland. The rash is of a brown appearance and is miliary, covering the entire body or appearing in patches here and there; well- marked delirium; more or less stupor; great debility, the patient being easily exhausted; great thirst, the tongue and lips being more or less cracked; the teeth are covered with a broAvn slime, or sordes; the skin may be very hot or feel rather cool to the touch; pulse very rapid and small. The color of the rash and the exhaustion are the most characteristic symptoms of this valuable remedy. Ammonium carb. When the rash continues out longer than the or- dinary period, and there is tendency to gangrenous ulceration of the tonsils, or enlarged tonsils, of a bluish appearance, and accumulation of much offensive mucus there. The rash is only faintly developed, Avith droAvsiness, stupor, dry mouth and burning pain in the throat. Apis. At the onset, A\-hen there are stinging pains in the sore throat, absence of thirst; the rash is characterized by red spots or points dif- fused here and there over the body; scanty and high-colored urine; considerable dyspnoea; great restlessness and uneasiness; sudden sharp outcry during sleep; squinting; skin has a bloated, swollen appearance, and may be either hot or cold; the rash may have dis- appeared suddenly, leaving the above-described red spots or points; general dropsy seems imminent. Argentum nit. Bluish or blackish eruption, with convulsions, with great restlessness and tossing about preceding every convulsion; emission of a large amount of flatus, which passes off, together with a quantity of greenish slime. Arnica. In typhoid states, with epistaxis, or haemoptysis, aggra- vated by coughing; or Avhen ecchymoses of various colors appear on different parts of the body, or eAren small boils. Arsenicum. The rash may be pale or petechial and attended with dyspnoea. The eruption has disappeared too quickly, and there is rapid prostration and sinking, or the throat becomes putrid Avith the same circumstances as under Aconite. Thirst for frequent sips of water; great restlessness and marked exhaustion after every move- ment. The surface is usually cool; sometimes there is a cold sweat; the patient does not Avish to be covered. Pulse Aveak. Arum tri. The lips, corners of the mouth and perhaps the nostrils are raw and bloody, and there is an apparent tendency for this state SCARLATINA—SCARLET FEVER. 839 of things to increase in depth and circumference. There may also be a profuse (acrid) discharge from the nose. The throat becomes ex- tremely sore and excessively putrid, and the fever very persistent. In such cases (of Scarlatina maligna) the Arum is the only remedy. Aurum. Foetid discharge of mucus from the nose; or for otorrhcea of a similar nature, especially if bones come from the ear. Baryta c. Where the sore throat is pale, instead of having the bright redness of Belladonna; the submaxillary and parotid glands are SAA'ollen and tender; the breath is putrid; the child scrofulous and dAvarfish. Belladonna. In the true Sydenham scarlet fever, where the eruption is perfectly smooth and truly scarlet; or scarlet fever in any form Avith the following symptoms : Eyeballs red and injected; the skin is so hot that it imparts a burning sensation to the hand; much de- lirium ; the child jumps up in the bed, and often Avants to walk about while yet asleep; jerking of the muscles; throbbing of the carotids ; bending of the head backAvard; lips, mouth and throat very red; dif- ficult deglutition; the child moans, whimpers and worries. Bryonia. The rash does not come out fully—it seems pale; there are frequent attacks of dyspnoea; nausea and faintness on sitting up; constipation; parched lips. There is great thirst; the child grasps the glass and drinks with great eagerness and in large quantities; although somewhat restless, the child is disposed to keep still, because it then feels better. The rash may have receded and left the above symptoms. Calcarea c. In cases of scarlatina where the temperament is leuco- phlegmatic, the nose sore and obstructed; the glands of the neck are swollen; slow fever, especially worse in the evening; the child ap- pears pale and languid—does not seem to conA^alesce. The face seems bloated and free from the rash. The throat is much inflamed, with patches on the tonsils; great anxiety and oppression, as if the lungs Avere giving out, Avith loud mucous rattling. Camphor. Extremities cold and blue; rattling in the throat; hot breath; hot sweat on the forehead, and the child refuses to be covered. Carbo veg. This remedy should be considered when the soreness of the throat continues after the disappearance of the eruption. Putrid sore throat; sloughing away of some of the swollen parts of the fauces. Rattling in the throat; rapid sinking of strength ; cold breath; cold extremities, covered Avith a sticky SAveat, yet the child may Avish to be fanned. 840 DISEASES OF INFANTS AND CHILDREN. Chamomilla. The child is exceedingly troublesome, and must be carried up and down in order to be relieved. China. In cases threatening to become anaemic, Avith diarrhoea or lienteria and other symptoms of the remedy in a marked degree. Cina. The child bores Avith its fingers in its nose; is very fretful, so that nothing pleases it; the urine turns milky on standing; colicky pains; the child is almost constantly hungry. Coffea. In some cases of extreme Avakefulness it may aid in bringing out the eruption, Avhere, from the predominance of the symptoms of nervous excitement over those of sanguineous excitement, it may appear indicated, rather than Aconite. Colchicum. In cases where there is bloody urine, or urine looking very black and containing albumen. Conium. In cases Avhere the parotid and submaxillary glands are SAvollen and hard as a stone; the lips and teeth are covered with black crusts; the skin is hot, and the patient delirious or senseless. Cuprum acet. When repercussion of the eruption or metastasis of the disorder to the brain has occurred, and there are convulsions, vomiting or gagging; face pale and twitching; much restlessness, tossing and turning; stupor and delirium, threatening paralysis of the brain. Dulcamara. This remedy may be called for Avhen suppression of the eruption has been caused by exposure to cold and damp air, unless some particular symptoms should require another medicine. Gelseminum. Great nerATous excitement; cold hands and feet; crim- son flush of the face; the tonsils are SAvollen and very red; the pulse is very rapid. There is not the heat of surface nor the jerking of muscles indicative of Belladonna. Hellebore. When a dropsical condition attends the scarlatina, and the urine is scanty and dark-colored, and deposits a sediment resembling coffee-grounds; terrible headache; dilated pupils. Hyoscyamus. There may be stupidity, drowsiness or vacant staring; indistinct speech, answering no questions; or there may be great nervous excitability, illusions of the imagination, indistinct mutter- ings; mouth dry and red, inability to SAvallow; the abdomen is tym- panitic ; the stools pass involuntarily and unnoticed; rolling of the head from side to side; twitching and jerking of single muscles here and there over the body, indicative of oncoming spasms. Ipecacuanha. Constant nausea and occasional vomiting. Kali carb. When the right parotid gland especially is SAvollen ; high fever and restlessness; the symptoms are aggravated about three SCARLATINA—SCARLET FEVER. 841 o'clock in the morning; dryness of the skin; sacculated SAvelling above the upper eyelids; stitching or sharp shooting pains. Lachesis. Scarlatina maligna, Avith external swelling of the neck and glands, and great sensith^eness to pressure of these swollen parts, so that the slightest touch seems to be perfectly unbearable; eA^en a light and thin cloth cannot be tolerated about the throat; the sore throat and the membranous deposit, if there be any, commence in the left tonsil and spread toAvard the right; the urine is very dark-colored. Lycopodium. This medicine is sometimes indicated at the commence- ment of the disease Avhen the sore throat begins on the right side and spreads toAvard the left. Stuffing of the nose; rattling in the throat; stupidity; the child is very unamiable on getting awake; it kicks off its coverings and behaves in an angry manner; the eruption is of a dark-red color, and is sometimes found only on the hands, face and back; urine scanty, dark-colored and frothy. Mercurius sol. The mouth is sore and studded Avith small vesicles. Ulcerated throat; the mouth and tongue are A/ery moist; dirty-yellow coating on the tongue; the breath is excessively foul-smelling; great thirst; SAvelling of all the glands of the neck; ptyalism; hawking and spitting; itching and restlessness; the perspiration seems to make the child feel Avorse. Mercurius prot. Useful in some cases Avhere the angina is very intense; or where it does not suit to give Merc. sol. or viv., although indicated; or, again, Avhere there has already been an abuse of mer- cury. It also folloAvs well after Lachesis, after the efficacy of that remedy appears to be spent. Muriatic acid. The rash assumes an intense redness all over the body, accompanied Avith great droAvsiness; or the eruption may be scanty and interspersed with petechias; the face is of a dark-red hue, the rest of the body purplish; great anxiety and restlessness; aggra- vation of the symptoms in the evening. The fauces have a dark-red, or rather bluish-red, appearance, and are extremely sore; foul breath; acrid discharge from the nose, excoriating the nostrils and upper lip; much sighing and groaning; the patient has a constant tendency to slide down in the bed, getting loAver and lower doAvn toward the foot. Nitric acid. The eruption presents a fine miliary appearance; the skin is very hot; the breathing intermits; the tonsils are SAvollen and very sore, and there is great difficulty in swalloAving; the angina seems to extend up into the nares and nostrils, and a thin purulent matter is discharged therefrom; the tongue is dry and cracked. Nux vom. The mouth and fauces are full of small and foetid ulcers; 842 DISEASES OF INFANTS AND CHILDREN. the mouth is particularly sore, Avith flow of bloody saliva and diffi- cult deglutition. Opium. The brain seems to be oppressed; extreme drowsiness; stertorous breathing; vomiting; convulsions, with coma and stertor- ous breathing continued betAveen the spasms. Phosphorus. Indicated Avhen the eruption suddenly disappears Avith- out apparent cause. It is likeAvise useful after Muriatic acid, Avhen the chest symptoms become very alarming. The patient seems to sink into an apathetic mood, wants nothing and cares for nothing; nevertheless there is much restlessness. Rhus tox. When the rash itches violently, and there is much rest- lessness at night; or when there is an ichorous or thick and yellow discharge from the nostrils, Avith swelling of the glands of the throat. Rhus becomes especially serviceable in some cases after the third day, Avhen perhaps the fever is still rising or increasing; the tongue gets red and smooth, and the patient becomes droAvsy and delirious; must change the position every few minutes, especially during the night; the scrotum and penis become swollen; SAvelling of the parotid gland, Avhich suppurates and discharges profusely, often on the left side at first, and subsequently on the right. Silicia. Where there is marked glandular involvement and suppura- tion. (See indications for this remedy under Scrofula.) Sulphur. Is especially adapted to children of psoric diathesis who are prone to skin affections. The patient lies quietly, in an uncon- scious condition, and apparently sleeping. The rash appears faintly, and the skin is sometimes hot and itching; the heat seems to come in flashes, when the clothing is thrown off. Zinc. Retrocession of the eruption; the child lies motionless and unconscious; involuntary jerking and twitching of the muscles; grinding of the teeth; screaming spells ; loss of speech ; occiput very hot and forehead coA^ered with a cold perspiration; the face is dis- torted ; body and limbs are cold and of a bluish-red hue; pulse thread-like and difficult to count. Dropsy after Scarlet Fever. The most common of the sequelae of scarlet fever is the dropsy, thence called post-scarlatinal dropsy. This affection is remarked to succeed as often to the mild as to the severer forms of scarlatina, and sometimes forms a disorder more dangerous than the original affec- tion. The dropsy usually appears first in the face, eyelids, hands and DROPSY AFTER SCARLET FEVER. 843 loAver extremities, but gradually becomes a complete anasarca, and if not arrested in its progress involves the different serous cavities. In these latter it may cause copious effusion—a condition more or less imminently dangerous according to the particular cavity which is thus affected. The post-scarlatinal dropsy generally comes on in ten or tAvelve days from the disappearance of the rash, but its approach is sometimes earlier and sometimes later. The appearance of the disorder, in some cases, may be announced by a certain paleness of the countenance, in- creasing languor, loss of appetite, furred tongue, costive bowels, scanty and turbid urine, and considerable gastric disturbance. But in the majority of cases the dropsical appearance in the face attracts atten- tion before any complaint is made of the other symptoms. The swell- ing, beginning on the face and hands, may be confined to these parts, but in most instances it gradually extends till the whole body be- comes cedematous. A puffy or SAvollen appearance in the lumbar re- gion, OArer the kidneys, should be regarded as indicating a very seri- ous form of the disease. So long as the dropsical effusion is confined to the subcutaneous cellular tissue, there is little immediate danger, but AAdien the effusion has taken place into the cavity of the abdomen (ascites), into the cavity of the chest (hydrothorax), or into the ven- tricles of the brain (hydrocephalus), the danger Avill be very great, and successively greater in a constantly increasing ratio in these successive states. In the last-mentioned stage of the dropsy, that in which the head has become involved, Ave find droAVsiness, coma or convulsions. These fatal symptoms may result from the simple pressure of the effused fluid in the ventricles upon the cerebral substance, from ursemic poisoning, the result of a suspension of the function of the kidneys, or from the combined influence of both these causes. The condition and appearances of the urine are very strongly marked and important in this disorder. In the milder cases the urine will usually be found albuminous; this condition may be de- tected by boiling or by the addition of nitric acid. " If the attack be more severe, the urine, Avhich is very scanty, is of a broAvn or smoke color, deep red or coffee-colored, and throAvs down a deposit chiefly of a reddish-broAvn color, Avhich, however, does not entirely disappear Avhen heated, Avhile albumen is present in it in extreme abundance. It is to the presence of the coloring-matter of the blood that this dark hue of the urine is to be attributed, but in some in- stances ■ blood is present in great abundance, and for a season the case is strictly one of hematuria. Usually, though not invariably, the 844 DISEASES OF INFANTS AND CHILDREN. presence at any time of a large quantity of blood in the urine indi- cates a very serious disturbance of the functions of the kidney, and forebodes a slow and imperfect convalescence. On the other hand, extreme degrees of anasarca and haematuria are by no means gene- rally associated, nor does the complete disappearance of the blood from the urine constantly imply a corresponding improvement in the patient's general condition."—West. Urine copious and red as madder dye may be a critical symptom of convalescence under the severe and aggravating action of large doses of homoeopathic medicines.* The causes of post-scarlatinal dropsy are usually supposed to be found in some undue exposure to the air, or in some similar influence of a change of the weather upon the tender skin. The desquamation of the cuticle itself, by interfering very considerably with the excretory action of the skin—if not for the time totally suppressing it—no doubt throAvs upon the kidneys a double burden—a burden greater than they can bear; hence the serous accumulations in the cellular tissue, and subsequently in the great (serous) cavities of the body. With this the constitution, as psoric or otherAvise, of the individual patient, has doubtless much to do; and since this sequela makes its appearance more frequently after the milder than after the more ma- lignant cases of scarlet fever, it is supposed by some that it constitutes an ultimate and necessary development of the poison, Avhich had not been sufficiently eliminated by the eruption upon the skin and by the accompanying affection of the mucous membranes. But, hoAvever this may be, there can be no doubt that in most cases the careful treatment of the original disorder with the appropriate homoeopathic remedies—especially the antipsoric—will almost entirely remove the disposition to the subsequent dropsy. It should not be forgotten in this connection—and it may be offered in support of the above-men- tioned opinion—that the post-scarlatinal dropsyr is but an after-part of the original fever in some cases—that some epidemics of scarlet fever are remarkably characterized by a disposition to be folloAved by dropsical effusion; yet the physician cannot be too particular in ex- plaining the importance of keeping a child convalescing from scarlatina sufficiently clothed to keep it warm, and insist upon it that such a child shall be kept from all exposure to cold, damp or draughts of air. Many little ones, recovering nicely from the disease, haA'e been absolutely killed by the carelessness of parents or the neglect of * See Am. Horn. Review, 1860, vol. ii., pp. 337 and 433, for detailed cases of this disease. DROPSY AFTER SCARLET FEVER. 845 physicians in warning them of the dangers resulting from exposure to cold under such circumstances. Treatment.— This affection, except in the very last stage, Avhen not only has the Avorst form of effusion taken place, but when even the kidneys themselves have already become disorganized, yields to the homoeopathic remedy in the most grateful and admirable manner. This assertion will be seen to be amply sustained by examining the cases reported in the American Homoeopathic Review, referred to above. The medicine should be carefully selected in accordance with all the symptoms, and, if the true simile be not found among those indicated beloAV, compare also those given under Hydrocephalus, or administer, without hesitation, any remedy called for by the characteristic symp- toms of the case, for these latter, belonging exclusively to the idiosyn- crasy of the patient, may be different from any before observed in other cases. Arsenicum. General anasarca of a Avaxy paleness; thirst for Avater in small quantities, but very frequent; great restlessness, particularly after tAvelve at night; much exhaustion after the least effort; undi- gested stools; sense of suffocation on lying down; palpitation of the heart. Apis m. Yery scanty urine; Avaxy paleness of the feet and legs, which are much SAvollen; absence of thirst; stinging pains here and there over the body; dyspnoea, Avith feeling as if "every breath Avould be the last;" the child must sit perfectly erect in order to breathe. Apocynum cann. General dropsy; hydrothorax; urine high-colored and very scanty; considerable gastric disturbance; pulse weak and irregular. Baryta c. Swelling of the cellular tissue of the neck; also of the submaxillary and parotid glands. Belladonna. Great paleness of the face, much moaning and grinding of the teeth. Stupidity, half sleeping and waking. Hellebore. The urine is scanty, and deposits a dark, coffee-ground- like sediment; pain in the back part of the head; dilated pupils. Kali c. The dropsy commences with a sacculated swelling above the upper eyelids, which continues to characterize the case throughout; the face is enlarged, pale and bloated; the child is worse about three o'clock in the morning. Lycopodium. The urine deposits red sand, while the urine itself is clear; it may be red or reddish, hoAvever; great commotion in the ab- domen from rolling and rumbling of flatus; the child begins to feel 846 DISEASES OF INFANTS AND CHILDREN. Avorse about four o'clock in the afternoon, and begins to feel better again about eight in the evening. Phosphorus. Urine deposits a gray sandy sediment. The scrotum and penis are enormously swollen, together Avith general anasarca, Avhich compels the patient to sit erect. Pulsatilla. There is much pain in one ear or the other, and some deafness; the urine is very scanty; there is a bad taste in the mouth, and nothing the patient takes has a good taste; the child is worse toAvard evening and throughout the night. Rhus tox. The eyelids present a bladder-like appearance and the child is very restless at night, particularly the last part. The patient is scarcely able to see in consequence of the bloating of the eyelids; great thirst, with dry tongue; general dropsy. Squilla. Great desire to urinate, with copious emissions of urine, which is as clear as Avater; great itching of the eyelids, which causes the child to rub the eyes, producing profuse lachrymation; sneezing and profuse coryza, which sometimes excoriates the nostrils; general anasarca and hydrothorax. Veratrum. Vomiting and purging, with much prostration. See also the treatment of other dropsical affections. Other Sequels of Scarlet Fever. Post-scarlatinal Rheumatism.—Among the most important, although perhaps not the most common, of the sequelae of scarlet fe\7er should be recorded the intense painfulness, with swelling of the back of the hands, wrists, and even of the feet, which sometimes appears as the eruption is going off. The back of the hands and wrists seems to have some especial relation to scarlet fever, for in some cases the original eruption, and in others even the subsequent dropsical affec- tion, are entirely confined to them. This is a very dangerous sequela, unless arrested by the proper remedies, to Avhich, hoAvever, it yields with great promptitude, and is thus described by a recent observer: " This (sequela) is seen in the inflammation, shining, SAvelling, and in- tense pains in the (wrist and ankle) joints, Avhich sometimes appear as the eruption subsides and desquamation commences. By allo- pathic Avriters this is termed scarlatinal rheumatism, and it may be said to resemble simple arthritic inflammation also in its disposition, so much greater in children than in adults, to metastasis to the heart. But it differs from all ordinary arthritic inflammation by an almost equally marked tendency to purulent effusion into the affected joints. This form of disease, though fortunately rather rare, is sometimes SEQUELS OF SCARLET FEVER. 847 epidemic. Sometimes also it is complicated with great swelling in the neck, enlargement of the sub-maxillary glands, and other indi- cations of acute scrofulosis." * " We meet now and then Avith sec- ondary inflammation of the joints, Avhich may even go on to the formation of pus. I saw the hand thus affected in a child Avho died on the sixth day of the disease. The Avrist and the back of the hands are the parts usually affected. The symptom is ahvays a very ill- omened one, even though it should be but evanescent," etc.— West. " I have several times, when the rash of scarlet fever was disappear- ing, known pain and swelling of the larger joints to supervene, simulating very closely the local phenomena of sub-acute rheuma- tism."— Watson. The remedies for this painful affection, especially where it appears by itself as the principal symptom, may be found in Apis, Belladonna, Bryonia, Lachesis, Rhus tox. or others, where other complications present. Neuralgic pains in extremities and other parts.—Study Lachesis, Colchicum, Merc, sol., Arsenicum, Digitalis, Cannabis, Rhus tox., Gelse- minum and others. Scrofula, in the form of enlarged and even suppurating cervical and submaxillary glands, in many cases forms an important sequela of scarlet fever. This affection may begin in the course of the original disorder, especially of the anginose variety, or it may be subsequently and more gradually developed. Dr. Condie's descrip- tion of this affection, as it appears in the course of the scarlet fever itself, Avith slight modification Avill apply equally well to its subse- quent development in other cases: " One of the most common and remarkable accompaniments of scarlatina anginosa is an inflamma- tory intumescence of the submaxillary ganglions, which in general presents itself the day subsequent to that in which the swelling occurs in the pharynx. There then takes place a swelling painful to the touch, and sometimes tense and red. The inflammation is at first confined to the glands, but in many cases soon extends to the sur- rounding cellular tissue, often producing an enormous tumefaction, reaching around the front of the throat from ear to ear, and prevent- ing the jaw from being opened wider than just to permit the tip of the patient's tongue to be protruded. Ordinarily, the swelling is produced by an cedematous condition of the cellular tissue of the * Am. Horn. Review, ii., p. 438. 848 DISEASES OF INFANTS AND CHILDREN. throat, and quickly disappears as the inflammation of the glands diminishes. Occasionally, hoAvever, a suppuration takes place, com- mencing either in the glands or in the cellular membranes, and an abscess results." Sometimes two, or even three or four, abscesses may be seen running at the same time in the slow convalescence after a severe attack of scarlatina in scrofulous children. The remedies needed in such cases may be found indicated under Scrofula in a succeeding chapter, to Avhich reference may be made. Silicia, Graphites, Hepar, Baryta c, Calcarea c, Calca- rea phos. and Merc. iod. may be mentioned as worthy of especial study in this connection. » Otorrhosa may be a very serious sequel of scarlatina. It is dne to the inflammation of the mucous lining of the throat extending up the Eustachian tube, and if not cured may result in destruction of the organ of hearing and permanent deafness. Such remedies as Calca- rea c, Bovista, Pulsatilla, Mercurius sol., Silicia and Sul- phur may be studied Avith advantage. But that remedy should be chosen and administered which bears in its pathogenesis the totality of symptoms presented by the individual case. Rubeola Morbilli—Measles. In frequency measles constitute the first, and in importance the second, of the eruptive fevers of childhood. Like scarlet fever, this disorder arises from a specific epidemic and infectious miasm, and usually occurs but once. The nature of the miasm itself, as in the case of other endemic, epidemic, infectious and contagious diseases, is by no means satisfactorily settled. A certain mould or fungous growth on damp straw or other decaying vegetable matter has been obsenTed to give rise to the measles in neAvly-enlisted soldiers lodged in bar- racks. In a similar manner, decaying animal matter—putrescent fish—has been knoAvn to cause the severest epidemics of this disorder. In both these classes of cases, in Avhich many lives were lost, the deATelopment of the measles as a malignant disorder seems to have been favored by the impurity of the air and low and damp tempera- ture of the climate.* Unlike scarlet fever, this disease is apt to be much more severe Avhen it occurs later in life than Avhen it appears in early childhood. The epidemic character of measles seems also * Compare Carpenter's Human Physiology, Chapter III., and Pereira's Treatise on Food and Diet. New York, 1843, p. 43. MEASLES. 849 rather more strongly marked than that of scarlet fever, and its con- tagiousness possibly a little less so, for its epidemic influence is much more universal in the districts where it breaks out than is the scarlet fever, and the disease itself is at once much more universal and far less dangerous. Diagnosis.—From scarlet fever, with which the measles is most apt to be confounded, it cannot always be certainly distinguished in spor- adic cases before the appearance of the eruption. But the absence of vomiting (although even this symptom may sometimes precede the appearance of measles) and of the sore throat, and the presence of catarrhal symptoms, such as injection of the sclerotica, coryza, sneez- ing, hoarse and scraping cough, will usually be sufficient to prevent the inexperienced practitioner from giving a wrong diagnosis, while the prevalence of one epidemic or the other Avill in most cases greatly assist him in his determination of their nature. In the early stage of the eruption it may be confounded Avith small-pox, but the papules of measles are larger, softer and less elevated, and have not the shot- like feel of the papules of variola; and in variola there is an absence of the catarrhal symptoms Avhich belong to measles. At any rate, where there is room for doubt it is far better to give a guarded diagnosis, and thus avoid the imputation of ignorance or inexperience which Avould arise in case of a mistake. Symptoms.—After a period of incubation of thirteen or fourteen days the eruption of measles makes its appearance; but about the tenth day after the exposure to the infection the introductory fever arises. This fever is often severe, attended with lassitude, shivering, thirst, dry cough. " The eyes become vascular and Avatery, the eye- lids heavy, turgid and red. The membrane which lines the nasal cavities, the fauces, the larynx, trachea and bronchial tubes is affected. Hence Ave have generally as symptoms much sneezing, as Avell as lach- rymation, a copious defluxion from the nostrils, soreness of the throat and an obvious redness of the fauces, and most commonly7 a dry, hoarse, peculiar cough; so that the symptoms which usher in an attack of measles are the symptoms of coryza and catarrh. In some instances there is diarrhoea also, indicating a simultaneous affection of the mucous membrane of the intestines, and not unfrequently vomiting ; but the vomiting, as in small-pox, ceases on the coming out of the eruption." — Watson. The eruption usually makes its appearance on the fourth day, sometimes much later. It comes out first upon the face, whence in the course of a couple of days it extends over the body and extremi- 54 850 DISEASES of infants and children. ties. The eruption of measles consists of a rash made up at first of minute papillae, slightly elevated, AA'hich, as they multiply, coalesce into blotches that have more or less a horseshoe or crescentic shape, and leave the intermediate portions of the skin of their natural color. "On the third or fourth day of the disease the skin begins to be covered with an eruption of small distinct red spots, these first be- coming visible about the throat and face. The blotches or eruptions are of an irregular circular or semicircular figure, and continue for the most part distinct from one another. The several spots or points in them rise slightly above the general level, and are felt to be rough and uneven under the fingers." * After about forty-eight hours from its appearance, and by the time it is at its height on the trunk, the eruption begins to disappear from the face, and by the ninth or tenth day it will have disappeared entirely', thus making its whole duration about six days. The desquamation of measles, less constant and noticeable than that of scarlet fever, takes place in minute branny scales, instead of the larger portions of cuticle which are sometimes throAvn off after the latter disease. In severe cases of measles, how- ever, as in scarlet fever, the desquamation is more extensive; and in some instances even the nails of the fingers are similarly throAvn off, and replaced by new growths. The cough often becomes most distressing, violent and incessant, and the fever itself more severe, after the appearance of the eruption; but this aggravation is but temporary, and will readily yield in a short time to the properly indicated remedy; and in favorable cases convalescence may be pretty well established in tAvelve or fourteen days from the commencement of the illness. The homoeopathic treat- ment, while it may not \rery materially abridge the natural duration of this or other eruptive disorders, will very greatly moderate the severity of their symptoms, pre\7ent, in a good measure, the accession of troublesome and even dangerous complications, and in almost all cases either entirely preclude the appearance of the usual sequelae, or render them the occasions of effecting a more radical and permanent improvement of the subsequent condition. Complications and Sequeke.—Diarrhoea sometimes makes it appear- ance upon the decline of the eruption, if it has not existed at an earlier period. This has been regarded as exerting no unfavorable influence upon the convalescence. The mucous membrane of the bronchia affords a seat for the development of measles, corresponding to that of the fauces and nasal fossse in scarlet fever. Hence the Illustrations of Cutaneous Disease, London, 1841. MEASLES. 851 cough, at first dry, but at the last loose, Avhich in greater or less degree accompanies the measles, and whose aggravation, above referred to, forms a most distressing complication. Under the old forms of treatment this irritation of the' bronchial mucous membrane Avas apt to be developed into a true bronchitis. But under homoeopathic treatment this tendency may almost always be entirely averted. Pneumonia forms the severest and most dangerous complication of measles, and also the most important sequelae to be guarded against. The revulsion of the eruption from exposure to cold is ahvays liable to be followed by this result at any stage of the original disorder. And in children of delicate constitutions and scrofulous habit may be observed a strong disposition to pneumonia, no less decided than the disposition to external scrofulous disease which is developed by scarlet fever in the same class of patients. And it may be remarked here, that in attending young people—and by this we mean also those par- tially and quite groAvn up—Avho are attacked with measles, the most sedulous care should be taken lest through its imperfect treatment and unfavorable convalescence this disease should lay the founda- tion for confirmed ill-health, or even of actual pulmonary consump- tion. And perhaps this remark may be more applicable to girls and young Avomen than to those of the other sex, although these latter are by no means exempt from the danger. We believe that more cases of this serious " poor health" may be traceable to badly- treated and badly-managed measles than to all the other exanthemata combined. Rubeola maligna, Rubeola nigra, or Black Measles may occur either as an epidemic or sporadically. Its existence as an epidemic is not very common, and its cause is inexplicable. The occurrence of sporadic cases of black measles must depend upon some deep-seated dyscrasia of the individuals thus affected. The symptoms usually attendant upon measles assume an exaggerated type, and the \vhole course of the disease exhibits an adynamic or typhoid and malignant character. There is great feebleness of pulse, general depression and weakness, and difficulty of breathing, and frequently either delirium or stupor. Petechias make their appearance, the skin presents a darkened or livid appearance, there is sore throat, bleeding from the nostrils, and sometimes an exhausting diarrhoea or dysentery sets in. The eruption comes out sloAvly and imperfectly, and is dark-colored or even black in consequence of the exudation of blood into the papules. This form of the disease frequently terminates fatally; otherwise the prognosis of measles is almost ahvays favorable. 852 DISEASES OF INFANTS AND CHILDREN. Treatment.—The room in Avhich the patient is confined should be kept at a comfortable temperature, say from 70° to 75°, Avithout ex- cluding fresh air; the patient should be kept as quiet and undisturbed as possible, and the remedy should be carefully selected to meet all the symptoms and conditions. Aconite. Dry, hot skin; heat in the head, with restlessness. Aconite is the most suitable remedy in a large majority of cases for the fever, the catarrhal symptoms,, the cough, even though croupy, and the stomach and bowel symptoms. Antimonium c. If there be pain in the ears, white coating on the tongue and much vomiting. Apis meL Absence of thirst; scanty urine; great restlessness and inability to sleep; stinging in the skin; dyspnoea; the measles do not come out properly. Arsenicum. AVhen there is much prostration; thirst for Avater, wishes to drink often, but little at a time; great heat of the skin. Too sudden disappearance of the eruption; pallor; great restlessness; vomiting and diarrhoea at the same time; exhausting cough; the child vomits water after drinking it; worse after midnight. Belladonna. Difficulty in swallowing; severe coughing spells, causing much redness of the face, constant moaning and droAvsiness; evident congestion of the head, with red eyes. Bryonia. The eruption does not fully develop itself; it appears pale, and there is much dyspnoea and violent cough, or there may be a partial retrocession, Avith similar symptoms; motion aggravates the symptoms. Camphor. When there is much coldness and blueness of the skin; the face is pale, the child does not Avish to be covered; the eruption does not appear. In these circumstances Camphor will bring out the eruption and relieve the patient. Dysuria. Coffea. When there is excessive sensitiveness of the skin and of the senses to every impression; weeping, irritability; great wakefulness, and much excitement. Dulcamara. Retrocession of the eruption from exposure to damp, cold' air. Drosera. Very hoarse cough accompanies or follows the disease, which is worse after midnight. Euphrasia. There- is much lachrymation, coryza and extreme pho- tophobia. MEASLES. 853 Hepar. Choking and croupy cough, which is Avorse after midnight or in the morning. Ipecacuanha. Much nausea; short, hurried breathing. Incessant and most violent cough with every breath; this symptom, sometimes fright- fully severe in delicate children suffering Avith measles, Ipecac, relieves like a charm. The measles do not come out properly. Kali bich. In those rare cases in which the cough is accompanied Avith tough and stringy expectoration. Mercurius. The glands of the throat are much swollen, and there is difficulty in swallowing; slimy stools streaked with blood ; tenesmus. Hyoscyamus. AVhen the cough is very racking and exhausting, and is Avorse on lying doAvn and relieved by sitting up. The rash does not come out well. Lachesis. The measles do not come out. When the child goes to sleep it is troubled Avith dyspnoea and cough until it gets awake; there seems to be a struggle betAveen difficulty of breathing and coughing. Phosphorus. For symptoms indicating bronchitis.; violent and very exhausting cough. (Compare Ipecac.) Pulsatilla. Very loose and rattling cough; lachrymation; photo- phobia; thick and yellowish coryza; absence of thirst; very bad taste; nightly diarrhoea; the rash is very sloAvto make its appearance; the child usually gets Avorse toward evening. Stramonium. The rash does not make its appearance; the child seems afraid of all objects when first seen, and shrinks from them; inclina- tion to spasms, or the child lies in an apparently natural sleep, with a red face and an occasional raising of the head from the pilloAV. Sulphur. The eruption fails to make its appearance, and the catarrhal symptoms become worse, with other Sulphur symptoms. Treatment of the Complications and Sequeke of Measles. Diarrhcea.—For the diarrhoea which attends or follows the measles, consult Bryonia, Mercurius, Pulsatilla and Sulphur. (See Diarrhoea?) Bronchitis.—For bronchitis study Bryonia, Ipecacuanha, Phos- phorus, Pulsatilla, etc. (See Bronchitis.) Pneumonia.—For pneumonia compare Belladonna, Bryonia, Phos- phorus, Sulphur, etc. (See Pneumonia.) Rubeola maligna.—In the congestive and malignant variety, Avhich, although very rare, may appear—the so-called black mea- sles__compare Arsenicum, Hamamelis, Lachesis, Phosph. ac, Pulsa- tilla, Rhus. 854 diseases of infants and children. Itching of the Skix.—In those cases in Avhich the itching is ex- cessiA'dy annoying, study Dolichos pruriens, Rhus tox and Sulphur. Roseola—Scarlet Rash. This disease, Avhich has also been denominated the French measles and Rubeola sine catarrho, is occasionally epidemic, but is not usually regarded as a contagious exantheme. The eruption of roseola, Avhich is preceded by febrile symptoms, makes its appearance as irregular- shaped patches of a rose-colored hue, and Avhich are unaccompanied by elevations or papulse. When not epidemic, it seems to depend chiefly upon derangements of the digestive apparatus as a producing cause, though it may likeAvise be due to sudden changes of tempera- ture, violent exercise, taking cold drinks while the body is Avarm and perspiring, etc. The eruption may appear suddenly during the night, and cover the entire body with its rose-colored patches, situated closely together, yet distinct. " In another and rather more violent form, occurring espe- cially during dentition, the eruption appears after vomiting, fever, diarrhoea and slight nervous symptoms, or possibly after slight con- vulsions, with the characters above mentioned, except that the rash is deeper in color, greater in extent, and that it lasts generally a longer time—tAvo, three, or four days. Again, in a yet more marked form, the Roseola cestiva and autumnalis, the disease is preceded by certain symptoms Avhich it is important to note. It begins with more or less chilliness, alternating Avith heat, with loss of strength and spirits, Avith headache, restlessness, sometimes mild delirium, and even, it is said, with slight convulsive phenomena. At the same time there is some febrile reaction, marked by accelerated pulse, heat and dryness of the skin, thirst and loss of appetite; the digestive function is shoAvn to be deranged by the presence either of constipation or diarrhoea. After these symptoms have continued for tAvo, three, four, or even six or seven days, the eruption appears first upon the face and neck, Avhence it extends in twenty-four or forty-eight hours to the rest of the body." —Meigs and Pepper. The rash of roseola sometimes bears a strong resemblance to that of measles, and fades aAvay gradually in two or three days; but it sometimes comes and goes for a Aveek or twro after the first appear- ance. Sometimes the rose-colored spots are arranged in the form of rings, Avith healthy skin within the circumference of each ring. AVhen this phenomenon presents itself the disease has been termed Roseola annulata. There can be no very great difficulty in distinguishing this PEMPHIGUS—POMPHOLYX. 855 affection from scarlet fever or measles when the prodromic and cha- racteristic symptoms of these latter diseases are taken into considera- tion. The prognosis is always favorable. Treatment.—The treatment of roseola is a very simple matter. The child should be kept in a suitable temperature and its diet corrected. Such medicines as Aconite, Belladonna, Bryonia, Mercurius sol., Pulsatilla, Rhus tox. and Sulphur may be administered to suit the presenting symptoms. Consult the remedies laid down for the treatment of Measles and Scarlet Fever. Miliaria—Miliary Fever. This eruption consists of clusters of minute red and white pimples, like the smallest millet-seeds, Avhich from being elevated give a rough feeling to the hand. The neck, chest and back are the principal seats of this eruption, which appears in successive crops, and is usually the result of excessive heating of the body. This overheating may be caused by the too great abundance of clothing, or it may be the nat- ural result of the summer temperature. A slight fever often precedes the eruption, which, hoAvever, like the eruption itself, is sometimes quite violent. From measles, which the miliary fever and eruption someAvhat resemble, it may be readily dis- tinguished by the absence of catarrhal symptoms, and also by the tem- porary nature of the affection itself. The symptoms, even in the severer cases, yield very readily to the appropriate homoeopathic remedy. Aconite. Affords prompt relief when indicated by the restlessness, heat and peculiar nature of the eruption. Bryonia. May be required in very warm weather; the child is bet- ter Avhen kept perfectly quiet. Chamomilla. The child is very fretful, and is relieved by being carried. Hepar. The eruption comes out in circles. Sepia is also indicated by this peculiarity. Sulphur. In the more inveterate cases; the skin is rough and scaly. Pemphigus—Pompholyx. This eruption appears in the form of large bulla}—vesicles like blis- ters—in which a Avatery fluid separates the cuticle from the skin. It is usually believed to indicate an unhealthy condition of the system; sometimes it shoAVS a disposition to assume a typhoid character, and 856 diseases of infants and children. in the worst cases it seems to have many features in common with the gangrenous form of infantile erysipelas. The approach of the disorder is sometimes thoroughly denoted by a livid suffusion, like that of erysipelas, slightly elevated. More fre- quently, hoAvever, the complaint comes on in apparently perfect health. The bullae or blisters are oval, filled with a yelloAvish serum, Avhich soon becomes turbid, of a dark brownish-red color, and the bulla either dries up and is transformed into a dark thin scurf, surrounded by a narroAv border, or else it breaks, leaving a flat excoriation, Avhich is likewise soon covered with a thin scurf. This eruption often appears soon after birth; sometimes, hoAvever, it is congenital. It does not seem to be confined to any particular part of the body, but breaks out behind the ears, on the neck, chest, back, inner surface of the thighs, on the groins, on the extremities, and on the palms of the hands and soles of the feet. Treatment.—Attention should be paid to the diet, and the digestiAre organs should be regulated by appropriate medication. One of the folloAving remedies may be administered: Arsenicum. May be required in the more malignant cases, especially Avhere Rhus seems indicated, but fails to arrest the disease or cure the cachexia by Avhich it is supported. Rhus t. Where each bulla is surrounded by a red, inflamed base. Thuya. Cures most all cases, particularly if painful. Camphor, Ranunculus bulb., Sabina or Secale c. may also prove useful in the treatment of this disease. Belladonna, Carbo veg. or Lachesis may be required if the bullae become darkened from the effusion of bloody serum into them. Variola—Small-Pox—Varioloid. Variola is the natural small-pox, as it appears in those who have not been vaccinated. Varioloid, or modified small-pox, is the corre- sponding disease, as it appears in those who are more or less protected by vaccination, by inoculation or by a previous attack of variola. Variola runs through a regular course of three distinct stages: 1, that of incubation; 2, that of development and maturation ; and 3, that of decline. Varioloid differs little from variola in the first stage; a severe attack of the former may be a much more dangerous illness than a mild attack of the latter. The principal difference is found in the fact that in modified small-pox the eruption is usually much less copious, VARIOLA—SMALL-POX—VARIOLOID. 857 and that it sooner begins to decline. In other respects the two forms of disease may for all practical purposes be considered as identical. 'Since the infection from the mildest case of modified small-pox is capable of causing the severest form of confluent variola in those un- protected, under suitable circumstances either disease may develop the other. In distinct small-pox, Variola discreta, the pustules admit of being counted, being placed at such distances from each other as not to coalesce or run into one another, even Avhen fully matured. In confluent small-pox, Variola confiuens, the pimples are set so close as to run into each other on the third or fourth day of the inflammation. In general, the latter variety is by far the more severe, and in this consists the only real difference. Symptoms.—I. Stage of Incubation and Initial Fever. The usual duration of the period Avhich intervenes betAveen the reception of the infection of variola and its initiatory development is from twelve to fourteen days. This has been called by nurses the period in Avhich the disease is breeding. In some instances, children, and older per- sons as Avell, are sensibhy affected, and experience a Arery considerable degree of languor, lassitude and fever during this period ; in others no particular inconvenience is perceived. II. The Stage of Development and Maturation. The first part of this period is occupied by the initiatory or eruptive fever. And as it is important to determine, if possible, the onset of this disorder, even before the eruption makes its appearance, Ave Avill endeavor to portray this fever in such a manner that it may be recognized, even in cases of children too young to speak of the intense, unusual and long- continued pain in the back, which in older persons at once excites suspicion of this disease. There are three strongly-marked symptoms which precede and accompany the eruptive fever of small-pox in children, and by means of which we think the disease may always be strongly suspected, if not absolutely determined, in advance of the eruption; and these are the vomiting, the coma, and the convulsions. The sickness Avith Avhich the eruptive fever of small-pox sets in is in general very severe, and the disorder of the stomach often continues for forty-eight hours, during Avhich time vomiting frequently recurs. The cerebral condition is often one rather of stupor than of delirium, although in milder cases this latter symptom prevails. In the severer cases convulsions sometimes take place and continue, alternating Avith coma, for as long a period as twenty-four or thirty-six hours. The persistence of the vomiting will readily distinguish the case from scarlet fever. Nor is the skin so hot and dry as in scarlet fever. 858 DISEASES OF INFANTS AND CHILDREN. The stupor or coma, in connection Avith the vomiting on the one side and the convulsions on the other, will serve to enable the practitioner to distinguish the case from one of incipient cerebral affection, in Avhich indeed there may be even prolonged vomiting, but in Avhich neither the coma nor the convulsions are so rapidly developed. Should there be severe diarrhoea, it is generally regarded as a dan- gerous complication; constipation generally lasting throughout the disease. There is generally great thirst, Avith loss of appetite. The urine is scanty and high-colored. The second part of the period of development of variola is occupied by the appearance of the papular eruption. This never occurs in less than forty-eight hours from the commencement of the actual illness, and it may be delayed somewhat longer. These papulae are at first slightly red, somewhat acuminated elevations, quite minute, and capable of being overlooked in a hasty examination, and yet conveying a dis- tinct sense of irregularity to the finger as it passes over them. "They increase in size, and in the course of forty-eight hours assume a vesic- ular character, and contain a whey-like fluid, while instead of a coni- cal form they now present a central depression. During another period of forty-eight hours, or thereabouts, these vesicles go on en- larging, their central depression grows more and more apparent, and their contents become Avhite and opaque; they are no longer vesicles, but have become converted into pustules, each of which, if they be distinct, has an areola of a red hue around its base. As the size of the pustules increases they lose that central depression which they had presented while vesicles; they assume a spheroidal form, and even become slightly conical. The next change observable in them is an alteration of their color from a white to a dirty-yellow tint, which they continue to retain until the desiccation of the eruption commences. The maturation of the pustules usually occupies from the commence- ment of the fifth to the commencement of the eighth day of the erup- tion, or from the eighth to the eleventh day of the disease, when the process of desiccation begins."— West. The pustules are generally most numerous on the face, neck and limbs, and less on the trunk than elsewhere. Indeed, the eruption on the face and neck may be of the confluent form, and yet discrete on the chest, abdomen and extremities. In almost all cases of variola, and in severe attacks of varioloid, the mucous membrane of the mouth, fauces and nares is likewise covered Avith the eruption. It here begins "Avith more or less vivid redness of the membrane, which is folloAved by the production of little elevations, the real nature of which, whether papu- VARIOLA—SMALL-POX—VARIOLOID. 859 lar or vesicular, seems not to be clearly determined. About the second or third day these elevations assume the appearance of small, Avhitish, rounded and umbilicated pseudo-membranous points, Avhich last gen- erally about five days, and are then detached, leaving usually a little ulceration or erosion, which heals Avithout leaving a cicatrix. Some- times the gums become inflamed, swollen and spongy, and there is generally more or less inflammation of the pharynx, with difficulty of SAvalloAving, and swelling and tenderness of the submaxillary glands. When the eruption extends to the mucous membrane of the larynx, Avhich it sometimes does, the voice becomes hoarse and Ioav, and there is considerable hoarse or barking cough. During this stage of the disease the fever generally subsides, if it has not done so before, and the pulse falls considerably in the number of its beats— from 130 or 140 to 100 or 80. After the eruption has continued for five or six days, and matura- tion of the pustules is going on in the face and extremities, there is a reneA\ral of the fever—secondary fever or the fever of maturation—the pulse rises again, and this fever continues for four or five days more, and then gradually declines. III. The stage of decline and the formation of the pustules into scales generally commences betAveen the sixth and ninth days, and terminates between the tenth and the fourteenth days. It commences upon the face, as does the eruption, and thence spreads to the ex- tremities and trunk, and from the eleventh or twelfth to the twentieth days, and even later, the process of desquamation goes on, the scabs or scales dropping off and leaving red blotches upon the skin, Avhich do not fade for a long time afterAvard. A\rhen there has been ulceration and loss of substance of the derma during the process of maturation, there is left beneath the scale a pit or depression, which is, in fact, a cicatrix—the small-pox pit—and which remains through- out life. The above description of the three stages of small-pox suffices for the disorder as it almost always appears, but there are many cases occurring during the prevalence of an epidemic of the disease—and this Avas noticeably the case during the malignant epidemic which pre- vailed in Philadelphia during the years 1871 and 1872—in which the disease runs an irregular course in any or all of its stages, or is accom- panied Avith phenomena unusual to variola. In these irregular cases any of the stages may be lengthened or shortened, or increased or de- creased in the severity of their attendant symptoms. The initial fever does not usually subside, as in ordinary cases, but rather increases, the 860 DISEASES OF INFANTS AND CHILDREN. pulse being full and reaching to 160 or 170, the skin being hot and dry. The eruption presents in different cases a varied appearance, differing in some cases very greatly from the ordinary variolous eruption. It may be pale, uneven, and destitute of the usual areola. " In other instances the papules and areolae are of a purple-red color, and the vesicles, instead of being transparent or whitish, are also red- dish, and appear to be filled Avith a bloody serum. The pustules in these cases also contain a sanguinolent fluid, and when broken their contents escape and form bloody scabs. In this variety of the disease, which is called hemorrhagic (Purpura variolosa, black small-pox), the papules and vesicles are Arery small; they are developed slowly, and remain flat and uudistended as a general rule, Avhilst in a feAv cases they are of a large size, but remain almost ahvays flattened in shape and unfilled." This form of the disease, indicathre of a profound alteration of the blood, has a tendency to terminate unfavorably. The mortality from small-pox differs in different epidemics, but it may be stated that in the ordinary form of the disease occurring in patients over five years of age, and Avho Avere in a fair state of health previous to the variolous attack, a fiworable termination may be looked for, whether the eruption be confluent or discrete. The younger the patient attacked, cceteris paribus, the greater the danger. Complica- tions may arise in connection Avith ordinary variola which may make what would otherwise have been a favorable case assume a very grave aspect. AVhen the disease runs an irregular course, such as has just been described, death very frequently results, and the hemorrhagic variety, as previously remarked, has a strong tendency to terminate fatally. Treatment.—The patient should be placed hi, a cool and well-ventilated room, and be sufficiently covered to be kept warm. The diet should be plain, yet nutritious and digestible, and cooling drinks should be alloAved plentifully. In the more severe attacks, Avhere there appears to be considerable loss of strength, a yet more nutritious diet may be given, carefully avoiding meat in every form. Aconite. Is absolutely demanded in some cases, especially in the first and early part of the second stage. There is great fearfulness and apprehension of an unfavorable termination; high degree of fever; great restlessness; especially suited to full-blooded and active children. Ammonium mur. In cases Avhere the eruption is sufficiently Avell developed upon the trunk and upper extremities, but upon the loAver VARIOLA—SMALL POX—VARIOLOID. 861 limbs it is thinly scattered, out of all proportion. Sore throat, with swelling about the neck; haemorrhages. Antimonium c. A great deal of vomiting; the tongue is covered thickly Avith a Avhite coating. Apis mel. Apis may be useful in the earlier stages: there are ery- sipelatous SAvellings, Avith stinging pains; soreness of the throat; absence of thirst. It may also be used at a later period, Avhen there are great dyspnoea, to the extent that the patient fears each breath he draAvs will be the last; great restlessness; scantiness of urine; very annoying stinging in the throat; the pustules seem to be retrogressing. Arnica. Partially developed eruption, Avith ecchymosed spots here and there; great restlessness; a bruised and sore feeling is markedly complaiued of; involuntary stools, passing Avhile the patient is sleep- ing; the head is hot, while, the body is comparatively cool. Arsenic. Haemorrhagic small-pox, black small-pox, and in other forms of irregularly developed variola Avith typhoid tendency; the pustules fill with a dark-colored bloody fluid; the pustules are too flat; the patient is Arery restless, and yet is greatly exhausted; thirst, but drinking of only small quantities at a time. Baptisia tinct. Typhoid symptoms; foetid breath; scales on the teeth and lips; profuse salivation; the pustules appear thickly in the nasal cavities, and in no other part; imagines himself disjointed and cannot bring the pieces together. Belladonna. This remedy is especially adapted to plethoric, thick-set patients. The patient is dull and sleepy; the skin is very hot; the eruption does not appear; flushed face, injected eyes, throbbing of the carotids, and all the evidences of determination of blood to the head; bleeding from the mouth or nostrils. Bryonia. Headache as though the head would burst; thirst, Avith desire for water in large quantities; great nausea, faintness and even vertigo on raising from a recumbent position ; dry and parched lips; the patient lies perfectly still, because motion aggravates the pains and other symptoms; a pale eruption may be seen under the skin. Camphora. Where coldness of surface and collapse set in suddenly; the pustules seem to shrink away at once; the patient does not Avish to be covered and is exceedingly Aveak. The dose must be very frequently repeated until reaction is being established. Cantharis. Dysuria and bloody urine, with cutting and burning pain on A-oiding it; very distressing headache and pain in the back; the eruption is not properly developed, or, being developed, assumes the haemorrhagic hue. 862 DISEASES OF INFANTS AND CHILDREN. Carbo veg. The pocks fill up Avith a dark and bloody scrum; the breath becomes cold, and there is very great exhaustion and depression of the vital forces. It differs from Arsenic by the absence of the characteristic thirst of that remedy. Chamomilla. May be required in some cases to allay the fretfulness of the little patient, Avhich is quieted only by being incessantly carried. China. The pustules fill Avith a black fluid; exhausting and painless diarrhoea; the child cannot bear to be touched. Cimicifuga. The muscular pains are unusually and peculiarly severe, partaking of a rheumatic character. Hamamelis. Haemorrhagic small-pox, Avith passive venous hsemor- rhages. Hepar s. c. A croupy cough is developed during the progress of the disease, Avith choking during each coughing spell. Hepar should then be given as an important remedy, to ward off the threatening complication. Hydrastis can. When the pustules are dark-colored and there is great prostration; the face is very red, itches and tingles, and there is facial oedema quite marked; the throat is very sore. Hyoscyamus. Great rage, anguish, delirium, coming on in paroxysms; the patient constantly Avants to get out of bed or to be uncovered; the eruption does not come out at the proper time. Ipecacuanha. The disease is characterized by continuous nausea. Lachesis. The child's symptoms are all worse after sleeping; it wakens in great distress, becomes more comfortable after getting Avide aAvake, and is worse again after another nap, and so on. Mercurius sol. Is especially indicated during the stage of matura- tion. The tongue is very moist; salivation; great thirst; swelling of the tongue; the mucous membrane of the eyes, nose and mouth looks red and raAV; diarrhoea or dysentery, with tenesmus, and other symptoms of Mercury. Phosphorus. Is especially adapted to tall and slender persons. There is a dry and exhausting cough, accompanied with pain or feeling of rawness in the chest; haemoptysis; Aveak feeling across the abdomen; the pustules begin to fill with blood. Phosphoric ac. The pustules do not fill properly; they look like blisters, burst and leave a raAV surface. The patient is dull and stupid, cares for nothing, wants nothing and notices nothing. When asked a question in a loud tone of voice, the patient opens his eyes, gazes stupidly and steadily at the questioner, and then ansAvers sloAvly, but otherwise will not talk. VARIOLA—SMALL-POX—VARIOLOID. 863 Pulsatilla. AVant of thirst; the patient constantly craves fresh air; changing sensations, the patient feeling now better and noAV worse; weeping mood; bad taste, the food does not have a good taste. Rhus tox. The disease is disposed to assume a decidedly typhoid type. The patient is excessively restless, constantly tossing about to find a rest Avhich is only momentary; sordes on the teeth and lips; the tongue is dry and cracked; great debility; the eruption seems to shrink and has a livid appearance; confluent small-pox. Sarracenia purp. Has been highly lauded as a remedy for small-pox, but no reliable characteristic indications for its administration have been evolved. It is probably overestimated in value. Secale corn. The patient cannot bear to be covered; is very thirsty; lies very quietly; the pocks have an unnatural and unhealthy ap- pearance, and either fill Avith a bloody serum or dry up too soon. Silicia. The stage of maturation is too long-lasting and exhausting; the pustules seemingly do not begin to dry up soon enough, and the stage of desiccation is delayed. Stramonium. The eruption does not make its appearance; the patient lies quietly in an apparently natural sleep, but ahvays wakes Avith an expression of fear; the face is red and bloated; there are frequent convulsions; retention of urine. Sulphur. May be indicated during any stage of the disease, under certain circumstances, to facilitate the appearance of the eruption, the maturation, or the desquamation. It is particularly suitable also if there be threatening cerebral involvement or metastasis to other of the noble organs. The pustules fill Avith a pale bloody serum. Tartar em. Nausea and vomiting; thirst for small and frequent drinks of Avater; the rash is sIoav in making its appearance; the patient is very droAvsy, and vomiting commences again after sleeping. The eruption has been suppressed. The disease assumes a typhoid and putrid type. Thuya. May be found useful in ordinary cases, after the eruption makes its appearance, especially if the pustules are painful to the touch. Vaccininum and Variolinum have been employed Avith apparently good results in some cases. Summary. IMien there is hemorrhagic complication: 1. Bell., Canth., Chin., Ipec, Merc, sol., Phos., Puis., Sulph. 2. Aeon., Ant. cr., Arm, Ars., 864 DISEASES OF INFANTS AND CHILDREN. Bry., Carbo veg., Cham., Hyos., Rhus tox., Sec. corn., Sil., Stram. 3. Amm. mur., Bapt., Hamam., Hydrast., Phos. ac, Thuya. When the pustules look dark and, bloody: 1. Apis, Ars., Carbo veg., Hamam., Lach., Rhus. 2. Bell., Can., Chin., Hydrast., Phos. Vaccination. In performing vaccination, either the cow-pox lymph or human- ized virus in the form of crusts is used. In making use of the tubed lymph, slightly scarify the arm by means of the sharp point of a lancet, break the end of the lymph tube and insert into it a fine needle, to the point of which a sufficient quantity will adhere to com- plete the operation. When humanized crusts are used, a portion of the crust should be moistened with a drop or tAvo of water or gly- cerine, and the material thus prepared reduced to a creamy pulp by being compressed and ground betAveen tAvo flat pieces of glass. The arm should be scarified as before, or the epidermic layer scraped off, and a portion of the pulp laid over the spot and pricked in with the point of a lancet. Great care should be taken in performing this operation that the scarifications are not made so deep as to draw a quantity of blood, or the vaccination will not succeed. If the vac- cination be successful, on the third or fourth day after the operation a small rose-colored blush or erythematous redness will be noticed, and on the fourth day, on running the point of the finger over the spot, a small kernel will be felt. The process then goes on, gradually developing the vaccination until it is completed finally by the falling off of the scab, AAdiich takes place sooner in some cases than in others. A dose of Sulphur should be given on the fourth day after the opera- tion. If any unpleasant symptoms, such as eruptions—the offshoots of latent psora—are developed, give a single dose of a high potency of Silicia. Psorinum may be needed, or even some other remedy, according to the presenting symptoms, such as Graphites, Petro- leum, etc. The first vaccination should be performed as early as the fourth week after birth in favorable cases—that is, if the child is Avell estab- lished in the way of living. In general, it is safer to vaccinate again at the sixth or seventh year, and repeat tAvice afterward. Vaccina- tion is a true prophylactic against small-pox. It is useless to go into any extended argument to prove this, as the statistics of the efficacy of vaccination are so abundant and convincing as to be entirely irrefutable. varicella—erysipelas neonatorum. 865 Varicella—Chicken-Pox. Varicella, or chicken-pox, is a mild, febrile, vesicular eruption. This affection seems to bear a similar relation, though in a far less degree, to varioloid that this latter eruption does to variola itself. If varioloid be taken for a bastard or spurious form of variola, then varicella may be considered a bastard or spurious form of varioloid, but Avith this difference (and this is the very thing which proves its hybrid nature), varicella is alike incapable of producing either variola or varioloid, or of propagating itself. Varicella occurs much more frequently in those who have been vaccinated than in others, but its symptoms differ materially in dif- ferent cases; in some the vesicles, which look like water-blisters or bullae, desiccate earby, the scabs leaving no cicatrices, Avhile in other cases the vesicles are more or less fully maturated, the scabs adhere for a longer time, and leave indelible pits in the skin when they finally fall of. Still, while this disease has been the occasion of much dispute among medical men as to its relation to natural and to modified small- pox, its treatment with homoeopathic medicines is at once simple and very successful. Study the following remedies : Aconite. AVhen much fever prevails. Belladonna. If there be very red face and eyes, headache, etc. Coffea. Very much restlessness and sleeplessness. Mercurius sol. Salivation; some thirst. The water-blotches turn yel- low and maturate; blisters form in the mouth. Rhus tox. The eruption assumes the form of spreading blisters, itches very much, and the child is very restless. Sulphur. The pocks do not heal; they are inclined to itch and to ulcerate. Hartmann recommends this medicine with reference to the local symptoms. Tartar e. The eruption fails to appear, and convulsions complicate the case. Belladonna, Sepia, Dulcamara and Clematis should be carefully studied. Mercurius, Sulphur, Hepar, Graphites, Calcarea and Sepia should be carefully compared in cases that degenerate, and where the bullae change to ulcers. Erysipelas Neonatorum. Infantile erysipelas is said to be of very unfrequent occurrence in this country in private practice. Its appearance, when it does occur, is 55 866 diseases of infants and children. usually only a feAv days after birth, in Avhich case it may take its rise in umbilical phlebitis. Sometimes also it is congenital, of intra- uterine origin. It may attack the face, scalp and ears, and even the back part of the neck. In any case, this disorder must be regarded as very dangerous, and by the old school it is set doAvn as almost invaria- bly fatal, even Avhen arising so late as the fourth month. Symptoms.—The erysipelas may be preceded by fever and other symptoms of constitutional disturbance, but in most cases the first evidence of the peculiar disorder appears in a certain suspicious red- ness, which, commencing upon the pubes or about the umbilicus, gradually spreads over the abdomen and thighs, the parts occupied by the inflammation being SAvollen, hard and extremely tender to the touch, as indicated by the movements and cries of the child, Avho can scarcely bear to be touched. After tAventy-four hours a few scattered vesicles make their appearance upon the inflamed surface, Avith in- flamed livid bases, Avhich rapidly terminate in gangrenous ulcerations. " When the redness extends to the hands and feet, these parts acquire a degree of redness and swelling far greater than that of any other part. The genital organs in some cases sphacelate, in consequence of the local inflammation, and in many acquire an emphysematous ap- pearance. In place of appearing upon the pubes first, the erysipelas has been known to extend from the areola of a vaccine vesicle; less fre- quently from an accidental laceration of the skin, or from the excora- tions so common in the cutaneous folds of the groin and other parts." Sometimes the disease begins in the form of a dark-red, shining spot, Avhich quickly extends in size and becomes of a purplish color; there, is little SAvelling, but the skin becomes tense and hard. (See Induration of Cellular Tissue.) When the erysipelas commences in the abdo- men, vesications, destruction of the cellular tissue and gangrene of the skin quickly follow; the genital parts are not unfrequently de- stroyed altogether. In such cases the fever is of a typhoid kind, and the whole disorder exceedingly malignant and capable of carrying off the child in a very short time. In this disease, even under its milder forms, it is easy to see that the vital forces are so greatly depressed, and the blood in such a depraved condition, that there is little power or hope of recuperation. Still, much may be done, even in malignant disorders, if we can remove the constantly sustaining cause. Where there is reason to think that the bad state of health of the mother or her general enfeebled condition is the cause of difficulty, the child should be provided with nourishment from other sources. Study the following remedies, and others Avhich may be indicated: URINARIA—NETTLE-RASH—HIVES. 867 Aconite. When a high state of febrile excitement prevails—a real synochal fever—this remedy alone will prove sufficient. Apis. When the child screams out suddenly, as if from stinging pains; sleepless nights; the eruption inclines to spread all over the child, or to become gangrenous. Arnica. When the disorder seems to result from bruises, or from rough handling of the umbilical cord. Belladonna. The eruption is very red, and extends in radii from a centre; jerking, tAvitching and moaning; the skin seems to be very hot; delirium; evidences of cerebral involvement. Bryonia. The inflamed parts seem indurated, pale and tender. Lips dry and parched. The least motion aggravates the suffering. Graphites. The eruption assumes a ATesicular appearance, or it exudes a transparent, glutinous fluid. Or the disease may assume a chronic form, and the child be ATery costive, with stools large and almost impossible to e\^acuatc Kali carb. The symptoms are aggravated at or about three o'clock in the morning. Lachesis. The affected part assumes a purplish hue; the patient talks deliriously on going to sleep; the erysipelas spreads from left to right. Lycopodium. Erysipelas Avhich spreads from the right to the left side of the body; the child gets worse every afternoon about four o'clock; red sand in the urine. Mercurius. In cases of syphilitic origin; salivation; thirst. Phosphoric ac. AVhen the disease seems to be produced by injury to the periosteum. The child appears to be perfectly apathetic. Pulsatilla. This remedy is often required when the disease appears about the buttocks, and inclines to spread all over the body. Rhus tox. The erysipelas spreads, with a red margin; vesicular erysipelas or any other form of the disease; the erysipelas spreads from the left to the right side of the body. Rhus rad. Phlegmonous erysipelas, spreading in the deeper tissues from beloAV upAvard. Ruta may be useful in erysipelas arising from wounds. Sulphur. Useful in cases of strongly-marked herpetic constitution. Urticaria—Nettle-r ash—Hives. The characteristics of this eruption upon the skin are found in the elevation of the patches, and in the burning, stinging nature of the pains in their dependence upon some recent disorder of the stomach 868 DISEASES OF INFANTS AND CHILDREN. or heat of the Aveather, in their usual sudden appearance and frequent equally sudden retrocession. By Dr. Condie urticaria is described as "an eruption of red inflamed patches (they may, however, be like white Avheals) irregularly distributed upon different and often dis- tant parts of the body; sometimes small in extent and number, at other times occupying a considerable portion of the skin." This eruption, both in external appearance and in the sensations which it occasions, remarkably resembles that produced by the application of stinging nettle, Urtica urens, to the skin. In such cases this medicine will be found capable of affording immediate and very sensible relief to the distress of the little patient. When the eruption seems to be principally brought out by the heat of summer, the Avarm bath will be found very useful in relieving the intense burning itching. In some instances the eruption disappears from one part of the body to reappear almost immediately in another and quite distant part. Most cases of urticaria are comparatively trifling and evanescent, but with some appear concomitant symptoms of more gravity, such as burning fever, diarrhoea, etc. These symptoms may be found enume- rated under the Ararious medicines. Mild cases of urticaria go by the common name of hives (Lichen urticatus, essera). Aconite. Much fever, restlessness and anxiety. Apis. Red, inflamed, raised patches, with burning, stinging pains; valuable and curative in: many of the severest cases. Arsenicum. Eruption worse at night, with much tossing. May be particularly suitable when the disorder is caused by unsuitable food. Belladonna. Red face and eyes; the eruption is also very red; moaning and starting, in sleep ; head hot. Bryonia. The eruption has been partially suppressed, so that it looks very pale; and there is oppression of the chest and difficult and rapid breathing. Calcarea C; The eruption is white and elevated quite above the skin; it is hard and seems to itch very much, causing the infant great uneasiness. Dulcamara. The eruption appears eArery time the babe is exposed to the damp cold air. Hepar. Catarrh of the chest, head, etc. accompanies the eruption. Nux v. Urticaria accompanied by gastric derangements, constipa- tion, etc. Pulsatilla. Urticaria with diarrhoea, Avorse at night. ECZEMA CAPITIS. 869 Rhust. AVhen rubbing the parts affected seems to increase the eruption. Sepia. The eruption makes its appearance in the cold air, and dis- appears in a warm room. Sulphur. The child appears to suffer from a suppression of the eruption. Urtica urens. When the eruption looks pale, like the stings of nettles, and requires to be rubbed all the time. Eczema Capitis—Crusta Lactea—Porrigo Larvalis. This eruption has been variously named by different authors, being termed Porrigo larvalis, Impetigo larvalis, Eczema impetiginodes, Tinea muciflua or granulata, etc Description and Symptoms.—This eruption is called larvalis when it invokes the face and covers it like a mask. It usually occurs during teething, and appears to be much connected with that process. It commonly commences on the forehead and cheeks by the breaking out of a number of small yelloAvish pustules, confluent and croAvded together upon a red surface. These pustules excite great itching, and are quickly broken, discharging a viscid fluid that subsequently con- cretes into thin, greenish-yellow scabs. The scabs are frequently rubbed off, but form again; fresh crops of pustules appear around the scabs, Avhich quickly extend to the scalp and even the face. When the scalp becomes engaged, the lymphatic glands at the back and sides of the neck enlarge and sometimes suppurate. The eruption appears upon or behind the ears, and patches will sometimes appear also upon the neck or breast. The discharge from the pustules is caught by the hair upon the head, and concretes into small, irregular, friable masses, Avhich may resemble the bruised yolk of a hard- boiled egg. The pustules, or achores, as the small superficial ulcera- tions which they form upon the skin are sometimes called, have an acuminated form, contain a straw-colored fluid, rest upon an in- flamed base and are succeeded by a thin, broAvn or yelloAvish scab. There is much irritation, heat of the scalp and itching; the dis- charge is very profuse, and Avith so much itching that it is rubbed off, leaving the surface raw and excoriated. Wherever this discharge is brought in contact with the skin—in the face, Avhere it trickles doAvn, upon the breast, Avhere it falls, and upon the backs of the hands, violently used by the child to rub Avith—it proves so acrid as to pro- duce there a fresh eruption. The same is true even of the arms of the nurse upon Avhich the child rests its head at night. 870 diseases of infants and children. The itching and burning acridity of the eruption and discharge are much Avorse at night. All external applications should be sedu- lously avoided, with the exception of tepid water or cold cream, Avhich has sometimes proved very grateful. The recession of the eruption should thus be carefully guarded against, since it might be followed by hydrocephalus or phthisis pulmonalis. Treatment.—Study the following remedies, and any others Avhich may more accurately cover the symptoms and conditions present. Indications will also be found among these medicines for various other forms of chronic cutaneous disease Avhich have not been partic- ularly described. Aconite. Where Ave find much fever, restlessness, anguish, the parts much inflamed, Aconite may remove every vestige of the complaint, if Ave Avait patiently upon its action as long as the improvement continues. Arsenicum. Eruption very dry and scaly; it even seems sometimes to cause the destruction of the hair in such places as are affected, leaving the scalp rough and dirty-looking. Baryta c. Particularly when the cervical, submaxillary and parotid glands become SAvollen and hard, as a concomitant. Bryonia. In cases complicated with some other affection which is always made Avorse by motion. The scalp is A7ery tender to the touch; the child cannot bear even a soft brush upon it. Calcarea c. In children of leucophlegmatic temperament, eruption with thick scales and yellow pus underneath. Stools having a chalky appearance. Sometimes the eruption appears in the form of a ring- Avorm. Chamomilla. When the child has been kept too warm; it is very fretful; must be carried more than usual. Cicuta V. Thick, whitish scurfs appear on the chin and upper lip; they secrete a dampness; sometimes scurfs from the nose. Clematis e. There appears a dark, burning miliary eruption, Avith violent itching; a dampness constantly exudes from this, which dries into scurfs as the disease spreads onAvard. Dulcamara. Indicated in thick broAvn herpetic crusts on the face, forehead, temples and chin, with reddish borders, bleeding when scratched. Graphites. The eruption exudes a transparent, glutinous fluid, Avhich causes the crusts to fall off, Avhen more form, to fall again in turn; meamvhile the eruption extends over a still larger surface. It appears PITYRIASIS—DANDRUFI 871 more particularly on the chin and behind the ears, although no por- tion of the surface is entirely exempt. Hepar. The eruption spreads by means of new pimples appearing just beyond the main disease, which finally become incorporated Avith those which came first. Jacea. Violently itching eruption, Avorse every night, and urine smelling like cat's urine. Lycopodium. AVhen the eruption has a bad smell and bleeds very easily; the disease seems to spread from the right side toAvard the left. Mercurius sol. Much salivation and scorbutic gums. Phytolacca dec. Moist, fearful itching, Avith little raw tubercles on scalp, face and arms. Psorinum. This remedy should be studied in seemingly intractable cases. Rhus t. A bright edge of inflammation surrounds eA7ery portion of the eruption, and there is much itching, particularly at night. Sarsaparilla. The entire base of the eruption is much inflamed; the child cries much and is very uneasy; also the crusts become detached in the open air, and the skin adjoining becomes chapped. Sepia. Eruption ATery moist, almost constantly discharging pus- like matter; the child often jerks its head to and fro, seemingly from the itching. Staphysagria. When the scales are yellow, moist, offensive and itch violently. Sulphur. Where the eruption extends more or less over the Avhole body, Avith much itching, although the main affection appears upon the head. Viola tri. Thick incrustations, pouring out a large quantity of thick yellow fluid, which agglutinates the hair. Pityriasis—Dandruff. This is a superficial, scurfy, bran-like eruption which appears sometimes on the forehead, but principally upon the hairy scalp of infants. The minute scales, exfoliation of the external cuticle, fall off, leaving temporarily a Avhite surface, to be replaced pres- ently by a similar scurfy formation; this process occurs again and again. Treatment.—Study the folloAving medicines, as well as those pre- viously mentioned under Eczema capitis. Be careful in cleansing the child's head not to try to Avash or rub off the dandruff. Cure the child, and that will disappear of itself. 872 diseases of infants and children. Arsenicum. Eruption dry and scaly; scurf or scales constantly falling off, often destroying the hair. Bryonia. When the scalp is extremely sensitive and the dandruff rough and uneven. Calcarea C The dandruff accumulates evenly all over the scalp, which is smooth and seems to become thickened. This remedy alone cures the most of such cases. Dulcamara. Marked aggravations in the child's general symptoms occur Avith every cool change in the weather. Graphites. Occasionally there is seen a transparent, glutinous exu- dation upon the scalp. Lycopodium. The head smells very badly. Mercurius. When there are general mercurial symptoms in con- nection with the dandruff. Psorinum, This remedy will sometimes be required when Sulphur or Calcarea fails to cure. Sepia. The dandruff seems to come in circles like ring-worm (annular herpes). Silicia. This remedy is indicated in cases similar to those cured by Calcarea, but the child has less of the leucophlegmatic temperament. Sulphur. General Sulphur symptoms with the dandruff. N-evi Materni—Mother's Marks—Moles. These spots are congenital, as their name indicates; and they are not only hardly ever amenable to surgical treatment, but have in many cases been rendered much worse by such injudicious inter- ference. Some remarkable naevi reproduce upon the skin of the child Avhile yTet unborn the vivid impression made upon the mind of the mother. Another and more profound influence of the same.kind, or one exerted in an earlier stage of pregnancy, results in actual deformities and monstrosities. Naevi materni may be arranged in three distinct classes, in the order of their gravity : I. 3Ioles, the most common of all, Avhose character and harmless- ness are well knoAvn, and which are generally attributed to some altera- tion in the structure of the rete mucosum. II. Venous Aneurisms—Anastomosis of Venous Capillaries.—These form a dark-red circumscribed .stain, Avhich generally appears on one side of the face, and is sometimes of considerable extent. These " marks," which appear to be simple dilatations of the sub-cuticular capillary vessels, may increase in extent till puberty, and then remain stationary. N^EVI MATERNI—MOTHER'S MARKS—MOLES. 873 III. Aneurisms and Dilatations of the Arterial Capillaries.—These form the most important of the naevi; they are apt to enlarge in after- life, especially when stimulated by external irritation, and they may give rise to dangerous haemorrhage if improperly meddled Avith. They form slightly elevated spots, Avith Avell-defined margin and a granular surface, which consists of an erectile vascular tissue. These granulated tumors, raised above the skin, may in fact be constituted of venous or of arterial vessels. • In the former case theyr may be of a dark-blue or livid color; in the latter, of a brighter red. Treatment.—The folloAving remedies should be carefully studied, in order to find the simile in each case: this being found, it should be given sufficiently high and at long intervals, in order to remove as rapidly as possible from the system the morbid condition Avhich sus- tains these irregularities of the circulation, and to enable nature to remedy the deficiency in structural organization from Avhich perhaps they originally sprung. If the arterial capillaries are involved: Belladonna. AVill be indicated by red radii extending from the centre. Calcarea c. In leucophlegmatic temperaments. Lycopodium. In hypertrophied capillary tumors, both Arenous and arterial. If the venous capillaries are involved: Carbo veg. Particularly when the slightest irritation causes free haemorrhage. Phosphorus. "Small wounds bleed much;" this may be either venous or arterial. Study also Nux v., Sulphur. Encysted Tumors.—For these tumors study the constitutional and concomitant symptoms and conditions of the patient, and select that remedy Avhich is homoeopathic thereto. The most frequently indicated are: Baryta carb., Calcarea carb., Hepar, Graph- ites, Phosphorus, Silicia and Sulphur. Warts, AVens.—In the treatment of these excrescences the same plan should be folloAved as in encysted tumors, and Avill be found efficient. Amongst the remedies that Avill be found to be most fre- quently called for are: Calcarea carb., Causticum, Dulcamara, Lycopodium, Nitric acid, Psorinum, Rhus tox., Sepia, Sulphur and Thuya. 874 diseases of infants and children. Cephalhematoma—Sanguineous Tumor of the Head. Of the sanguineous tumors sometimes developed upon the pericra- nium and bones of the head of new-born children, the writer has met Avith quite a number, and he has ahvays been successful in curing them in a few days Avith a single dose of Calcarea c, high. Hartman recommends Arnica or Rhus30. If there should result an ichorous discharge and caries of the bone and prostration, the same author prescribes China, and afterward Silicia. But in my opinion Calcarea c, given at the first, will save any further trouble. Ecchymoses on the surface of the scalp of young infants are the result of contusion of the cranium in parturition. They disappear by absorption, but their removal may be hastened by the application of Arnica lotion. Ranula. This swelling under the tongue consists in an enlargement of the sublingual bursae mucosae, or of a dilatation of Wharton's duct from previous obstruction. The cyst contains usually a limpid or thick albuminous fluid, although there have been instances in which the contents were more solid concretions. The puncture of the tumor, although evacuating the contents, does no good, and should in no case be resorted to. The disease takes its rise in some scrofulous (or pos- sibly syphilitic) dyscrasia, and can only be radically cured by remedies capable of removing such taint from the system. Ambra g. Is recommended by Jahr. Calcarea c. Should ahvays be studied in connection with cases of this kind occurring in leucophlegmatic temperaments. Mercurius. Much salivation. Suspicion of a syphilitic taint. Natrum mur. In the opinion of Hartman deserves the preference over Ambra. Rhus t. Has cured several cases under my care—a greater number, in fact, than any other remedy. Sulphur. May also be studied when it appears to correspond to the disposition of the patient and to the cause of the disease. Thuya. AA7hen the tumor is decidedly of a blue color or compli- cated Avith syphilis. Intertrigo or Chafing. Excoriation, soreness or chafing frequently occurs in those parts of the skin of infants which are either rubbed together in the natural INTERTRIGO OR CHAFING. 875 movements of the limbs, or are liable to be fretted by friction of the diaper or other articles of clothing. Thus, the groins, the surfaces between the genitals and the thighs, betAveen the nates, behind the ears, the axillae and even the folds of the neck in fleshy children, may become the seat of these excoriations. Such tenderness of the skin is due in the first instance, in great part at least, to a psoric dyscrasia in the constitution, and for its com- plete j remo\ral it will require, therefore, a suitable antipsoric remedy. But this original disposition to such excoriation will be greatly in- creased by Avant of proper attention to the state of the skin, and by neglecting to remove as soon as possible all those excretions from the bladder and bowels, and from the skin itself, Avhich alone are capable of originating such irritations and of causing them to proceed to ulceration. Very fat children are particularly liable to be troubled in this manner. The use of the gum-cloth diaper will also produce chafing, pustular eruptions and other infantile troubles. Physicians should caution mothers against its use. Treatment.—Directly contrary to the general custom, no poAvder or other external application should ever be used to keep the skin from chafing. It will be far better to pay strict attention to cleanliness, to wash clean and dry the skin carefully and as perfectly as possible with soft toAvels, never using the first particle of powder. If,the parts become very sore, omit Avashing entirely; use no external ap- plication of any sort Avhate\7er, not even dry linen; but with the great- est care select the most appropriate medicines. Calcarea c. Will be suitable in leucophlegmatic constitutions; in very fat and fleshy infants. Carbo V. If there is much rawness of the parts opposed, and a gen- eral disposition to excoriation, particularly in very AArarm AAreather. Chamomilla. If the child is very irritable, cries much, and requires to be carried continually up and doAvn the room. Graphites. The affected parts discharge a quantity of transparent glutinous fluid, especially behind the ears and betAveen the thighs. Hepar. The intertrigo seems to extend by means of pimples Avhich arise just beyond the raAV surface; these become involved in the ex- coriation, and neAv pimples appear a little farther beyond. Lycopodium. The excoriation becomes offensive and bleeds much; worse after four p. m., and better after eight in the evening. Mercurius sol. The excoriation is much Avorse at night; it is very raAV and bloody; the child does not sleep much. 876 DISEASES OF INFANTS AND CHILDREN. Pulsatilla or Ignatia may be indicated and are recommended Avhere much chamomile tea has been taken by the nurse. Sepia. The skin is very delicate; the least injury tends to ulcera- tion. Sulphur. There is much itching of the skin in general and of the parts affected. Induration of the Cellular Tissue. This is more common in foundling hospitals than in private prac- tice. It chiefly attacks the children of persons suffering from impov- erished nutrition, and usually appears in the first five or ten days after birth. The infants in Avhora the induration of the cellular tissue is developed are Aveakly and often premature, and the difficulty is thought to result from imperfect expansion—Atelectasis pulmonum—or from subsequent collapse of the lungs. In many instances a livid redness of the Avhole surface is obvious from birth, but the appearance of a circumscribed hard spot on one or the other extremity, or on some prominent part of the face, as the end of the chin or the cheek-bone, is the first sign of the commencement of this affection. Other spots of a similar kind are soon discovered on different parts of the surface, and the body generally and the hardened spots in particular are found to present a temperature much beloAV the natural warmth of the body. "The skin which covers the diseased part is slightly rose-colored, or purple, violet, or livid. If the disease runs a rapid course the tem- perature of the body decreases rapidly, the pulse is scarcely percepti- ble, the breathing becomes more and more labored, the child's cries diminish and gradually cease altogether; the face becomes livid, and the little ones die as of suffocation, generally on the third day. Some- times the disease is more chronic, and passes off again from the fourth to the eighth day, but these cases are exceedingly rare, and under the old treatment most children die in a feAv days."—Jalir. In this country, as in Great Britain, this disease is comparatively rare; its occurrence in the ill-ventilated Avards of foundling hospitals in large cities on the Continent, especially in Paris, is more common. Jahr, Avho seems to have had better opportunity for observing this disease than any other writer of our school, affirms that it is readily cured under homoeopathic treatment, and he recommends Aconite, Bryonia and Sulphur, to which may be added Calcarea c, Conium and Dulcamara. syphilis neonatorum. 877 Induration and Swelling of the Breasts. The breasts of female infants are liable to SAvelling, inflammation and induration, or suppuration, in consequence of the absurd practice in vogue Avith some nurses of squeezing them, on pretence that unless the milk is squeezed out of them they Avill subsequently prove useless for lactation. Such notions, remnants of old wives' fables and the fruits of erroneous AneAA'S in physiology, cannot be too strongly discountenanced. But unless the physician is on the Avateh such things may be done. Such a course of procedure as squeezing the child's breast, should it result in suppuration, as is not unlikely, may, by causing structural disorganization of the gland, produce the very mischief it was in- tended to prevent. In these cases Hepar or Silicia, or even Phos- phorus, may be needed. But the disorder may arise without any- apparent cause, such as mechanical injury, and in such instances is doubtless due to constitutional taint thus manifesting itself; just as Ave see, in after life, when the woman comes to the process of lacta- tion, sore nipples and a gathered breast in spite of the utmost care and the most skillful medication—the cropping out of the latent psora. Treatment.—The disorder . must be treated with reference to its cause and to the totality of the symptoms present. Aconite. If there be much fever at the outset, this remedy may dispel the whole difficulty. Arnica. If the breasts are merely hard, with no apparent inflam- mation, or if the redness has not yet appeared. Belladonna. The inflammation is of an erysipelatous kind; it runs in radii as it extends to the adjacent parts. Bryonia. The breasts are quite hard, and of a pale red color. Calcarea c. This remedy will be found indicated in some cases of leucophlegmatic temperament, with very large fontanelles, light, fair complexion ; breasts hard, but not red. Chamomilla. The child is very fretful; it must be carried in order to be appeased ; the breasts are very tender to the touch. Hepar. AVill be useful if matter or pus has already formed. Silicia. This remedy will be needed sometimes after Hepar, par- ticularly to heal the ulceration. Syphilis Neonatorum. The syphilis of new-born infants requires the nicest care for its management. The following remedies are mentioned because they 878 diseases of infants and children. are most frequently called for in the treatment of this saddening affection; but the practitioner should gather together the symptoms and conditions which make up the totality of the case, and select a remedy in accordance therewith; the remedy being well chosen, its action should be continued, and not interfered with by another remedy. Aurum. If the nasal or palate bones are affected. Ozaena syph- ilitica. China or Phosph. acid. AVhen the child appears very Aveak, and has great coldness of the skin. Hepar. This remedy will be found useful Avhen the mother has been allopathically treated Avith poisonous doses of Mercury. Mercurius. When chancrous ulcers appear about the child. Nitric acid. AVhen the child has aphthae or ptyalism. Syphilitic Ophthalmia.—In this affection may be indicated Mercurius, Thuya, Nitric acid, Carbo veget. and Phytolacca dec. Study also the remedies under Inflammation of the Eyes, Syphilitic Cutaneous Affections.—These various forms of eruptive disease require, according to their accompanying symptoms and conditions, Nitric acid, Hepar, Thuya, Sulphur, Phosph. acid, Dulcamara and Phytolacca dec. Condylomata—Figwarts.—In their severer form these excres- cences present a red surface and hard base, and discharge an acrid, purulent, contagious matter. Mercurius sol. AATien there are general mercurial symptoms. Nitric acid. This remedy may be indicated in some cases where there is evidence of mercurial influence in the constitution. Thuya. Indicated in a majority of cases. Phytolacca dec. Itch fearfully. Comedones—Acne Punctata. These appear like little black points, in consequence of obstruction and enlargement of sebaceous follicles on the nose, chin or forehead. The folloAving remedies may be studied in such cases: Eugenia jambos, Bryonia, Calcarea c, Natrum m., Graph- ites, Sabina, Sulphur and Thuya. cyanosis. 879 CHAPTEE XXXVIII. DISEASES OF CHILDREN—CONTINUED. Cyanosis. THE patency of the foramen ovale, or imperfect closure at birth of the opening through Avhich the blood in the foetal circulation had passed directly from the right heart to the left, was formerly sup- posed to occasion a partial mixture of the \Tenous blood with the arte- rial, and hence the cyanosis or blue disease. But more recent research has shown that this diseased condition may be due to a great variety of lesions of the circulatory apparatus, especially of the heart and principal vessels, such as obstruction of the pulmonary artery, mal- formation of the heart cavities, some of which are Avanting; transposi- tion of the pulmonary artery and the aorta, etc. A cyanotic condition may likewise result from any cause that interferes with or prevents the proper oxygenation of the blood ; as, for instance, in atelectasis pul- monum. The cyanotic hue is frequently seen in croup, laryngismus stridulus and hooping cough. In cases of cyanosis there is a general bluish or blue color $f the integuments, but it is principally marked in situations where the skin is delicate and highly vascular, and in the extremities. The blue tint, when limited to certain spots, is a result of local congestion. A transient blueness of the skin has also been noticed in a few cases in various parts of the surface, but its internal cause is unknoAvn.* The term chronic cyanosis is used by Virchow to express the gen- eral venous congestion Avhich is consequent upon chronic affections of the heart and lungs. Acute cyanosis, he states, occurs in acute affec- tions of the lungs; as, for example, in pertussis. This eminent patho- logist affirms, contrary to the opinion formerly entertained, as stated above, that cyanosis, even when produced by congenital malformation of the heart, does not arise from a commingling of arterial and venous blood, but from obstructions to the venous circulation.! This, how- ever Avould appear to depend upon the occasioning cause; in some instances, doubtless, it is due to venous congestion, while in others there is a mixture of the venous with the arterial blood; and, again, in a third class of cases there is both venous obstruction and admix- ture of venous and arterial blood. * Kokitansky, iii., p. 71. t Cellular Pathohay, p. 372. 880 DISEASES OF INFANTS AND CHILDREN. This affection generally destroys life at an early period, but some- times the adult age may be reached, Avith some distress and impaired health. A very large proportion, hoAvever, die within a feAv weeks or months, or at most Avithin a year or two after birth; some such dis- ease as hooping cough or one of the eruptive fevers attacking the cya- notic patient is very7 badly borne, and is apt to terminate fatally. Treatment.—An important part of the treatment of cyanosis is hy- gienic Good nutritious food, plenty of fresh air, and in older chil- dren moderate exercise, will do much to correct the disordered circu- lation. In cyanotic infants the position recommended under laryngismus stridulus may be resorted to, because the action of the heart may be more free and unincumbered if the child lies upon its right side, with its trunk elevated at an angle of about 45°. One of the following medicaments may prove useful. Consult also the indications for remedies under Laryngismus stridulus, Croup and Atelectasis pulmonum. Aconite. If at any time there should be much vascular excitement, heat or restlessness, this remedy may be needed; if so, let it act as long as the improvement continues, and it may entirely cure. Arnica. In cases Avhere there is haemorrhage from the- nose and mouth, and great strangling and suffocation. The case seems almost hopeless. In such cases a feAv doses of Arnica will do much good. Arsenicum. The symptoms are much aggraA7ated by the least exer- cise. Much emaciation; cold SAveat; great debility. Calcarea C This remedy may be indicated in leucophlegmatic chil- dren, with large, open fontanelles; the head perspires very much. Carbo v. The veins stand out Arery full, and are remarkably blue. China. In some collapsed stages, with Avaxy paleness and coldness of the skin. Digitalis. The child can hardly be turned or its position changed without causing fainting, or nearly so, and almost always causing vomiting. The eyelids, lips, tongue and nails become very blue; pulse unequal, or very slow. Lachesis. When the suffocating spells and the increased blueness become Avorse after sleeping. Great tenderness of all the flesh; it is exceedingly difficult to handle the child at all; the least touch seems to hurt it, and to leave a deeper blueness, like a bruise. Laurocerasus. This remedy, in my practice, has cured permanently some very bad cases of this disorder, with the following indications: A little exercise produces gasping for breath and increased blueness. ICTERUS NEONATORUM—JAUNDICE. 881 The ends of the fingers and toes are knobby, and larger than any portion of these extremities; the child is better when lying still. Phosphorus. In very tall and slim children, Avith much oppression of the respiration and swelling of the feet. Secale C. In very thin, scrawny children with shriveled skin; especially Avhen there are spasmodic tAvitchings, sudden cries, fever- ishness, etc Sulphur. This remedy Avill be found useful in many cases charac- terized by the real sulphur constitution. Icterus Neonatorum—Jaundice. The jaundice of neAV-born babes is scarcely to be considered an actual and distinct disease. It mayT indeed be caused by undue and prolonged exposure to cold of the tender and unprotected body of the infant immediately after birth. Often, hoAvever, it is the result of a more interior, physiological shock, Avhich the system receives in changing from intra-uterine life to independent existence. From the second to the fourth day after birth the entire surface of the skin, and also of the conjunctiva, may assume the yellow hue peculiar to this affection; this, continuing tAvo or three days, gradually fades away, until by the eighth or tenth day the natural, rosy-Avhite color returns. The absence of other morbid phenomena, and the frequency of icterus among neAv-born babes, proves that this is not really a state of disease. Such at least is the opinion generally adopted, confirmed by the transitory nature of the affection itself. Seemingly it results from a slight interruption in the physiological action of the liver, or from the temporary hesitation Avhich this organ experiences in adapting itself to the neAv order of things in the independent state of existence; for it may result from a temporary disturbance in the hepatic portion of the fcetal circulation from the same cause; and this condition Avill of course be particularly aggravated, as already stated, by exposure of the surface of the body to the cold air. The small amount of exercise that pregnant Avomen take, and the costive- ness that so frequently attends their condition, may have some influence in causing Icterus gravidarum, and in consequence in pre- disposing to the same condition in the new-born infant. AAratson accounts for some supposed cases of this disorder in the folloAving manner: " The Icterus neonatorum occurs, they say, a few days after birth • is not attended Avith any suffering or obvious disturbance of the bodily functions, and soon disappears. Noav there seems reason 56 882 DISEASES OF INFANTS AND CHILDREN. to believe that this is not icterus at all, and has no relation to the biliary organs. The surface of the infant at its birth is frequently of a deep red, from hyperaemia or congestion of blood, presenting a condition which falls little short of a mild but universal bruise. By degrees the redness fades, as bruises fade, through shades of yellow into a genuine flesh-color. Such, I am assured by those Avho are more conversant with these matters than myself, is the pathology of the Icterus infantum." It has been claimed that, by alloAving the effete blood, contained within the body of the child at the time of severing the umbilical cord after birth, to escape from the vessels—not ligating the cord— infantile jaundice Avill not occur, or rather is not nearly so likely to occur. We believe that non-ligation of the funis has some of the effect claimed for it in this direction, but there are not sufficient data as yet upon which to found an opinion. Treatment.—If anything should be required, Avhich is not ahvays the case, a single dose of Aconite will in the majority of cases set all right. Should the case prove a true jaundice, and be complicated with constipation or other morbid symptoms, the remedies appended to this article should be attentively studied. Cases sometimes occur in Avhich, from the unhealthy nature of the mother's milk, it proves so poisonous as to derange the liver of the babe, as Avell as its stomach and boAvels. In such cases, however, by administering the proper homoeopathic remedy, this disordered condition in the mother will be overcome, and the secretion of good, healthy milk will be secured. Should the mother become seriously ill, it may become necessary to remove the child from the breast, and have it committed to another nurse, or brought up by hand upon such diet as has previously been recommended in this work. Care must be taken to ascertain posi- thTely that it is the milk which disagrees with the child, as very often this appears to be the case Avhen not so in reality. Then the child will, of course, require treatment. Aconite. The infant is hot, restless, sleepless and in distress. Arsenicum. Undigested, light-colored, offensive stools; dry scald- head ; yellow skin. Bryonia. Vomiting of food soon after taking it; the child Avishes to keep perfectly still. Skin yellow. Calcarea c. Yellowness of the skin; other symptoms similar to those put doAvn for this medicine under Dentition (\vhich see). Chamomilla. A cold seems to have been the cause of the difficulty; HEPATITIS—CHRONIC DISEASE OF THE LIVER. 883 light-colored and offensive stools; the child is very fretful; wishes to be carried. China. There is tenderness in the region of the liver; distension of the abdomen. Undigested and painless stools in large quantity. Colocynth. Much colic, with writhing, twisting and doubling up. Digitalis. The stools are almost Avhite; scanty brown urine; fre- quent and empty retching; much debility. Dulcamara. The child gets Avorse at every cool change of the weather. Hepar. In children Avith dry, pimply eruptions. Ignatia. The child is inclined to spasms as a prominent symptom; frequent sighing. Ipecacuanha. Almost constant nausea. Mercurius sol. General mercurial symptoms, such as salivation, SAvelling of the glands, slimy stools, abundant and strong-smelling urine. Nitric acid. Urine scanty and strong-smelling; very restless after twelve o'clock at night. Nux V. Constipation; sleeping toward morning; colic; the nurse is a high-liver or takes much coffee. Pulsatilla. Entire loss of appetite; vomiting of mucus; no thirst; very changeable in appearance; worse toward evening. Sulphur. The child Avakens often; it inclines to intertrigo and to general papular eruptions. Hepatitis—Chronic Disease of the Liver. Hepatitis, or acute inflammation of the liver, may be developed, especially in those constitutionally predisposed thereto, in connection Avith derangement in other portions of the digestive apparatus, or it may arise and assume the intermittent form in consequence of the miasm Avhich develops chills and fever. Fever, restlessness, loss of appetite, constant nausea, constipation, and a yellowness of the scle- rotica and skin, constitute some of the principal symptoms of this condition. Palpation will discover enlargement and tenderness in the hepatic region; young infants will shrink from the pressure and cry. Chronic Disease of the Liver may be the result of the long- continued influence which causes the acute form. Or the liver may become enlarged by fatty deposit in its substance—fatty enlargement or degeneration—or it may become the subject of albuminoid enlarge- 884 diseases of infants and children. ment. Such chronic diseases of the liver Avill ahvays be found asso- ciated with, and measurably dependent upon, corresponding disorder in the stomach and intestines, and especially the glandular and tuber- cular diseases of the latter organs. Chills and Fever—Intermittent Fever, may occur in young children, either in connection with lh?er complaints or independently of them, particularly after undue exposure to the night air in mias- matic regions. Under favorable circumstances these affections AA'ill be speedily removed by a single dose of the remedy (not too low) which is suited to all the symptoms of the chill and the fever, to the concomitant symptoms, such as thirst, pains in limbs, perspiration, etc., and to the attendant conditions, such as the aggravations or amelioration of time, place, circumstances, etc. Treatment.—The folloAving remedies Avill be found adapted to meet any of the above-mentioned conditions: Aconite. Much fever; dry heat; restlessness and anguish. Belladonna. Much moaning. Can't bear to be moved. Short breath; flushed face; red eyes ; if able to explain its sufferings, there will be much pain in the right shoulder complained of. Bryonia. Very short breath; cannot bear the least motion ; dry lips and mouth; stools dark, dry and hard as if burnt. Calcarea c. Leucophlegmatic temperament; perspiration about the head; stools like chalk. China. The region of the liver is swollen and hard; much flatu- lency; undigested stool. Digitalis. Stools very light, almost Avhite; much debility; nausea ; sIoav or irregular pulse. Lachesis. Always Avorse after sleeping; awakens in distress. Lycopodium. Much flatulency and rattling in the abdomen; this is a very characteristic symptom of this remedy in this as also in other forms of disease. Mercurius. Tenderness of the abdomen; it is hard and tense. Mucous stools, or stools too light and very offensive. Salivation. Strong-smelling urine. Nux v. Constipation of large difficult stools; no appetite; sleep- lessness, particularly after three A. m. PulsatiUa. In children of mild, gentle dispositions; pale face; blonde hair and blue eyes ; no appetite. Or the case may be clearly traced to some gastric disturbance from eating rich or fat food. SCROFULA. 885 Sulphur. The patient partially recovers, and then relapses; or there is a tendency of the patient to get Avorse, Avithout any previous improvement. Scrofula. Scrofula is a general name for various forms of disease arising in children of a psoric constitution. In the previous chapters we have seen hoAV persons of a strumous or scrofulous or psoric constitution are peculiarly liable to suffer severely from the different disorders inci- dent to infancy and childhood—Iioav children of this class suffer far more than others in dentition and in all the accompanying disorders of the gastro-intestinal system, in those Avhich affect in various ways the respiratory mucous membrane and adjacent organs, and finally in the eruptive fevers of all kinds. Many of the forms of cutaneous disease to Avhich Ave have referred are but manifestations of the same psoric element in the system, and as such are properly as well as popularly termed " scrofulous humors." In different families this psoric or " scrofulous " diathesis tends to develop itself in different ways, and the same is true of the different ages of life. Thus, not to repeat what has already been said of other external developments of scrofula, the same element in early child- hood affects the glandular system Avhich in other families, or in other individuals of the same families, and even in the same individuals at different periods of life, results in tuberculization. " Scrofulous children are broadly divisible into two classes—those of dark, dusky, coarse features, heavy and sluggish in their move- ments, intellectually dull; and those of bright rosy complexion, fair, Avith fine skin and hair, highly nervous, susceptible, sharp and precocious. Both are easily fatigued by exertion or excitement; soon take cold; the stomach and bowels are easily deranged; the appetite is fitful and capricious; they rapidly lose flesh; soon get pasty and flabby, and they do not soon shake off any ailment of which they are the subjects." The term scrofula as used in this section refers principally to disorders of the glandular system. The cervical glands are those most frequently affected—enlarged and ulcerated. Sometimes these produce deformity similar to goitre, but show no disposition to sup- purate. The corresponding disorder of the mesenteric glands con- stitutes Tabes mesenteric^, and their ulceration " consumption of the bowels." The causes of scrofula—that is, of this especial development of the 886 DISEASES OF INFANTS AND CHILDREN. inherited psoric diathesis—are to be found in scanty, unsuitable and too uniform food; in defective ventilation; in deprivation of light; in over-exertion, and in exposure to cold and dampness. Young infants imbibe the disease from their nurses' milk, or have it developed in them by other and unsuitable substitutes for it. Scrofula is, however, a very general term, and among Avhat may be properly termed scrof- ulous diseases may be mentioned a large part of those to Avhich the in- fantile life is heir. Some of these, such as Rachitis, Hydrocephalus, Spasms, etc., will be more particularly described. Arsenicum. Great emaciation; waxy paleness; great fatigue on the least exertion; nocturnal restlessness. Can hardly go up stairs. Scrofulous atrophy. Baryta C Painful glandular swellings and indurations in the neck or near the articulations of the lower jaAV. The mesenteric glands be- come affected, and atrophy commences to show itself. Belladonna. Bleeding of the nose; distended abdomen; the throat frequently becomes sore; the eyes are often inflamed; bloated face; no good sleep; hears all that is going on at night. Calcarea c. Head large; fontanelles open, or are unusually sIoav in closing; much perspiration about the head. Sympathetic swelling in the neck and in other places; enlargement of the abdomen. Cina. I deem it not a little remarkable, and a fact that disproves many theories of old-school origin, that Cina1000 so often cures scrofu- losis in children Avho are continually boring Avith the finger in the nose, Avho are cross and exceedingly unamiable, Avhose urine turns milky on standing, Avhom nothing pleases, Avho are constantly turn- ing and twisting at night, with frequent calls for water, and Avho are often ravenous for food. Hepar. Is also suitable in many cases, as indeed are many other remedies, according to their characteristics. Compare Rachitis. Iodine. This remedy is very frequently indicated when there are glandular swellings. Compare all the symptoms. Bromine is closely allied to Iodine. Mercurius sol. Cold and clammy SAveat upon the lower extremities at night. Night SAveats; swollen and inflamed glands, with a tend- ency to ulceration. Salivation. Scorbutic gums. All the symptoms are always Avorse in cold, damp Aveather. Mezereum. May be indicated Avhen there is constant excoriation of the nose, and often of the throat also. Psorinum. In many respects this remedy is similar to Sulphur. RACHITIS—RICKETS. 887 Silicia. Useful in children with large bellies, weak ankles, much perspiration about the head, and inclination to uncover. Sulphur. In children who are exceedingly sensitive to the open air or Avind; they do not like to be bathed, to touch water, to have their hair combed or brushed, or made to look nice. Skin rough and scaly. Burning heat in the soles of the feet; short naps of sleep at night; papular eruptions. Rachitis—Rickets. Scrofulous disease affecting the bones—called rickets, curvature of the bones—is an affection of early childhood, being noticed usually toAvard the end of the first dentition, if not before. It presents itself in a great variety of degrees and forms. The disorder seems to con- sist in an excessive preparation for the process of ossification, which, from deficiency of assimilative force, fails to be completed. The bones of the skull seem to be the first affected, and Avith this is invariably associated some enlargement of the ends of the long bones. With this species of deformity of particular bones may also be found in some cases a general deformity of shape, as seen in those Avho are pigeon- breasted or affected Avith curvature of the spine; and in fact some of these latter deformities of general structure naturally grow out of the first-mentioned deviations in particular osseous formation. Besides these direct deformities there are others, such as bending or curving of particular bones, which arise indeed from mechanical pressure, from gravity or from muscular contraction, but Avhich are in reality due to softness or incomplete osseous development in the bones themselves. The one general and sufficient cause for the innumerable variety of deformities AA'hich may be described under the head of Rachitis, in- cluding very slow development of the teeth, inability to Avalk, easy fracture and spontaneous luxation of the bones, is to be found in im- perfect nutrition and unhealthy food, deA'eloping in these forms some dyscrasia inherent in the system, some Aveakness inherited from parents. " The softening of the bones is fully accounted for by the diminu- tion in the proportion of their calcareous salts. Thus, Jenner states as the mean of the analysis of several observers that the bones of healthy children yield about thirty-seven parts of organic and sixty-three of inorganic matters; whereas those of rickety children yield about. seA^enty-nine parts of organic to tAventy-one parts of inorganic mat- ters. In addition to this, it Avould appear that the inorganic matters themselves undergo change." 888 DISEASES OF INFANTS AND CHILDREN. The characteristic deformities of the bones are not produced at once, but are preceded, for a longer or shorter period, by a general cachectic condition of the system. This sIioavs itself in various dis- orders of the digestive system, such as capricious or voracious appe- tite ; diarrhoea; general sore feeling of the body, so that the child dislikes to be touched or moved; profuse SAveating about the head during sleep or after every exertion; heat and dryness of the skin, the slightest covering being oppressive. In some cases there is a pre- cocity of intellect, while in others there is more or less mental dullness. After these symptoms haA'e lasted for some time the osseous system shows that it is being affected, and the various deformities of the bones present themselves, differing greatly in degree in different cases—such as bending of the femora and deformities of the head, spine, thorax and pelvis. Rickets is not a fatal disease per se, but the condition of system Avhich leads to it, and the depressing effect upon the vitality of the child produced by the rachitic condition, leaA7e it liable to the super- vention, in a severe form, of some secondary disease, such as chronic hydrocephalus, convulsions, laryngismus stridulus, and (particularly where the thorax is badly implicated) to diseases of the lungs and air- passages. Treatment.—In no disease is it more important that the patient should have nutritious and easily digestible food than in rickets. If it be suspected that the mother's milk is not of suitable quality for the infant, it should be provided with a Avet-nurse, or fed upon good coav's milk where that is not possible. The diet of larger children should contain a large proportion of animal food. If the teeth are defective, the food taken by the child should be chopped very finely. Plenty of pure, fresh air is also essential. Select one of the folloAving remedies, or such other as may be indicated: Baryta c. Will be found suitable to many cases in dAvarfish children, i. e., in those of imperfect development. Bryonia. Lips dry and parched; vomiting immediately after eating; constipation, with stools dry and hard, as if burnt. Wishes to keep very quiet. Calcarea C In those children whose temperament, figure and symp- toms correspond to this remedy it may be repeated once a Aveek or month, according as the condition of the patient may require. Ipecacuanha. Indicated by constant nausea. OPHTHALMIA. 889 Nux v. Sleepless, particularly toward morning; constipation, large, difficult stools. Phosphoric acid. AVhen there is a pale, sickly look; great debility; painless diarrhoea; tottering gait. Ruta graveolens. Tottering gait, as if the thighs were weak, and there is much pain in them in walking. Silicia. Much like Calcarea, only the temperament is less strongly marked and leucophlegmatic, and the osseous system is better de- veloped. Staphysagria. AVhen the teeth turn black and crumble, with the progress of the disease, into little fragments. Sulphur. Indicated when the child is subject to intertrigo, pimples, short naps at night, etc. Veratrum. In cases complicated Avith diarrhoea or constipation, Avith cold sweat on the forehead. Ophthalmia. NeAv-born infants and older children are subject to purulent ophthal- mia, or inflammation of the eyes. The disorder is always serious, for, unless speedily cured—Avhich it is not always easy to effect—the inflammation will result in opacity of the cornea, impaired vision, or even total blindness. And in neglected cases, especially those in which the necessary attention to cleanliness has not been enforced, ulceration of the cornea may take place, and the contents of the eye- ball be discharged, causing permanent deformity as Avell as hopeless blindness. " The first indication of the disease is generally the eyelids becoming glued together during the night, with swelling and redness externally. AVhen the lid is raised there occurs a gush of tears, and its conjunc- tiva is found to be uniformly red, and slightly thickened, and covered often Avith a purulent, tenacious, transparent coating. As the disease proceeds the lids become more constantly agglutinated, and an in- creased secretion from the surface of the inflamed conjunctiATa takes place of a thick, purulent matter, a portion of Avhich exudes from between the lids, but the greater part is retained, causing a considera- ble bulging of the palpebrae, the integuments of Avhich assume a dark red hue."—Condie. With the continuance of the disease the discharge becomes still more copious, and must be constantly wiped aAvay from the exterior surface of the lids. Gonorrheal and syphilitic ophthalmia are the most rapidly destruc- tive, and their treatment Avill require all the skill, caution and dis- 890 DISEASES OF INFANTS AND CHILDREN. cretion of the physician, Avho must, hoAvever, avoid Avounding the mother's feelings by suspicions, the statement of Avhich, Avhether they are justly founded or not, can afford little help in prescribing. So many cases of purulent ophthalmia occur in babes Avhose mothers are affected with leucorrhcea that we must conclude a discharge from the genitals of the mother is a very frequent cause of purulent oph- thalmia in new-born infants. The matters discharged are very apt to be highly contagious, and it is but a dictate of prudence always to consider them so. Scrofulous ophthalmia is one of the developments of the scrofulous diathesis. It generally attacks both eyes, going from one to the other. There is intense photophobia Avith this form of the disease, and the symptoms are consequently mitigated as night comes on, and aggra- vated during the day. Pressure upon the eyeballs, which the child often resorts to, seems to afford some relief. It is a disease very diffi- cult to eradicate, and requires the most patient and accurate treatment to bring about a happy result. Treatment.—The most scrupulous attention should be paid to clean- liness of the affected organs and of the whole body; let the tempera- ture of the room be made perfectly7 comfortable; avoid fatiguing the inflamed eyes with too much light; carefully look after the health of the mother or nurse, and no less carefully select the remedy best suited to all the symptoms, circumstances and conditions. Aconite. AVhere from exposure to cold air there arises a high state of inflammation; general fever, with restlessness, distress and sleeplessness. Belladonna. The eyes look very red; cannot bear the light, opening the eyes only Avhen in a dark place. Bleeding from the lids. Calcarea c. In leucophlegmatic temperaments; excessive secretion of mucus in the eyes. Chamomilla. Discharge of blood from the eyes; the lids are closed in the morning. If the inflammation be caused by exposure to cold, damp atmosphere, or if aggravated by every cold change in the weather. Euphrasia. Great lachrymation, almost continuous. Hepar. Little pimples surround the inflamed eyre. Ignatia. Inflammation of the eyes, something like that of Belladonna, but not so intense, with much sighing. Lachesis. The eyes are always Avorse for a while after sleeping. Mercurius. The eyelids are much swollen, and contain, underneath PAROTITIS—MUMPS. 891 them, much purulent matter, which pours out in quantities on opening the eyes. Compare Nitric acid. Nux V. The eyes are ahvays worse in the morning. Pulsatilla. The eyes are always Avorse toAvard evening; better in open air. Rhus t. The lids are principally affected; they look red and fiery, like erysipelas, and seem to itch much; protruding conjunctiva when shut. Sulphur. There are pimples more or less diffused over the body; short naps; the eyes seem to itch very much, and to contain much mucus; the canthi appear raAV. Thuya. Hard inflammation of the eyelids; they seem indurated. Pa rotitis—Mumps. This acute inflammation of the parotid gland, which has likewise been termed Cynanche parotidea, differs from an ordinary glandular swelling in being epidemic and contagious, and in not tending to sup- puration. The disease appears in the form of an external swelling, which occupies the gland of one side, and, as the inflammation de- clines in the one first affected, it commences to develop itself in the other in many cases, but not in all. The swelling, Avhich Avas at first remarkable and circumscribed, soon becomes extensive and diffused, often involving the maxillary glands in the inflammation, and continu- ing to increase till the fourth day. The pain is very considerable—a steady and severe aching, as stated by those old enough to express their feelings—but the general fever is comparatively unimportant. The duration of the SAvelling is variable—from five or six days in some cases to a fortnight in others. The metastasis of the disease from the parotid to the mamma, testicle or brain—rare in proportion to the tender age of the patient—Avould seem scarcely possible under judicious homoeo- pathic treatment. Baryta C. If the swelling becomes very hard. Belladonna. In cases characterized by red eyes and face; fever in the afternoon; tendency to erysipelatous inflammation; lethargy and delirium, and pain in head on disappearance of the tumor. The SAvelling is red and shining, the redness runniug in rays from the centre; especially when the right parotid is affected. Carbo veg., Conium and Coccus cacti are very useful in these cases. Carbo veg. if the SAvelling is bluish or purple; Conium if it be exces- sively hard. 892 diseases of infants and children. Lachesis. If the swelling commences on the left side, and aftenvard affects the right gland. Lycopodium. Commences in the right side and goes to the left. Mercurius. This is the remedy in the majority of cases, particularly if they are apparently caused by a cold, and in cases Avhere there are chills and fever and thirst at night; sweat at night; no appetite; can- not open the jaAvs; difficulty of deglutition; some salivation. Pulsatilla. If metastasis to the mammae or testicles takes place. Nux or Mercurius may also be suitable for this condition in some cases. Rhus. AVhere there is much restlessness at night, and in cases com- plicated Avith erysipelatous inflammation. Hepar, Silicia, Arsenicum or Rhus may be required if suppuration takes place. Hiccough. Singultus, or hiccough, belongs to the class of inspiratory convul- sions, and has usually been deemed an affection of the diaphragm alone. But Romberg affirms that its cause not unfrequently resides in the central nervous organs; this, however, is most probably true rather of adults than of neAv-born infants. Hiccough consists of attacks of sudden jerking inspiration with a peculiar sound, folloAved by a short expiratiou. And in each of these respects it is exactly opposite to hooping-cough, in which the expirations are quick, noisy and jerking, while the inspirations are anxious, protracted and still more noisy. This affection may be very readily relieved sometimes by giving the child the breast or by a few teaspoonfuls of Avarm water. The folloAving remedies have been recommended, and that one Avhich is most indicated will certainly relieve the little ones suffering from this form of nervousness, except in those cases in Avhich it results from exhaustion of the vital powers, and is thus evidently symptomatic of approaching dissolution : Belladonna. Flushed face; red eyes; crying on account of pain from the hiccough. Hyoscyamus. Twitching and jerking of the limbs as an accompany- ing symptom. Ignatia. Frequent sighing as an attendant symptom. Ipecacuanha. Much and constant nausea Avith the hiccough. Nux V. Constipation attends or causes the hiccough. Pulsatilla. Hiccough occurring mostly at night. HERNIA. 893 Hernia. Infantile hernia may be congenital or developed subsequent to birth, and a predisposition to this affection may sometimes be ob- served in children Avhose parents are similarly affected. The hernial tumor may occur on either side, constituting inguinal hernia: this, de- veloped to its fullest extent, becomes scrotal hernia in males, Avhile in female children the corresponding tumor appears in the labia pudendi. Exomphalos (umbilical hernia) is also a common form of infantile rupture: in such cases the tumor appears at the navel) as indicated by the name. Besides, there may be femoral hernia, Avhich appears more frequently in female than in male children. It is very important for the physician to detect an infantile hernia at as early a period as possible, especially before it occasions serious mischief by becoming strangulated. This latter accident indeed but seldom occurs in very young children, except in consequence of seArere fits of crying in those already ruptured, or in cases of hooping-cough, in Avhich the violent paroxysms may have induced the rupture in the first place. Thus, Avhen, either from its OAvn observation or from that of the mother or nurse, any tumor or unusual formation is detected, the child should be as carefully examined as an adult Avould be in case of suspected hernia. The most difficult to detect, and at the same time one of the most common forms of herhia, is that which may be developed in the scrotum of the male infant not long after its birth. In these cases of congenital hernia " the intestine or omentum passes out of the abdomen, accompanies the testicle in its descent, and be- comes lodged in the pouch of the peritoneum, which accompanies the tunica vaginalis testis, before its communication Avith the general per- itoneal cavity has become obliterated. In the encysted variety of congenital hernia the communication between the cavity of the tunica vaginalis and that of the abdomen is closed at its upper part, but the former is unusually large and continues high on the cord, containing more or less serous fluid ; behind this the hernia descends invested by the ordinary peritoneal sac." * In the femoral variety the hernia appears in the groin, where it may readily be distinguished from tumors resulting from other causes by accompanying symptoms and by the condition and history of the case. Besides these varieties, the intestine may effect its passage through the parietes of the abdomen at other points, constituting ventral hernia. The strangulation of the protruded intestine will give rise to similar * Helmuth's Surgery, p. 571. 894 DISEASES OF INFANTS AND CHILDREN. symptoms of pain, colic, vomiting and obstinate constipation, or ob- struction of the boAvels, in young infants as in adults. And while such strangulation is far less apt to occur, it can ahvays be traced to some definite cause, such as violent straining in crying or in severe paroxysms of coughing. And both the hereditary predisposition to rupture and the congenital or subsequently developed hernia may be entirely remedied by the administration of the appropriate medi- cine in single doses, and not too often repeated. And even in severe cases of strangulation the physician will have the satisfaction of Avit- nessing the happiest effects from the homoeopathic treatment. By ex- tensive observation I am persuaded that it is never useful to apply bandages or trusses in these cases, Avhether the hernia be congenital or otherwise. The properly selected homoeopathic remedy is always suf- ficient to cure the case.* Study the follow'-^ remedies: Aconite. There is a constant fever; uneasiness and distress by spells; the parts are very tender to the touch. Antimonium c. A great deal of crying; white tongue; vomiting; diarrhoea; cough. Borax V. The child cannot bear a downAvard motion; it is very nervous; cries much day and night. Even when it is sound asleep the downward motion of putting it into the bed or cradle will surely aAvaken it. Calcarea c. In children of leucophlegmatic temperament, with large, open fontanelles; much perspiration about the head ; the child cries much. It may have two or three ruptures, yet in such cases Calca- rea alone will effect a perfect cure in a few weeks or months. Chamomilla. The child is very fretful, and finds quiet and comfort only in being carried about up and doAvn the room. Constant diarrhoea. Cina. Very restless even during sleep. It will not lie awake five minutes Avithout crying. It must be rocked, carried or dandled upon the knee constantly, day and night; the mother and nurse are worn out taking care of the child till it gets Cina, when it becomes quiet and the hernia subsequently gets well. Lycopodium. Much croaking, rattling and commotion in the abdo- men clay and night; colic and crying. Red sand in the urine; screaming Avhen passing water. Always Avorse soon after 4 p. m. Nux V. The child has much colic; it draAvs up its feet, and then thrusts them down again. Constipation, the stools being large and * Vide Hahnemannian Monthly, vol. ii., p. 8. WORMS—VERMICULAR AFFECTIONS. 895 difficult. Poor appetite; crying much at night. The hernial tumor looks blue. Nux is indicated oftener than any other remedy. Opium. Redness of the face; abdomen hard and distended; the child is soporous. Silicia. Frequent colic, relieved by the discharge of offensive flatus. Tenderness about the hernial tumor; vomits much milk after nursing. Stannum. The child is relieved by pressure of the knee, shoulder or hand upon the abdomen. Sulphur. Scurfy skin, Avhich is easily abraded; sleeps only in short naps; other Sulphur symptoms generally. Is very frequently called for in these derangements. Sulphuric acid. AVhen some general, deep-seated dyscrasia prevails, and the child is Aveak and exhausted, and there are no other more par- ticular symptoms. A great variety of other remedies may be indicated in these cases. The Materia Medica should be carefully scanned. Tongue-Tie. This deformity, Avhich differs greatly in degree, is produced by the insertion of the fraenum being too far forAvard toward the tip of the tongue, which it sometimes reaches. It interferes with lactation very greatly Avhen extensive, and in such case should be removed at once. But Avhere the tongue-tie is slight, it Avill be better to wait until the child is two, three or more months old before resorting to operative procedures. In order to remove the deformity the tongue should be raised and the fraenum transfixed by a bistoury, Avhich should then cut outAvard toward the child's gums and aAvay from the tongue. Or a suitable instrument, having a groove to accommodate the fraenum, should be passed under the tongue and the organ raised. Then Avith a pair of scissors cut through the fraenum a sufficient distance, cutting in a direction a little doAvmvard and backward toAvard the floor of the mouth. In this Avay no blood-vessels of consequence Avill be wounded. AVorms—Vermicular Affections. " AVorms," in popular language, constitute one of the most com- mon disorders of children, and people imagine that if the worms are expelled their children will be cured. This, however, is a great mis- take for children are not ill so much because they have Avorms, as they have Avorms because they are ill. Consequently, the violent 896 DISEASES OF INFANTS AND CHILDREN. medicines, drugs, and even mechanical means—such as dolichos and tin filings—used to destroy and expel the Avorms, either entirely fail of their object, or, in effecting it, inflict still greater injury upon the health. The indications afforded by the symptoms enable the homoeopathic physician to prescribe the remedy for the entire disordered condition which leads to the development of the symptoms themselves. Besides, in many cases of supposed " Avorms," they in reality do not produce the sufferings, or they may even be entirely absent. Hence is seen the importance of prescribing for the patient to restore him to health; not to attempt to destroy Avorms by means Avhich in many instances but add to the existing disorder. There is a Arery great variety of animal parasites infesting the human body, both entozoa and ectozoa, and there is scarcely a tissue of the body that has not been inA'acled by one or more of these. Those, hoAvever, which especially attract attention as " Avorms," and are by far the most common, occupy the intestinal canal, and are of three varieties—viz., Oxyuris vermicularis, or small thread-Avorm; the Ascaris lumbricoides, or long round Avorm; and the Taenia, or tape-Avorm, less common than the other varieties, and very rarely affecting children until after the third year. The Oxyuris vermicularis, Avhich was formerly called Ascaris ver- micularis, and is sometimes denominated the " maAV-Avorm," usually occupies the rectum, is thread-like, white, from one-sixth to one-half inch in length, the male Avorm being much smaller than the female. It gives rise to an intolerable itching and burning about the anus and rectum, Avhich prevents the child from sleeping sometimes, and makes it A^ery cross and fretful, and almost beside itself; constipation and tenesmus; depraved appetite ; rubbing and picking of the nose ; foul breath, etc. The local irritation may spread to the vagina in little girls, or the Avorms themselves may crawl there, and give rise to inflammatory state of the parts and a mucous or bloody discharge ; or, by craAvling into the urethra, may occasion severe urinary symptoms, such as urging, scalding and strangury. AVhen these parasites either directly or indirectly attack the genital organ, the itching and titilla- tion they sometimes occasion may lead to masturbation. The Trico- cephalus dispar, or long thread-Avorm, is usually found in the cEecum and large intestines, is about two inches in length, and gives rise to few or no symptoms by Avhich its presence can be known. The Ascaris lumbricoides bears some resemblance to the common earth-Avorm, but is generally longer, and sometimes of a much paler WORMS—VERMICULAR AFFECTIONS. 897 color. It inhabits chiefly the small intestines, but sometimes visits the stomach and is vomited up, or the lower boAvels and is voided with the stool, and even visits other situations, such as the gall-blad- der, oesophagus and the air-passages. It varies in length from six to tAvelve inches. The folloAving symptoms indicate approximately its presence: Disturbed sleep, with tossing about, groaning, and grind- ing of the teeth; foetid breath; great thirst; pallor of the face and general unhealthy appearance of the skin; enlargement of the abdo- men, which is usually tense and hard; falling away of the limbs; depraved appetite—noAV voracious hunger and now aversion to food; diarrhoea, Avith slimy stools, or constipation, or alternation of these states; itching of the nostrils, which occasions rubbing and picking at them; tenesmus; itching of the anus. Sometimes nervous symptoms likewise present themselves, even chorea or convulsions. A dry and hacking cough is a not infrequent accompaniment of the other symptoms. The Taenia, or tape-AVorm—the principal varieties of Avhich are the Taenia solium and Taenia medio canellata, the latter being the most common—exists in the small intestines, and varies in length from five to thirty feet, being from one to fh7e lines broad. It consists princi- pally of a series of jointed segments. It does not produce any very marked symptoms by Avhich its presence may be certainly knoAvn, and in fact its existence is usually not suspected until portions of the Avorm am passed with the evacuations. There are in some cases, hoAvever, constant craving for food, pain in the stomach, loss of flesh and de- bility, and itching about the anus and nose. The Taenia solium is said to be the mature form of the Cysticercus cellulosae or pork " measle," Avhile the Taenia medio canellata is the mature form of the Oysticerus bovis, or beef and veal " measle." The Bothriocephalus lotus, or broad tape-worm, is a variety met Avith in special localities, such as Switzerland, SAveden, Russia, Poland and Ireland. Treatment.—The diet of the child affected with worms should be carefully regulated, the food chosen being easily digestible as Avell as nutritious. Pastry and SAveetmeats should be especially avoided. Se- lect one of the folloAving remedies: Aconite. AVhen a real synochal fever prevails, or there is much itch- ing of the anus; worse at night; much fear manifested, the child being even afraid to go to bed. Argentum nit. In many cases of taenia and thread-worms; the latter particularly when there is much and violent itching of the anus. 57 898 DISEASES OF INFANTS AND CHILDREN. Asarum. The child passes shaggy masses of mucus full of oxyuri. Belladonna. InA7oluntary discharges of faeces and urine; A'iolent startings; flushed face; red eyes; moaning; delirium. Calcarea c. In leucophlegmatic children; the itching at the anus becomes very great toward and in the evening. Also causes tape- Avorm to disappear Avhen indicated by the symptoms. Carbo veg. AVhen a peevish wrathfulness becomes developed; the child Avishes to Arent itself in rage; it strikes, kicks, bites, etc.; nightly fear of ghosts; the Aveakness of the limbs becomes more and more developed. China. Painless diarrhoea. Abdomen much distended, particularly after every meal; tremor and debility. Cicuta virosa. Fever, colic and convulsions, Avith the other symp- toms of Avorms. Cina. Boring at the nose; exceedingly unamiable, nothing pleases the child. Short, hacking cough; frequent swalloAving, as if to swal- low doAvn something. The urine turns milky. Tossing during sleep. Is often sullen and unwilling to play during the day. Digitalis. Stool in the evening, passing great quantities of thread- worms. Ferrum aceticum. Much itching about the anus, and slimy stools Avith Avorms. Vomiting of food, and a flow of water from the mouth. Filix mas. Has been highly lauded as a remedy for tape-Avorm. ♦ Ignatia. In many cases Avhere there is itching of the anus at night; the child is nervous and spasmodic. Ipecacuanha. Itching of the anus; nausea and retching. Lachesis. Itching of the anus in the morning or ahvays after sleeping. Lycopodium. Worms, Avith much rumbling in the boAvels or red sand in the urine. Itching about the anus. Mercurius sol. AVorms creep out of the anus, and can be seen on the perineum and buttocks, even at night in bed. Lumbricoides escape easily and freely; the abdomen is hard and distended. Nux V. Picking at the nose; loss of appetite; constipation; sleep- lessness in the latter part of the night; pain in the abdomen. Phosphorus. Itching in the anus, and at times sharp shooting pains, causing the child to scream out. These troubles come on Avorse toAvard evening. Pulsatilla. The child has vomiting of mucus; bad smell from the mouth; slimy passages from the anus; eructates a watery fluid. URINARY DIFFICULTIES. 899 SabadUla. Itching of the anus, nose and ears; much pain in the abdomen. AVorse every fourth day. Silicia. AVhen worm fevers assume a sIoav, chronic form in scrofu- lous children with large bellies and much perspiration about the head. Worse Avith the change of the moon. Spigelia. When the child refers to the navel as the most painful part. The action of its heart seems unusually violent. Very pale face, and a yelloAV margin around the eyes. Stannum. The child has spells of abdominal pain, during which it wishes to lean over on something hard for relief; there are many other symptoms, but this condition forms a reliable key-note for Stannum. Stramonium. Abdominal spasms and frequent desire for stool. On aAvaking the child shrinks from the sight of objects, even from those with Avhich it is perfectly familiar. Sulphur. AVhen there is redness and rawness about the anus much of the time; papular eruptions on the skin; the skin has a rough or scaly look. Teucrium m. v. The irritation produced by the thread-worms comes on at regular periods every day, and is followed by nightly restless- ness and sleeplessness. Urtica urens. Loss of appetite; itching of the anus; itching of the nose; nocturnal restlessness. Stinging, burning sensations in any part. Valerian. Nightly itching; muscular spasms; sleeplessness. Veratrum album. Attacks of vomiting and purging, Avith cold sweat on the forehead, and symptoms of worms. Selected from these symp- toms, this remedy has cured tape-Avorm. Viola odorata. May be given in cases calling for Cina when this remedy fails to relieve. Urinary Difficulties. There are not uncommon in babes and young children a variety of urinary difficulties. These various disorders are so obvious as to need but little description. Their most prominent symptoms will be found stated in their proper places under the indicated remedies. In some cases the babe passes no Avater during the first few days after birth. Dysuria.—Young infants and little children frequently suffer with difficulty of urinating. This is very easily recognized, and will be 900 DISEASES OF WOMEN AND CHILDREN. greatly relieved by the timely administration of the most suitable remedy. Retention or Suppression of Urine.—This difficulty will be less easily observed in very young children. The bladder may be unusually distended, and there may be evident distress, and even convulsions. The mother or nurse should of course be able promptly to inform the attending physician if there is any difficulty of this kind—i. e., if the child's urine is scanty or suppressed. If there is no malformation the proper remedy will afford prompt relief. Aconite. This medicine may be given if the babe passes no Avater in the first feAv days after its birth. Arnica. If the difficulty—ischuria or retention—appears to have been caused by an injury, such as a fall or a bruise. Belladonna. If there is much moaning, distress, a sudden crying out, in retention of urine. Cantharis. If a feAv drops only flow, Avith much screaming. Colocynth. Dysuria; ineffectual straining; worse before, during and after urination; urine is scanty. Dulcamara. The retention is caused by damp, cold air. Ipecacuanha. Ischuria, with convulsions. Lycopodium. Dysuria, with much rolling and rumbling of flatus, and a reddish and sandy deposit with the urine. Nux V. When there are retention and constipation. Opium. The child is very drowsy and sleepy, the face is bloated. Pulsatilla. If Aconite or Nux fail to relieve. Sulphur. In scrofulous children in whom the retention occurs every time the child takes cold. Compare the patient's symptoms, in case they do not seem to be met by either of the above, with Stramonium, Hyoscyamus, Can- nabis s., Arsenicum, Apis m., Petroselinum, Mercurius sol., Rhus tox., Sepia, Plumbum, Nitric acid, Causticum, etc. Diuresis—Profuse Urination. Muriatic acid. Passes large quantities of urine, accompanied each time with a small stool. Phosphoric acid. When the trouble is worse at night, and the urine is rather offensive. Rhus tox. Very restless at night. URINARY CALCULI—GRAVEL. 901 Silicia. In large-bellied children, Avho perspire much about the head. Study also Argentum nit., Spigelia, Squilla and Verbascum. Incontinence of Urine—Wetting the Bed. Calcarea c. In leucophlegmatic temperaments, Avith open fontanelles; much perspiration about the head. Causticum. In Aveakly, feeble constitutions. Cina. In those affected Avith vermiculous symptoms, pieking at the nose, etc. Creasote. In children Avho are very hard to awaken. Lycopodium. Red sand is found on the sheets or in the diaper. Phosphoric acid. Very large quantities of urine are passed at night; the bed is literally flooded. Sepia. The bed is wet almost as soon as the child goes to sleep— ahvays during its first sleep. Silicia. In children Avith enlarged abdomens (pot-bellied) and other symptoms similar to those of Calcarea, Thuya. The child has fig-Avarts or condylomata. Study also Arsenicum, Belladonna, Benzoic acid, China, Conium, Carbo veg., Gelseminum, Pulsatilla, Sulphur, Graphites, Hepar, Rhatania, Sarsaparilla, Phosphorus, Cantharis, etc. There is hardly a remedy in the Materia Medica but may be useful in this complaint if the other symptoms correspond; all the symptoms must be collated and the prescription made accurately. Urinary Calculi—Gravel. Sometimes children appear to be attacked with a severe colic, in paroxysms or in continued distress, Avhich may last for hours. This may be from an actual Avind-colic, from indigestion, from the passage of gall-stones through the hepatic duct, or from the passage of gravel or calculi through the ureters or urethra. When the difficulty arises from the last-mentioned causes the fact will usually be evident from the attendant symptoms, and great relief will be derived from the exhibition of the appropriate remedy. The following have most fre- quently been indicated in such cases: Lycopodium. Much pain, even to screaming, before passing water. Red sand or gravel upon the diaper or in the urine. Phosphorus. Much gray sand in the urine. Sarsaparilla. Much pain at the conclusion of passing Avater. 902 diseases of infants and children. Silicia, Berberis vulg., Calcarea c, Phosphoric acid, Alumina should also be studied in these cases. Inflammation of the Brain—Meningitis. By this term is understood a simple inflammation of the brain and its membranes Avhich is not produced by tuberculosis. It occurs most frequently in children between the first and ninth year, and for that reason has been associated with the process of dentition. It also occurs more frequently in boys than in girls, Avhile strong and hearty children are more likely to be attacked by this form of cerebral disease than are more delicate children ; the latter being more liable to be- come the victims of tubercular meningitis. The causes of the disease are rather obscure. It may be due in some instances, as above remarked, to the irritation produced by den- tition, to injuries, to exposure to the rays of the sun, and it may result as a complication of some other form of disease. It occasionally appears as an epidemic. Sometimes this disease sets in very suddenly, a prolonged convul- sion being the first intimation the parents of the child may have that anything is wrong,—the slight malaise which precedes scarcely excit- ing the attention. The convulsions are accompanied or followed by a high degree of fever and quickness of respiration, and, if the patient be old enough to describe symptoms, severe headache will be com- plained of. " After a Avhile the convulsions cease, and the child remains for the time in a state of quiet somnolence or coma, when they return with renewed violence. The returns of the convulsions generally take place at intervals of one or two hours or more. In the intervals between the crises the child is restless or drowsy, or in a state of partial stupor, attended with tremulous movement of the ex- tremities ; there is strabismus, contraction of the pupils, trismus, and sometimes hemiplegia. The skin retains its warmth, the pulse is accelerated, irregular and unequal; the face is pale; the stools are spontaneous. It is unusual to see the child regain its consciousness so as to recognize objects in the intervals between the con\rulsions, or after the appearance of coma and other cerebral symptoms. This form of the disease has been termed the convulsive. In other cases the disease shows itself quite as suddenly, but the convulsions come on at a later stage. Here the first symptoms are— fever, with shortness of breath, almost constant droAvsiness, followed by a high degree of nervous excitement, staring eyes, loud cries or screams, dilated pupils and sometimes vomiting. TUBERCULAR MENINGITIS—ACUTE HYDROCEPHALUS. 903 Another form of the disease, Avhich has been termed the phrenitic, commences usually with a chill, folloAved by fever, violent frontal headache, great sensibility to light and noise, profuse bilious vomiting, loss of appetite and great thirst. " About the end of the first day generally, or, in rare instances, after two or three days, appear various disorders of the intelligence. The first symptom of this kind is ob- servable in the expression of the face, which becomes a little Avild or wandering, and sometimes grimacing. Soon afterward occurs restless- ness, Avhich is sometimes extreme, and in succession delirium, somno- lence, and, late in the attack, coma. The restlessness and somnolence often alternate early in the case, though the former generally predom- inates, and soon passes into delirium, which is usually violent. AVhen in this condition the child seldom recognizes any one, and either re- fuses to answer questions or answers incoherently. In connection with the disorders of the intelligence there exist also trismus, grinding of the teeth, subsultus tendinum, partial convulsive movements, stiff- ening of the extremities or trunk, retraction of the head, strabismus, contraction first and then dilatation of the pupils, and in some cases violent convulsions, followed by deep coma. Frequently at this period death relieves the little patient of suffering, but in other instances the disease goes on, deA7eloping other and more profound symptoms, some of those Avhich first appeared subsiding or disappear- ing, until the child falls into a state of collapse, and thus dies, or a violent convulsive fit ends the scene." The prognosis of this form of cerebral disease is of course very grave, but is far from being hopeless. Treatment.—On page 909 et seq. are given the indications for a great variety of remedies suitable for the treatment of the Ararious forms of meningitis and hydrocephalus, from one of Avhich the appro- priate remedy should be selected. In this special form of disease the following medicines are most likely to be appropriate: Aconite, Apis m., Belladonna, Bryonia, Cimicifuga, Gelseminum, Cam- phor, Cuprum aceticum, Hellebore, Hyoscyamus, Opium and Stramonium. Tubercular Meningitis—Acute Hydrocephalus. " This disease is characterized by violent cerebral symptoms, de- pendent upon the existence of tubercular granulations in the pia mater, as the essential anatomical lesion, accompanied, in the great majority of cases, by coincident inflammation of that membrane, by softening of the central parts of the brain, by effusion of serum into 904 diseases of infants and children. the ventricles, and in many instances by tubercular deposits in other organs." That portion of the pia mater Avhich lines the ventricles is the most frequent seat of the disease at its onset, but in some instances it is de- veloped at the base of the brain, and is termed basilar meningitis. Children of a scrofulous (tubercular) diathesis are most frequently attacked, especially betAveen their first and eighth years, and in such children there are generally to be found evidences of tuberculous dis- ease elseAvhere. The disease may be excited by a blow or fall, by the systemic irritation of dentition, in consequence of the repeated cerebral congestion induced by paroxysms of hooping-cough, or by some of the exanthemata, such as measles or scarlatina. The disease may come on either insidiously or suddenly, and in the majority of cases the former is the case, there being usually well- marked prodromata, lasting \rariously from ten or fifteen days to two or three months. During this prodromic period there appears to be a general running down of health; the child loses its appetite, or it becomes capricious, groAvs thin and pale and does not care for play; complains of being tired or weak, the debility sometimes becoming excessive ; is very restless at night; complains of headache, and some- times of pain in the abdomen. These symptoms having lasted for a longer or shorter period, others set in AAdiich are more marked and alarming, and which are usually the first to which the attention of the physician is called. Many of these symptoms are common to the various forms of cerebral disease, such as headache, squinting and grat- ing of the teeth during sleep, sensitiveness to light and noise, tAvitch- ing of the muscles. Other symptoms are—" Vomiting, not after eat- ing, but especially on being raised up, Avith constipation of the bowels ; the abdomen is hard and sunken in; the pupils are generally contracted; the pulse is hard and quick. After exudation has taken place Ave ob- serve a very peculiar piercing shriek (cri hydrencephalique), Avhich is repeated occasionally, and Avhich, if heard once, is scarcely ever for- gotten. The head is bent backward into the cushions, and is rolled from side to side. In this stage of the disease convulsions frequently occur, and the children bring their hands frequently and automati- cally to their heads; they become insensible to light and noise; the vomiting ceases; the pupils dilate; the eyes squint; the pulse becomes quite slow, falling doAvn to sixty or less in a minute; respiration is irregular; sometimes the breathing seems to cease altogether,folloAved by a deep, long, sighing inspiration. The face frequently changes color—now pale, and again red—and sometimes one side is pale and CHRONIC HYDROCEPHALUS. 905 the other red. The blood-vessels of the eyes become injected, espe- cially those of the inner canthi. The anterior fontanelle, Avhen not closed, protrudes."—Raue. As a general thing, there is little or no disturbance of the intellect- ual faculties during the first few days of the disease; the child is either dull or irritable by turns ; shuns the light; is unusually sharp of hearing. Diplopia is occasionally present in the earlier stages, and excites marked attention. Convulsions rarely occur in the first days of the disease, and delirium does not set in until about the sixth or seventh day, or even later. Trousseau refers to a red line which will remain upon the skin of the abdomen or forehead after the finger has been draAvn across it, and to Avhich he gave the name of " tache men- ingitique " or " tache cerebrate^ which may serve as a diagnostic mark of the disease. The duration of this disease differs greatly in different cases, although it seldom lasts a shorter time than ten or a longer time than thirty days ; yet in some cases it is very lingering. The prognosis is decidedly unfavorable. Treatment.—This disease will require for its treatment such rem- edies as Aconite, Apis mel., Apocynum cann., Argentum nit., Arnica, Belladonna, Bryonia, Calcarea carb., Calcarea phos., Cuprum met. and acet., Hellebore, Opium, Silicia, Sulphur and Zinc. Refer to the indications for these and other remedies on page 909. Chronic Hydrocephalus. The term chronic hydrocephalus is applied to a disease characterized by the accumulation, either Avithin the ventricles of the brain or the sac of the arachnoid membrane, of a larger or smaller quantity of serous fluid in excess of that which is normal. It may be either con- genital or acquired, and has been divided into external and internal; the former term indicating that the fluid has accumulated Avithin the sac of the arachnoid, and consequently lies exterior to the brain sub- stance ; Avhile in the latter the effusion takes place Avithin the brain —into the A^entricles. The most marked of the symptoms of this disease is the enlarge- ment of the head, Avhich in some cases appears even monstrous, its circumference measuring as much as tAventy-three inches or more. AVhen the disease sets in before the ossification of the sutures has Avell advanced, the bones of the cranium are separated by pressure of the accumulating fluid, the parietals are pushed outward, the occipital 906 diseases of infants and children. bone backward and the frontal bone forward, so that the forehead projects beyond and overarches the face, A\diieh is usually pinched and diminished in size in consequence of the general atrophy Avhich usually accompanies the disease. In such cases fluctuation may be detected in the track of the sutures and under the fontanelles, and the scalp in these situations ATery frequently projects beyond its natural level. As a general thing* the hydrocephalic condition is preceded by symptoms of disordered nutrition, such as impaired digestion, debility and wast- ing, and by nervous disturbances of various kinds. Some of the symptoms of chronic hydrocephalus depend upon the impaired condi- tion of the system which gives rise to the watery effusion, while others again are due to the pressure exerted upon the brain by the effusion itself. AVhen the disease is congenital there are evidences of cerebral derangement noticeable at birth or shortly after Avard, such as strabismus, convulsions, etc. In acquired cases either the intelligence of the child remains unaltered, or is even increased, Avhile in others there is a gradual decline of intelligence and derangement of vision. Some- times the patients are troubled Avith attacks of laryngismus stridulus; in others there is more or less complete paralysis or tonic contraction and rigidity of the whole or a part of the extremities. The suffer- ings of children afflicted with this disease do not appear to be very great, or, at all events, not very acute; but it is difficult to pronounce positively upon this point. " Children born with this complaint frequently die during birth or shortly afterward. Others sIioav in the first weeks no signs of this malady ; even during the whole of the first year it may be overlooked, until the inability of the child to hold up its head calls attention to it. But even then there may be no enlargement of the head visible, yet the child is sIoav in all its mental developments; it does not make any attempt to talk or Avalk ; it remains uncleanly and its actions look strange; when in joy or fear it makes antics and struggles with its extremities; frequently such children are throAvn into convul- sions."—Raue. " The generalcondition of children suffering from chronic hydrocepha- lus varies greatly. In some cases they preserve their appetite and diges- tion, and appear well-nourished and strong to a late period in the attack, but more frequently they present marked evidences of im- pairment of nutrition. The appetite may indeed remain, but the child loses both flesh and strength; the bowels are irregular, usually con- stipated, but alternating Avith temporary attacks of diarrhoea. In the majority of cases, perhaps, these symptoms are not sufficiently pro- CHRONIC HYDROCEPHALUS. 907 nounced to establish the character of the attack until the increasing size of the head becomes manifest and the child acquires the distinc- tive physiognomy of hydrocephalus. Even after marked enlargement of the head has occurred, however, the advance of the case is far from being uniform. In almost every instance there are pauses of the most variable frequency and duration, during Avhich the child seems free from pain, improves in general condition, and the development of the head is temporarily arrested."—Meigs and Pepper. Tanner thus sums up the symptoms and course of this disease, in addition to the enlargement of the head: " Subsequently emaciation, great appetite, dullness, peevishness, disordered digestion, muscular weakness, squint- ing, rolling of the eyes, Aveak sight, great Aveight of head, staggering gait, screaming and grinding of the teeth occur, to be followed by stupor, alteration of the pupils, great prostration, compulsions, par- 4 alysis and death in the one instance, or an abatement of the symptoms when recovery is about to take place in the other." It is wellnigh impossible to diagnose this disease during its earlier stages, the prodromic symptoms being of that character common to almost all forms of cerebral lesion, and, indeed, to other diseases having reflex action through the nerve-centres; but when effusion is advancing, and the head begins to enlarge and the face to look smaller, it is almost an impossibility that any error of diagnosis should be made. The prognosis is decidedly unfavorable, especially Avhere there is evidence of large serous accumulation and of serious cerebral lesion; but where the accumulation is not so great, and the functions of the brain remain unimpaired, hopes of recovery may reasonably be entertained, especially in children who exhibit a good degree of vitality and strength, and more especially under homoeopathic treat- ment. Death often takes place in consequence of some intercurrent malady Avhich apparently has no connection with the brain disease; in other instances the children die of marasmus and exhaustion; while in others, again, they die suddenly from convulsions or a sharp aggravation of the disease. Treatment.—The same remedies as have been mentioned as most likely to prove useful in the treatment of acute hydrocephalus may be required in this disease, but the reader is especially referred to the list of remedies on page 909 et seq. We must here especially enjoin, how- ever, that in a disease of this nature, which has its origin in the dys- crasia of the mother, and is implanted in her offspring as disease, or as disease-o-erm so to speak, the practitioner must not limit himself in choosing remedies to the simple array Ave have presented, but the 908 DISEASES OF INFANTS AND CHILDREN. whole Materia Medica should be scanned rather than a prescription be made that is not strictly homoeopathic to the tout ensemble of the in- dividual case. And Ave may remark that this is also true regarding the treatment of all other forms of cerebral disease and of all diseases. Hydrocephaloid Disease. Hydrocephaloid, or hydrencephaloid disease, Avas first described by Dr. Marshall Hall. It is a secondary brain affection, resulting from exhaustion of nervous vitality and anaemia of the brain, the results of debilitating diseases, such as cholera infantum, diarrhoea, or any other malady Avhich severely drains the system. Its symptoms resemble to a very great extent those of hydrocephalus, and the con- dition may be diArided into two stages—viz., first, the stage of irri- tation, and second, the stage of torpor. The stage of irritation, or the premonitory stage—Avhich sometimes comes on insidiously and lasts for some time, and at others appears suddenly, and is very soon followed by the stage of torpor—is charac- terized by restlessness, feverishness, sudden starting from noise or on being touched; bloating of the abdomen ; diarrhoea ; starting suddenly from sleep and giving utterance to a piercing cry; grinding of the teeth ; quick pulse; hot and dry skin. The stage of torpor sooner or later follows the first stage, and has the folloAving distinguishing symptoms: Apathy ; pallor of counte- nance, Avith coldness; the eyes are half closed, frequently " turned up in the head," and unsteady; they are unmoved by the approach of light or of objects, such as flies; the breathing becomes irregular and sighing; the voice is weak and husky, and there is sometimes a trouble- some cough; the pulse is quick and small, gradually becoming weaker and more Aviry; coldness gradually spreads over the body, commencing in the face; and if the disease runs on to a fatal termi- nation complete coma and collapse supervene. The disease is one of cerebral anaemia, the cerebral circulation being lessened. The fontanelles are depressed, instead of being elevated as in hydrocephalus. Treatment.—In this disease there is a marked necessity for proper nourishment and an abundance of fresh air. The effect of these im- portant hygienic measures is A'ery noticeable in some cases, and many children's lives are saved byr a resort to them. Indeed, Ave have seen the condition of a child changed from one of apparent hopelessness to one in Avhich there Avas good reason for making a favorable prognosis, by merely changing the foul and heated air of a pent-up city neigh- REMEDIES FOR DISEASES OF THE BRAIN. 909 borhood for the bracing atmosphere of the river, the parks or the sea-shore. Such remedies as China, Phosphorus, Calcarea carb., Calcarea phos., Phosphoric acid, Zincum and others are suited to this condition. Consult the remedies below. Remedies for Diseases of the Brain. Aconite. This remedy will be indicated especially in the earlier stages of these diseases, when there is marked febrile excitement, great heat and dryness of surface, nervousness, particularly fearfulness, restlessness and distress. JEthusa cyn. AVhere the disease seems to have supervened upon long- continued indigestion, especially that form in which milk does not agree Avith the stomach, and the child almost invariably vomits soon after taking the breast or the bottle. Great irritability, or the little patient lies stretched out in a semi-comatose condition; pupils dilated and insensible to light, as are the eyes to the approach of objects; the features are expressive of great anguish; pulse very feeble; mouth very dry or \rery moist; the child is very weak and cannot hold up its head. Apis mel. This remedy is especially suited to cases of hydrocephalus. There is great restlessness at night; the child screams out very sharply and shrilly during sleep or when awake—cri cerebrate—especially during the latter part of the night; the urine is generally scanty, though it may be quite profuse. Apocynum cann. "Sutures opened; forehead projecting; sight of one eye totally lost, the other slightly sensible; stupor; constant in- voluntary motion of one leg and arm; urine suppressed."—Roue. Hydrocephalus, especially acute hydrocephalus. Argentum nit. This remedy has been recommended by von Grauvogl for the last stage of hydrocephalus. Convulsions, with great restless- ness betAveen the attacks, or every successive spasm is announced by a very marked degree of restlessness. Arnica. This remedy is indicated by the fact that the brain disease has originated in a blow, fall or other mechanical injury. A charac- teristic symptom of Arnica is, that Avhile the head is hot the rest of the body is comparatively cool or even absolutely cold. Arsenicum. Great depression of the vital forces, manifested by great prostration; emaciation; pallor; the face, and sometimes the Avhole body has a Avaxy look; thirst, the child desires cold Avater often, but drinks but little at a time; sometimes the child strikes its head Avith its fists, as though for temporary relief. 910 DISEASES OF INFANTS AND CHILDREN. Artemisia vulg. While the left side is paralyzed, the right is in a state of clonic spasm ; the child lies in a sleepy or dreamy state, and yet will drink large draughts of Avater without being entirely aroused; the surface of the body is cold; the child passes stools involuntarily. Belladonna. This remedy is suited to all forms of brain disease during certain of their stages. It is especially useful in inflammation of the brain, and if given early enough—i. e., during the cerebral congestion—will often cut off the attack. Great headache; redness of the face and sparkling eyes; throbbing of the carotid arteries; dilated pupils; injection of the sclerotica; great heat of the-head and of the surface of the body, from which the heat seems to radiate; almost constant moaning; the child lies in a drowsy or semi-comatose state, is constantly starting and jumping, bores its head backAvard into the pillow, or tries to bend its body backward. Bryonia. Almost constant motion of the jaws, as though the child were chewing something; the lips are dry and parched; the bowels are constipated, and the stools passed are A7erydryand hard; the child evidently desires to be kept still, and when it sits up or is held erect it is attacked with nausea and a faint feeling. Calcarea carb. This remedy will be indicated in cases of brain disease originating in, and apparently depending upon, a " scrofulous" or " psoric" diathesis. Children of leucophlegmatic temperament, Avhose fontanelles are unusually large and are very sIoav to close, and who sweat very heavily about the head and upper part of the body; the child has frequent spells of screaming without apparent cause. Calcarea phos. The reader is referred to the very full indications for the use of this remedy given under the article on Dentition. Camphora. Great coldness of the skin, and yet the child cannot bear to be covered. Carbo veg. Great prostration and collapse; Hippocratic countenance; cold breath and coldness of the limbs, especially the knees; the patient wishes to be fanned all the time. China. Hydrocephaloid, or any other form of cerebral disease, Avhich has groAvn out of a severe drain of fluids from the body, such as diarrhoea, summer-complaint, loss of blood, etc. The symptoms appear to undergo an exacerbation every other day; offensive, pain- less stools, or lienteria, Avith much distension of the abdomen. Cimicifuga. Delirium and wild fancies ; intense pressing and throb- bing in the vertex and occiput; feeling as if the brain Avere too large, and as if the top of the head would be forced off; pain in the eyes. Cina. The child gives indications of being troubled Avith Avorms, REMEDIES FOR DISEASES OF THE BRAIN. 911 picks its nose or picks at the bed-clothes, has a bloated abdomen, passes milky-looking urine, is cross and peevish, Aromits frequently, although its tongue is quite clean, and Avants to be in motion almost constantly—to be rocked or carried about. Cuprum acet. Convulsions and cramps are marked features of the case requiring Cuprum. The cerebral disease is the result of metas- tasis during an attack of catarrhal or exanthematic fever. The spasms and cramps commence in the extremities, and especially in the fingers and toes. Inability to hold the head up. Grinding of the teeth. Digitalis. The characteristic sIoav pulse of this remedy, or irregular pulse; Avhite eA^acuations from the boAvels; bilious vomiting. Gelseminum. FeA^erishness; dark-red hue of the face; vertigo, drow- siness and stupor or apathetic mood; convulsions; Avhen occurring during dentition. Hellebore. The urine is scanty and dark-colored, and deposits a sedi- ment looking like coffee-grounds; involuntary throwing or whirling about of one arm and one leg; rubbing of the nose; strabismus; dilated pupils; wrinkled forehead, Avhich is bathed in a cold sweat; great irritability; soporous sleep, with screaming spells; dryness of the nostrils; the loAver jaw hangs doAvn, or there is a motion of the jaAvs similar to that of chewing; the child drinks water greedily. Hyoscyamus. Delirium; jerking of the limbs; Avatery diarrhoea; red face; Avild, staring look; throbbing of the carotids; droAvsiness and loss of consciousness; muttering and indistinct speech, and picking at the bed-covers; distorted eyes, with diplopia, convulsions, frothing at the mouth. Ignatia. The child sighs and sobs frequently. (See Ignatia indica- tions under Spasms and Convulsions.) Ipecacuanha. The case is characterized by an almost constant nausea, from which there is scarcely a moment of relief. Kali carb. There is a daily aggravation of the symptoms at three o'clock in the morning; the hair is remarkably dry and brittle; swell- ing above the upper eyelids; the child cannot bear to have its feet touched. Mercurius sol. Scorbutic condition of the gums ; salivation; glandu- lar enlargement; slimy or clay-colored evacuations; cold and clammy SAveat upon the thighs and legs, especially during the night; moist tongue, Avith great thirst; grayish ulcers on the mucous lining of the cheeks, lips, gums, tongue and palate; the child is very sensitive to pressure on the lower abdomen and epigastric region. Nux vomica. The child has been having too much meat and highly- 912 DISEASES OF INFANTS AND CHILDREN. seasoned food; it sleeps badly, and is particularly Avakeful and rest- less after three o'clock in the morning; there is an aggravation of all the symptoms in the morning; frequent calls to stool; the child is very irritable and wishes to be alone; it constantly passes its hand over its face, as though trying to brush something off; spasms, Avhich are reneAved when the feet are touched. Opium. This remedy is sometimes called for in the early stages of cerebral disease, though usually indicated at a later period. The child goes off into a heavy and stupid sleep, Avith red face, or it seems to be dull and droAVsy, as though under the influence of morphia or laudanum; the child is stupid after waking; the hearing in some cases is inordinately acute; the child seems to be afraid of something, and starts as if in affright; the bowels are constipated, the faeces passed resembling little black balls. Phosphorus. The child is dull, and inclined to sleep almost all the time; is no sooner roused than it Avants to go to sleep again, there being nothing unnatural in the character of the sleep; after the Avater Avhich it drinks remains in the stomach long enough to get warmed it is vomited; coldness of the feet and legs; green-colored stools, or Avhite stools, Avhich are sometimes watery, and gush out like water from a hydrant; loss of hearing; hydrocephaloid disease. Phosphoric acid. The child is perfectly listless and apathetic, does not Avant to do any thing or to talk, will hardly answer questions, and haA'ing done so, relapses into its apathetic mood; passes large quanti- ties of colorless urine, especially during the night. Pulsatilla. The child whimpers and is ready to cry at any little annoyance, shedding tears copiously; the child is of a gentle and yielding disposition ; the symptoms are someAvhat changeable, and the child seems occasionally better and then \vorse; the symptoms are aggra- vated as e\7ening approaches; the child seems to have a craving for fresh air, and cannot bear Avarmth; scanty urine; absence of thirst. Sepia. The child is in a torpid condition, with great depression of the vital power; the urine has a putrid odor, and deposits a clay- colored sediment, which adheres to the vessel or the diaper. Silicia. The child grasps at its gums continually, as though they were painful; profuse SAveat about the head at night; the child is of the scrofulous diathesis. Squilla. The child rubs its face and eyes a great deal, especially its eyes, as though to relieve itching; profuse urination; passes much urine. Stramonium. The child, when it awakens, seems to be afraid of CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 913 the objects near it, or it does not notice surrounding objects at all; stupor; great loquacity; merry delirium; desire to escape from the bed and room; grinding of the teeth; glittering eyes; staring look; the stools are dark-colored or black; during a convulsion the head is jerked up from the pillow and falls back again alternately. Sulphur. In cases when the suppression of an eruption or of otorrhcea has preceded the disease; scrofulous or psoric dyscrasia, Avhich not only has led to the disease, but overshadows the little patient, and seems to prevent his convalescence; flashes of heat; the child gives evidence of having occasional sinking spells, and these come on with great regularity about the middle of the day; great hunger; redness and excoriation around the anus; the child sleeps almost all the time, although only in short naps. Veratrum alb. The child's forehead is constantly covered with a cold and clammy sweat, and the general surface is cold and damp; the pulse is very small and weak, and the child is greatly debilitated; the child is very thirsty, and desires only ice-cold water or ice; great prostration after a stool. Veratrum vir. Cold sweat on the face, hands and feet; the skin is shriveled: the child bends its body far backward, amounting to opisthotonos during a spasm ; very quick pulse ; nervous symptoms. Zinc. The child has its feet in constant motion; distension of the abdomen; constipation, Avith hard and dry faeces; on awaking the child gives evidences of fear, and rolls its head from side; it cries out, starts and jumps during sleep. Cerebro-spinal Meningitis—Spotted Fever. Natural History.—As to its scientific determination, Cerebro-spinal Meningitis, or inflammation of the meninges of the brain and spinal cord, is comparatively a new disease. Although described by Syden- ham as Typhus petichialis novis more than two hundred years ago, it was originally designated as a distinct epidemic disorder by Vieus- seux as late as 1805. Its first appearance in America was in Med- field, Mass., in March of the folloAving year. And since then, in Europe, in Africa and upon this continent, it has prevailed as an epidemic at intervals of a few years—sometimes in successive years; besides the numerous sporadic cases Avhich may or may not have been recognized as such by the attending physicians. It has been chiefly observed in young persons and males, although not confined to any age or to either sex. Infants are often seized Avith this disorder, which destroys life in many cases almost before the physician has time to 58 914 DISEASES OF INFANTS AND CHILDREN. ascertain the nature of the affection or notify the parents of the ex- ceeding danger. In some children, and adults even, it has proved fatal in from six to forty-eight hours.* Fortunately, it is neither in- fectious nor contagious. Etiology.—The exact nature of the cause or causes of cerebro-spinal meningitis is unknoAvn, as well as its period of incubation. Niemeyer affirms its miasmatic character from observation and experience in Europe, f According to Dr. H. M. Paine, this disorder is especially prevalent in warm and damp seasons; this, together with other simi- lar facts, points to a malarious origin. It appears in the latter part of Avinter and spring much more frequently than in any other seasons of the year. In Alabama a very large proportion of all the cases occurred in Ioav, moist localities and during Avet weather. In Mis- souri it preA'ailed with great fatality in a region that had previously been overfloAved by the river; and in many places in New York State its origin was clearly ascribable to miasmatic influences.\ Dr. Kempf, of Indiana, observed that it seemed to be checked by mild weather—that is, as a spreading epidemic—but reappeared upon the occurrence of a damp, chilly atmosphere.§ Drs. Watson || and Woodward ^[ discountenance the idea of the mala- rious nature of the cause of this disorder. But the two following practi- cal observations may be deemed sufficient to sustain the opinion already advanced: First, the disorder is developed in hot and dry tempera- * Dr. Armstrong (allopathic) states that in his very extensive observation of the disease among the soldiers and laborers in and around Mobile, he never saw a single case recover.—Am. Jour. Med. ScL, 1866, p. 280. Of over one hundred cases of cerebro-spinal meningitis which occurred in Lewis, Clay county, Indiana, in the spring of 1873, only thirteen recovered, and these were saved, not by the " regular" practice, but "by a sweating process with boiled corn." In a report made to the Boston Medical Society in 1866, it is stated that in two hundred and seventy-eight cases allopathically treated, one hundred and seventy proved fatal. Per contra, Dr. S. Lilienthal reports having treated, during the winter and spring of 1872, ten cases of this disorder, of which only one was fatal.—Trans. Am. Inst. Horn., 1872, p. 330. Dr. J. H. Baker reports the care of about sixty cases in all stages and in all degrees of malignancy during the past seven years in Western New York, losing none.— Hahnemannian Monthly, vol. viii., p. 42. t Text Book of Practical Medicine, New York, 1870, vol. ii., p. 219. % Trans, of N. Y. Horn. Med. Society, 1864, p. 132. § Am. Jour. Med. Sciences, July, 1866, p. 55. || Trans, of N. Y. Horn. Med. Society, 1864, p. 127. If U. S. Med. and Surg. Journal, July, 1872, p. 401. CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 915 tures as well as in those warm and moist,* and this is equally true of diseases confessedly malarious. Second, the almost invariable com- mencement of the disorder Avith a chill, the more or less constant re- currence of the chills in protracted cases, and the seat of the chill itself—taking its rise in the posterior spinal nerves, and finding much of its ultimate development in the liver—would seem to afford suffi- cient cumulative proof of the malarious nature of this form of menin- gitis. And it has often been the experience of the Avriter to see in malarious districts cases of this kind which were at first mistaken for simple intermittents. This great similarity of the two diseases— which goes far to prove the miasmatic origin of the former equally Avith the latter—has been remarked by many observers. Says the Indiana physician already quoted, " I have visited patients in whom the analogy between intermittent fever and the disease under con- sideration Avas so perfect that the most circumspect would be de- ceived. The intermittent character of the disease, the herpes about the mouth, and the 'spots' or petechia? Avhich appeared in the epidemic intermittent fe\'ers of the summer and fall of 1865, Avould seem to indicate some kind of relation between the two diseases—cerebro- spinal meningitis and intermittent fever." f One more circumstance which should be borne in mind in considering the etiology of this form of meningitis we state in the language of Dr. Com ins of Mas- sachusetts: "I have found, on careful examination of about one hun- dred cases, both by personal observation and the assistance of others, that about ninety-five per cent, of the cases in New England were of strumous diathesis." J Course.—In those cases Avhich are sufficiently protracted to allow a progressive development of the symptoms, the orderly course of this disease very much resembles its analogue, simple meningitis, the more remarkable difference consisting in the earlier addition of cervical and spinal affections, such as tenderness and opisthotonos, which, indeed, may appear almost from the very first, Cerebro-spinal meningitis is, hoAvever, so much more immediately violent and prostrating that many of its symptoms of the first forty-eight hours equal in severity the corresponding symptoms of pure meningitis of a whole week's duration. In its simplest form, cerebro-spinal meningitis is a conges- * According to Dr. Wolford, spotted fever prevails most extensively when the atmos- phere is unusually clear and dry.—North Am. Journal of Horn., xiii., p. 145, quoted by Dr. S. Lilienthal, Trans, of Am. Institute of Horn., 1872, p. 328. fAm. Jour, of Med. Sciences, July, 1866, p. 62. X Trans, of N. Y. State Eclectic Med. Society, 1869-70, p. 492. 916 DISEASES OF INFANTS AND CHILDREN. tiATe fever, ushered in by a chill, and resulting in effusion Avith its ulti- mate consequences. The reaction, like that of other fevers, may be of higher or lower grades—simulating the inflammatory, the typhoid or-the typhus form—according to the quantity and quality of its pro- ducing cause, and to the nature of the individual constitution in which it is developed. Hence the immense variety of the symptoms, far exceeding Avhat may come Avithin the observation of a single physi- cian—exceeding even the totality of those presented in any particular epidemic. This variety—Avhich Ave have endeavored adequately to represent by collating the reports of many observers, in addition to Avhat Ave have ourselves witnessed—is rendered still greater by the extension @f the disorder through a nervous centre that involves the entire sys- tem. The manner in which this extension naturally produces symp- toms so various and universal is well illustrated by those resulting from pressure artificially applied to different portions of the affected spine. " Pressure made upon the cervical portion of the spine pro- duces pain in the head, frequently darting to the forehead, eyes and temples, and also to the top of the sternum. Pressure on the dorsal vertebras produces pain in the middle of the sternum, at the epigas- trium or in the abdomen, according as the pressure is exerted at a higher or lower portion of the spine."* Whatever section of the meninges is primarily affected, it Avould seem that the posterior or sen- sory spinal nerves are implicated—producing hypersesthesia and in- tense pains—before the disturbance of the anterior or motor spinal nerves results in muscular contractions, spasms or paralysis. And in this direction is observed much of the analogy betAveen intermit- tents and cerebro-spinal meningitis which so strongly indicates the malarious origin of the latter disorder. Complications.—Hahnemann has shown that two dissimilar diseases cannot exist together in the same system ;f but in later times we have seen the combination of different disorders, Avhich, however unlike in their original cause, have a similar development. Such is the case Avith scarlatina and diphtheria. And just as two dissimilar and even antagonistic chemicals will combine in the presence of a neutral ter- tium quid, so may these tAvo diseases, and others, in like manner, *Wm. H. Watson, A.. M., M. D., Trans, of N. Y. Horn. Med. Society, 1864, p. 127. f The Homoeopathic Medical Doctrine, or Organon of the Healing Art. A System of Physic. Translated from the German of S. Hahnemann, by Charles H. Devrient, Esq., with notes by Samuel Sutten, M. D., Dublin, 1833, pp. 121-126 (first English edition of the Organon). CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 917 find simultaneous entertainment and development in a scrofulous con- stitution. But Avhether in the case of some great disease the concomi- tant presence of another disorder be owing to dissimilarity of cause or to similarity of development, it becomes important in such cases to be aAvare not only of the complications most likely to arise, but also of all that may appear. In addition to the particular morbid affections and conditions whose tout ensemble makes up the disorder called cerebro-spinal meningitis, and Avhich we have arranged under the head of "Symptomatology," there are other distinct groups of symptoms or forms of disease, which may have existed in the system previous to the accession of this disorder, and so continue on with it, or which may arise during its course. These additional affections cannot but complicate the whole case in such a manner as to render the diagnosis more difficult, the prognosis more doubtful and the treatment itself more dangerous; for in these severe and mixed diseases the conscientious physician finds himself embarrassed at every step, lest the remedy, however carefully selected to suit the Avhole case, should mitigate one class of symptoms only to intensify and render fatal another. The pre-existence of ague, which in some instances seems to run into this form of meningitis, leads to a very troublesome complication. Difficult dentition, Avhether considered as a cause or as a concomitant merely of the disease in question, by reason of its persistence is still more to be dreaded. Of ninety-eight hospital cases reported by Dr. Githens,* four Avere complicated with bronchitis, of which one proved fatal; three Avith pneumonia, tAvo of the right side, of Avhich one proved fatal; one Avith pleuro-pneumonia of the right side, fatal; one Avith pneumonia and free epistaxis, fatal; one with pre-existing pneumonia of the right side and puerperal convulsions, fatal; one with double pneumonia and pericarditis, convalescent on the thirteenth day; two with puerperal peritonitis, both fatal; one with scrofula (white SAvell- ing of the knee), fatal; one Avith pharyngitis, convalescent on the four- teenth day; one Avith circumscribed pneumonia., coming on in the second week, coiwalescent on the tAventieth day; and tA\ro Avith delirium tre- mens, one convalescent on the fourteenth day, the other in four weeks —deafness remaining for both. Diagnosis.—The diagnosis of cerebro-spinal meningitis varies in difficulty and in the indications upon which it depends according to the ao-e of the patient and the stage of the disorder itself. In the case of young infants, especially when first attacked, there may be * Am. Jour, of Medical Sciences, July, 1867, p. 17. 918 DISEASES OF INFANTS AND CHILDREN. little else than the excessive painfulness on being touched or moved, and the constant moaning and distress, to show the exact nature of the disease. But these symptoms Avill suffice to excite suspicion, par- ticularly Avhen the case is otherwise obscure, and to render the physi- cian doubly cautious in his prescription. To start right is obviously of the first importance, or else by the time the error is discovered it may be too late to save the little sufferer. In children and older per- sons there are but tAvo symptoms Avhich, taken by themselves, may be considered as pathognomonic; these are the peculiar soft white fur on the tongue, with clean tip and edges, and the opisthotonos or torticollis. But Avith either of these symptoms will usually be found plenty of others corroborative; Avhile both of them may be Avanting in cases Avhere the totality of the symptoms leaves no room to doubt the nature of the disease. The remarkable violence of the primary attack, con- joined to the great obscurity of the Avhole case or total absence of any sufficient cause, may lead to the apprehension of the disorder in ques- tion. When the initial symptoms are still more pronounced and severe, although no one or even two of them may determine the nature of the disorder, the whole will speak in language too plain to be misunderstood by any physician, however inexperienced in this kind of pestilence, Avho shall have perused the resume of symptoms presented in a subsequent portion of this article. From diphtheria, Avhich resembles cerebro-spinal meningitis in its prostration and certain cervical symptoms, the latter disease may be distinguished by the absence of false membrane in the fauces; from typhoid fever by the petechial eruption appearing very much earlier in the former disease than in the latter ;* and the same early and even sudden onset of the gravest symptoms which characterizes severer forms of this disorder will also serve to distinguish it from the more gradually-arising simple meningeal or cerebral affections. The unusual sensibility and rigidity of the cervical spine will preclude the possibility of mistaking the nature' of any cases presenting these symptoms. Of course there is little danger of such a mistake during the prevalence of the epidemic disorder. Indeed, so powerfully does the epidemic cerebro-spinal meningitis influence the general health that, in the language of Dr. O. P. Baer, " From the commencement of this disease to the present time all our diseases of whatsoever type * In cerebro-spinal meningitis the eruption may appear in the first two or three days, seldom before the third week in typhoid fever. Dr. William Cole, London, 1702, mentions a case of epilepsy reported by Dr. Hobart, in which " the paroxysm ends in a great many red spots upon the forehead, which in a day or two turn black." CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 919 or order have had more or less of its marked characteristics, such as sudden attacks of stupefying, paralytic pain in the nape of the neck and doAvn the spinal column, accompanied Avith violent, throbbing headache extending from the occiput to the coronal region, often sending radiating pains around the whole chest, and even dovra the arms." * The real need of accurate diagnosis is for those sporadic cases which, arising unsuspectedly, occur in constitutions most predisposed to this kind of disorder, and therefore most liable to succumb to its influence. It is in order to provide against such contingencies that we have arranged in a schedule, corresponding to that of the Materia Medica, the symptoms compiled from more than two hundred cases hitherto recorded or occurring in our own practice. From cases re- ported by allopathic physicians those symptoms alone are taken which presented themselves before any treatment was commenced. In some few instances, as will be observed, mention is made of the day on which the particular symptom first made its appearance. This plan, if carried out, might show the progressive development of the dis- order in the less violent class of cases, but it Avould be found of little practical utility on the Avhole, since in many instances the gravest symptoms, those apparently of the most advanced stages, appear on the first day or two, sometimes even from the very onset of the disease. Prognosis.—The prognosis of cerebro-spinal meningitis should ahvays be very guarded. Much will depend upon the skill and ex- perience of the attending physician. The extremes of allopathic mortality and homoeopathic success may be found stated in notes at the beginning of this chapter. Recently Ave Avere called to treat a babe of nine months who had vomiting and diarrhoea, cough, excessive sensibility of the abdomen and Avhole body, intense thirst, bending backward of the head, stiffness of the neck and spine, petechial erup- tion and convulsions; these latter, however, Avere not very prominent, and seemed to result from debility; the mother could not lift the child from the cradle Avithout bringing them on. As convalescence set in the little patient was tormented, especially at night, Avith a bad cough and soreness in the lungs, but at the end of the second Aveek he was able to be placed on the floor by himself. This case is given to show the possibility of recovery even under hopeless circumstances. We add another, reported by Dr. J. F. Baker of Batavia, XeAV York: "A lad of eight years, Avhen at school, suddenly grasped his knee * Medical Investigator, vol. ix., p. 530. 920 DISEASES OF INFANTS AND CHILDREN. with his hands and screamed fearfully. Immediately aftenvard he was seized with convulsions and insensibility, the head being perma- nently retracted. There Avere high fever, A'omiting, dilated pupils, double vision, ashy paleness of the face, one diarrhoeic stool, and then constipation. Cicuta v. 2, once in two hours to once in twenty- four hours, cured in four days." * Pathology.—From notes of ninety-eight cases of epidemic cerebro- spinal meningitis,f reported by Dr. Githens, we take the following pa- thological resum6: " The post-mortem examination of several cases revealed marked evidences of blood-poison, with inflammatory tend- ency. The membranes of the brain were congested, there Avas serum in large quantity in the subarachnoidean spaces, at the base of the brain and within the membranes of the spinal cord. Fibrin Avas deposited along the margins of the longitudinal fissures of the brain, about the commissure of the optic nerve, in fact, freely all over the base of the brain; and in one case it could be separated in masses weighing from three to five grains from within the fissure of Sylvius, where it had firmly glued the two surfaces together. The quantity of this deposit of fibrin, its color, consistence and strength of attach- ment, Avere influenced chiefly by two causes observed during life. In some cases Avhere the inflammatory symptoms were of an active cha- racter, as shown by the congestion of face and eyes, the character of the pulse and the violence of the delirium, death occurred early, and an autopsy showed little or no deposit of solid lymph, but a large quantity of serum, and in one case pus, in all the serous cavities con- nected Avith the brain and spinal cord, with turgescence of all the vessels of the pia mater and nervous substance. If, on the other hand, death did not intervene so quickly, there Avere deposits of fibrin, becoming larger, firmer and more adherent in proportion to the grade of inflammatory action and the time alloAved for its coagulation. The deposits were of the same character as those found in the cavity of the abdomen after an attack of peritonitis. No particular lesion of the cord itself was noticed ; the membranes Avere congested, and there Avere small deposits of fibrin about the roots of the spinal nerves. The erector-spinse muscles Avere darker than normal, and softened. The blood was fluid, of the color and appearance of port-wine lees; under the microscope the corpuscles were shriveled and crenated, aud there Avas a space apparent between them, as they Avere arranged in rouleaux. There were, in tAvo cases, white, firm fibrinous heart-clots extending * Hahnemannian Monthly, vol. viii., p. 42, August, 1872. f Am. Jour, of Med. Sciences, July, 1867. CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 921 through both ventricles and auricles, and into the vessels leading to and from the heart." The particular results of post-mortem examinations in three cases are thus summed up by the same author: 1. "Very extensive deposits of fibrin and about five ounces of serum at the base of the brain; spinal cord congested, Avith deposit of fibrin beneath the arachnoid; a small quantity of pus round the cord in the cervical region." 2. " Large masses of closely adherent lymph at the base of the brain and on the medulla oblongata." 3. " Large quantities of tough, adherent lymphy deposits at the base of the brain." " I have ascertained," writes Dr. J. H. Bennett, " that Avhat is generally called a recent layer of coagulable lymph covering the con- volutions in meningitis is in point of fact a layer of pus." * Sequelae.—In order to bring the "symptomatology" in closer prox- imity to the "therapeutics" of cerebro-spinal meningitis, Ave place both the " pathology" and the " sequelae" out of the natural order. Parotidis, pneumonia, and even bed-sores, have been mentioned as among the consequences of this disorder. But the more direct and constant sequelae may be arranged in three classes: The first, in- cluding all paradytic symptoms—of "the loAver limb," "left foot" or other parts—reminds one of the analogous effects of diphtheria. The second (deafness) is equally suggestive of typhoid fever. The third (loss of memory), as a permanent result of acute disorder, is believed to be peculiar to the disease under consideration. Symptomatology. — Sensorium. — Delirium. Muttering delirium. Wild raving delirium. Wild and at times uncontrollable delirium, with jactitations, startings and incoherent cries. Constant delirium (first day); seems terrified Avith fearful apprehensions of impending evil. Wakes delirious; her mind wanders; she is apparently de- lirious, but on being questioned rouses up and ansAvers correctly. Slightly delirious all night, talking quietly about his family and business. Talkative delirium. Walking and talking delirium. Delirium on the evening of the first day, with frequent spasms during the nio-ht. Violent mania the second day; constant moaning and talking for forty-eight hours; the spine Avas completely arched, the hands thrown Avildly about, and he screamed so that he could be heard some blocks aAvay. Mind perfectly clear in an adult, although * Clinical Lectures on the Principles and Practice of Medicine. Third edition. Edin- burgh, 1859, p. 345. For further discussion of the various products of disease in the base of the brain, see Halmemannian Monthly, vol. iv., pp. 194-197. 922 DISEASES OF INFANTS AND CHILDREN. there is a slight deafness; face wears a peculiar anxious expression; the corners of the mouth are draAvn down; eyelids Avidely open, ghnng the eyes a staring appearance; the patient Avatches very nar- rowly the motions of his attendants, moving the eyes to keep them in vieAv, although the head remains in one position. Delirium, usually cheerful, singing or laughing, occasionally, hoAvever, screaming loudly, then relapsing for a short time into Ioav muttering; he had many short lucid intervals, and then Avas usually free from pain. Gentle, Avakeful delirium, or comatose, with low muttering. Stupor; never speaks except to answer questions, and then quite slowly. Sight, hearing and consciousness are evidently seriously impaired, and he appears to be verging upon a complete comatose and tetanic con- dition. Muttering and talking aloud all night until 9 a.m., fifth day —a patient that finally recovered. Stupid; ansAvering slowly Avhen spoken to; perfectly indifferent to all surroundings; half conscious; moaning while asleep; complains of general malaise; pulse Aveak; expression stupid and heavy. Stupor, with low muttering delirium; sensitive to light and noise. The child screams from the violence of the pain. Trembling as if the child Avere frightened and on the verge of spasms. (Verat. viride.) Loss of memory and deafness as sequela?. Head, Neck and Back.—Headache; obstinate headache; violent head- ache; headache increasing during the day; became almost insupportable toward evening; the pain is constant, very severe, lancinating, "jump- ing," in all parts of the head, especially in the region of the ears. Frontal headache; stupefying headache, Avith pressure in the eyes. In- tense cephalalgia, Avith a feeling in the frontal region as if the head would burst; the pain was continuous and increased by light and sound. Fulness in the occiput—the veins feel as if ready to burst; no pain in the forehead. Sensation in the occiput as if he had received a bloAV. Headache sharp and neuralgic, varying in location at first, but soon becoming settled in the occiput, followed by the backward draw- ing of the head; severe chill; terrible headache, extending from the occiput all over the brain, especially severe in the temporal regions; inability to bear the least noise or light; head drawn backward ; com- plained of headache, and Avas delirious ; head draAvn back upon the shoulders. Violent spasms ; head drawn back upon the shoulders. The pain in his head, he said, resembled the compression of a band of iron. Pain and tenderness in the neck along the back; pain in the head de- scribed as very intense, and located in the occipital and temporal re- gions ; continued intense headache; vertigo. CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 923 Pain at the first cervical vertebra, Avith sensibility to touch ; tonic spasms of the muscles of the neck, drawing the head back, and great tenderness of the cervical region of the spine; muscular pains in the neck and back, with stiffness of legs and back. Neck rigid. Neck stiff and sore ; pain on pressure over sixth cervical and second dorsal vertebrae; hips very painful and draAvn back. Rigid spine. Pain on pressure over the lumbar vertebrae; pain in the head, back, shoulders and legs on pressure OA^er third dorsal ver- tebra; muscular pains in limbs, back and neck ; head, neck and back involved ; the disorder commences with a violent chill, darting pain through the head, pain along the spine and bilious vomiting ; pain on pressure along the entire length of the vertebral column; the Avhole spinal column stiff and immovable, and severe pain in the head; pain and soreness in the back of the neck and occiput; neck rigid and drawn back upon the spine; strongly inclined to opisthotonos; the face is turned to the right side, and cannot be moved without greatly aggra- vating the pain (fourth day). Opisthotonos, in various degrees in differ- ent cases. Slight opisthotonos Avith subsultus. Marked opisthotonos, body forming an arch. Opisthotonos so marked that the body formed a bow, resting on the head and heels. Torticollis, neck stiff and sore; face turned to the left side and back upon the spine, strongly tending to opisthotonos (seventh day). Pain commencing in the back and pro- gressing upward toward the head; lies almost constantly upon his back; is unwilling to be moved (fifteenth day). He lies on his back Avith his face turned to the left side, and his head cannot be moved to its natural position or raised from the pillow without producing great pain; his right arm describes almost a complete circle several times a minute ; it is raised from his side to his head, the dorsal surface of his hand passing across his forehead, and then down to his side, Avhere it is alloAved to remain for a few seconds; his right loAver extremity is almost incessantly in motion; it is flexed, then extended outward, ren- dering it extremely difficult to keep him covered or in bed (third day). Picture of a closing scene, a man who died on the 22d day : "at three P. M., unconscious since morning; head thrown back; ret- roversion of the eyes; sclerotica much inflamed ; left side paralyzed ; right hand in constant motion; would swallow to 7 p.m.; hiccough constant- breathing stertorous; vomiting and subsultus tendinum; death at 11 A. M. Face and body became spotted all over soon after death:' * J^es.—Intolerance of light. Eyes congested. Eyes injected, with * U. S. Med. and Surg. Journal, July, 1872, p. 497. 924 DISEASES OF INFANTS AND CHILDREN. a brilliant and Avild look; pupils contracted and very sensitive to the light. Eyes injected and rolling about the sockets, Avith vacant ex- pression. Chemosis of the right eye; ecchymosis of the left. Con- juncth'a injected, and the Avhole surface of the body acutely sensitive. Conjunctiva deeply congested, with photophobia and a secretion of pus around the corner of the right eye; beneath the conjunctiva occur- red a large effusion of blood, disappearing on convalescence. Pus flowed from the eye on the third day. Eyes closed; pupils contracted. Eyes tightly closed ; marked pho- tophobia, pupils Arery much contracted. " Pin-head pupils." Pupils contract and dilate unequally. Pupil contracting and dilating by turns; on the approach of light it Avould contract for a moment, then immediately dilate again. The right pupil contracted, the left dilated, and appeared to dilate more under the influence of light. Eyes Avild and injected; the pupils contract, but oscillating. Pupils dilated, and next contracted on exposure to light. Double vision. Pupils fully dilated, but contract upon the application of strong light, to Avhich the eyes are quite sensitive (first day). Pupils largely dilated, but there is no photophobia (second day). During the first Aveek the patient Avas excessively annoyed by double vision; one or both eyes were most of the time turned toward the inner canthus. Photophobia so great that he kept his eyes closed almost constantly. Relief from keeping the eyes closed. Double vision; eyes have a peculiar vacant look (sixth day). Sight and hearing both much impaired. Eyes prominent and staring, and corners of the mouth draAvn doAvn. Wild look of the eye. Eyelids partially closed : eyes injected and rolling about the sockets; pupils contracted. Twitching of the muscles of the eyelids—not of the eyeballs. Bright spots before the eyes; disposi- tion to become frenzied Avith headache,, with pricking and numbness of the hands and feet. Strabismus, indicating an adAranced stage or very severe form of the disease. Loss of vision; eyes no longer sen- sitive to the light. Total blindness and deafness several days before death. Ears.—Intolerance of sound in the earlier stage. Partial deafness (sixth day). Total deafness in the last stage of the disorder. Con- siderable pain in the right ear, rather more than in the other parts of the head. Left ear deaf (eleventh day). The parotid glands Avere inflamed and suppurated; the right opened spontaneously into the ear; the left was lanced, very free discharge; deafness. Deafness is a not uncommon sequela. Nose.—Epistaxis, two or three times in the night (third day). CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 925 Repeated epistaxis. Frequent and constant epistaxis. Epistaxis and pneumonia as a complication. Face.—Face flushed. Expression dull and anxious. Countenance stupid and heavy, and seems indicative of pain. Eruption of erythema and petechiae on the face only. Petechial spots on the face and thorax, on the face and other parts. Ashy paleness of the face. Mouth, Tongue, Teeth and Jaws.—Corners of the mouth draAvn doAvn. Lips dry and cracked. Tongue red in the centre, Avhite on the borders. Tongue feels so sore that she cannot eat. Vesicles on the tongue. The tongue is at first clear, moist and enlarged, and covered Avith a white skin; soon it becomes coated Avith a black, dry crust; sordes form on the teeth. Constantly grating his teeth (second day). Tbngue coated with soft white fur, but clean on the tip and edges. Tongue coated with moist white fur, but clean at tip and edges; after- ward dry and brown (age 46; pulse 125; died on the third day after admission to hospital). Tongue brown and dry, Avith clean edges. Tongue dry and broAvn in a case resembling typhoid fever, but with eruption Avhich Avas petechial in character from the very first. Tongue pointed, dry, cracked and tremulous, but coated with a thick tenacious mucus. Tongue broAvn, dry and bleeding. Tongue broAvn and pasty. May be fissured or cracked. Tongue and breath cool, the former SAvollen and slightly coated. Tongue slightly coated and yelloAV. Tongue first Avhitish, then thick, brown and dry. The jaAvs Avere set firm part of the time, then they could be pried open.* Pain in the inferior maxillary bone. Does not articulate distinctly; speech slow and thick. Dumbness. In the more grave and malignant form of the disease the tongue may be broad and flabby, and indented round the edges by the pressure of the teeth. Tongue coated broAvn in the centre; brown and flabby; broad and flabby. When requested to put the tongue out, did so, but allowed it to remain Avithout return- ing it. Tongue, previously clean, is covered on the third day with a light-broAvn coating in the centre, Avith white edges. Large, flabby tongue. Tongue coated light broAvn ; increased flow of viscid saliva. Tongue coated Avhite, moist, quite swelled and sore on the right side, as if it had been injured. Excessive Aoav of viscid saliva. Consider- able secretion of thick, viscid mucus from the mouth (nineteenth day). Throat and Larynx.—Sore throat is frequently a premonitory symptom. Dysphagia. Dryness in the throat with dysphagia. He * H. Bennett, M. D., N. A. Jour, of Horn., August, 1867, p. 9. 926 DISEASES OF INFANTS AND CHILDREN. complained of sore throat, and on inspection a deep blue color of the Avhole mucous surface of the pharynx Avas disco\Tered. SeArere dry cough, often a precursory symptom. Cough, Avith pain in the hypogastrium. Cough excited by irritation in the chest. Cough and headache, Avith high feA^er iu the early stage of the disease. Cough aggravating the pain in the head and neck. Coughs more at night. Cough Avith expectoration of blood, at first coagulated, then bright. Expectoration of mucus and yellowish matter streaked Avith blood. Appetite—Thirst.—Loss of appetite. Appetite very good at inter- A'als of the unconscious state, even in the advanced stage of the disease and in hopeless cases.* Thirst.—Slight but continual thirst which Avater Avould not relieve. Severe thirst. Insatiable thirst. Stomach.—Distress in the stomach, nausea and bilious vomiting. Vomited (first day) every hour or tAvo during the night, until 8 a.m., a green Avatery fluid; vomiting of very green fluid com- menced in the P. m. of the second day. Vomiting all day. Frequent vomiting. Daily vomiting. Nausea, Avith severe chill. Nausea on motion. Occasional vomiting of bilious matter, with pain com- mencing in the back and progressing upAvard toward the head. During the night he vomited occasionally a green bilious matter. Vomiting of dark-colored matters (toward the last). Abdomen.—Abdomen, chest and thighs thickly covered with a red- dish-brown petechial eruption. Abdomen covered with an eruption consisting of small round reddish-brown spots about one-quarter of an inch in diameter. Petechial mottling on the abdomen and thighs. Slight hypersesthesia over the abdomen. She complained of pain in the head and loAver part of the abdomen—the latter not very acute. Marked abdominal hyperaesthesia. Abdomen rather sunken in. " Ab- domen caves in." " The belly is sunken." BoAvels perfectly flat and shaped like a boot. Stool.—Constipation. Constipation, although diarrhoea preceded the vomiting at first. Five small but thin and dark-colored stools daily. Diarrhoea. Involuntary evacuations. Urine.—Urine normal. Urine scanty and high-colored, and re- tained in some cases. The urine continues to be secreted, but the bladder becomes insensible to its presence, necessitating the use of the catheter. Urine dark, sufficient in quantity (fifth day). Suppression of urine (fifth day). Eleventh day, dysuria, milky, scanty urine. The third and fourth weeks Avere marked by entire inability to * Compare a similar condition in meningeal tuberculosis, Hahnemannian Monthly, vol. vii., p. 207. CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 927 urinate; the secretion was abundant, however, and was removed by means of the catheter. Incontinence of urine from paralysis. Chest.—Respiration increases to thirty or forty per minute. Res- piration irregular aud very laborious. Respiration labored and very noisy. Mean range from tA\enty-four to forty per minute. Very irregular in many cases; sometimes sIoav. A few rude and moist rales in different parts of the chest. Complicated with bronchitis; death on the twelfth day from choking up of the bronchial tubes Avith thick mucus. On applying the ear to the chest the bronchial sounds Avere dry and metallic. Most violent bronchial cough, with expec- toration and blood, in an old man. Irritation of the chest, exciting cough. Complicated with double pneumonia and epistaxis. Bron- chial complication in many cases. Coma, with labored, stertorous respiration. Female Sexual Organs.—Great and distressing bearing doAvn. Men- struation comes on, from which she had but just recovered the Aveek before. * Extremities.—Pain in one or more of the extremities of a violent character. Some hyperesthesia of the upper limbs, but no impair- ment of motion. Hands constantly clasped together. His right arm describes almost a complete circle several times a minute; it is raised from his side to his head incessantly. (See " Head, Back," etc.) Sub- sultus tendinum lasting for a Aveek in a man who recovered. Great sensibility of the lower extremities and pain in them; some sensibility of the upper extremities; moans. Extreme sensibility of the loAver extremities; cannot bear the slightest touch on any part of them; screams Avhen they are touched. Muscular pains in legs and arms. Pains in the calves of the legs, gradually traveling upward through the thighs and back until it reaches the head. Extremities cold, ex- cept in the exacerbation of fever. Coldness of the lower limbs ; coldness of the surface; hands cool; skin cold and clammy; hands and feet cold. (See " Fever" and "General Symptoms.") Very restless, con- stant motion of the arms and limbs; rapid movement from side to side (third day). Spasmodic tAvitching of the extremities Avhile asleep. Slight twitchings of the extremities. Paralysis, with pain and sore- ness of the feet&and limbs, from the fourth to the eighth week. The child grasps or pulls at its hair with its hands.f Frequent picking at the bed-clothes and reaching after imaginary objects (third day). Paralysis of the left foot as a sequela. Constant picking at the bed- * Chas. H. Carpenter, M. D., Trans, of N. Y. Horn. Med. Soc, 1869, p. 768. t H. F. Adams, M. D., Trans. N. Y. Horn. Med. Soc, 1868, p. 379. 928 DISEASES OF INFANTS AND CHILDREN. clothes and other clothes and whiskers of her husband while near her; seems to be reaching for something. * Sleep.—Slept uneasily, moaning while asleep; when aroused Avould grasp her sister Avith a sort of spasmodic movement, then become quiet and fall asleep again (when first taken). Complains of being unable to sleep day or night. Sleep comatose, or very distressing and exhaust- ing on account of frightful dreams. Morbid vigilance, ending in coma. Coma. Avith labored, stertorous respiration. Convulsions and coma alter- nated (third day). Stupor and coma Avere constant several days before death. Appears to be asleep, but if spoken to opens her eyes and replies. Fever—Pulse.—High fever, pulse 130 and small. Pulse increases from 95 in the A. m. to 110 p. m. Pulse 140 to 150. Pulse sIoav and of little volume—not over 50 per minute. Temperature Ioav. Pulse very slow, sinking sometimes to 48 or 50 per minute. Pulse perfectly normal (Avhen comatose, blind and deaf), a very unfavorable symptom, f The pulse is at first sIoav, then accelerated, but diminished in volume and strength; respiration is slower than natural in many cases ; the skin has almost ahvays at the beginning an abnormally low temperature. Pulse strong and irritable, varying from 116 to 120. Pulse 100 in A. m., 112 p. m. Pulse entirely imperceptible. Pulse- less, Avith unconsciousness and cold surface. When first taken he was suffering from a very intense and pro- longed chill, his teeth were chattering, and he AAras trembling with cold ; the Avhole surface of the body was blue. Chill every second day, followed by high fever; then fever followed by sweat. Frequent recurrence of chills in the course of a protracted case; chill in the P. M. of the 7th, 16th, 18tb" and 24th day in a patient who recovered.^ This disorder may folloAV and apparently result from intermittent or ma- larious fever. Some cases, hoAvever, which were at first supposed to have originated in ague, are found to have been in reality spotted fever from the first, the chill being no more than belongs to this lat- ter disorder. Great coldness of the surface. Remarkable coldness of the lower limbs (afterward of the whole body), and yet the child will not bear to be covered; if the clothes are drawn over her, even Avhen she is ap- parently asleep, she immediately becomes restless and kicks every- thing off. Skin.—Purple spots on the legs; dark, petechial eruption in pretty * J. T. Wallace, M. D., Trans. N. J. Horn. Med. Soc, 1870, p. 442. f Am. Jour. Med. Set',, July, 1866, p. 56. X H. M. Paine, M. D., Trans, of N. Y. Horn. Med. Soc, 1867, p. 132. CEREBRO-SPINAL MENINGITIS—SPOTTED FEVER. 929 large spots all over the body. Early in the disease, in some cases, the first symptoms pointing to a grave form of the disease are the appearance on the face and thorax, also on the extremities, of pete- chial spots, varying in size and number; in some instances there are but few spots, and these rather obscure; in others the whole surface is covered. In a few cases this eruption was absent until after death, and in one or tAvo cases it was not observed at all.* The eruption ap- pearing only after death will mostly occur in the case of young infants, Avhose delicate systems succumb to the disorder before its ulti- mate pathological changes are manifested. The petechial spots are due to the failure of nerve-power to carry on the capillary circulation.! Eruptions of bright cherry spots OA7er the whole surface of the body, more numerous on the hands and arms; chest and abdomen thickly coA7ered with an eruption consisting of small round, reddish spots about one quarter of an inch in diameter; chest, abdomen and thighs thickly covered Avith a small petechial eruption, not at all raised, or disappearing on pressure. Eruption of erythema and urticaria in a case in Avhich the other symptoms were Avell marked. Eruption of erythema and petechwe. Copious eruptive exanthem, changing to pete- chia?. Surface cool, and mottled Avith purple spots, some as large as a split pea, others again as large as a fifty-cent piece; surface bluish, presenting a mottled appearance; cool and bedewed with damp per- spiration. "Dark spots like bruises would appear on the body and limbs, and. in some cases in twelve or twenty-four hours the attack would terminate in apoplexy and death."J The surface maybe dry, or moist as if with some little perspiration. "On the morning of the ninth day, the third after the chill, nu- merous irregular, deep-red spots were observed on the Avhole surface of the body. They varied in size from a pin's head to half an inch in diameter, and Avere more numerous on the hands and arms than on any other part of the system. The color did not disappear on pres- sure, neither were the spots sensitive to the touch. They remained four or five days, gradually turning to a deep mahogany color, and finally disappeared." This case proved fatal on the twenty-first day. § General Symptoms.—Complains of feeling sore and tired in all parts of the system (third day). " So tired" (fourth day). Profound pros- * B. F. Joslin, M. D., Trans. N. Y. State Horn. Med. Society, 1870, p. 430. f Hahnemannian Monthly, vol. iv., p. 251. X L. Stanton, M. D., "Spotted Fever" of Carthage, Jefferson co., New York, of 1865 : Trans, of N. Y. Eclectic Med. Society, 1868-69, p. 483. § H. M. Paine, M. D., Trans. N. Y. Horn. Med. Soc, 1867, p. 134. 59 930 DISEASES OF INFANTS AND CHILDREN. tration, much greater than the other symptoms Avould seem to Avarrant. Utter prostration and terrible headache. General feeling of uneasi- ness, with thirst and loss of appetite. Hyperesthesia general or in particular places, sometimes confined to one side or limb. Anaesthesia. Complains of general malaise. Every movement is painful. Great suffering, frightful screams and groans almost continuous. Suffers from pains, a buzzing in the head and soreness. Feels cold; skin cool. No pulse to be felt; great prostration and great sensibility to the touch. At intervals the child Avould appear perfectly Avell and free from any distress or morbid symptom. Symptoms of the most formidable character may present themselves at the very outset of the disorder, and intermissions of a periodic nature—apparently complete relief from all sufferings—are not uncommon in its course. Involun- tary twitchings of the muscles and want of prehension. Restlessness, with much tossing. The child has constant crying and restlessness; head hot, extremities cold; clonic spasms. Aggravation from being moved. Cannot be moved on account of extreme sensitiveness to the touch. Remarkable coldness of the lower extremities, subsequently extending over the AArhole body. Spasms. Unconscious; face flushed; cold extremities, with drawing back of head to right side; spasm about every ten minutes, during Avhich the head would be draAvn completely down on the shoulder, also rigidity of the Avhole body. Opisthotonos, with hands clenched and occasional cramps of the extremities. Marked opisthotonos, the body forming an arch. Paralysis. Vital, force Avorn out; death from exhaustion. Characteristics.—As already stated, some few of the symptoms of cerebro-spinal meningitis are pathognomonic almost individually. Such are the peculiar white furred tongue with clean tip and edges; tongue swollen, broad and flabby, the early appearing petechial, opisthoto- nos and torticollis. Of the following, no one or two would necessarily indicate this dis- order, but several occurring together would do so very strongly : Headache. Delirium. Sensibility at the base of the brain and pain- ful stiffness of the cervical spine. Eyes congested, staring, double vision, early loss of sight. Deafness. Tongue broAvn and dry, with clean tip and edges. Sore throat. Cough. Bilious vomiting. Ab- domen sunken. Constipation. Great coldness of the loAver limbs. Pulse sIoav or very quick. Commencing chill. Severe pains. Hyper- cesthesia excessive, general or local. Aggravation from being moved, not from self-movement. Prostration. Restlessness; constant motion. Paralysis, deafness and loss of memory as sequelae. cereero-spinal meningitis—spotted fever. 931 Treatment. Aconite. At the onset of the disease, Avhen there is much fear mani- fested, restlessness, no position is satisfactory, thirst for cold water, act- ive inflammatory symptoms, particularly in plump and full-blooded patients. iEthusa. Very nervous. Delirium, particularly with visions of dogs and cats. Lancination and throbbing in the occiput. Feeling of contraction of the hairy scalp. The head inclines to fall back- ward ; brilliant, injected eyes; fixed look; lancinating pains down the back. Linea nasalis. Features express great anguish; face puffed and spotted with red. Aphthae and pustules in the throat. Violent vomiting of frothy matter, sometimes white. Abdomen tight and hard. Constipation; anxious respiration; dark spots more or less numerous all over the body. Great prostration. Irregular or imper- ceptible pulse. Apis mel. Great restlessness and tossing which affords no relief. Crying oid and screaming loudly as from stabbing pains. Irritable disposition; great pain in the occiput. Sensation of stiffness in the neck and back. Scanty urine; great dyspnoea, and sensation as if every respiration would be the last; seldom any thirst; numerous spots or little elevations all over the body, red or purplish. Smoky opacity of the cornea and obscuration of sight. Constipation. Stu- pefaction and stertorous respiration, with an occasional start as if from a sharp pain. Aggravations at night, especially after twelve. Argentina nit. If there be epileptiform convulsions, each one of which is preceded by great restlessness. Arnica. Great heat of the head, Avhile the body is comparatively cool. Very restless ; sensation of soreness as if bruised. Diarrhoea, often involuntary. Purple spots appear here and there. Frequently aAvakens with much heat in the head. A low state of the system. Arsenicum. Great restlessness and frequent calls for cold Avater, only a sip of Avhich is taken ; aggravations at night, after twelve par- ticularly ; much exhaustion after every movement; cold, chilly, wishes to'be covered, even when very warm. Purple spots appear on the skin. At night the delirium, the tossing and the expressions of anguish are truly alarming. There is often cold perspiration and sometimes cold breath. Belladonna. Face is flushed; eyes injected; throbbing of the caro- tids- skin hot, so as to impart a burning sensation to the hand; great muscular jerking and twitching during sleep; grinding of the teeth; inclination to bite. 932 DISEASES OF INFANTS AND CHILDREN. Bryonia. Aching all over; head aches as if it would burst; desires to keep very still; dreads motion, because it hurts, though he must move occasionally. Very thirsty for large drinks of cold water; worse in the evening till after twelve at night. Pain in back of neck, in the back, at the shoulders and under the shoulder-blades, particularly the right. Purple spots appear on the skin. Constipation of hard, dry, black stools. Bu& sah. Great anguish; lancinations in the occiput inclining the head to fall backward. Beating of the heart reverberates in the ears. Red or purplish streaks in the neck, back, or in other parts. Camphora. When there is great coldness and paleness; the skin seems cold as marble,, yet the patient does not desire covering; often cramps in stomach, and the pulse small, weak and slow. Cicnta \dr. Moaning and complaining; pupils dilated or contracted; dumbness; deafness; dysphagia; ashy paleness or bluish face; cramp in the muscles of the neck, Avith inability to move or turn the head; head drawn back, with stiff neck. Trembling or starting and jerking of limbs; irregular respiration ; starting at the least noise; violent jerks in any part or throughout the whole body; rigidity of the spine; strangulation on attempting to drink; violent convulsions, after which the patient lies as if dead for some time; trismus in some cases. Cantharis. Paroxysms of rage and fury; pain deep in the brain, with an expression of great suffering in the countenance; the base of the brain is the chief point of pain. Urine dribbles or passes in drops, Avith burning, cutting pain. Cocculus. Indicus. Violent headache with persistent vomiting; ver- tigo and semi-consciousness; painful stiffness of the neck when mov- ing it; complete paralysis of the lower limbs. Cuprum. AVhen the convulsions commence distinctly in the ex- tremities. Gelseminum. When the attack is ushered in by blindness, then head- ache and a feeling as if a band were around the head; hardness of hearing ; loss of speech or very Aveak voice; trembling and weakness of limbs; drowsy; itching of head, face and neck; if perspiration sets in, it relieves the symptoms. Glonoine. Pains seem to ascend from the chest and neck to the occi- put ; pain the whole length of the spine; oppression of the chest; blindness, with; faintness and nausea; congestion to the head with sense of expansion. Can't bear heat about the head. Hydrocyanic acid. Insensibility, with half-open eyes, dilated, immova- CHOREA—ST. VITUS'S DANCE. 933 ble pupils; roaring in the ears; bloated and bluish face; tongue paraly- zed and sometimes protruded; loss of speech; rattling, slow respira- tion ; heat in the head; general coldness of the body ; great prostration. Hyoscyamus. Indomitable rage, horrible anguish; complains of hav- ing been poisoned ; loss of consciousness; loquaciousness; staring and distorted eyes; cannot see; bluish or brownish-colored face; trismus; foam at the mouth; inability to swalloAV; retention of urine; stiff neck, sometimes with torticollis; brown or black spots or vesicles on the surface of the body. Lachesis. Great depression of spirits and apprehension of death; aggravation of the symptoms as soon as sound sleep is obtained;; the neck is stiff, and so sensitive that the least touch is painful; blue spots or blue blisters on the skin; epistaxis; haemorrhage from the bowels, of decomposed blood; great prostration, and very great weariness. Lycopodium. Desire for company; irritable and peevish on awaken- ing from sleep; headache, with pain extending down the neck; great weakness, loAver jaw often hanging down; acuteness of hearing and smell; SAvelling of tongue; much flatulency; red sand in the urine; pain in back before urinating. Nux vomica. Tendency to paralysis of the limbs; fear of sleeping on account of the frightful character of the dreams; sudden shocks from some one portion of the body to the brain; hypochondriasis, Avith irritability of temper. Opium. Stupefaction; eyes fixed and half closed, immovable pupils; staring, glassy look; face bloated; tAvitching of the lips; stertorous breathing; intense thirst; abdomen hard and bloated,; opisthotonos ; hot SAveat; tAvitching and jerking of the limbs. Plumbum. Great sinking of the pulse, even down to 40, and early paralysis of the limbs. Phosphorus. Where there are pneumonic combinations indicating this remedy. Pulsatilla. Mild, gentle disposition ; inclined to weep; very restless; no thirst; Avishes to have the doors and windows open; pain in the back on SAvalloAving; stiffness in back of neck; much pain in turning the head to either side; sleeplessness Avith great desire to sleep ; almost constant crving out or moaning; cough, Avith pain in the back; pain in the back at every motion. Rhus tox. Great restlessness, Avhen every change of position affords temporary relief; feels very tired; bleeding of the ears and nose; pain in the back as if sprained; tearing pain down the legs; feeling of stiffness in muscles and joints; eruptions, Avith itching. 934 DISEASES OF INFANTS AND CHILDREN. Stramonium. The patient is either in a supplicative mood, pleading for help, or is \Tery irritable, Avith raving and disposition to strike, bite, or injure others; staring eyes; shrinking look, as if from fear; raising of the head from the pillow and falling back again ; desire for light and company; loss of voluntary motion, stiffness of the whole body, or there may be violent motion of the limbs. Sulphur. When patients are very liable to relapse. Tartar emetic. Great drowsiness; nausea; cough with much rattling of mucus; pulse full, hard, quick and trembling. Veratrum album. Cold sweat all over the body, vomiting, with cramps in the stomach; great thirst for icy cold Avater; muscles of the neck too weak to support the head. Pulse irregular, very weak and slow; coldness predominates; great debility persistent; there may be also cramps in the legs; Avants to escape from the bed; heaA7y, comatose sleep. Consult also the remedies, and their indications, laid doAvn for Diseases of the Brain, page 909. In this grave disease I have the best success from using remedies ranging from the 200 always Avithholding the remedy at every amelioration, and usually repeating at every aggravation. Chorea—St. Vitus's Dance. Chorea is a disease characterized by irregular spasmodic contrac- tions of different muscles or sets of muscles, especially those of the upper and loAver extremities; these irregular movements being not altogether involuntary, Avhile they exhibit an inability to properly co-ordinate muscular movements. It occurs most frequently in chil- dren from five to twelve years old, and in girls much more frequently than in boys. The generally rapid growth and the accession of second dentition Avithin the above years are supposed to be, and no doubt are, the chief predisposing causes of chorea. It occurs, however, most frequently in connection Avith, or as a consequence of, rheumatic fever. " M. See asserts, after much examination of this subject, that one-half of the cases of chorea are dependent upon the rheumatic poison. Thus, of one hundred and nine cases of rheumatism admitted into the Hopital des Enfants, he found that sixty-one were complicated Avith chorea. Trousseau also states that in his experience rheumatism Avas undoubtedly the most marked cause of chorea. M. Henri Roger asserts their connection even more strongly, and states that ' the co- incidence of chorea and rheumatism is so common a fact that it ought to be regarded as a pathological law, just as much as the coincidence of heart disease and rheumatism.'" Exciting causes are—terror, CHOREA—ST. VITUS'S DANCE. 935 irritation, violent mental emotions, such as anger, onanism, dys- menorrhcea of puberty, injuries to the head, Avorms, etc. The disease has also been knoAvn to occur during, or to folloAV after, attacks of various acute diseases, such as typhoid fever, pneumonia, etc. Preg- nancy is a not unfrequent cause of chorea, but the disease thus occa- sioned has been referred to elsewhere. The pathology of chorea is A^ery obscure. As yet there has been no anatomical lesion determined Avith sufficient accuracy to be acceptable as a solution of the singular phenomena presented by the disease. The general results of post-mortem examinations, so far as ascertain- ing the cause of the disease is concerned, have been decidedly negative. Symptoms.—The agitation of the muscles is generally confined to a group, usually amongst those of the upper part of the body; sometimes but one side is affected ; sometimes an arm of one side and a leg of the other. Sometimes the jerking and twitching, Avhich commences with a single group of muscles, extends until the Avhole body becomes Ado- lently agitated. The patient loses control over the affected arms and legs; cannot convey food to the mouth ; walking is more or less diffi- cult, and sometimes even impracticable. The child often falls Avhile Avalking, or runs in an irregular and zigzag direction, as though by fits and starts. " The convulsive movements of the face and head are not less singular than those of the limbs. The face is distorted into all kinds of expressions, so that it assumes by turns that of the most opposite emotions—sadness, terror, joy or grief. The mouth is opened and shut, or its corners draAvn apart, with the greatest irregu- larity ; the tongue is occasionally protruded between the teeth, and sometimes moved rapidly in the mouth, so as to cause a clacking sound ; the lower jaAV is depressed and elevated, or moved in a lateral direction, and with such violence perhaps as to injure the tongue and teeth. In consequence of the irregular motions of the tongue and mouth, articulation becomes difficult, and the child either stutters or speaks sloAvly and badly, or can pronounce only monosyllables. . . . While the face and limbs are contorted, the head is moved rapidly from side to side, or backAvard and forAvard, or undergoes constant rotation. In severe cases the choreatic movements affect the trunk also so that the patient cannot lie upon a bed, but rolls and tAvists about the floor Avith such violence as to bruise and excoriate the skin."—Meigs and Pepper. The above account describes a Avell-developed case of chorea, but in some instances the symptoms are developed in a milder degree, while in others they are much Avorse than those described. 936 DISEASES OF INFANTS AND CHILDREN. Chorea, as ordinarily developed, will run along for a longer or shorter period if left to itself, until it reaches its height, when the symptoms will gradually subside, and finally disappear. Under homoeopathic treatment, hoAveA'er, the disease is greatly mitigated and health is restored, while in others, again, the attack is cut off short by the appropriate medicament, and a cure effected in a few days. Relapses are quite common. It is sometimes a fatal malady, hoAvever, especially when attacking \rery delicate children, or when there is serious cardiac or other involvement. " In fatal cases the symptoms are constantly aggravated; the movements become so Ariolent as to make it necessary to secure the child in bed or in a strait-jacket; the patients, deprived of sleep, become feeble and emaciated; the res- piration becomes difficult; intelligence is abolished; the pupils are contracted, and the child dies." Treatment.—The folloAving remedies are especially useful in the treatment of chorea, but the practitioner should not confine himself to the list here given: Aeon. After a fright and the child remains unnaturally timid; un- usual fatigue may have been the cause; much trembling of the ex- tremities; it may have resulted from exposure to a very cold, dry atmosphere. Agaricus m. Itching spots on the skin like chilblains; a variety of involuntary movements in the waking hours; perfect freedom from them during sleep. Bell. The motions of the body are generally backward, sometimes quite extreme; boring of the head into the pillow; grinding of the teeth; moaning; injected eyeballs; flushed face usually attends the development of other symptoms. Calc. C In leucophlegmatic children; after a fright the child falls doAvn easily ; during second dentition. Caust. Child not exempt at night; often prevents sleep; right side of face and tongue often paralyzed; twisting and jerking of limbs; constipation. Cina. Very peevish and irritable; picking of nose; ravenous appe- tite ; urine turns milky on cooling; child loses its playfulness, and has no pleasure in anything. Cicuta. The attacks twist the child into the most curious and some- times frightful contortions, sometimes causing it to scream out. Cimicifuga. Besides the twitching and jerking there are nervous tremors apparent; the motions are constant, but confined to one side; CHOREA—ST. VITUS'S DANCE. 937 all quiet during sleep; great difficulty in SAvalloAving; often confined to left side. Cocc. Right arm and right leg principally affected; all quiet during sleep; legs become more and more useless. Crocus. Jumping, dancing, laughing, whistling; very affectionate, Avants to kiss everybody ; nose-bleeding, of dark stringy blood. Cuprum. The tAvitchings and jerkings are often perceived to com- mence in the fingers; cramps often attend; often affect only one side; the attacks are often painful; attacks one side, and then spreads over the Avhole body. Hyos. Seems very silly and laughs at everything, sometimes immod- erately ; head seems to fall from side to side; don't care to be dressed or coArered. Ignat. After fright with grief; Avorse after eating; relieved by lying on the back; sighing and sobbing are often characteristic. Laurocerasus. The child seems violent and destructive in its motions; the speech becomes indistinct Avhen the child seems angry because not understood; it can neither stand, sit nor lie on account of the inces- sant motion ; gasping for breath ; Avasting away. Lycop. Red sand in the urine or the urine stains everything red; very feverish and fretful, particularly on Avaking from sleep. Nat. mur. Paroxysms if jumping up high ; jerkings of the right side and of the head; from a fright or the suppression of eruptions of the face. Nux V. Loss of appetite and constipation; worse in the early morn- ing; despondency. Opium. Convulsive movements of one or the other arm to and fro; the left arm trembles in paroxysms; constipation of round black balls; the twitchings continue during sleep. Phosph. During rapid groAvth tall and rather slender; Avalks like one paralytic; very weak. Secale. The muscular twitchings usually commence in the face and spread thence all over the body, sometimes increasing to dancing and jumping. Sepia. Ringworm eruptions on the skin; stammering speech; con- stant desire to change from place to place. Sticta. The disease seems to develop itself mostly in the feet, causing one to dance and jump around; even when lying down the feet move about in the air. Stram. The motions are rather violent and crossAvise; inclination to 938 DISEASES OF INFANTS AND CHILDREN. pray and beseech; stammering speech, or loss of speech; often puts the hands to the genitals. Sulphur. Particularly after suppressed eruptions, or if the skin is very full of eruptions itching very much in the \vrarmth; faint, hun- gry spells. Veratrum viride. Unusual twitchings and contortions of the body, unaffected by sleep ; a little froth constantly at the lips ; chewing of the teeth during sleep ; difficulty in swalloAving. Zinc. Characterized by a fidgety condition of the feet Avhilst lying in bed; jerks through the Avhole body during sleep, sometimes with screaming. Infantile Remittent Fever. That form of disease long known as infantile remittent fever might more properly be designated typhoid fever. It is, at all events, a fever having a typhoid type and tendency, whatever may be its occasioning cause, but differing greatly in degree in different cases. It is a disease very frequently met Avith, particularly during the fall and spring months, seldom attacking children under two years of age, and proving, in some instances, very intractable, even under the most careful management. The disease commences with languor and debility; the child com- plains of feeling tired, and will leave its play to lie doAvn on the sofa or floor; there is general malaise and want of childish cheerfulness, loss of appetite, more or less coating upon the tongue, and in some cases there is diarrhoea, while in others constipation exists. After these symp- toms have lasted for a few days or a Aveek or more, febrile symptoms are ushered in, frequently commencing Avith flushes of heat, alternating Avith coldness and shivering; the pulse is quick and full, there is nausea and sometimes vomiting, headache, drowsiness, red eyes or a heavy appearance of the eyes; moaning, starting and crying out dur- ing sleep; muttering delirium ; the urine voided is dark-colored and scanty, and if there be diarrhoea the stools are usually dark-colored and offensive, sometimes Avorms being passed with the stools; the ab- domen is distended, and sometimes tender of pressure; the tongue usually becomes red at the tip, and dry. As the fever runs higher the body becomes very hot, the heat being especially great in the palms of the hands, and often in the soles of the feet, and the respiration is short and quick. Sometimes a slight moisture may be perceived upon the skin, Avhich, hoAvever, lasts but a short time, and there are frequent remissions of the symptoms, especially the fever, and then a con- infantile remittent fever. 939 tinuance for some time longer, to be followed by other temporary re- missions or gradual recovery. These remissions do not amount to a complete apyrexia, but during their continuance the child seems better and brighter in every way, although in some cases there is more irri- tability during these periods, Avith picking at the lips, tongue and fingers, and picking and boring at the nose until it bleeds. After the disease has lasted for ten days or two weeks there may be a more de- cided period of remission, which will continue into convalescence, or the feA-er will return Avith its former force, together Avith the other symptoms, and the disease will run on again. If convalescence sets in, the pulse runs doAvn gradually from 160 or 120 beats per minute until it approaches the normal standard; the skin becomes softer and moist Avith perspiration ; the tongue gradually cleans off; the urine loses its high color and begins to deposit a sediment, and there is a general cooling of the body. The thermometer will be very useful in determining the degree of remission, as well as heralding the onset of com^alescence. If the disease lasts for any great length of time, the patient becomes very much emaciated. Frequently cases presenting most, if not all, of the above symptoms in a much milder degree are met with, in Avhich there is a remission almost amounting to complete apyrexia every day, generally in the morning, and the child may be comparatively well and as cheerful and playful as usual during the morning, until toward noon, Avhen it will begin to droop again, the fever will come on and run very hio-h until after midnight or toward morning again, when another amelior- ation and remission of symptoms will occur. This form of fever is especially associated in the minds of the people with the presence of " AArorm« " in the intestinal canal, and in such instances the common opinion is generally correct. Such a fever—worm fever—may be mild or otherwise, even reaching to the intense degree Ave have first described. This disease may not only be complicated with the presence of worms in the alimentary canal, but Avith other diseases, such as aph- thous sore mouth, violent and prostrating diarrhoea, inflammation of the lungs or bronchia; and symptoms resembling hydrocephalus may arise during its course, increase its gravity, and render a fatal termina- tion not unlikely. Its causes are of course both predisposing and exciting. Children of a scrofulous diathesis, and Avhose organs of digestion give evidence of being Aveak, are most liable to be attacked by the disease. Living in a damp house or in a neighborhood exposed to the influences of 940 DISEASES OF INFANTS AND CHILDREN. marsh miasmata or of stagnant Avater is also a predisposing, and may be an exciting, cause. Worms and other forms of intestinal irritation and exposures to cold and Avet are the chief exciting causes. Treatment.—In most cases this disease, especially when it sets in mildly, may be cut short by judicious medication. The following remedies are most frequently required for its treatment, from which that one should be selected Avhich is homoeopathic to the case: Aconite. Hot, dry skin; thirst; sleeplessness; restlessness and dis- tress during the febrile stage. Antimonium c. White tongue; frequent vomiting and Avatery diar- rhoea, or lienteria. Apis. Red points scattered over the body here and there; absence of thirst. Arsenicum. Much restlessness and tossing after twelve at night; putrid, undigested stools; symptoms of nervous exhaustion set in, with unquenchable thirst; great heat in the bowels; aphthae. Belladonna. Much moaning, starting and jumping; very flushed face; red eyes; great heat of the head, and other symptoms of cere- bral congestion. Bryonia. Parched lips; dry mouth ; dry and burnt-looking stools, which are passed but seldom; Avants to be kept very still; cries if moved ; the symptoms are Avorse at night; the child gets giddy and sick if raised up; there is a typhoid tendency. Calcarea C Leucophlegmatic constitution; open fontanelles; SAvell- ing at the pit of the stomach, like a saucer turned bottom up ; profuse SAveat about the head. Chamomilla. Wants to be carried all the time; one cheek red, the other pale; cross and irritable; stools smell like rotten eggs, or are green and yelloAv; very sensitive to pain; dyspnoea ; bilious vomiting. China. Worse every other day. Cina. Picks its nose; desires many things, which it refuses Avhen they are offered; nothing pleases or satisfies the child; after standing awhile the urine turns like milk; cerebral symptoms, with dilated pupils, shrieking out during sleep; squinting; alternate paleness and redness of the face; colic, costiveness and vomiting; worm symptoms. Colocynth. Spells of colic pain, in which the child curls up double, and writhes and cries very hard. Gelseminum. The symptoms are Avorse at night; the face is dark red or has a dusky hue; there is a great deal of nervous restlessness; vertigo, the child complains that it is falling; sensitiveness to light DIPHTHERIA. 941 and sound; defectiveness of sight and hearing; inability to move the limbs in obedience to the A\Till. Ipecacuanha. One constant nausea, not relieved by the vomiting; loss of appetite ; general gastric derangement. Magnesia c. Constant, sour, rather Avhitish, Avatery diarrhoea. Mercurius. Tenderness of the pit of the stomach and abdomen; green, slimy stools, with tenesmus; is not much relieved by perspira- tion ; yellowish tinge of the countenance; the urine is dark and of- fensive ; sore mouth. Muriatic acid. The fever assumes a Ioav type; the patient is very much prostrated, and sinks doAvn in the bed ; there are evidences of intestinal ulceration. Nux V. Ahvays worse toAvard morning, and in the morning; no appetite at any time; the child is very cross and irritable; flatulence and pain in the abdomen ; better in the morning ; constipation, large, difficult stools. Pulsatilla. Vomiting of mucus; stools variable in color; worse toAvard evening ; no thirst; the child refuses the breast. Phosphorus. When there is much cough and rather a typhoid type seems to threaten ; diarrhoea; distension of the abdomen. Rhus t. The tongue appears dry and brown, and the child seems very Aveak, and very restless through the night; trembling of the hands ; pains in the back and limbs. Sulphur. The fever seems to exacerbate in alternate flushes and paleness; the child has weak spells; the skin is scaly; intertrigo is easily provoked. Tartar e. Much nausea and vomiting, day and night, with drowsi- ness ; red, itching rash over the body, developed by the fever; diar- rhoea. Diphtheria. Diphtheria is an epidemic specific disease, and is to some extent infectious. It runs a very rapid course; is characterized by remark- able prostration, the formation of a false membrane on the tonsils, uvula, palate, the nares and other parts of the body, and in some cases with remarkable nervous symptoms. In some epidemics of this disorder there is an equally characteristic external eruption, " Avhich appears in the form of a rash and is sometimes of a dark or purplish color bearing a close resemblance to that of measles; at others, bright and scarlet, as in scarlet fever."* There may be considerable SAvelling in the external throat and sides of the neck; such cases are * Ludlam on Diphtheria. 942 DISEASES OF INFANTS AND CHILDREN. usually severe, if not malignant, Diphtheria is a disorder which may be very mild or exceedingly malignant, and almost universally fatal. To Avhat extent this disease is infectious and contagious does not yet appear to be a settled question. It occurs at all seasons of the year, but is particularly prevalent during the fall and winter months, the minimum of cases occurring in Philadelphia in June. Bretonneau, Avho was one of the earliest writers on diphtheria, re- garded the disease as a local affection, and the constitutional disturb- ance manifested during its course as secondary. It is, however, noAV generally admitted that diphtheria is a " blood disease," with very decided systemic disturbance, which is very generally of a decidedly asthenic character. Bouchut, in his treatise on diseases of infants, divides diphtheria into two varieties, one of which he regards as false and non-infectious, or a mere pseudo-membranous sore throat, while the other he regards as true diphtheria, which is a constitutional dis- order, involving the entire system, having infectious powers. The pseudo-membrane of diphtheria, which is one of its most con- stant and remarkable phenomena, is a fibro-plastic membrane, which commences as a sero-mucous, transparent and viscid exudation, Avhich gradually acquires color and consistence until it becomes a somewhat dense and strongly adherent membrane, Avhich is, however, very friable. The color is variable, according to the seat of the deposit and the length of time which has elapsed since its formation; it is, however, generally of a white, grayish-white or yellowish hue. " In severe cases there is usually a bloody sanious fluid effused which imbues the pseudo-membrane, discolors it and promotes its decomposition, so that it forms dark-colored shreddy patches, exhaling a foetid gangrenous odor. Sometimes the mucous membrane of the throat is seen to be reddened and swollen before an exudation takes place, and Avhen the membrane is detached it has the appearance of being raw and somewhat bloody. In most cases the mucous membrane itself is not ulcerated but only inflamed and SAvollen. There are cases, however, in Avhich very extensive ulceration and sloughing of the throat-tissues occur. All cases of diphtheria may be divided into those Avhich are mild and those Avhich are malignant. Fortunately the mild cases are most numerous, and yield readily to appropriate treatment. They are characterized by slight membranous deposit and a mild form of con- stitutional disturbance, with more or less difficulty of deglutition pain in the throat, pains in the limbs, etc. It generally comes on insidiously; the fever sets in, but the appetite remains good and the strength is not impaired. Sometimes, in these mild cases, there is DIPHTHERIA. 943 very little or no complaint of difficult deglutition or pain in the throat, and this the physician should bear in mind, otherwise mild cases of diphtheria may be allowed to assume malignant proportions or to run into diphtheritic croup, Avith perhaps a fatal termination. These cases are generally very amenable to treatment, and the only danger arises from the possibility of the exudation extending into the larynx in consequence of the true nature of the disease not having been detected in time to prevent it. The more malignant form of diphtheria is ushered in with severe rigors and high fever, vomiting, and sometimes purging, great rest- lessness, anxious expression of countenance and great prostration. Soreness of the throat, Avith difficulty of SAvalloAving, is complained of, and upon examination the diphtheritic condition is detected. The fever subsides, leaving the surface of the body pale and of an un- natural coolness, the pulse remaining quick, but weak and com- pressible; and there is a general appearance of a profound depression of the vital forces. The child's mental condition is usually not much disturbed, although it may be dull and indisposed to play; during sleep there may be muttering delirium. There are few symptoms in- dicative of gastric disturbance excepting loss of appetite. The urine is generally scanty, and often albuminous. The submaxillary glands usually become enlarged, sometimes to a very great extent, but do not often suppurate; salivation is generally present, the saliva being somewhat offensive; or there may be a discharge from the nostrils, Avhich is sometimes acrid and makes the skin which it touches sore, and it is sometimes offensive. The voice may be husky and nasal, or even hoarse, although the larynx may not be involved; cough may be present, and, as before remarked, an eruption resembling that of scarlet fever may make its appearance upon the skin. It has been thought that in this latter case the poisons of diphtheria and scarlet fever were acting conjointly upon the system. " The further course of these cases varies widely. If the result is to be unfavorable, the depression and loss of strength increase rapidly; the surface groAvs pale or sallow, and is below the natural temper- ature; the pulse becomes exceedingly frequent and feeble; the fauces assume a gangrenous appearance, from decomposition of the false membranes ; the swelling of the cervical glands increases, and the patient often refuses to make the effort to SAvalloAV, though deglutition is still generally possible. There is a constant fetid discharge from the mouth and nostrils; the breath is horribly offensive, and death ensues amid the most profound prostration. Or at a much earlier 944 DISEASES OF INFANTS AND CHILDREN. period of the disease the fatal event may be precipitated by the extension of the exudation to the larynx. If, on the other hand, the case tends toAvard recovery, the false membrane becomes de- tached and throAvn off, the strength improves, the pulse becomes fuller and stronger, and the appetite returns." A very quick and feeble, or, as is sometimes found, a very slow, pulse, persistence of the vomiting, drowsiness and delirium, bleeding from the nose and suppressien of the urine may be regarded as symp- toms indicative of danger, whether they supervene upon mild attacks or occur in those of a more severe character. This disease presents itself occasionally in a more malignant form than has yet been described, in Avhich the symptoms are of the most asthenic type. Occasionally epidemics of this character have appeared, in which a very large proportion of all those attacked died. In these cases, " the anginose affection, though it may be severe, rarely attracts much attention. The pseudo-membranes in the fauces are soft and pulpy, and when examined microscopically highly corpuscular and granular; they soon decompose and become discolored by the blood which exudes from the mucous membrane. There is, moreover, a strong disposition for the exudation to extend to the posterior nares, or to appear on various portions of the external cutaneous surface. The breath and the discharge from the mouth and nostrils are indes- cribably fetid. In some cases true ulceration, and even gangrene, of the fauces occurs. There is, hoAvever, less pain complained of, and less indisposition to swallow, than in many lighter cases, OAving prob- ably to the depression of the nervous centres from the poisoned state of the blood. There may be high fever during the first feAv days, but this soon disappears, and is replaced by a deadly pallor of surface; extremely feeble, running pulse, and at times Ioav muttering delirium. Passive haemorrhages from the mouth, nostrils, rectum or other mucous passages are of frequent occurrence. The result of these cases of pro- found diphtheritic infection is almost invariably fatal, death result- ing quietly from pure exhaustion, Avithout the development of any complications."—Meigs and Pepper. The prognosis of diphtheria is generally favorable in its milder forms; though no case, hoAvever mild, is entirely free from danger, inasmuch as a fatal termination may be reached either by the false membrane extending into the larynx and bronchial tubes, by diph- theritic croup, by heart-clot, or by the supervention of some sequela which may have a fatal termination. But even in the more malignant cases, and even in these we have last described, a favorable result may DIPHTHERIA. 945 be attained by careful and judicious medication, especially under homoeopathic treatment, Usually, under the most favorable circum- stances, the disease will last five or six days or a week, or it may con- tinue for ten days or tAvo weeks, or be prolonged for a much greater period, through its sequelae. The complications and sequelae of diphtheria are not very numerous, but are all of a very serious character. We have already referred to albuminuria as a possible complication. Heart-clot may be the means of taking the life of a diphtheritic patient othenvise fiworably situated. Endocarditis may complicate diphtheria, and continue as a serious malady long after all other symptoms have disappeared. Paralysis is one of the most common and most important of the sequelae of diphtheria. It does not usually show itself until all the anginose and other symptoms have disappeared, and is progressive, affecting first the muscles of the parts that were involved by the disease, and thence spreading to the face and finally to the extremities unless arrested. There is frequently impairment of vision, deafness. " The paralysis is rarely confined to loss of motion, but, in a majority of cases, sensation is either much modified or lost; and indeed in some instances there has been no loss of motion, the sentient nerves alone being affected. In other cases the sensibility has been found exalted, or there has been in the same case hyperaesthesia in the upper, with anaesthesia in the lower extremities." In some cases this post-diph- therial paralysis takes the form of progressive locomotor ataxia, in which, Avhile there is little or no loss of muscular power, there is a partial or complete inability to co-ordinate muscular movements, especially Avhen the patient is in the dark. Paralysis after diphtheria is very rarely fatal. It generally yields, though oftentimes slowly, to appropriate treatment. Treatment.—Local applications are objectionable. Avoid fatiguing the patient by too much treatment; do not force food upon the child, but try to please its appetite; allow as much ice or iced water as may be desired. Select the remedy with the greatest accuracy, and good results may be looked for in most cases, and often will be met with in even the worst forms of the disease. Apis mel. Great debility characterizes the case even from the onset; absence of thirst; scantiness of urine; the membrane has a dirty-gray color; the pulse is very quick—at least 140; puffiness about the eyes; an eruption appears upon the skin, which itches and stings. Arsenicum. The membrane is dry-looking and wrinkled, and may 60 946 DISEASES OF INFANTS AND CHILDREN. cover the entire fauces; very foetid breath; great dysphagia; very great prostration; the child frequently wants water, but in small quantities at a time; great restlessness, particularly after midnight; warm drinks are sometimes desired instead of cold drinks. Belladonna. The throat has a highly inflamed appearance, is very red and shining; drowsiness; the eyes are very much injected; the face is flushed, there is throbbing of the carotids; the pulse is very rapid; the child complains of chilliness occasionally; great difficulty in swallowing, with pain running up into the ear. Bromine. When the disease commences in the larynx and comes up into the fauces, and in some cases in which it runs down into the larynx and produces a croupy cough, with much rattling of mucus. In either case there is rattling of mucus in the larynx on coughing, and the cough has a croupy sound. Capsicum. When—if a description can be given—the throat smarts as if from Cayenne pepper ; the diphtheritic deposit covers a considera- ble portion of the fauces. There is a sensation of constriction on swalloAving. Cantharis. There is marked disturbance of the urinary organs; fre- quent desire to urinate, Avith burning and cutting pain; the membrane appears in patches upon the posterior wall of the throat, with burning in the throat. Kali bi. The disease extends into the throat (and bronchia), pro- ducing a croupy cough, in paroxysms, with expectoration of viscid, tough mucus, which may be drawn out into long strings; tough and stringy discharge from the nostrils; pain in the left ear; swelling of the parotid and submaxillary glands; eruption upon the skin which looks like that of measles; the tongue is red, raAV and shining. Lachesis. When the disease first makes its appearance in the left side of the throat, and there remains, or extends from thence to the right side. The throat is very sensitive to touch or pressure. Lachnanthes. If the child has a very stiff and painful neck, drawn to one side, with diphtheria. Lycopodium. When it appears first on the right side, and from thence inclines to spread to the left, or it begins in the nose and extends down into the throat. Mercurius sol. Profuse salivation; profuse perspiration; offensive breath; swelling of the submaxillary glands. Mercurius prot. Great difficulty in swallowing, with great pain in the throat; the salivary glands are very much swollen and painful; SPA SMS—CONVULSIONS. 947 very offensive smell from the mouth, and foetid discharge from the fauces and nares; swelling of the cervical glands. Sulphur. The Avhole back part of the throat, posterior to the palatine arch, appears to be in a condition of ulceration and sloughing; very quick pulse; flashes of heat; frequent sinking spells. Phosphorus, Phytolacca dec, Croton tigl., Cubebs, Mu- riatic acid, Carbolic acid, Permanganate of Potash, Bap- tisia tinct. and Ammonium carb. have likewise been recommended in the treatment of this disease, and may prove useful when indicated by the symptoms. Spasms—Convulsions. Even in very young infants spasms, or general convulsions, are of frequent occurrence. They are present at the commencement of many diseases of children, and they attend the fatal termination of nearly all. Convulsions may be occasioned by morbid conditions of the ner- vous system—idiopathic convulsions—or they may be merely sympa- thetic, symptomatic of disorders in other organs, especially in those of the alimentary canal. Among the former may be enumerated those Avhich arise from primary disease of the brain, or other large nervous centres, and those which result from general exhaustion of the vital forces, as in cases of difficult dentition and in the advanced stages of Avhooping-cough. Among the latter class, or sympathetic con- vulsions, may be enumerated those cases which arise from the irrita- tion of intestinal worms, from the presence of unwholesome food, such as curdled milk, and from the influences which are about to develop eruptive disorders, or typhoid fevers. The convulsions, or rather local spasms of the glottis, which constitute laryngismus strid- ulus, seem to result either from direct pressure upon the trunk of some nerve or from irritation of its peripheral extremities. Convulsions or spasms may be tonic, where the muscles are perma- nently, involuntarily contracted, or clonic, when the contraction more or less rapidly alternates Avith the relaxation. Tonic spasms are called tetanus; and if confined to the muscles which raise the lower jaw, they are called trismus. Spasms of separate muscles are called subsultus tendinum ; these are clonic, and may be seen in severe nervous fevers. Clonic spasms are more frequently observed and less dangerous than the tonic. Convulsions Avhich appear immediately after nursing, and especially if there is vomiting of curdled milk, may be attributed to the unsuitable character of the milk. Such cases occur in the children even of mothers perfectly healthy, if they 948 DISEASES OF INFANTS AND CHILDREN. give suck while in a state of high physical excitement or moral dis- tress. In cases which come on suddenly and Avithout apparent cause, especially if the convulsions are associated Avith feA^er, stupefaction, and vomiting, there may be reason to apprehend the accession of some eruptive disorder, such as scarlatina, variola, etc.; and this opinion Avill be strengthened by the prevalence of one or the other of these epidemics at the time. Many cases of encephalic disease commence with vomiting and convulsions; in such instances, upon minute inquiry, it will always be found that some indications of cerebral disorder have been present for several days, and there is usually severe pain in the head immediately before the attack. In general, clonic convulsions may be considered dangerous Avhen the paroxysms become more and more prolonged, when they return after shorter intervals, and when, from the gradual development of opisthotonos or of emprosthotonos, the irritation is seen to extend itself along the entire course of the spinal cord. In most cases it will not be difficult to find out the exciting cause of the spasms, which may be suppression of some cutaneous eruption or its too tardy appear- ance in the first instance, direct injury of the head or some portion of the nervous substance, fright of the child, or even of the nurse, a feverish condition of the mother's milk, the influence of some epi- demic miasm, the onset of some form of cerebral disease, etc., etc. Treatment.—Remove as far as possible the exciting cause, whether it exists in the nurse or in the child itself; do not place the child in a warm bath; avoid every excitement, and keep the child perfectly quiet and free from every disturbing influence of noise, light, etc., and very carefully administer the remedy which appears to be indi- cated by the nature of the case and by the attendant conditions. Aconite. The febrile excitement is very great; hot, dry skin, anx- iety and anguish. Arnica. Where the spasms arise in consequence of a fall or other injury. iEthusa cyn. Spasms, Avith stupor, delirium; turning of the eyes doAvmvard. Agaricus mus. Spasms, Avith tremor of the body. Arsenicum. The child lies as if dead; pale but warm; is breathless for some time; finally it twists its mouth first to one side, then to the other; a violent jerk appears to pass through the whole body, and its respiration and consciousness gradually return. These spasms SPASMS—CONVULSIONS. 949 return at longer or shorter intervals, unless relieved by this remedy, until death closes the scene. Belladonna. Starting from sleep with a Avild look, dilated pupils, heat of the head and hands, red eyes and flushed face; soporous after the spasm. Bryonia. When the spasms recur from the repercussion of measles. Camphor. When the spasms result from suppressed catarrh, either of the head or chest. Causticum. Convulsive motions of the upper part of the body, with feverish heat and coldness of the hands and feet. Convulsive motions of the extremities in the evening when the child is sleeping, Avith dis- turbed eyes and icy coldness of the body. Chamomilla. One cheek red, the other pale ; very cross and fretful; jerking and tAvitching in its sleep; or the nurse may have had a fit of anger which causes the convulsions in the child. Cicuta vi. Violent shocks through the head, arms and legs, which cause them to jerk suddenly. Spasmodic rigidity of the body, either opisthotonos or emprosthotonos. The child seems well and in great spirits, Arhen suddenly it becomes rigid ; then relaxation sets in, with much prostration. Cina. The child exhibits vermiculous symptoms; discharges worms; picks its nose or anus; has a hacking cough, continually making attempts at deglutition, as if to swallow something down; is very difficult to be pleased Avith anything. Coffea. The attack has been brought on by excessive laughing and playing. The child is very excitable and weakly, and in consequenec frequently suffers Avith spasms. Cuprum met. The spasm is often preceded by violent vomiting of phlegm. After the convulsion the child screams and turns and twists in all directions till another spasm occurs; the spasms commence in the extremities. Cuprum aceticum. When the spasms result from retrocession of the eruption in scarlet fever. Helleborus. The urine is very dark and has a sediment like coffee grounds; intense and intolerable pain in the head. Hydrocyanic acid. When the muscles of the back, face and jaws are principally affected, and the body assumes a bluish tint. Hyoscyamus. Every muscle in the body is convulsed—the eyes, the eyelids, the muscles of the face, and all—and there is frothing at the mouth. Ignatia. The spasms return at the same hour every day. Screaming 950 DISEASES OF INFANTS AND CHILDREN. and violent trembling all over. Single parts seem to be convulsed— the muscles or single limbs. Ipecacuanha. Much nausea and vomiting, either before, during or after the spasm; the child is spasmodically drawn in some direction. Creasote. When the convulsion occurs from the swelling of a gum over a tooth Avhich is not quite through. Lachesis. The spasms come on during sleep. Laurocerasus. There is much gasping for breath, either before, dur- ing or after the spasm, and there may also be a bluish tint of the skin. Mercurius sol. Much salivation; SAvelling of the gums; hard, dis- tended abdomen. INIay generally be relied upon when spasms occur from suppressed salivation. Nux V. The spasm appears to result from indigestion; there is con- stipation, or the nurse lives high, making use of coffee, wines and rich food. The spasms are reproduced whenever the feet are touched. Opium. If the spasms occur from fright, or if in new-born babes there is screaming before or during the spasm. Secale c. Twitching of single muscles; twisting of the head to and fro; contortion of the hands and feet; labored and anxious respiration. Silicia. Spasms which return at the change of the moon. Stannum. In some form of A^ermicular affections (see also Spigelia), Avhen neither Cina nor Silicia seem indicated. There is more excita- bility, more disturbance of the brain and more fear. Stramonium. Suppression of an eruption is the cause, or the eruption does not come out sufficiently. The child seems afraid, and shrinks back from objects on first seeing them. Tart. e. Spasms caused by repelled eruptions, with paleness of the skin and much difficulty of breathing. Veratrum a. When a cold sweat appears on the forehead after or during the spasm. Zinc. The child cries out during sleep, and if awakened expresses fear, and rolls its head anxiously from side to side. The child has been cross and irritable for days previous, with hurried motions, dis- tended abdomen and more frequent passages of urine than usual. CLINICAL INDEX. Acetic acid. Nausea and Vomiting, 297. Aconite. Treatment of Child after Labor, 213; Nausea and A'omiting, 297 ; Constipation, 310; Retention of Urine, 329; Haemorrhoids, 347; False Pains, 362; Neuralgia, 372; Hysteria, 381; Labor-Pains, 384; Rigidity of the Os, 388; Syncope, 390; Uterine Haemorrhage, 406; Puerperal Convulsions, 421; Disordered Condi- tions of the Lochia, 428 ; Puerperal Mania, 459; Secretion of Milk, 467 ; Scanty Supply of Milk, 469 ; Mastitis, 474; Abortion, 492 ; Amenorrhcea, 410; Menorrhagia, 533; Hysteria, 565 ; Erysip- elatous Inflammation, 574; Strangulation of Prolapsed Portion of A'agina, 588 ; Uterine Dis- placements, 632 ; Leucorrhoea, 645 ; Metritis, 660; Gangrene of the Uterus, fo4; Hydatids, 715; Inflammation of the Ovaries, 730; Indiges- tion, 764; Dentition, 770; Constipation, 781; Diarrhoea, 786; Dysentery, 790; Coryza, 803; Bronchitis, 807; Pneumonia, 811; Croup, 816; Pertussis, 820; Atelectasis Pulmonum, 829; Scarlet Fever, 837; Measles, 852 ; Roseola, 855 ; Miliaria, 855; Small-pox, 860; Varicella, 865; Erysipelas, 867 ; Urticaria, 868 ; Eczema Capi- tis, 870; Induration of the Cellular Tissue, 876; Induration of the Breasts, 877 ; Cyanosis, 880; Jaundice, 882; Intermittent Fever, 884; Oph- thalmia, 890; Hernia, 894; AVorms, 897; Reten- tion of Urine, 900; Aleningitis, 903; Acute Hy- drocephalus, 905 ; Disease of the Brain, 909 ; Cerebro-spinal Meningitis, 931; Chorea, 935; Remittent Fever, 939; Spasms, 948. iEsculus liip. Fissure of the Anus, 326; Hsem- orrhoids, 347; Lame Pelvis, 367 ; Amenorrhoea, 510; Leucorrhcea, 645. jEtlmsia cyn. Secretion of Milk, 467 ; Child Vomits the Milk soon after Nursing, 475; Ma- rasmus, 759; Indigestion, 764; Aphthae, 779; Constipation, 781 ; Cholera Infantum, 796; Re- gurgitation, 801 ; Disease of the Brain, 909; Cer- ebro-spinal Meningitis, 931; Spasms, 948. Agaricus. Nausea and A'omiting, 297 ; Constipa- tion, 310; Diarrhoea, 317; Sore Nipples, 464; Menorrhagia, 533; Nymphomania, 551; Leu- corrhcea, 615; Chorea, 936; Spasms, 948. Agnus castus. Secretion of Milk, 467; Scanty- Supply of Milk, 469 ; Amenorrhoea, 510. Ailanthus gland. Scarlet Fever, 838. Aletris far. Abortion, 493; Amenorrhcea, 510; Metrorrhagia, 533 ; Leucorrhoea, 645. Alium cepa. Coryza, 803. Aloes. Diarrhoea, 317; Haemorrhoids, 347; Lame Pelvis, 367 ; Marasmus, 759 ; Dysentery, 790. Alum. Nausea and Vomiting, 297 ; Constipation, 310; Diarrhoea, 317 ; Haemorrhoids, 347 ; Tooth- ache, 374; Amenorrhcea, 510; Dysmenorrhcea, 520; Neuralgia of Vagina, 591 ; Leucorrhcea, 645; Marasmus, 759; Constipation, 781; Dysen- tery, 790; Gravel, 902. Ambra grisea. Menorrhagia, 533; A'ulvitis, 571; Leucorrhcea, 645; Inflammation of the Ovaries, 730 ; Ranula, 874. Amnion, carb. Haemorrhoids, 347; Amenor- rhcea, 510; Dysmenorrhcea, 520; Menorrhagia, 533 ; Erysipelatous Inflammation, 574; Leucor- rhcea, 646; Coryza, 803 ; Scarlet Fever, 838. Ammon. mur. Diarrhoea, 317; Haemorrhoids, 347; Dysmenorrhcea, 520; Metrorrhagia, 533 ; Uterine Displacements, 632; Leucorrhcea, 646 ; Small-pox, 860. Anacardium. Constipation, 310; Hysteria, 381, 565; Leucorrhcea, 646. Angustura. Nausea and Vomiting, 297 ; Diar- rhoea, 317. Antlmoniuin c. Nausea and A'omiting, 297 ; Constipation, 310; Diarrhoea, 317; Haemor- rhoids, 347 ; Uterine Haemorrhage, 406; Menor- rhagia, 533; Nymphomania, 551; Vaginal Fis- tula, 604; Leucorrhcea, 646 ; Ulcerations of the Uterus, 683; Inflammation of the Ovaries, 730 ; Marasmus, 760 ; Dentition, 770; Diarrhoea, 786 ; Cholera Infantum, 797 ; Measles, 852 ; Small- pox, 861; Hernia, 894; Remittent Fever, 939. Apis mel. Nausea and Vomiting, 298; Constipa- tion, 310; Haemorrhoids, 347; Varicose Veins, 353; Uterine Haemorrhage, 406; Ulceration of the Umbilicus, 431; Phlegmasia Dolens, 462; Abortion, 494; Amenorrhcea, 510; Dysmenor- rhcea, 521; Menorrhagia, 533; Erysipelatous In- flammation, 574 ; Eczema and Pruritus, 576 ; Strangulation of Prolapsed Portion of Vagina, 588; Gangrene of Vagina, 605; Metritis, 660; Gangrene of the Uterus, 704; Dropsy of the Uterus, 707; Inflammation of the Ovaries, 730; Ovarian Tumors, 741; Mammary Cancer, 748; Marasmus, 760; Dentition, 770; Constipa- tion, 781; Dysentery, 790; Scarlet Fever, 838; Dropsy after Scarlet Fever, 845 ; Post-scarlatinal Rheumatism, 847; Measles, 852; Small-pox, 861; Erysipelas, 867 ; Urticaria, 868 ; Retention 951 952 CLINICAL INDEX. ofUrine,900; Meningitis, 903; Acute Hydroceph- alus, 905; Disease of the Brain, 909; Cerebro- spinal Meningitis, 931; Remittent Fever, 939 ; Diphtheria, 945. Apocynum cann. UUrine Haemorrhage, 407; Amenorrhoea, 510; Menorrhagia, 533; Ovarian Tumore, 742; Dropsy after Scarlet Fever, 845; Acute Hydrocephalus, 905 ; Disease of the Brain, 909. Aralia. Leucorrhoea, 646. Argentum n. Nausea and Vomiting, 298; Diar- rhoea, 317; False Pains, 362; Uterine Haemor- rhage, 407 ; Puerperal Convulsions, 421; Men- orrhogia, 534; Ulcerations of the Uterus, 684; Marasmus, 760; Diarrhoea, 786; Scarlet Fever, 838; Worms, 897 ; Diuresis, 901; Acute Hydro- cephalus, 905; Disease of the Brain, 909; Cer- ebro-spinal Meningitis, 931. Arnica. Nausea and Vomiting, 298; Constipation, 310; Diarrhoea, 317; Varicose Veins, 353 ; False Pains, 362; Lame Pelvis, 367; Hysteria, 382; Labor-Pains, 384; Syncope, 390; Uterine Haem- orrhage, 407; Puerperal Convulsions, 421; Re- tention of Urine after Parturition, 425 ; After- Pains, 426; Phlegmasia Dolens, 462; Sore Nip- ples, 464; Abortion, 494; Menorrhagia, 534; Vulvitis, 571; Haemorrhage from Erectile Tu- mors, 581; Prolapse of the Aragina, 587 ; Uterine Displacements, 632; Metritis, 660; Ovarian Tu- mors, 741; Mammary Cancer, 748; Marasmus, 760; Dysentery, 790; A'omiting of Blood, 800; •Bronchitis, 807; Pertussis, 821; Scarlet Fever, 838; Small-pox, 861; Erysipelas, 867; Ceph- alaematoma, 874; Ecchymosis, 874; Induration of the Breasts, 877; Cyanosis, 880; Retention of Urine, 900; Acute Hydrocephalus, 905; Disease of the Brain, 909; Cerebro-spinal Meningitis, 931; Spasms, 948. Arsenicum. Nausea and Vomiting, 298; Diar- rhoea, 317; Fissure of the Anus, 326; Retention of Urine, 330; Haemorrhoids, 347; Varicose Areins, 353; Toothache, 374; Hysteria, 382; Syncope,390; Debility, 391; Uterine Haemorrhage, 407 ; Re- tention of Urine after Parturition, 425; Ulcera- tion of the Umbilicus, 431; Phlegmasia Dolens, 462; Amenorrhcea, 510; Menorrhagia, 534; Nymphomania, 551; Hysteria, 565; Erectile Tumors, 581; Strangulation of Prolapsed Por- tion of Vagina, 588; Neuralgia of Vagina, 591; Gangrene of Vagina, 605; Leucorrhcea, 646; Metritis, 660; Sensation of Coldness in the Ul- cers, 685; Cancer of the Uterus, 700; Gangrene of the Uterus, 704; Dropsy of the Uterus, 707; Hydatids, 715; Inflammation of the Ovaries, 730; Ovarian Tumors, 741; Mammary Cancer, 748; Marasmus, 760; Indigestion, 764; Denti- tion, 771; Aphthae, 779; Diarrhoea, 786; Dysen- tery, 790; Cholera Infantum, 797; Vomiting of Blood, 801; Bilious A'omiting, 801; Bronchitis, 807 ; Croup, 816; Pertussis, 821; Asthma of Millar, 826; Scarlet Fever, 838; Dropsy after Scarlet Fever, 845 ; Neuralgic Pains in Extrem- ities and other parts after Scarlet Fever, 847; Measles, 852; Rubeola Maligna, 853; Pemphigus, 856; Small-pox, 861; Urticaria, sr>8 ; Eczema Capitis, 870; Pityriasis, 871; Cyanosis, 880; Jaundice, 862; Scrofula, 886; Mumps, 892; Retention of Urine, 900; Incontinence of Urine, 901; Disease of the Brain, 909; Cerebro- spinal Meningitis, 931; Remittent Fever, 939 ; Diphtheria, 945 ; Spasms, 948. Artemisia vulg. Disease of the Brain, 910. Arum tri. Coryza, 80S; Scarlet Fever, 838. Asafoetida. Diarrhoea, 317; Scanty Supply of Milk, 469; Hysteria, 565; Hysteralgia, 673; Ulcerations of the Uterus, 684. Asaruin. Abortion, 493; Dysmenorrhcea, 521; Vaginal Fistulas, 603; Worms, 898. Asclepias syr. Dysmenorrhcea, 521. Asterias rubens. Uterine Displacements, 632; Hysteralgia, 673; Mammary Cancer, 748. Aurum. Diarrhoea, 317 ; Impaired Vision, 570; Hysteria, 381; Labor-Pains, 384; Puerperal Mania,459; Amenorrhcea, 510 ; Nymphomania, 552; Hysteria, 565 ; Concomitant Symptoms of ATaginal Fistulas, 604; Vaginal Growths, 608; Uterine Displacements, 632; Hysteralgia, 674 ; Cancer of the Uterus, 700; Inflammation of the Ovaries, 730 ; Scarlet Fever, 839 ; Syphilis Neo- natorum, 878. Baptisia. Disordered Conditions of the Lochia, 428 ; Eczema and Pruritus, 578;' Marasmus, 760; Aphthae, 779; Dysentery, 790; Small-pox, 861. Baryta carb. Dysmenorrhcea, 521; Tumors of the A'ulva, 579; Leucorrhcea, 646; Indiges- tion, 764; Scarlet Fever, 839; Dropsy after Scarlet Fever, 845 ; Scrofula after Scarlet Fever. 848 ; Eczema Capitis, 870; Encysted Tumors 873; Scrofula, 886; Rickets, 888; Mumps, 891. Belladonna. Treatment of Child after Labor. 213; Nausea and Vomiting, 298; Constipation. 310; Diarrhoea, 317; Retention of Urine, 330; Haemorrhoids, 347 ; False Pains, 362; Impaired Vision, 370; Neuralgia, 372; Toothache, 374; Chorea, 377 ; Hysteria, 382, Labor-Pains, 384; Rigidity of the Os, 388 ; Hour-glass Contractions, 389; Uterine Haemorrhage, 407; Puerperal Convulsions, 421; Retained Placenta, 424; Re- tention of Urine after Parturition, 425; After- Pains, 426 ; Disordered Conditions of the Lochia, 428; Pendulous Abdomen, 430 ; Puerperal Ma- nia, 459 ; Phlegmasia Dolens, 463 ; Secretion of Milk, 467 ; Scanty Supply of Milk, 469; Galac- torrhea, 473; Mastitis, 474; Abortion, 493; Amenorrhoea, 511; Menorrhagia, 533; Hysteria, 565 ; Vulvitis, 571; Erysipelatous Inflammation, 574; Strangulation of Prolapsed Portion of A'a- gina, 588; Spasms of Vagina, 589 ; Neuralgia of Vagina, 591; Indurations of Vagina, 600; Vaginal Fistulas, 603 ; Gangrene of A'agina,605 ; Uterine Displacements, 632; Leucorrhcea, 646; Metritis, 660; Cancer of the Uterus, 700; Gan- grene of the Uterus, 704; Dropsy of the Uterus, 707; Hydatids, 715; Inflammation of the Ova- ries, 730; Ovarian Tumors, 742; Mammary Can- cer, 748; Marasmus, 760; Indigestion, 764; CLINICAL INDEX. 953 Dentition, 771; Diarrhoea, 787 ; Dysentery, 790; Cholera Infantum, 797 ; Fcecal Vomiting, 801; Bronchitis, 807; Pneumonia, 811; Croup, 816; Pertussis, 821; Asthma of Millar, 826; Atelectasis Pulmonum, 829; Scarlet Fever, 839; Dropsy after Scarlet Fever, 845; Post- scarlatinal Rheumatism, 847; Measles, 852; Pneumonia after Measles, 853; Roseola, 855; Pemphigus, 856; Small-pox, 861; A'aricella, 865 ; Erysipelas, 867 ; Urticaria, 868 ; Nsevi Materni, 873; Induration of the Breasts, 877 ; Intermit- tent Fever, 884; Scrofula, 886; Ophthalmia, 890; Mumps, 891; Hiccough, 892; AVorms, 898 ; Retention of Urine, 900 ; Incontinence of Urine, 901; Meningitis, 903 ; Acute Hydroceph- alus, 9i>5; Disease of the Brain, 910; Cerebro- spinal Meningitis, 931; Chorea, 936 ; Remittent Fever, 939 ; Diphtheria, 945 ; Spasms, 948. Benzoic acid. Marasmus, 760; Cholera Infan- tum, 797; Incontinence of Urine, 901. Berberis v. Dysmenorrhcea, 521; Neuralgia of Vagina, 591; Gravel, 902. Borax. Nausea and Vomitftig, 298; Diarrhoea, 318; Labor-Pains, 384; Secretion of Milk, 467; Galactorrhea, 473; Amenorrhcea, 511; Dysmen- orrhcea, 521; Menorrhagia, 533; Leucorrhcea, 646; Marasmus, 760; Indigestion, 764; Dentition, 771; Aphthae, 779; Hernia, 894. Bovista. Dysmenorrhcea, 521; Menorrhagia, 533; Nymphomania, 552; Leucorrhcea, 646; Otor- rhcea, 848. Bromine. Dysmenorrhcea, 521; Menorrhagia, 534; Neuralgia of A'agina, 591; Physometra, 711; Croup, 816; Diphtheria, 945. Bryonia. Nausea and Vomiting, 298 ; Constipa- tion, 310; Diarrhoea, 318; False Pains, 362; Neuralgia, 372 ; Syncope, 391; Uterine Haem- orrhage, 407: Puerperal Convulsions, 421; Af'ter- Pains, 426 ; Disordered Conditions of the Lochia, 428; Phlegmasia Dolens, 463; Secretion of Milk, 467 ; Scanty Supply of Milk, 469; Galac- torrhea, 473 ; Mastitis, 474; Abortion, 493 ; AmenorrhceH, 511; Dysmenorrhea, 521; Men- orrhagia, 534; Eczema and Pruritus, 576; Uterine Displacements, 633 ; Metritis, 660; Hysteralgia, 674; Sensation of Coldness in the Ulcers, 685; Dropsy of the Uterus, 707 ; Inflammation of the Ovaries, 731; Mammary Cancer, 748 ; Marasmus, 760 ; Indigestion, 7C4; Dentition, 771; Aphthae, 779; Constipation, 781; Diarrhea, 787; Dysen- tery, 791; Cholera Infantum, 797; Regurgita- tion, 801; Bilious Vomiting, 801; Bronchitis, 807 ; Pneumonia, 811 ; Pertussis, 821; Atelec- tasis Pulmonum, 829; Scarlet Fever, 839 ; Post- scarlatinal Rheumatism, 847; Measles, 852; Diarrhea after Measles, 853; Bronchitis after Measles, 853; Pneumonia after Measles, 853 ; Roseola, 855; Miliaria, 855; Small-pox, 861; Erysipelas, 867 ; Urticaria, 868 ; Eczema Capitis, 870; Pityriasis, 872; Induration of the Cellular Tissue, 876; Induration of the Breasts, 877; Comedones, 878; Jaundice, 882; Intermittent Fever, 884; Rickets, 888 ; Meningitis, 903 ; Acute Hydrocephalus, 905; Disease of the Braiu, 910; Cerebro-spinal Meningitis, 932; Remittent Fe- ver, 939; Spasms, 94S. Bufo. Cerebro-spinal Meningitis, 932. Cactus grand. Menorrhagia, 534. Caladium. Eczema and Puritus, 578. Calcarea carb. Nausea and Vomiting, 299; Constipation, 311; Diarrhea, 318; Haemor- rhoids, 348; False Pains, 363; Lame Pelvis, 367; Impaired Vision, 370; Neuralgia, 372; Toothache, 374; Chorea, 377; Hysteria, 382; Debility, 391; Uterine Haemorrhage, 407; Dis- ordered Conditions of the Lochia, 428 ; Phleg- masia Dolens, 463 ; Sore Nipples, 464; Secretion of Milk, 467; Scanty Supply of Milk, 469; Ga- lactorrhea, 473 ; Deterioration of Health from Nursing, 473; Child Vomits the Milk soon after Nursing, 475 ; Abortion, 493 ; Amenorrhea, 511; Dysmenorrhea, 521; Menorrhagia, 534; Nym- phomania, 552; Hysteria, 566; Vulvitis, 571; Erysipelatous Inflammation, 574; Eczema and Pruritus, 576; Condylomata, 579 ; Tumors of the Vulva, 580 ; Ascarides of the Vulva, 583; Neu- ralgia of Vagina, 591; Indurations of Vagina, 601; A'aginal Fistulas, 603; Gangrene of Vagina, 605 ; A'aginal Growths, 608 ; Granular Vegeta- tions, 610; Uterine Displacements, 633 ; Leucor- rhea, 646; Metritis, 661; Hysteralgia, 674; Cancer of the Uterus, 700; Dropsy of the Uterus, 708 ; Hydatids, 715 ; Mammary Cancer, 748 ; Marasmus, 760; Indigestion, 765; Dentition, 772; Constipation, 781; Diarrhea, 787 ; Cholera Infantum, 797 ; Regurgitation, 801; Vomiting of Ingesta, 801; Coryza, 803 ; Bronchitis, 808 ; Pneumonia, 812; Asthma of Millar, 827; Scarlet Fever, 839 ; Otorrhea, 848 ; Scrofula after Scar- let Fever, 848 ; Varicella, 865 ; Urticaria, 868 ; Eczema Capitis, 870; Pityriasis, 872; Naevi Ma- terni, 873; Encysted Tumors, 873; Warts, 873 ; Cephalaematoma, 874; Rauula, 874; Intertrigo, 875; Induration of the Cellular Tissue, 876; Induration of the Breasts, S77 ; Comedones, 878 ; Cyanosis, 880; Jaundice, SS2 ; Intermittent Fe- ver, 884; Scrofula, 886; Rickets, 5,88; Ophthal- mia, S90; Hernia, 894; Worms, 83S ; Inconti- nence of Urine, 901 ; Gravel, 902 ; Acute Hy- drocephalus, 905 ; Hydrocephaloid Disease, 909 ; Disease of the Brain, 910; Chorea, 936 ; Remit- tent Fever, 939. Calcarea oxalata. Mammary Cancer, 748. Calc. phosph. Lame Pelvis, 367 ; Deterioration of Health from Nursing, 473 ; Uterine Displace- ments, 633 ; Dentition, 772 ; Scrofula after Scar- let Fever, 848 ; Acute Hydrocephalus, 905 ; Hydrocephaloid Disease, 909; Disease of the Brain, 910. Calendula. Vulvitis, 572. Camphora. Treatment of Child after Labor, 213 ; Retention of Urine, 330; False Pains, 363 ; Labor-Pains, 385; Syncope, 391; Abortion, 494 ; Erysipelatous Inflammation, 574; Dropsy of the Uterus, 708; Cholera Infantum, 797; Atelectasis Pulmonum, S29; Scarlet Fever, 839; Measles, 852; Pemphigus, 856; Small- 954 CLINICAL INDEX. pox, 861; Meningitis, 903; Disease of the Brain, 910; Cerebro-spinal Meningitis, 932; Spasms, 948. Cannabis. Retention of Urine, 330; Abortion. 494; Menorrhagia, 534; Nymphomania, 552; Neuralgic Pains in Extremities and other Parts after Scarlet Fever, 847; Retention of Urine, 900. Cantharis. Nausea and Vomiting, 299; Diar- rhea, 318 ; Retention of Urine, 330; Uterine Haemorrhage, 407; Puerperal Convulsions, 422; Retained Placenta, 424; Retention of Urine after Parturition, 425; Abortion, 494; Dysmen- orrhea, 521; Menorrhagia, 535; Nymphomania, 552; A'ulvitis, 572; Eczema and Pruritus, 576; Neuralgia of Vagina, 592; Uterine Displace- ments, 683 ; Leucorrhea, 646 ; Metritis, 661 ; Dropsy of the Uterus, 708 ; Inflammation of the Ovaries, 731; Dysentery, 791; Small-pox, 861; Retention of Urine, 900; Incontinence of Urine, 901; Cerebro-spinal Meningitis,932; Diphtheria, 945. Capsicum. Diarrhea, 318; Retention of Urine, 330; Haemorrhoids, 348; Impaired Hearing, 369; Diphtheria, 945. Carbo animalis. Impaired Hearing, 369; Dis- ordered Conditions of the Lochia, 429 ; Secretion of Milk,467; Cramps in Stomach from Nursing, 473 ; Great Sense of Emptiness in Stomach from Nursing, 473; Mastitis, 474; Dysmenorrhea, 522; Menorrhagia, 535 ; Erysipelatous Inflam- mation, 574; Erectile Tumors, 581; Uterine Displacements, 633; Leucorrhea, 646; Metritis, 661; Cancer of the Uterus, 700 ; Mammary Can- cer, 748. Carbo veg. Nausea and Vomiting, 299; Consti- pation, 310; Diarrhea, 318 ; Haemorrhoids, 348 ; Varicose Veins, 353; Labor-Pains, 385; Syncope, 390; Uterine Haemorrhage, 407; Cramps in Stomach from Nursing, 473; Abortion, 494; Amenorrhea, 511; Dysmenorrhea, 522; Men- orrhagia, 535; Nymphomania, 552; Vulvitis, 572; Eczema and Pruritus, 577 ; Erectile Tumors, 581; Haemorrhage from Erectile Tumors, 581; Vaginal Fistulas, 603; Leucorrhea, 646; Me- tritis, 661; Gangrene of the Uterus, 704; Aph- thae, 780; Diarrhea, 787; Dysentery, 791; Cholera Infantum, 797 ; Coryza, 803 ; Pertussis, 821; Scarlet B'ever, 839; Pemphigus, 856; Small- pox, 862; Naevi Materni, 873; Intertrigo, 875; Syphilitic Ophthalmia, 878; Cyanosis, 880; Mumps, 891; Worms, 898; Incontinence of Urine, 901; Disease of the Brain, 910. Cascarilla. Haemorrhoids, 348. Castor equorum. Sore Nipples, 465; Dys- menorrhea, 522. Caulophyllum. Labor-Pains, 385 ; Rigidity of the Os, 388; Uterine Haemorrhage, 407; Puer- peral Convulsions, 422 ; Retained Placenta, 425; After-Pains, 426; Disordered Conditions of the Lochia, 428 ; Abortion, 494 ; Menorrhagia, 535 ; Hysteria, 570; Eczema and Pruritus, 578 ; Neu- ralgia of Vagina, 592; Uterine Displacements, 638; Hydatids, 715. Causticum. Nausea and Vomiting, 299; Consti- pation,311; Diarrhea,318; Fissureof the Anus, 326; Retention of Urine, 330; Haemorrhoids, 348; A'aricose Veins, 353; Impaired Hearing, 369; Impaired Vision, 370; Chorea, 377; Labor- Pains, 385 ; Puerperal Convulsions, 422 ; Reten- tion of Urine after Parturition, 425; Secretion of .Milk, 467; Scanty Supply of Milk, 470; Amen- orrhea, 511 ; Dysmenorrhea, 522 ; Menorrhagia, 535; Hysteria, 566; Vaginal Fistulas, 604; Leu- corrhea, 646; Hysteralgia, 674; Dentition, 772; Pertussis, 821; AVarts, 873; Retention of Urine, 900; Incontinence of Urine, 901; Chorea, 936; Spasms, 948. Chamomilla. Nausea and A'omiting, 299; Diar- rhea, 318; Haemorrhoids, 348; False Pains, 363; Toothache, 374; Labor-Pains, 385; Rigidity of the Os, 388; Hour-glass Contractions, 389; Syncope, 390; Uterine Haemorrhage, 408 ; Puer- peral Convulsions, 422; After-Pains, 426; Dis- ordered Conditions of the Lochia, 428 ; Sore Nipples, 464; Secretion of Milk, 467; Scanty Supply of Milk, 470; Abortion, 494; Amenor- rhea, 511; Dysmenorrhea, 522 ; Menorrhagia, 535; Hysteria, 566; Neuralgia of Vagina, 592; Uterine Displacements, 633 ; Leucorrhea, 646 ; Metritis, 661; Hysteralgia, 674 ; Alammary Can- cer, 748; Marasmus, 760; Indigestion, 765: Dentition, 773; Aphthae, 780; Diarrhea, 787; Dysentery, 791; Vomiting of Ingesta, 801; Bil- ious Vomiting, 801; Coryza, 803; Croup, 816; Pertussis, 821; Scarlet Fever, 840; Miliaria, 855 ; Small-pox, 862; Eczema Capitis, 870; In- tertrigo, 875; Induration of the Breasts, 877; Jaundice, 882 ; Ophthalmia, 890 ; Hernia, 894 ; Remittent Fever, 940 ; Spasms, 948. Chelidonium. Nausea and A'omiting, 299; Constipation, 311; Diarrhea, 318 ; False Pains, 363; Amenorrhea, 511; Menorrhagia, 535; Pertussis, 821. Chimaphila. Mammary Cancer, 749. China. Treatment of Child after Labor, 213; Nausea and Vomiting, 300; Constipation, 311; Diarrhea, 318; Haemorrhoids, 348; Impaired Vision, 370; Hysteria, 382; Labor-Pains, 385; Syncope, 390 ; Debility, 391; Uterine Haemor- rhage, 408; Puerperal Convulsions, 422 ; Secre- tion of Milk, 468 ; Scanty Supply of Milk, 470 ; Galactorrhea, 473; Deterioration of Health from Nursing, 473; Cramps in Stomach from Nursing, 473; Abortion, 494; Amenorrhea, 511 ; Dysmenorrhea, 522; Menorrhagia, 535; Nym- phomania, 552; Hysteria, 566; Indurations of Vagina, 601; Gangrene of A'agina, 605 ; Uterine Displacements, 633; Leucorrhea, 646; Metritis, 661; Hysteralgia, 674 ; Cancer of the Uterus, 701; Gangrene of the Uterus, 704; Dropsy of the Uterus, 703; Hydatids, 715; Inflammation of the Ovaries, 731; Ovarian Tumors, 742; Mar- asmus, 761; Indigestion, 765; Diarrhea 787- Dysentery, 791; Cholera Infantum, 798 ; Vomit- ing of Ingesta, 801; Bilious Vomiting, 801; Atelectasis Pulmonum, 829; Scarlet Fever, 840; Small-pox, 862; Cephalaematoma, 874; Syphilis CLINICAL INDEX. 955 Neonatorum, 878; Cyanosis, 880 ; Jaundice, 863; Intermittent Fever, 884: Worms, 898; Inconti- nence of Urine, 901; Hydrocephaloid Disease, 909 ; Disease of the Brain, 910; Remittent Fever, 940. Chininum. Dysmenorrhea, 522. Chromic acid. Condylomata, 579. Ciouta vir. Impaired A'ision, 370; Puerperal Convulsions, 422; Dysmenorrhea, 522; Denti- tion, 772; Eczema Capitis, 870; Worms, 898; Cerebro-spinal Meningitis, 932 ; Chorea, 936 ; Spasms, 948. Cimicifuga. False Pains, 363 ; Neuralgia, 372 ; Labor-Pains, 385 ; Rigidity of the Os, 388 ; Puer- peral Convulsions, 422; Retained Placeuta, 424 ; After-Pains, 426; Abortion, 494; Amenorrhea, 511; Dysmenorrhea, 522; Menorrhagia, 535; Hysteria, 570 ; Neuralgia of Vagina, 592; Uterine Displacements, 638 ; Inflammation of the Ovaries, 731; Small-pox, 862; Meningitis, 903; Disease of the Brain, 910; Chorea, 936. Cina. Nauseaand Vomiting,300;Impaired A'ision, 370; Secretion of Milk, 468 ; Menorrhagia, 535 ; Marasmus, 760; Indigestion, 765; Dentition, 772; Regurgitation, 801; Bronchitis, 808; Per- tussis, 827; Scarlet Fever, 840; Scrofula, 8S6; Hernia, 894: AVorms, 898; Incontinence of Urine, 901; Disease of the Brain, 910; Chorea, 936; Remittent Fever, 940 ; Spasms, 948. Cinchoninum sulph. Menorrhagia, 535. Cinnabaris. Dysmenorrhea, 522; Chancres, 578; Condylomata, 979 ; Leucorrhea, 647. Cinnamon. Abortion, 494. Cistus c. Mastitis, 474; Mammary Cancer, 749. Clematis erec. Induration of A'agina, 601; Can- cer of the Uterus, 701; Mammary Cancer, 749 ; Varicella, 865; Eczema Capitis, 870. Cocculus. Nausea and Vomiting, 300; Constipa- tion, 311; Diarrhea, 318; False Pains, 363; Neuralgia, 372; Chorea, 377 ; Labor-Pains, 385; Hour-glass Contractions, 389; Syncope, 391; Puerperal Convulsions, 422; Abortion, 491; Amenorrhea, 511; Dysmenorrhea, 522; Men- orrhagia, 535; Nymphomania, 552; Hysteria, 566; Spasms of A'agina, 589; Uterine Displace- ments, 634; Leucorrhea, 647; Metritis, 661; Hysteralgia, 674; Cerebro-spinal Meningitis,932 ; Chorea, 936. Coccus cacti. Retention of Urine, 330; Menor- rhagia, 536 ; Haemorrhage from Erectile Tumors, 581; Leucorrhea, 647 ; Pertussis, 821; Mumps, 891. • Coffea. False Pains, 363 ; Neuralgia, 373 ; Labor- Pains, 385 ; Syncope, 390 ; Uterine Haemorrhage, 40S; Puerperal Convulsions, 422; After^Pains, 427 ; Disordered Conditions of the Lochia, 429; Scanty Supply of Milk, 470; Dysmenorrhea, 522; Menorrhagia, 536; Nymphomania, 552; Hysteria, 566; Eczema and Pruritus, 577 ; Leu- corrhea, 647; Metritis, 661; Hysteralgia, 674; Indigestion, 765; Dentition, 773 ; Scarlet Fever, 840; Measles, 852 ; Varicella, 865 ; Spasms, 948. Colchicum. Dropsy of the Uterus, 708 ; Dysen- tery, 791; Scarlet Fever, 840; Neuralgic Pains in Extremities and other Parts after Scarlet Fever, 847. Collinsonia. Haemorrhoids, 348 ; Menorrhagia, 536; Eczema and Pruritus, 578; Constipation, 782. Colocynthis. Diarrhea, 318; Retention of Urine, 330; Haemorrhoids, 349; False Pains, 363 ; Disordered Conditions of the Lochia, 429 ; Amenorrhea, 511; Dysmenorrhea, 523; Neu- ralgia of Vagina, 592: Uterine Displacements, 634; Metritis, 661; Inflammation of the Ovaries, 731; Mammary Cancer, 749; Indigestion, 765; Dentition, 773 ; Diarrhea, 787 ; Dysentery, 791; Jaundice, 883; Retention of Urine, 900; Remit- tent Fever, 940. Conium. Nausea and Vomiting, 300; Constipa- tion, 311; Diarrhea, 318; Retention of Urine, 330 ; Labor-Pains, 385 ; Hour-glass Contractions, 389; Galactorrhea, 473; Abortion, 494 ; Amen- orrhea, 512; Dysmenorrhea, 523; Nymphoma- nia, 552 ; Hysteria, 566 ; Vulvitis, 572; Eczema and Pruritus, 577; Neuralgia of Vagina, 592; Induration of Vagina, 601; Vaginal Fistulas, 603; Vaginal Growths, 608; Uterine Displace- ments, 634; Leucorrhea, 647; Metritis, 662; Hysteralgia, 674; Cancer of the Uterus, 701; Dropsy of the Uterus, 708; Inflammation of the Ovaries, 731; Ovarian Tumors, 742j Mammary Cancer, 749 ; Marasmus, 761; Pertussis, 821; Scarlet Fever, 840; Induration of the Cellular Tissue, 876 ; Mumps, 891; Incontinence of Urine, 901. Cornus cir. Eczema and Pruritus, 578. Coralia rub. Chancres. 578 ; Pertussis, 821. Creasotum. Uterine Haemorrhage, 408; Dis- ordered Conditions of the Lochia, 429 ; Abor- tion, 494 ; Dysmenorrhea, 523; Menorrhagia, 536 ; Vulvitis, 572 ; Eczema and Pruritus, 577 ; Erectile Tumors, 581; Haemorrhage from Erec- tile Tumors, 581; Neuralgia of A'agina, 592; Gangrene of the A'agina, 605; Leucorrhea, 647; Metritis, 662; Cancer of the Uterus, 701; Gan- grene of the Uterus, 704; Mammary Cancer, 749; Marasmus, 761; Dentition, 773; Inconti- nence of Urine, 901; Spasms, 949. Crocus. Nausea and Vomiting, 300; Diarrhoea, 319; Chorea, 377; Uterine Haemorrhage, 408; Disordered Conditions of the Lochia, 429 ; Pen- dulous Abdomen, 430 ; Abortion, 494 ; Amenor- rhea, 512; Dysmenorrhea, 523; Menorrhagia, 536 ; Metritis, 662 ; Hysteralgia, 674; Chorea, 936. Croton tig. Sore Nipples, 465; Secretion of Milk, 468; Erysipelatous Inflammation, 474; Eczema and Pruritus, 577; Diarrhea, 787 ; Cholera Infantum, 798. Cuprum. Nausea and A'omiting, 300 : Diarrhea, 319; False Pains, 363 ; Chorea, 377 ; Labor-Pains, 386 ; Hour-glass Contractions, 389 ; Puerperal Convulsions, 422; After-Pains, 427; Amenor- rhea, 512; Dentition, 774; Pertussis, 821; Atelectasis Pulmonum, 829; Scarlet Fever, 840; Meningitis, 903 ; Disease of the Brain, 911 ; Cer- ebro-spinal Meningitis, 932; Chorea, 936; Spasms, 949. 956 CLINICAL INDEX. Cuprum acet. Spasms, 949. Cyclamen. Nausea and A'omiting, 300; Menor- rhagia, 536. Cypripedlum. Hysteria, 570; Neuralgia of Va- gina, 592. Digitalis. Nausea and Vomiting, 301; Diarrhea, 319; Syncope, 390; Nymphomania, 552; Dropsy of the Uterus, 708; Neuralgic Pains in Extrem- ities and other Parts after Scarlet Fever, 847; Cyanosis, 880; Jaundice, 883; Intermittent Fever, 884; Worms, 898; Disease of the Brain, 911. Dolichos p. Itching of the Skin after Measles, 854. Drosera. Nausea and Vomiting, 301; Diarrhea, 319: Leucorrhea, 647; Bronchitis, 808 ; Pertus- sis, 821; Measles, 852. Dulcamara. #Nausea and A'omiting, 301; Diar- rhea, 319; Retention of Urine, 331; Disordered Conditions of the Lochia, 429; Secretion of Milk, 4C8 ; Scanty Supply of Milk, 470; Abortion, 494 ; Amenorrhea, 512; Nymphomania, 552; Eczema and Pruritus, 577; Uterine Displacements, 634; Dropsy of the Uterus, 708; Indigestion, 765; Dentition, 774 ; Diarrhea, 787 ; Dysentery, 791; Cholera Infantum, 798 ; Coryza, 803; Bronchitis, SOS; Pertussis, 821; Scarlet Fever, 840; Measles, 852; Varicella, 865; Urticaria, 868; Eczema Capitis, 870; Pityriasis, 872 ; Warts, 873 ; Indu- ration of the Cellular Tissue, 876; Syphilitic Cutaneous Affections, 878; Jaundice, 883; Re- tention of Urine, 900. Erigeron. Disordered Conditions of the Lochia, 429 ; Menorrhagia, 536; Leucorrhea, 647. Eugenia. Dysmenorrhea, 523; Comedones, 878. Eupatorinm. Ovarian Tumors, 742. Euphorbium. Diarrhea, 319. Euphrasia. Amenorrhea, 512 ; Dysmenorrhea, 523; Hysteria, 567 ; Condylomata, 578; Coryza, 803; Measles, 852; Ophthalmia, 890. Ferrum. Nausea and Vomiting, 301; Diarrhea, 319; A'aricose Veins, 353; Debility, 391; Uterine Haemorrhage, 408; After-Pains, 427 ; Abortion, 495; Amenorrhea, 512; Dysmenorrhea, 523; Menorrhagia, 536; Vulvitis, 572; Eczema and Pruritus, 577; Ascarides of the Vulva, 5S4; Uterine Displacements, 634; Leucorrhea, 647; Metritis, 662; Hysteralgia, 674; Dropsy of the Uterus, 708; Hydatids, 715; Marasmus, 761; Dentition, 774; Diarrhea, 787; Pertussis, 821; Worms, 898. Pilix mas. AVorms, 898. Fluoric acid. Varicose Veins, 353; Menor- rhagia, 536. Galium aper. Mammary Cancer, 749. Gelseminum. Diarrhea, 319; False Pains, 363 ; Lame Pelvis, 367; Neuralgia, 373; Toothache, 375; Labor-Pains, 386 ; Rigidity of the Os, 388 ; Puerperal Convulsions, 422; Retained Placenta, 424; After-Pains, 427; Abortion, 495; Amenor- I rhea, 512 ; Dysmenorrhea, 523; Hysteria, 570 ; Leucorrhea, 647; Asthma of Millar, 826; Scar- let Fever, 840; Neuralgic Pains in Extremities and other Parts after Scarlet Fever, 847 ; In- continence of Urine, 901; Meningitis, 903; Dis- ease of the Brain, 911; Cerebro-spinal Meningi- tis, 932 ; Remittent Fever, 940. Glonoine. Neuralgia, 373 ; Cerebro-spinal Me- ningitis, 932. Gossypium. Nausea and Vomiting, 301; Labor- Pains, 386; Retained Placenta, 425. Graphites. Nausea and Vomiting, 301; Consti- pation, 311; Diarrhea, 319 ; Retention of Urine, 331; Haemorrhoids, 319; Varicose Veins, 353; Impaired Hearing, 369; Labor-Pains, 386 ; Sore Nipples, 465; Mastitis, 475; Amenorrhea, 512; Dysmenorrhea, 523; Nymphomania, 552; Vul- vitis, 572; Erysipelatous Inflammation, 574; Eczema and Pruritus, 577 ; Tumors of the A'ulva, 580 ; Neuralgia of Vagina, 592; Serous Cysts of the Vagina, 610 ; Uterine Displacements, 634 ; Leucorrhea, 647; Metritis, 662; Hysteralgia, 674; Cancer of the Uterus, 701; Hydatids, 715 ; Inflammation of the Ovaries, 731; Ovarian Tu- mors, 742 ; Mammary Cancer, 749; Marasmus, 761; Dentition, 774; Constipation, 782; Diar- rhea, 787; Scrofula after Scarlet Fever, 848; A'accination, 864; Varicella, 865; Erysipelas, 867; Eczema Capitis, 870; Pityriasis, 872; En- cysted Tumors, 873; Intertrigo, 875; Come- dones, 878; Incontinence of Urine, 901. Gratiola. Fissure of the Anus, 326; Dysmenor- rhea, 523; Nymphomania, 553; Cholera In- fantum, 798. Hamamelis. Haemorrnoids, 349; A'aricose A'eins, 353; Uterine Haemorrhage, 408; Menorrhagia, 536; Eczema and Pruritus, 578; Mammary Cancer, 749; Rubeola Maligna, 853; Small-pox, 862. Hedeoma. Amenorrhea, 512 ; Leucorrhea, 647. Helleborus. Nausea and A'omiting, 301; Diar- rhea, 319; Retention of Urine, 331; Puerperal Convulsions, 422; Amenorrhea, 512 ; Dropsy of the Uterus, 708 ; Dentition, 774; Scarlet Fever, 840; Dropsy after Scarlet Fever, 645 ; Meningi- tis, 903 ; Acute Hydrocephalus, 905; Disease of the Brain, 911; Spasms, 949. Helonias. Dysmenorrhea, 523; Menorrhagia, 536; Uterine Displacements, 638; Leucorrhea, 647. Hepar s. Nausea «nd Vomiting, 301; Constipa- tion, 311; Diarrhea, 319 ; Retention of Urine, Hhagades, 431: Mastitis, 475; Menorrhagia, 536; Erysipelatous Inflammation, 574; Chancres, 578 ; Tumors of the A'ulva, 580 ; Leucorrhea, 647 ; Metritis, 662; Ulcerations of the Uterus, 684; Inflammation of the Ovaries, 731 ; Mammary Cancer, 749; Marasmus, 761; Indigestion, 765; Dentition, 774; Diarrhea, 787 ; Bronchitis, 808; Pneumonia, 812; Croup, 816; Pertussis, 821; Scrofula after Scarlet Fever, 848 ; Measles, 853 ; Miliaria, 855; Small-pox, 862; Varicella, 865; Urticaria, 868 ; Eczema Capitis, 871; Encysted CLINICAL INDEX. 957 Tumors, 873; Intertrigo, 875 ; Induration of the Breasts, 877; Syphilis Neonatorum, 878 ; Syph- ilitic Cutaneous Affections, 878 ; Jaundice, 883; Scrofula, 8S6; Ophthalmia, 890; Mumps, 892; Incontinence of Urine, 901. Hydrastis. Eczema and Pruritus, 578; Leucor- rhea, 647; Ulcerations of the Uterus, 684; Ovarian Tumors, 742; Mammary Cancer, 749; Constipation, 782 ; Small-pox, 862. Hydrocyanic acid. Cerebro-spinal Meningi- tis, 933; Spasms, 949. Hyclrophobin. Puerperal Convulsions, 422. Hyoscyamus. Diarrhea, 319; Impaired Vision, 371; Toothache, 375; Chorea, 377; Hysteria, 382; Labor-Pains, 386; Hour-glass Contractions, 389 ; Uterine Haemorrhage, 408 ; Puerperal Con- vulsions, 423 ; Retention of Urine after Parturi- tion, 425; After-Pains, 427; Disordered Condi- tions of the Lochia, 429 ; Puerperal Mania, 459 ; Abortion, 495 ; Amenorrhea, 512; Dysmenor- rhea, 524; Menorrhagia, 536; Nymphomania, 553 ; Hysteria, 567 ; Metritis, 662 ; Hysteralgia, 674; Hydatids, 715; Dentition, 775; Pertussis, 822 ; Atelectasis Pulmonum, 829 ; Scarlet Fever, 840; Measles, 853; Small-pox, 862; Hiccough, 892; Retention of Urine, 900 ; Meningitis,903; Disease of the Brain, 911; Cerebro-spinal Men- ingitis, 933; Chorea, 936; Spasms, 949. Hypericum. Dysmenorrhea, 524; Leucorrhea, 647. Ignatia. Nausea and Vomiting, 301; Constipa- tion, 312; Diarrhea, 320; Fissure of the Anus, 326: Haemorrhoids, 349 ; Neuralgia. 373 ; Chorea, 377; Hysteria, 382 ; Labor-Pains, 386; Syncope, 391; Uterine Haemorrhage, 408 ; Puerperal Con- vulsions, 423; After-Pains, 427 ; Disordered Con- ditions of the Lochia, 429 ; Great Sense of Emp- tiness in Pit of Stomach from Nursing, 473; Abortion, 495; Amenorrhea, 512; Dysmenor- rhea, 524 ; Menorrhagia, 536; Nymphomania, 553; Hysteria, 567; Ascarides of the Vulva, 584; Spasms of Vagina, 590; Uterine Displace- ments, 634: Leucorrhea, 647; Metritis, 662; Hysteralgia, 675; Inflammation of the Ovaries, 731; Indigestion, 765; Dentition, 775 ; Inter- trigo, 876; Jaundice, 883; Ophthalmia, 890; Hiccough, 892; Worms, 898; Disease of the Brain, 911; Chorea, 936 ; Spasms, 949. Indigo. Dysmenorrhea, 524. Iodine. Debility, 392; Leucorrhea, 647; Cancer of the Uterus, 701; Marasmus, 761; Regurgi- tation, 801; Croup, 817 ; Scrofula, 886. Ipecac. Nausea and Vomiting, 301; Diarrhea, 320; False Pains,363; Labor-Pains,386; Uterine Haemorrhage, 409; Puerperal Convulsions, 423 ; Abortion, 495; Dysmenorrhea, 524; Menor- rhagia, 537 ; Hysteria, 567 ; Metritis, 662 ; Hys- teralgia, 675 ; Marasmus, 761; Indigestion, 765; Dentition, 775; Diarrhea, 787 ; Dysentery, 791; Cholera Infantum, 798 ; Vomiting of Blood, 801; Regurgitation, 801; Vomiting of Ingesta, 801; Bilious Vomiting, 801; Bronchitis, 808; Per- tussis, 822; Asthma of Millar, 826; Scarlet Fever, 840; Measles, 853; Bronchitis after Measles, 853; Small-pox, S62; Jaundice, 883; Rickets, 888; Hiccough, 892; AVorms, 898; Retention of Urine, 900; Disease of the Brain, 911; Remittent Fever, 940; Spasms, 949. Iris vers. Diarrhea, 320; Indigestion, 765; Diarrhea, 787 ; Vomiting of Ingesta, 801. Jacaranda. Chancres, 678. Jacea. Eczema Capitis, 871. Jalapa. Indigestion, 765. Jodium. Nausea and Vomiting, 302; Constipa- tion, 312; Diarrhea, 320; Uterine Haemorrhage, 409; Amenorrhea, 512; Dysmenorrhea, 524; Menorrhagia, 537; Nymphomania, 553; Hys- teria, 567 ; Metritis, 662; Ovarian Tumors, 742 ; Asthma of Millar, 826. Kali b. Nausea and Vomiting, 302; Secretion of Milk, 468 ; Dysmenorrhea, 524 ; Chancres, 578 ; Uterine Displacements, 634; Leucorrhea, 647; Coryza, 803; Croup, 817 ; Pertussis, 822 ; Measles, 853; Diphtheria, 945. Kali c. Nausea and Vomiting, 302 ; Constipation, 312; Diarrhea, 820; Haemorrhoids, 349; Lame Pelvis, 367 ; Labor-Pains, 386; Hour-glass Con- tractions, 389; Debility, 392; Puerperal Convul- sions, 423; After-Pains, 427; Puerperal Mania, 459; Phlegmasia Dolens, 463; Abortion, 495; Amenorrhea, 513; Dysmenorrhea, 524; Vul- vitis, 572; Eczema and Pruritus, 577; Tumors of the Vulva, 580; Neuralgia of A'agina, 592; Uterine Displacements, 634; Leucoz-rhea, 648; Metritis, 662 ; Hysteralgia, 675 ; Dropsy of the Uterus, 709; Hydatids, 715; Pertussis, 822; Scarlet Fever, 840 ; Dropsy after Scarlet Fever, 845 ; Erysipelas, 867 ; Disease of the Brain, 911. Kali hyd. Dysmenorrhea, 524; Chancres, 578; Leucorrhea, 648. Kali nit. Dysmenorrhea, 524. Kalmia. Dysmenorrhea, 524. Kaolin. Croup, 817. Lachesis. Diarrhea, 320; Fissure of the Anus, 326; Retention of Urine, 331; Haemorrhoids, 349; Impaired Hearing, 369; Hysteria, 382; Syncope, 391; Uterine Haemorrhage, 409 ; Puer- peral Convulsions, 423 ; Ulceration of the Um- bilicus, 431; Secretion of Milk, 468; Mastitis, 475 ; Amenorrhea, 513 ; Dysmenorrhea, 524 ; Menorrhagia, 537 ; Nymphomania, 553; Hys- teria, 567 ; Erysipelatous Inflammation, 574 ; Haemorrhage from Erectile Tumors, 582; Stran- gulation of Prolapsed Portion of A'agina, 5S8; Concomitant Symptoms of A'aginal Fistulas, 604; Gangrene of Vagina, 605; Uterine Dis- placements, 635; Leucorrhea, 648; Metritis, 663; Cancer of the Uterus, 701; Inflammation of the Ovaries, 731; Ovarian Tumors, 742; Mam- mary Cancer, 749 ; Dentition, 775; Diarrhea, 787; Dysentery, 791; Croup, 817 ; Pertussis, 822 ; Asthma of Millar, 826 ; Scarlet Fever, 841 ; Post-scarlatinal Rheumatism, 847; Neuralgic Pains in Extremities and other Parts after Scar- 958 CLINICAL INDEX. let Fever, 847; Measles, 853; Rubeola Maligna, 853; Pemphigus, 856 ; Small-pox, 862; Erysipe- las, 867; Cyanosis, 880; Intermittent Fever, 884; Ophthalmia, 890; Worms, 898; Cerebro- spinal Meningitis, 933 ; Diphtheria, 946; Spasms, 949. I.achnantes. Diphtheria, 946. Lactuca. Dropsy of the Uterus, 709. Laurocerasus. Nausea and A'omiting, 302; Con- stipation, 312; Diarrhea, 320; Retention of Urine, 331; Puerperal Convulsions, 423; Dys- menorrhea, 524; Menorrhagia, 537; Cholera Infantum, 70S ; Asthma of Millar, 826; Cyanosis, 880; Chorea, 936 ; Spasms, 949. Ledum. Constipation, 312; Diarrhea, 320; Dys- menorrhea, 525; Menorrhagia, 537; Vaginal Fistulas, 603; Uterine Displacements, 635; Dropsy of the Uterus, 709. Leptandria. Diarrhea, 320; Leucorrhea, 648. Lilium t. Amenorrhea, 513; Dysmenorrhea, 525 ; Uterine Displacements, 635. Lobelia infol. Rigidity of the Os, 388; Dys- menorrhea, 525. Lycopodium. Nausea and Vomiting, 302 ; Con- stipation, 312; Diarrhea, 320; Retention of Urine, 331 ; Haemorrhoids, 349 ; A'aricose Veins, 353; False Pains, 363; Hysteria, 382; Labor- Pains, 386; Debility, 392; Uterine Haemorrhage, 409 ; Retention of Urine after Parturition, 425 ; Ulceration of the Umbilicus, 431; Phlegmasia Dolens, 463; Sore Nipples, 465; Deterioration of Health from Nursing, 473; Abortion, 495; Amenorrhea, 513; Dysmenorrhea, 525; Men- orrhagia, 537; Nymphomania, 553; Hysteria, 567; Vulvitis, 572; Eczema and Pruritis, 577; Condylomata, 579; Erectile Tumors, 581; Neu- ralgia of Vagina, 592; Induration of Vagina, 601; Vaginal Fistulas, 603; A'aginal Growths, 608; Serous Cysts of the Vagina, 610; Granular Vegetations, 610; Uterine Displacements, 635; Leucorrhea, 648 ; Metritis, 663; Ulcerations of the Uterus, 084; Cancer of the Uterus, 702; Dropsy of the Uterus, 709 ; Physometra, 711; Hydatids, 715; Inflammation of the Ovaries, 731; Ovarian Tumors, 742; Mammary Cancer, 749; Marasmus, 761; Indigestion, 765; Dentition, 775; Constipation, 782; Regurgitation, 801; Vomiting of Ingesta, 801; Bronchitis, 808; Pneumonia, 811; Scarlet Fever, 841; Dropsy after Scarlet Fever, 845; Erysipelas, 867; Eczema Capitis, 871; Pityriasis, 872; Naevi Materni, 873; Warts, 873 ; Intertrigo, 875; Intermittent Fever. 884; Hernia,894; AVorms, 898; Retention of Urine, 900; Incontinence of Urine, 901; Gravel, 901; Cerebro-spinal Meningitis, 933; Chorea, 936; Diphtheria, 946. Magnesia c. Nausea and Vomiting, 302; Diar- rhea, 320; Neuralgia, 378; Toothache, 375; Amenorrhea, 513 : Dysmenorrhea, 525 ; Men- orrhagia, 537 ; Marasmus, 761; Indigestion, 765 ; Dentition, 775; Diarrhea, 787; Remittent Fe- ver, 940. Magnesia mur. Nausea and Vomiting, 302; Constipation, 312; Labor-Pains, 386; Amen- orrhcea, 513 ; Dysmenorrhea, 525 ; Hysteria, 567; Indurations of Vagina, 601; Uterine Dis- placements, 635; Leucorrhei, 648; Metritis, 663; Hysteralgia, 675; Cancer of the Uterus, 702; Dentition, 775; Diarrhea, 787. Magnesia sulph. Dysmenorrhea, 525. Manganum. Lame Pelvis, 367 ; Dysmenorrhea, 525; Leucorrhcea, 648. Mephitis. Pertussis, 822. Mercurius cor. Dysentery, 791. Mercurius jod. Chancres, 578 ; Asthma of Mil- lar, 827 ; Scrofula after Scarlet Fever, 848. Mercurius prot. Scarlet Fever, 841; Diph- theria, 946. Mercurius sulph. Nausea and Vomiting, 302; Constipation, 312; Diarrhea, 320; Retention of Urine, 331; Haemorrhoids, 349 ; Impaired Hear- ing, 369 ; Toothache, 375 ; Uterine Haemorrhage, 409; Puerperal Convulsions, 423; Disordered Conditions of the Lochia, 429; Sore Nipples, 465; Secretion of Milk, 468 ; Scanty Supply of Milk, 470; Mastitis, 475; Abortion, 495 ; Amen- orrhea, 513; Dysmenorrhea, 525 ; Menorrhagia, 537 ; Nymphomania, 553 ; Hysteria, 567 ; A'ul- vitis, 572; Erysipelatous Inflammation, 575; Eczema and Pruritus, 577; Chancres, 578; Pro- lapse of the A'agina, 587; Spasms of Vagina, 590; Neuralgia of A'agina, 592; Induration of Vagina, 601; Vaginal Fistulas, 604; Vaginal Growths, 608; Granular Vegetations, 610; Uterine Displacements, 635; Leucorrhcea, 648; Metritis, 663; Sensation of Coldness in Ulcers, 685 ; Cancer of the Uterus, 702; Dropsy of the Uterus, 709; Mammary Cancer, 749; Maras- mus, 761; Indigestion, 765; Dentition, 776; Aphthae, 780; Constipation, 782; Diarrhea, 787; Dysentery, 792; Cholera Infantum, 798; Bilious Vomiting, 801; Coryza, 804; Pneumo- nia, 811; Pertussis, 822 ; Scarlet Fever, 841; Neuralgic Pains in Extremities and other Parts after Scarlet Fever, 847; Otorrhea, 848; Measles, 853; Diarrhea after Measles, 853 ; Roseola, 855; Small-pox, 862; Varicella, 865; Erysipelas, 867; Eczema Capitis, 871; Pityriasis, 872; Ranula, 874; Intertrigo, 875 ; Syphilis Neonatorum, 878 ; Syphilitic Ophthalmia, 878 ; Condylomata, 878 ; Jaundice, 883 ; Intermittent Fever, 884 ; Scrof- ula, 886; Ophthalmia, 890 ; Mumps, 892 ; Worms, 898; Retention of Urine, 900; Disease of the Brain, 911; Remittent Fever, 940; Diphtheria, 946; Spasms, 949. Mercurius viv. Chancres, 578. Mezereum. Diarrhea, 321; Fissure of the Anus, 326; Toothache, 375; Vaginal Growths, 608; Leucorrhea, 648 ; Scrofula, 880. Most bus. Nausea and Vomiting, 303; Hysteria, 382; Dysmenorrhea, 525; Menorrhagia, 537; Nymphomania, 653; Hysteria, 568; Asthma of Millar, 826. Murex. Dysmenorrhea, 525; Cancer of the Uterus, 702. Muriatic acid. Diarrhea, 321; Hsemorrhoids, 350; Debility, 392; Dysmenorrhea, 525; Men- CLINICAL INDEX. 959 orrhagia, 537; Neuralgia of Vagina, 592; Leu- corrhea, 64S ; Ulcerations of the Uterus, 684; Scarlet Fever, 841; Diuresis, 900; Remittent Fever, 940. Natrum c. Hysteria, 382; Labor-Pains, 386 ; Dysmenorrhea, 526 ; Menorrhagia, 537 ; Nym- phomania, 553; Leucorrhea, 648; Hydatids, 715. Natrum mur. Nausea and Vomiting, 302; Constipation, 312; Diarrhea, 321; Fissure of the Anus, 326; Haemorrhoids, 350; Impaired Vision, 371; Labor-Pains, 386; Amenorrhea, 513; Dysmenorrhea, 526; Menorrhagia, 537 ; Nymphomania, 553 ; Hysteria, 568 ; Vulvitis, 572; Eczema and Pruritus, 577; Neuralgia of Vagina, 592; Uterine Displacements, 635; Leu- corrhea, 648 ; Hysteralgia, 675; Rauula, 374; Comedones, 878 ; Chorea, 936. Natrum sulph. Dysmenorrhea, 526. Niccolum. Dysmenorrhea, 526; Leucorrhea, 648. Nitric acid. Nausea and Vomiting, 303; Con- stipation, 312; Fissure of the Anus, 327; Re- tention of Urine, 332 ; Haemorrhoids, 350 ; Im- paired Hearing, 369; Uterine Hemorrhage, 409 ; Dysmenorrhea, 526 ; Menorrhagia, 537 ; Vulvitis, 572 ; Eczema and Pruritus, 577 ; Chan- cres, 578: Condylomata, 579 ; Tumors of the Vulva, 5S0; Erectile Tumors, 581; Neuralgia of A'agina, 592; Vaginal Fistulas, 603 ; Vaginal Growths, 608; Granular A'egetations, 610; Uterine Displacements, 636; Leucorrhea, 648; Cancer of the Uterus, 702; Mammary Cancer, 749; Constipation, 782; Scarlet Fever, 841; Warts, 873; Syphilis Neonatorum, 878; Syph- ilitic Neonatorum, 878 ; Syphilitic Cutaneous Af- fections, 878 ; Condylomata, 878; Jaundice,883; Retention of Urine, 900. Nitrum. Leucorrhea, 648. Nux juglans. Dysmenorrhea, 526; Menorrha- gia, 537 ; Chancres, 578. Nux mosch. Nausea and A'omiting, 303; Con- stipation, 312 ; Diarrhea, 321; Toothache, 375 ; Uterine Haemorrhage, 409 ; Puerperal Convul- sions, 423 ; Abortion, 495; Amenorrhea, 513; Dysmenorrhea, 526 ; Menorrhagia, 537 ; Hys- teria, 568; Uterine Displacements, 636; Leucor- rhea, 649; Dentition, 776. Nux vomica. Nausea and Vomiting, 303 ; Con- stipation, 313 ; Diarrhea, 321; Fissure of the Anus, 327 ; Retention of Urine, 332; Haemor- rhoids, 350; A'aricose Veins, 353; False Pains, 363; Impaired Vision, 371; Neuralgia, 373; Toothache, 375 ; Chorea, 377 ; Hysteria, 382; Labor-Pains, 387 ; Hour-glass Contractions, 389 ; Syncope, 390; Debility, 392; Uterine Haemor- rhage, 409; Puerperal Convulsions, 423 ; Reten- tion of Urine after Parturition, 426; After- Pains, 427 ; Disordered Conditions of the Lochia, 429 ; Phlegmasia Dolens, 463; Secretion of Milk, 468 ; Abortion, 495 ; Dysmenorrhea, 526; Men- orrhagia, 537 ; Nymphomania, 553; Hysteria, 568; Vulvitis, 572; Eczema and Pruritus, 577; Ascarides of the Vulva, 584; Strangulation of Prolapsed Portion of Vagina, 588; Spasms of A'agina, 590 ; Neuralgia of A'agina. .102; Uterine Displacements, 636; Leucorrhea, 649; Metritis, 663; Hysteralgia, 675; Inflammation of the Ovaries, 731; Marasmus, 761; Indigestion, 765 ; Dentition, 776; Constipation, 782; Diarrhea, 788 ; Dysentery, 792 ; Cholera Infantum, 798 : Vomiting of Blood, 801; Regurgitation, 801 ; Vomiting of Ingesta, 801; Bilious Vomiting, 801; Faecal A'omiting, 801; Coryza, 804 ; Bron- chitis, 808; Pertussis, 822; Scarlet Fever, 841; Urticaria, 868; Naevi Materni, 873; Jaundice, 883 ; Intermittent Fever, 8S4 ; Rickets, 889 ; Ophthalmia, 891; Hiccough, 892 ; Hernia, 894 ; Worms, 898; Retention of Urine, 900; Disease of the Brain, 911; Cerebro-spinal Meningitis, 933 ; Chorea, 937 ; Remittent F'ever, 940; Spasms, 949. Oleander. Constipation, 313; Great Sense of Emptiness in Pit of Stomach, 473 ; Marasmus, 761. Oleum anim. Dysmenorrhea, 526. Opium. Nausea and A'omiting, 303; Constipa- tion, 313 ; Diarrhea, 321; Hysteria, 382; Labor- Pains, 387; Puerperal Convulsions, 423; Dis- ordered Conditions of the Lochia, 429 ; Abortion, 496; Menorrhagia, 538; Nymphomania, 553; Strangulation of Prolapsed Portion of A'agina, 588 ; Uterine Displacements, 636 ; Metritis, 663 ; Hysteralgia, 675 ; Indigestion, 766 ; Constipa- tion, 782; Diarrhea, 788; Faecal Vomiting, 801; Scarlet Fever, 842; Hernia, 895 ; Retention of Urine, 900; Meningitis, 901; Acute Hydro- cephalus, 905; Diseaso of the Brain, 912; Cere- bro-spinal Meningitis, 933; Chorea, 937 ; Spasms, 949. Palladium. Hysteria, 568; Inflammation of the Ovaries, 732. Petroleum. Nausea and Vomiting, 303; Diar- rhea, 321; Haemorrhoids, 350; Puerperal Mania, 459; Dysmenorrhea, 020; Vulvitis, 573; Eczema and Pruritus, 577; Indurations of Vagina, 601; Concomitant Symptoms of A'aginal Fistulas, 604 ; Vaginal Growths, 609 ; Uterine Displacements, 636; Leucorrhea, 649; Marasmus, 761; A'accination, 864. Petroselinuin. Retention of Urine, 900. Phosphorus. Nausea and Vomiting, 304; Con- stipation, 313; Diarrhea, 321; Fissure of the Anus, 327; Haemorrhoids, 350 ; Impaired Hear- ing, 369; Impaired A'ision, 371; Toothache, 375; Hysteria, 382; Labor-Pains,387; Uterine Haem- orrhage, 409; Puerperal Convulsions, 423; Sore Nipples, 465 ; Galactorrhea, 473; Deterioratiou of Health from Nursing, 473; Cramps in Stom- ach from Nursing, 473; Mastitis, 475 ; Abortion, 496 ; Amenorrhea, 514; Dysmenorrhea, 526; Menorrhagia, 538; Nymphomania, 554; Hys- teria, 568; Vulvitis, 573; Chancres, 578; Erec- t.le Tumors, 6S1; Haemorrhage from Erectile 1 n.ors, 582; Vaginal Growths, 609; Uterine 960 CLINICAL INDEX. Displacements, 636; Leucorrhea, 649; Hyster- algia, 675; Cancer of the Uterus, 702; Dropsy of the Uterus, 709; Hydatids, 715; Mammary Cancer, 749; Marasmus, 761; Dysentery, 792; Cholera Infantum, 798; A'omiting of Ingesta, 801; Bronchitis, 808; Pneumonia, 811; Croup, 817 ; Pertussis, 822 ; Asthma of Millar, 826 ; Atelectasis Pulmonum, 829; Scarlet Fever, 842 ; Dropsy after Scarlet Fever, 846; Measles, 853; Bronchitis after Measles, 853; Pneumonia after Measles, 853; Small-pox, 862; Noevi Materni, 873; Encysted Tumors, S73 ; Induration of the Breasts, 877; Cyanosis, 881; AVorms, 89S; In- continence of Urine. 9ol; Gravel, 901; Hydro- cephaloid Disease, 909; Disease of the Brain, 912; Cerebro-spinal Meningitis, 933; Chorea, 937 ; Remittent Fever, 940. Phosphoric acid. Nausea and Vomiting, 304; Constipation, 313 ; Diarrhea, 321; Retention of Urine, 332; Scanty Supply of Milk, 470; Deter- ioration of Health from Nursing, 473; Amenor- rhea, 514; Dysmenorrhea, 527; Menorrhagia, 538; Condylomata, 578; Vaginal Growths, 609 ; Leucorrhea, 649; Metritis, 663; Hysteralgia, 675 ; Ulcerations of the Uterus, 684 ; Physometra, 711; Marasmus, 761; Diarrhea, 788 ; Cholera Infantum, 798 ; Rubeola Maligna, 853 ; Small- pox, 862 ; Erysipelas, 867 ; Syphilis Neonatorum, 878; Syphilitic Cutaneous Affections, 878 ; Rick- ets, 889 ; Diuresis, 900; Incontinence of Urine, 901; Gravel, 902; Hydrocephaloid Disease, 909 ; Disease of the Brain, 912. Phytolacca dec. Constipation, 313, 782; Masti- tis, 475; Amenorrhea, 514 ; Dysmenorrhea, 527; Menorrhagia, 538; Condylomata, 579; Mam- mary Cancer, 749 ; Eczema Capitis, 871. Platina. Constipation, 313; Hysteria, 382; La- bor-Pains, 387 ; Hour-glass Contractions, 389; Uterine Haemorrhage, 409; Disordered Condi- tions of the Lochia, 429; Pendulous Abdomen, 430; Puerperal Mania, 459; Abortion, 496; Amenorrhea, 514; Dysmenorrhea, 527 ; Men- orrhagia, 538 ; Nymphomania, 554; Hysteria, 568; Eczema and Pruritus, 577; Erectile Tu- mors, 581; Spasms of Vagina, 590; A'aginal Growths, 609; Uterine Displacements, 636; Leucorrhea, 649; Metritis, 664; Hysteralgia, 675 ; Inflammation of the Ovaries, 732; Con- stipation, 782. Plumbum. Constipation, 313; Fissure of the Anus, 327; False Pains, 363; Abortion, 496; Dysmenorrhea, 527 ; Metrorrhagia, 538 ; Nym- phomania, 554 ; Strangulation of Prolapsed Por- tion of Vagina, 588; Leucorrhea, 649; Consti- pation, 782 ; Faecal A'omiting, 801; Retention of Urine, 900: Cerebro-spinal Meningitis, 933. Podophyllum Diarrhea, 321; Haemorrhoids, 350; Pendulous Abdomen, 430; Abortion, 496 ; Amenorrhea, 514 ; Dysmenorrhea, 527 ; Uterine Displacements, 636; Leucorrhea, 649; Maras- mus, 762; Indigestion, 766: Dentition, 776; Diarrhea, 788; Dysentery, 792 ; Cholera Infan- tum, 798. Prunus spinosa. Leucorrhea, 649. Psorinum. Dentition, 776 ; Eczema Capitis, 871; Pityriasis, 872; Warts, 873 ; Scrofula, 886. Pulsatilla. Nausea, and A'omiting, 304; Consti- pation, 313; Diarrhea, 321; Retention of Urine, 332; Haemorrhoids, 350; A'aricose Veins, 353; False Pains, 363; Lame Pelvis, 367; Impaired Hearing, 369 ; Impaired Vision, 371; Neuralgia, 373; Toothache, 375; Hysteria, 382; Labor- Pains, 387 ; Hour-glass Contractions, 389 ; Uter- ine Haemorrhage, 409; Puerperal Convulsions, 423 ; Retained Placenta, 425 ; Retention of Urine after Parturition, 426; After-Pains, 427; Dis- ordered Conditions of the Lochia, 429; Puer- peral Mania, 459; Phlegmasia Dolens, 463 ; Sore Nipples, 465; Secretion of Milk, 468; Scanty Supply of Milk, 470; Galactorrhea, 473 ; Abortion, 496; Amenorrhea, 514; Dysmenor- rhea, 527 ; Menorrhagia, 538 ; Nymphomania, 554; Hysteria, 568; Erysipelatous Inflamma- tion, 575 ; Haemorrhage from Erectile Tumors, 582; Spasms of Vagina, 590; Indurations of Vagina, 601; Vaginal Fistulas, 604; Vaginal Growths, 609; Serous Cysts of the A'agina, 610; • Uterine Displacements, 637 ; Leucorrhcea, 649; Metritis, 664; Hysteralgia, 676; Mammary Cancer, 749; Marasmus, 762 ; Indigestion, 766; Diarrhea, 788; Dysentery, 792; Vomiting of Ingesta, 801; Bilious Vomiting, 801; Coryza, 804; Bronchitis, 808; Pertussis, 822; Dropsy after Scarlet F'ever, 846; Measles, 853; Diar- rhea after Measles, 853; Bronchitis after Measles, 853; Rubeola Maligna, 853; Roseola, 855 ; Small-pox, 863 ; Erysipelas, 867 ; Urticaria, 868; Intertrigo, 876; Jaundice, 883; Intermit- tent Fever, 8S4 ; Ophthalmia, 891; Mumps, 892; Hiccough, 892; Worms, 898 ; Retention of Urine, 900; Incontinence of Urine, 901; Disease of the Brain, 912; Cerebro-spinal Meningitis, 933; Remittent Fever, 940. Ranunc.bulb., Leucorrhea,649; Inflammation of the Ovaries, 732; Pemphigus, 856. Rhatania. Constipation, 313; Incontinence of Urine, 901. Rheum. Diarrhea, 322 ; Secretion of Milk, 468; Indigestion, 766; Dentition, 776; Diarrhea, 788. Rhododendron. Constipation, 313; Amenor- rhea, 514; Serous Cysts of the Vagina, 610. Rhus rad. Erysipelas, 867. Rhus tox. Nausea and A'omiting, 304; Con- stipation, 314; Diarrhea, 322; Retention of Urine, 332; Haemorrhoids, 350 ; False Pains, 363; Lame Pelvis, 368; Toothache, 375; Hour- glass Contractions, 389 ; Debility, 392; Uterine Haemorrhage, 409; After-Pains, 427 ; Disordered Conditions of the Lochia, 430 ; Phlegmasia Do- lens, 463; Secretion of Milk, 469; Scanty Supply of Milk, 470; Galactorrhea, 473; Abortion, 496; Amenorrhea, 514 ; Dysmenorrhea, 527 ; Men- orrhagia, 538 ; Vulvitis, 573; Erysipelatous In- flammation, 575; Neuralgia of A'agina, 592; Uterine Displacements, 657 ; Metritis, 664; Hys- teralgia, 676; Sensation of Coldne6S in Ulcers, CLINICAL INDEX. 961 685; Cancer of the Uterus, 702; Dropsy of the Uterus, 709; Marasmus, 762; Diarrhea, 788; Dysentery, 792; Scarlet Fever, 842; Dropsy after Scarlet Fever, 846; Post-scarlatinal Rheu- matism, 847; Neuralgic Pains in Extremities and other Parts after Scarlet Fever, 847 ; Rube- ola Maligna, 853; Itching of the Skin after Measles, 854; Roseola, 855; Pemphigus, 856; Small-pox, 863; Varicella, 865; Erysipelas, 867 ; Urticaria, 868; Eczema Capitis, 871; Warts, 873 ; Cephalaetnatoma, 874; Ranula, 874; Ophthal- mia, 891; Mumps, 892; Retention of Urine, 900; Diuresis, 900; Cerebro-spinal Meningitis, 933 ; Remittent Fever, 940. Ruta. Constipation, 314; Retention of Urine, 332; Labor-Pains, 387; Amenorrhea, 514; Leucor- rhea, 649; Erysipelas, 867 ; Rickets, 889. 428; Disordered Conditions of the Lochia, 430; Pendulous Abdomen, 430; Rhagades, 431; Ul- ceration of the Umbilicus, 431; Sore Nipples, 465; Secretion of Milk, 469; Great Sense of Emptiness in Pit of Stomach from Nursing, 473; Abortion, 496; Amenorrhea, 515; Dysmenor- rhea, 528; Menorrhagia, 538; Hysteria, 569; Vulvitis, 573; Eczema and Pruritus, 578; Tu- mors of the Vulva, 580; Erectile Tumors, 581; Prolapse of the Vagina, 587; Neuralgia of A'a- gina, 592; Indurations of Vagina, 601; Vaginal Fistulas, 604; Uterine Displacements, 637; Leu- corrhea, 649; Metritis, 664; Hysteralgia, 676; Cancer of the Uterus, 703; Dropsy of the Uterus, 709; Hydatids, 715 ; Ovarian Tumors, 742; Mam- mary Cancer, 749; Dentition, 777; Constipation, 782; Diarrhea, 788; Bilious Vomiting, 801; Pertussis, 822; Varicella, 865; Urticaria, 868; Eczema Capitis, 871; Pityriasis, 872; Warts, 874; Intertrigo, 876; Retention of Urine, 900 ; Incontinence of Urine, 901; Disease of the Brain, 912; Chorea, 937. icia. Nausea and Vomiting, 305; Constipation, 314; Fissure of the Anus, 327; Haemorrhoids, 350; Lame Pelvis, 368; Impaired Hearing, 369; Hysteria, 382 ; Uterine Haemorrhage, 410; Dis- ordered Conditions of the Lochia, 430; Rhagades, 431; Ulceration of the Umbilicus, 431; Sore Nipples, 465; Secretion of Milk, 469 ; Deteriora- tion of Health from Nursing, 473 ; Mastitis, 475; Child Vomits the Milk soon after Nursing, 475 ; Abortion, 497 ; Amenorrhea, 515; Dysmenor- rhea, 528; Menorrhagia, 538; Nymphomania, 554; Eczema and Pruritus, 578 ; Chancres, 578; Tumors of the Vulva, 580; Erectile Tumors, 581; Ascarides of the Vulva, 584; Neuralgia of Vagina, 592; Vaginal Fistulas, 604; Vaginal Growths, 609; Serous Cysts of the Vagina, 610 ; Uterine Displacements, 637 ; Leucorrhea, 650 ; Sensation of Coldness in Ulcers, 685 ; Cancer of the Uterus, 703 ; Hydatids, 715 ; Indigestion, 766; Dentition, 777; Constipation, 782; Regur- gitation, 801; Vomiting of Ingesta, 801; Bron- chitis, 808; Pertussis, 822; Scarlet Fever, 842 ; Scrofula after Scarlet Fever, 848; Otorrhea, 848; Small-pox, 863; A'accination, 864; Pityri- asis, 872; Encysted Tumors, 873; Cephalaema- toma,874; Induration of the Breasts, 877; Scrof- ula, 887 ; Rickets, 889 ; Mumps, 892 ; Hernia, 895 ; Worms, 899; Incontinence of Urine, 901; Diuresis, 901; Gravel, 902 ; Acute Hydroceph- alus, 905 ; Disease of the Brain, 912; Spasms, 949. tigelia. Neuralgia, 373; Worms, 899; Diuresis, 901. >ongia. Dysmenorrhea, 528; Menorrhagia, 539; Croup, 817; Atelectasis Pulmonum. 829. [uills. Pertussis, 822; Dropsy after Scarlet Fever, 846 ; Diuresis, 901; Disease of the Brain, 912. annum. Constipation, 314; Labor-Pains, 387 ; Debility, 392; Dysmenorrhea, 528; Menorrha- gia, 539; Hysteria, 569 ; Prolapse of the A'agina, 587 ; Uterine Displacements, 637 ; Leucorrhea, Sabadilla. Nausea and Vomiting, 304; Consti- pation, 314; Amenorrhea, 514; AVorms, 899. Sabina. Constipation, 314; Diarrhea, 322; Haem- orrhoids, 350; Uterine Haemorrhage, 410; Re- tained Placenta, 425; After-Pains, 427 ; Abor- tion, 496; Amenorrhea, 514; Dysmenorrhea, 527; Menorrhagia, 538 ; Nymphomania, 554; Hysteria, 569; Condylomata, 578; Tumors of the Vulva, 580 ; Neuralgia of Vagina, 592 ; Leu- corrhea, 649; Metritis, 664; Hysteralgia, 676; Hydatids, 715; Pemphigus, 856; Comedones, 878. Sarracenia purp. Small-pox, 863. Sambucus. Menorrhagia, 538; Coryza, 804; Asthma of Millar, 827. Sanguinaria. A.menorrhea, 514; Dysmenor- rhea, 527; Leucorrhcea, 649. Sarsaparilla. Constipation, 314; Dysmenor- rhea, 527; Leucorrhea, 649; Eczema Capitis, 871; Gravel, 901; Incontinence of Urine, 901. S ecale c. Diarrhea, 322 ; False Pains, 363; Labor- Pains, 387; Hour-glass Contractions,389; Uterine Haemorrhage, 410; Puerperal Convulsions, 424 ; Retained Placenta, 425; After-Pains, 427; Dis- ordered Conditions of the Lochia, 430; Pendu- lous Abdomen, 430; Scanty Supply of Milk, 470; Abortion, 496; Amenorrhea, 515; Dysmenor- rhea, 527 ; Menorrhagia, 538; Vulvitis, 573; Gangrene of the Vagina, 605 ; Uterine Displace- ments, 637; Leucorrhea, 649; Metritis, 664; Hysteralgia, 676; Ulcerations of the Uterus, 684; Gangrene of the Uterus, 704; Hydatids, 715; Cholera Infantum, 798; Pemphigus, 856 ; Small-pox, 863; Cyanosis, 881; Chorea, 937; Spasms, 949. Selenium. Nausea and Vomiting, 304. Senecio. Amenorrhcea, 515; Dysmenorrhea, 528; Hysteria, 570. Senna. Colic or Indigestion, 766. Sepia. Nausea and Vomiting, 304; Constipation, 314; Diarrhea, 322; Fissure of the Anus, 327 ; Retention of Urine, 332 ; Haemorrhoids, 350; False Pains, 364; Neuralgia, 373; Hysteria, 383; Labor-Pains, 387 ; Hour-glass Contractions, 389 ; Syncope, 391; Debility, 392 ; Uterine Haemor- rhage, 410; Retained Placenta, 425 ; After-Pains, 61 962 CLINICAL INDEX. 650; Marasmus, 762; Indigestion, 766; Denti- tion, 777; Hernia, 895; Worms, 899; Spasms, 949. S ta physagria. Nausea and Vomiting, 305; Con- stipation, 314; Toothache, 375; Hysteria, 383; Amenorrhea, 515; Nymphomania, 554; Hys- teria, 569 ; Vulvitis, 573; Eczema and Pruritus, 578; Condylomata, 579; Vaginal Growths, 609; Granular Vegetations, 610; Uterine Displace- ments, 637 ; Cancer of the Uterus, 703; Inflam- mation of the Ovaries, 732; Indigestion, 766; Dentition, 777; Aphthae, 780; Eczema Capitis, 871; Rickets, 889. Sticta p. Coryza, 804; Chorea, 937. Stramonium. Nausea and Vomiting, 305; Diar- rhea, 322; Retention of Urine, 333; Chorea, 377; Hysteria, 383; Syncope, 391; Uterine Haemorrhage, 410; Puerperal Convulsions, 424; Retention of Urine after Parturition, 426; Dis- ordered Conditions of the Lochia, 430; Puer- peral Mania, 459; Galactorrhea, 473; Abortion, 497 ; Amenorrhea, 515; Dysmenorrhea, 528; Menorrhagia, 539 ; Nymphomania, 554; Hys- teria, 569; Metritis, 664; Dentition, 777; Asthma of Millar, 827 ; Measles, 853; Small-pox, 863 ; AVorms, 899; Retention of Urine, 900; Menin- gitis, 903; Disease of the Brain, 912; Cerebro- spinal Meningitis, 934; Chorea, 937; Spasms, 949. Strontiana. Leucorrhea, 650. Sulphur. Nausea and Vomiting, 305; Constipa- tion, 314; Diarrhea, 322; Fissure of the Anus, 327; Retention of Urine, 333; Haemorrhoids, 350; A'aricose Veins, 353; False Pains, 364; Lame Pelvis, 368; Impaired Hearing, 369; Im- paired A'ision, 371; Hysteria, 383 ; Labor-Pains, 387; Hour-glass Contractions, 389; Debility, 392; Uterine Haemorrhage, 410; After-Pains, 428; Disordered Conditions of the Lochia, 430; Rhagades, 431; Ulceration of the Umbilicus, 431; Puerperal Mania, 460 ; Phlegmasia Dolens, 464; Sore Nipples, 465; Scanty Supply of Milk, 470 ; Deterioration of Health from Nursing, 473; Mastitis, 475; Child A'omits soon after Nursing, 475; Abortion, 497 ; Amenorrhea, 515 ; Dys- menorrhea, 528 ; Menorrhagia, 539 ; Nympho- mania, 554; Hysteria, 569; Vulvitis, 573; Ec- zema and Pruritus, 578; Chancres, 578 ; Tumors of the Vulva, 580; Erectile Tumors, 581; Haem- orrhage from Erectile Tumors, 582; Ascarides of the Vulva, 584; Prolapse of the Vagina, 587; Strangulation of Prolapsed Portion of A'agina, 588; Neuralgia of Vagina, 593; Indurations of Vagina, 601; Vaginal Fistulas, 604; Serous Cysts of the Vagina, 610; Uterine Displacements, 637 ; Leucorrhea, 650; Metritis, 664; Hysteralgia, 676; Cancer of the Uterus, 703; Dropsy of the Uterus, 709; Hydatids, 715; Mammary Cancer, 749; Marasmus, 762 ; Indigestion, 766; Denti- tion, 778; Aphthae, 780; Constipation, 782; Diarrhea, 788 ; Dysentery, 792; Cholera Infan- tum, 798; Regurgitation, 801; Vomiting of Ingesta, 801; Coryza, 804; Bronchitis, 808; Pneumonia, 812; Pertussis, 822; Scarlet Fever, 842; Otorrhea, 848 ; Measles, 853; Diarrhea after Measles, 853; Pneumonia after Measles, 853; Itching of the Skin after Measles, 854;' Roseola, 855; Miliaria, 855; Small-pox, 863; Vaccination, 864; Varicella, 865; Erysipelas, 867; Urticaria, 868 ; Eczema Capitis, 871; Pity- riasis, 872; Naevi Materni, 873; Encysted Tu- mors, 873 ; Warts, 873 ; Ranula, 874 ; Intertrigo, 876; Induration of the Cellular Tissue, 876; Syphilitic Cutaneous Affections, 878; Come- dones, 878 ; Cyanosis, 881; Jaundice, 883; Inter- mittent Fever, 885 ; Scrofula, 887 ; Rickets, 889 ; Ophthalmia, 891; Hernia, 895; Worms, 899; Retention of Urine, 900; Incontinence of Urine, 901; Acute Hydrocephalus, 905 ; Disease of the Brain, 913; Cerebro-spinal Meningitis, 933; Chorea,937; Remittent Fever, 940; Diphtheria, 946. Sulphuric acid. Nausea and Vomiting, 305; Constipation, 315 ; Diarrhea, 322; Uterine Haem- orrhage, 410 ; After-Pains, 428 ; Dysmenorrhea, 528 ; Menorrhagia, 539 ; Vulvitis, 573 ; Strangu- lation of Prolapsed Portion of A'agina, 588; Gangrene of the A'agina, 605; Uterine Displace- ments, 638; Leucorrhea, 650; Dentition, 778; Aphthae, 780; Hernia, 895. Tabacum. Diarrhea, 322; Leucorrhea, 650. Tartar emetic. Treatment of Child after Labor, 213; Nausea and Vomiting, 305 ; Diarrhea,322 Dysmenorrhea, 528 ; Eczema and Pruritus, 578 Granular Vegetations, 610; Leucorrhea, 650 Coryza, 804; Bronchitis, 808; Croup, 817; Ate- lectasis Pulmonum, 829; Small-pox, 863; Vari- cella, 865; Cerebro-spinal Meningitis, 933; Re- mittent Fever, 940; Spasms, 950. Teucrium marum verum. Vaginal Growths, 609; Worms, 899. Thuya. Constipation, 315; Fissure of the Anus, 327; Haemorrhoids, 350; Lame Pelvis, 368; La- bor-Pains, 387 ; Dysmenorrhea, 528; Nympho- mania, 554; Vulvitis, 573; Eczema and Pruri- tus, 578 ; Condylomata, 578; Chancres, 578; Erectile Tumors, 581; Neuralgia of Vagina, 593; Vaginal Fistulas, 604; Vaginal Growths, 609; Granular Vegetations, 610; Uterine Displace- ments, 638; Hysteralgia, 676; Cancer of the Uterus, 703; Inflammation of the Ovaries, 732 ; Pemphigus, 856; Small-pox, 863; Warts, 873; Ranula, 874; Syphilitic Ophthalmia, 878 ; Syph- ilitic Cutaneous Affections, 878; Condylomata, 878; Comedones, 878; Ophthalmia, 891; Incon- tinence of Urine, 901. Trillium pend. Uterine Haemorrhage, 410; Menorrhagia, 539; Leucorrhcea, 650. Urtica urens. Urticaria, 868; Worms, 899. Ustilago. Menorrhagia, 539. Vaccininum. Small-pox, 863. Valerian. Nausea and Vomiting, 305; Amen- orrhea, 515; Hysteria, 570; Worms, 899. Variolinum. Small-pox, 863. Veratrum. Nausea and Vomiting, 305; Consti- CLINICAL INDEX. 963 pation, 315; Diarrhea, 322; False Pains, 364; Hysteria, 383; Labor-Pains, 387 ; Syncope, 391; Debility, 393 ; Puerperal Mania, 460; Abortion, 497; Amenorrhea, 516; Dysmenorrhea, 529; Menorrhagia, 539; Nymphomania, 554; Hys- teria, 570; Prolapse of the Vagina, 577; Strangu- lation of Prolapsed Portion of Vagina, 588; Uterine Displacements, 638; Indigestion, 766; Dentition, 778; Constipation, 782; Diarrhea, 788; Dysentery, 792 ; Cholera Infantum, 799; Bilious Vomiting, 801; Pertussis, 822; Atelec- tasis Pulmonum, 829; Dropsy after Scarlet Fe- ver, 846; Rickets, 889; Worms, 899 ; Disease of the Brain, 913; Cerebro-spinal Meningitis, 933; Spasms, 950. Veratrum viride. Puerperal Convulsions, 424 ; Mastitis, 475 ; Disease of the Brain, 913; Chorea, 937. Verbascum. Constipation, 315; Diuresis, 901. Viola odor. Hysteria, 570; Worms, 899. Viola tricola. Eczema Capitis, 871. Zinc. Nausea and Vomiting, 305; Constipation, 315; A'aricose A'eins, 354 ; Puerperal Convul- sions, 424; Puerperal Mania, 460 ; Secretion of Milk, 469; Abortion, 497; Amenorrhea, 516; Dysmenorrhea, 529; Menorrhagia, 539; Nym- phomania, 555; Hysteria, 570; Condylomata, 578; Uterine Displacements, 638 ; Leucorrhea, 650 ; Hysteralgia, 676; Ulcerations of the Uterus, 684; Inflammation of the Ovaries, 732; Ovarian Tumors, 742; Scarlet Fever, 842; Acute Hydro- cephalus, 905 ; Hydrocephaloid Disease, 909 ; Disease of the Brain, 913; Chorea, 937; Spasms, 950. Zizia. Leucorrhea, 650. INDEX. Abnormal secretions during pregnancy, 357. secretion of milk, remedies for, 466. Abortion, 284, 477. induction of, 488. induction of, criminality of the, 488. treatment of anticipated or threatened, 490. Abscess a cause of dystocia, 235. of the vulva, 579. Absence of menstruation, 501. Accidental haemorrhage, 394. and unavoidable haemorrhage, diagnosis be- tween, 396. Accumulation of faeces a cause of dystocia, 235. Acidity of the stomach during pregnancy, 306. Acute and chronic inflammation of the uterus, 637. and chronic inflammation of the uterus, treat- ment of, 660. endometritis, 639. uterine leucorrhea, 639. uterine catarrh, 639. inflammation of the ovaries, 726. suffocative catarrh of children, 806. hydrocephalus, 903. Acne punctata, 878. Adhesions of the vulva, 231. Affections, disorders of the, during pregnancy, 379. alienation of the, during pregnancy, 380. After-birth, the formation of tho, 146. delivery of the, 200. mode of extracting, 202. After-pains, 209. remedies for, 426. Agglutination of the os a cause of dystocia, 237. Agminated follicles, 50. Albuminuria during pregnancy, 333. in its relation to puerperal convulsions, 413. Allantois, the, 142. Amenorrhea, 501. remedies for, 510. Amnion, the, 142. Anaemia during pregnancy, 342. Anasarca during pregnancy, 344. Anaesthetics during labor, use of, 268. Anchylosis of fetal articulations a cause of dystocia, 244. Aneurisms occurring in infants, 872. Anomalous pregnancy, 167. Anorexia during pregnancy, 290. Anticipated or threatened abortion, treatment of, 490. Anteversion of the uterus, 620. of the uterus during pregnancy, 355. Anteflexion of the uterus, 623. Anterior commissure, 43. Antipsoric prophylactic treatment, 755. Anus, fissure of the, 325. Apparent death of the new-born child, 212. Appendages of the uterus, 43. Apex of the uterus, 55. Aphthae, thrush, 778. Appetite and taste, disorderti of, during pregnancy, 290. Arbor vitae of the uterus, 58. Areolar hyperplasia, 657. Arm, presentation of the, general directions in, 260. Arnica after parturition, 205. Arteries of the uterus, 62. Articulations of the pelvis, 20. Ascarides infesting the external genital organs, 583. Ascites as a cause of dystocia, 244. during pregnancy, 344. Asthma complicating labor, 243. Asthma of Millar, 823. Asphyxia of the new-born babe, 212. Atelectasis pulmonum, 827. Atrophy of infants, 756. Auscultation in the diagnosis of pregnancy, 124. Axis of the superior strait, 26. of the inferior strait, 30. of the pelvic excavation or cavity, 32. Ballottement, 119, 123. Bandage after labor, the, 204. Black measles, 851. Bladder, over distension of, as a cause of dystocia, 218, 235. rupture of the, 241. hernia of the, 586. Blood-vessels of the uterus, the, 61. Blood-spitting during pregnancy, 328. Bloody or oozing tumors of the external genitals, 582. Blue disease, 879. Blunt hook in breech presentations, the, 259. Body of the uterus, the, 56. of the uterus, cavity of the, 58. Bones of the pelvis, the, 10. Bowels, derangements of the, during pregnancy, 309 Brain, diseases of the, 902. diseases of the, remedies for, 909. inflammation of the, 902. dropsy of the, acute, 903. dropsy of the, chronic, 905. 965 966 INDEX. Brain, anaemia of the, 908. Breasts, inflammation of the, 473. of infants, swelling and hardness of the, 877. Breech presentations, mechanism of, 186. presentations, general direction in, 259. presentations, use of the blunt hook in, 249. presentations, use of forceps in, 250. Broad ligaments, 60. Bronchitis of children, 804. of children, sub-acute and chronic forms of, 807. Bronchial catarrh of children, 804. Bulimy during pregnancy, 291. Csesarean section, the, 279. Canal of the cervix, the, 57. of Nuck, the, 64. Cancer, 685. of the uterus, 693. of the uterus, indurated, 693. of the uterus, ulcerated, 696. of the uterus, encephaloid, 698. of the uterus, colloid, 698. of the uterus, treatment of, 700. of the uterus as a cause of dystocia, 236. of the breast, 693, 745. of the ovaries, 742. Cancroid, 699. Capillary bronchitis of children, 806. Carunculce myrtiformes, 47. Carcinoma (see Cancer). Care of the woman during labor, 192. of the child during labor, 197. of the woman after labor, 200. Casanova's tocological flexible forceps, 267. " Catarrh on the breast," 804. Catarrh, acute suffocative, 806. acute uterine, 639. Catarrhal inflammation of the external genitals, 575. fever of children, 804. fever of children, congestive, 806, Catheter, introduction of the, 46. Cauliflower excrescences, 699. excrescences as a cause of dystocia, 236. Causes of menstruation, 77. of labor, 172. of pelvic deformities, 227. Cavity of the pelvis, 31. of the body of the uterus, 58. Cephalaematoma, 874. Cephalic version, 257. presentations, general directions to be observed in, 258. Cephalalgia during pregnancy, 371. Cephalotripsy, 278. Cerebro-spinal meningitis, 913. Cervix uteri, the, 65. Cervical canal, the, 57. Cessation of the menses, the, 76. Chancres on the external genital organs, 578. Change of life, the, 542. Chafing of infants, 874. Chicken-pox, 865. Child, treatment of, after birth, 211. apparent death of the, 212. Child-crowing, 823. Child-bed fever, 431. Children, diseases of, 750. Chills and fever in children, 884. Cholera infantum-, 792. Chorea, 933. during pregnancy, 375. Chorion, the, 145. Chronic liver complaint of children, 883. hydrocephalus, 905. endometritis, 641. metritis, 657. ovaritis, 728. Cicatrices in the vagina, 232. Circulation of the fetus, 166. Clitoris, the, 45. Coccyx, the, 11. Coccygeal junction, the, 11. Cold in the head, in children, 801. Colic of infants, 762. Colitis, 788. Colloid cancer of the uterus, 698. Combined internal and external version, 255. Comedones, 878. Complicated presentation a cause of dystocia, 249. Commissure, Anterior, 43. Posterior, 43. Concealed accidental hsemorrhage, 395. Conception, 86. Condylomata, syphilitic, of infants, 878. of the external genitals, 578. of the vagina, 610. Congestive dysmenorrhea, 517. Constipation during pregnancy, 309. of infants and children, 780. Constructions or spasms of the vagina, 588. Contraction and rigidity of the vulva, 231. Convulsions, puerperal, 411. puerperal, remedies for, 421. of infants and children, 946. Cord, prolapse of the, 247. shortness of the, 248. Corroding ulcer of the uterus, 681. Coryza of children, 801. Cough and dyspnea during pregnancy, 338. Cracks on the abdominal walls after child-birth, 431. Cramps of the vagina, 588. and pain during pregnancy, 354. Craniotomy, 274. Croup, 812. spasmodic or false, 823. Crusta lactea, 869. Curve of Carus, 267. Cutaneous affections of the external genital organs. 575. Cyanosis, 879. Cynanche laryngea, 812. Cystocele, 582, 586. as a cause of dystocia, 235. Cysts of the vagina, 609. of the ovaries, 734. Cysto-sarcoma of the ovaries, 734. Cysto-adenoma of the ovaries, 734. Cysto-fibronia of the ovaries, 734. INDEX. 967 Cysto-carcinoma of the ovaries, 734. Dandruff, 871. Debility during labor, 391. Decapitation of the fetus, 279. Decidua, development of the, 139. vera, 87. reflexa, 87. Deformity, pelvic, method of determining, 227. Delivery of the placenta, 200. Dentition, 766. Derangements of the circulation during pregnancy, 341. of tho nervous system during pregnancy, 368. Deterioration of health from nursing, 473. Development of the ovum, 130. of the decidua, 139. of the fetus, 151,156. of the temporary teeth, 767. Diameters of the pelvis, 27. of the superior strait, 27. of the inferior strait, 30. of the pelvic excavation, 32. Diagnosis of pregnancy, 109. Diarrhea during pregnancy, 314. of infants and children, 782. Diet and regimen of women in labor, 200. Difficult labor, 215. menstruation, 516. Digestiye'system, disorders of the, during pregnancy, 290. Dimensions of the pelvic excavation, 32. of the uterus externally, 58. and weight of the fetus at different periods, 152, Directions for weaning, 476. Discus proligerus, 72. Diseases of women, 498. of women, general remarks on the treatment of, 498. of the external genital organs, 570. of the vagina, 584. of the uterus, 611. of the ovaries, 734. of infants and children, 750. of the brain, 902. of the brain, remedies for, 909. Disorders incidental to pregnancy, 285. of the digestive system during pregnancy, 290. of secretion and excretion during pregnancy, 328. of respiration during pregnancy, 338. of locomotory apparatus, 364. of the affections, emotions and feelings during pregnancy, 379. of lactation, 464. Diphtheria, 941. sequelae of, 944. Displacements of the womb, 611. of the womb during pregnancy, 355. Diuresis of children, 900. Dropsy during pregnancy, 343. of the amnion, 358. of the uterus, 705. of the ovaries, 734. of the brain, acute, 903. Dropsy of the brain, chronic, 905. • of the brain as a cause of dystocia, 243. of the chest and abdomen of the fetus as a cause of dystocia, 246. after 6carlet fever, 842. Duration of labor, 178. Dysentery, 788. Dysmenorrhea, 516. neuralgic, 516. congestive, 517. inflammatory, 517. membranous, 518. mechanical or obstructive, 519. remedies for, 520. Dyspnea and cough during pregnancy, 338. Dystocia, 215. causes of, 215. mechanical causes of, 217. excessive liquor amnii a cause of, 217. premature rupture of the membranes a cause of, 217. impaired action of the abdominal muscles a cause of, 218. overdistension of the bladder a cause of, 218,235. from malformation of the pelvis, 218. from malformation of the vulva, vagina or uterus, 231. from morbid conditions of the uterus, 236. in consequence of previously existing disease,242. from abnormal conditions of the fetus, 243. Dysuria of children, 899. Ecchymoses of the scalp, in infants, 874. Eclampsia parturientium, 411. Eczema of the external genitals, 575. capitis, 869. Effects of labor upon mother and child, 178. Effusion of lymph into the uterine tissues, 656. Emansio mensium, 501. Embryulcia, 278. Emotional disorders during pregnancy, 379. Emphysema as a cause of dystocia, 244. Encephaloid cancer of the womb, 698. Encysted tumors occurring in infants, 873. tumors of the vulva, 580. Endometritis, acute, 639. chronic, 641. Epithelioma, 699. Erectile tumors of the vulva, 580. of the vulva, haemorrhage from, 581. Erysipelatous inflammation of the external genital organs, 573. Erysipelas neonatorum, 865. Erythema of the external genital organs, 576. Essera, hives, 868. Evolution, spontaneous, 190. Excavation of the pelvis, the, 31. Excessive menstruation, 529. Excoriation of the external genitals, 579. of infants, 874. Exhaustion during labor, 391. Exostosis of the pelvis a cause of dystocia, 232. External surface of the pelvis, 23. os, the, 55. )EX. 968 ind External dimensions of the uterus, 58. genital organs, diseases of the, 570. genital organs, cutaneous disease of the, 575. genital organs, erythema of the, 576. genital organs, herpes of the, 576. genital organs, lichen of the, 576. genital organs, excoriation of the, 579. Extracting the placenta, mode of, 201. Extra-uterine pregnancy, 89,168. Eyes, affections of the, during pregnancy, 369. inflammation of the, in children, 889. Face presentations, general directions to be ob- served in, 258. presentations, mechanism of, 183. Fainting during labor, 390. Fallopian tubes, the, 66. Falling of the womb, 612. False pregnancy, 89, waters, 357. Fever, remittent, of children, 937. typhoid, of children, 937. Fibroid tumors of the uterus, 719. Fibrous tumors of the vagina, 607. Fibro-cellular growths of the vagina, 606. First menstruation, 75. Fissure of the anus, 325. Fistula, vaginal, 602. Fluid tumors of the ovaries, 734. Fetal heart, sounds of the, 125. Fetus, development of the, 151. successive dimensions and weight of the, 152. development of the parts and organs of the, 156. at full term, the, 158. presentation and position of the, at full term, 161. abnormal conditions of the, complicating labor, 243. inclined position of the, a cause of dystocia, 249. Fetal circulation, 166. Follicular system of the external organs of genera- tion, 49. Follicles, agminated, 50. vestibular, 50. urethral, 50. vaginal, 50. Follicular ulcer of the uterus, 681. Forceps, use of the, 261. method of applying the, 261, 265. long and short, 262. cases in which they are applicable, 264. cases in which they are not applicable, 265. locking the blades of the, 266. , general directions for applying the, 266. long, method of applying the, 267. Dr. Casanova's tocological flexible, 269. Formation and development of the placenta, 146. and development of the funis, 149. Fourchette, the, 45. Full-term fetus, the, 158. presentation and position of the fetus at, 158. Fundus, the, 55. Funis, formation and development of the, 149. prolapse of the, 247. Funis, shortness of the, 248. Galactorrhea, 470. Gangrene of the vagina, 604. of the uterus, 655. of the uterus, treatment of, 704. Gastric derangements during pregnancy, 294. Gathered breast, 473. Gelatinous cancer of the uterus, 698. Generation, 79. Generation, organs of, 41. Genital organs, external, 41. organs, external, diseases of the, 570. organs, external, eczema of the, 575. organs, external, erythema of the, 576. organs, external, herpes of the, 576. organs, external, lichen of the, 576. organs, external, condylomata of the, 578,579. organs, external, excoriation of the, 579. organs, external, edema of the, 579. organs, external, abscess of the, 579. organs, external, tumors of the, 579. organs, external, varicose veins of the, 582. organs, external, hernia of the, 582. Germinal vesicle, the, 69. spot, the, 69. Gestation, 88. Glandular system of the external genital organs, 49. Glands, sudoriparous, 49. sebaceous, 49. vulvo-vaginal, 50. of Bartholine, 50. Gonorrheal ophthalmia, 889. Graaffian vesicles, the, 68. Granular ulcer of the uterus, 677. Gravel, 901. Haematemesis complicating labor, 242. Haemoptysis complicating labor, 242. Haemorrhage during labor, 393. accidental, 394. unavoidable, 398. post-partum, 402. uterine, remedies for, 406. from erectile tumors of the external genitals, 581. Haemorrhoids, 346. Head, presentations of the, general directions to be observed in, 258. Headache during pregnancy, 357. Heart disease complicating labor, 243. Heartburn during pregnancy, 306. Hearing, loss of, during pregnancy, 357. Helminthiasis, 895. Hepatitis, 883. Hernia, vaginal, a cause of dystocia, 235. vesical, a cause of dystocia, 235. of the uterus, 238. of the external genital organs, 582. perineal, 582. of tho bladder, 586. in infants and children, 893. Herpes of the external genital organs, 576. Hiccough, 892. INDEX. 969 Hives, 867. Hooping cough, 817. Hour-glass contraction, 203,384. Hydrocephalus, acute, 903. chronic, 905. as a cause of dystocia, 243. Hydrocephaloid disease, 908. Hydrothorax as a cause of dystocia, 244. Hydraemia during pregnancy, 341. Hydrorrhea during pregnancy, 357. Hygiene of pregnancy, 288. and treatment of the babe after birth, 211. Hymen, the, 47. Hyperplasia, areolar, of the uterus, 657. Hypertrophy of the uterus, 655. Hysteralgia, 671. Hysteria, 555. treatment of, 564. during pregnancy, 377. Icterus neonatorum, 881. Ilium, the, 15. Impregnated uterus, the, 54. Impaired action of the abdominal muscles a cause of dystocia, 218. Inclined planes of the pelvis, 24. position of the fetus a cause of dystocia, 249. Incontinence of urine in children, 901. Indigestion of infants and children, 762. Induction of premature labor, 283, 488. Induration of the vagina, 600. of the cellular tissue of infants, 876. and swelling of the breasts of infants, 877. Indurated cancer of the womb, 693. Infants and children, diseases of, 350. and children, antipsoric prophylactic treatment of, 755. milk as a food for, 750. atrophy of, 756. sour stomach of, 762. vomiting of, 762, 799. aphthae of, 778. constipation of, 780. diarrhea of, 782. dysentery of, 788. coryza, cold in the head, of, 801. erysipelas of, 865. swelling of the scalp of, 874. ecchymosis of the scalp of, 874. chafing, excoriation of, 874. induration of the cellular tissue of, 876. swelling and hardness of the breasts of, 877. jaundice of, 881. ophthalmia of, 889. hernia of, 893. remittent fever of, 937. Infantile nutrition, physiology and lesions of, 750. indigestion, 762. colic, 762. hernia, 893. remittent fever, 937. Inferior strait of the pelvis, 28. Inflammation of the pelvic articulations dunng pregnancy, 365. Inflammation of the vulva, 570. erysipelatous, of the vulva, 573. catarrhal, of the external genital organs, 575. of the vagina, 594. of the uterus, 637. of the ovaries, 726. of the lungs in infants and children, 808. of the liver in infants and children, 883. of the brain in infants and children, 902. Inflammatory dysmenorrhea, 517. ulcer of tho stomach, 681. Infiltration of pus into the tissues of the uterus, 656. Insanity after child-birth, 454. resulting from excessive lactation, 475. Intertrigo, 874. Intermittent fever of children, 884. Internal surface of the pelvis, 23. metritis, 639. Intestinal parasites, varieties of, 895. affections during pregnancy, 309. Intellectual faculties, disorders of, during preg- nancy, 378. Introduction of the catheter, 46. Inversion of the vagina, 232, 585. of the uterus, 618. Irregular menstruation, 509. Irritable uterus, 668. Ischium, the, 17. Itching of the external genital organs, 575. of the skin after measles, 854. Jaundice of infants, 881. Kiesteine, the, 117. Labia majora, 43. minora, 45. edema of the, 232. Labor, 171. premature, 171. retarded, 171. natural, at term, 172. causes of, 172. physiology of, 173. first stage of, 173. second stage of, 174. third stage of, 177. duration of, 178. effects of, upon mother and child, 178. mechanism of, 179. care of the woman and child during, 192. diet and regimen of the woman during, 200. care of the woman after, 200. no bandage to be used after, 204. arnica to be used after, 205. delay in urinating after, 206. difficult, 215. precipitate, 218. complicated by previously existing disease, 242. premature, induction of, 283. therapeutics of, 384. pains of, remedies for, 384. rigidity of the os during, 388. rigidity of the vaginal walls during, 388. 970 INDEX. Labor, fainting and swooning during, 396. weakness, debility, exhaustion during, 396. haemorrhage during, 393. complicated by accidental haemorrhage, 394. complicated by placenta praevia, 398. complicated by concealed accidental haemor- rhage, 395. complicated by convulsions, 411. Laceration of the perineum, 241. Lactation, disorders of, 464. excessive, 470. Lancing the gums during dentition, 769. Laryngismus stridulus, 823. Lateroversion, 631. Lateroflexion, 631. Leucorrhea during pregnancy, 357. vaginal, 596. uterine, 639. Lesions of the respiratory muccms membrane in children, 801. Lichen of the external genital organs, 576. urticatus, hives, 868. Lice infesting the external genital organs, 584. Ligaments of the uterus, 60, 64. broad, the, 60. round, the, 64. Liquor amnii, the, 144. amnii, excess of, a cause of dystocia, 217. Liver, acute inflammation of the, 883. chronic inflammation of the, 883. Lochia, 210. Locomotion, derangements of, during pregnancy, 364. Longings during pregnancy, 291. Lung-fever of children, 808. Lungs, inflammation of the, in children, 808. Lungs, non-development of the, 827. Luxation a cause of pelvic deformity, 230. Lymphatics of the uterus, 62. Malaria or longing during pregnancy, 291. Male and female pelvis compared, 34. Malformation of the pelvis, dystocia from, 218. of the vagina, 232. Malignant ulceration of the womb, 681. Mammae, alteration of, in pregnancy, 114. Mammary cancer, 693. cancer, 745. glands, inflammation of the, 473. Mania, puerperal, 454. Marasmus of infants and children, 756. Mastitis, 473. Mastodynia apostematosa, 473. Measles, 848. black, 851. sequelae of, 853. itching of the skin after, 855. Meatus urinarius, 46. Mechanism of labor, the, 179. of vertex presentations, 180. of facial presentations, 184. of breech presentations, 186. of transverse presentations, 188. Mechanical or obstructed dysmenorrhea, 519. Medullary cancer of the womb, 698. Melancholia during pregnancy, 379. after child-birth, 454. Membrana granulosa, the, 68, 72. Membrane, the vitelline, 68. Membranes, premature rupture of, a cause of dys- tocia, 217. Membranous dysmenorrhea, 518. Meningitis, 902. tubercular, 903. cerebro-spinalis, 913. Menopause, the, 542. Menorrhagia, 529. functional, 529. organic, 530. sympathetic, 532. remedies for, 533. Menstrual derangements, 500. Menstruation, the uterus during and after, 65,69,74. in its relation to ovulation, 74. first, 75. cessation of, 76. symptoms of, 76. causes of, 77. treatment of the disorders of, 500. absence of, 501. suppression of, 505. vicarious, 507. premature cessation of, 507. irregular or partial, 509. absence of, remedies for, 510. suppression of, remedies for, 510. difficult, 516. painful, 516. excessive, 529. Metritis, internal, 639, 650. chronic, 657. Metrorrhagia, 539. Miliaria, 855. Miliary fever, 855. Milk-leg, 460. Milk, secretion of the, 214. remedies for abnormal secretion of the, 466. failure or scanty supply of the, 467. spontaneous running of the, 470. excessive supply of the, 470. as food for infants, 750. Miscarriage, 477. criminality of producing, 489. treatment when anticipated or threatened, 490. Molar pregnancy, 714. Mollities ossium a cause of pelvic deformity, 228. Moles, 711, 713. on infants, 872. Mons veneris, 41. Monstrosities a cause of dystocia, 244. Morbilli, 848. Morbid growths of the vagina, 605. Morbus, 879. Morning sickness of pregnancy, 111, 294, Mouth of the womb, the, 55. Mother's marks, 872. Muciparous organs, 49. Mucous coat of the uterus, 60. INDEX. 971 Multiple pregnancy, 167. pregnancy a cause of dystocia, 244. Mumps, 891. Muscles of the perineum, 39. Muscular tissues of the pelvis, 36. coat of the uterus, 60. Naevi materni, 872. Narrowness of the vagina, 601. Natural labor at term, 172. Nausea and vomiting during pregnancy, 294. Neck of the uterus, 55. Nerves of the uterus, 63. Nervous system, disorders of, during pregnancy, 368. irritation, 665. Nettle rash, 867. Neuralgia during pregnancy, 371. of the vulva, 583. of the vagina, 590. of the uterus, 671. after scarlet fever, 847. Neuralgic dysmenorrhea, 516. Nipples, soreness of the, 464. Nocturnal enuresis, 901. Non-ulcerated cancer of the uterus, 693, Nuck, the canal of, 64. Nursing, disorders of the period of, 464. loss of health from, 473. insanity occurring during the period of, 471. cramps in the stomach from, 473. Nutrition of embryo and fetus, 163. Nymphae, 45. edema of the, 232. Nymphomania, 549. treatment of, 551. Obliquity of the uterus a cause of dystocia, 237. Obliteration of the cervex uteri a cause of dystocia, 238. * Obstetric operations, 250. Obstructive dysmenorrhea, 519. (Edema of the labia and nymphae, 232. of the lower extremities during pregnancy, 343. of the vulva during pregnancy, 233. CEstruation, 74. Odontalgia during pregnancy, 374. Old age, condition of the uterus in, 65. Ophthalmia, syphilitic, of infants, 878. of infants and children, 889. Organs of generation, 41. muciparous, 49. Organic menorrhagia, 530. Orifice of the urethra, 46. of the vagina, 47. Os sacrum, 11. coccygis, 11. innominatum, 13. externum, os uteri, os tincae, 55,57. uteri, rigidity of, a c*ause of dystocia, 236, 388. uteri, rigidity of, during labor, 388. Osteo sarcoma a cause of dystocia, 232. Otorrhea after scarlet fever, 848. Ovarian tumors a cause of dystocia, 233. irritation, 722. Ovarian tumors, 732. dropsy, 734. cysts, 734. tumors, treatment of, 739. Ovaries, the, 66. diseases of the, 721. acute inflammation of the, 726. chronic inflammation of the, 728. tumors of the, 732. cancer of the, 742. Ovaritis, acute, 726. chronic, 728. Over distension of the bladder a cause of dystocia, 235. Ovisacs, the, 68. Ovum, the, 68. development of the, 130. unimpregnated, 130. Ovulation, 69, 71. Pains of labor, the, 177. of labor, significance of, 177. and cramps during pregnancy, 354. experienced during pregnancy, 361. of labor, remedies for, 384. Painful menstruation, 516. Palpation in the diagnosis of pregnancy, 119. Palpitation of the heart complicating labor, 243. Paralysis after diphtheria, 944. Parenchyma, the, 68. Parasites infesting the external genital organs, 583. Parotitis, 891. Partial menstruation, 509. Parturition, 171. the uterus after, 65. no bandage to be used after, 204. arnica to be used after, 205. delayed urination after, 206. retention of urine after, 425. after pains of, remedies for, 426, pendulous abdomen after, 430. rhagades or cracks on the abdomen after, 431. ulceration of umbilicus after, 431. Pavilion, the, 66. Pelvic presentation, 186. deformities, to determine the existence and ex- tent of, 227. deformities, causes of, 227. deformities from rachitis, 228. deformities from mollities ossium, 228. deformities from deviation of spinal column, 229. deformities caused by luxation, 230. deformities caused by lesions of the inferior extremities, 230. deformities from absolute narrowness, 230. articulations, inflammation of, during preg- nancy, 364. articulations, relaxation of, during pregnancy, 365. Pelvis, the, 10. bones of the, 10. articulations of the, 20. as a whole, the, 23. external surface of the, 23. 972 INDEX. Pelvis, internal surface of the, 23. the inclined planes of the, 24. the straits of the, 25. the cavity of the, 31. differences between male and female, 34. the, in childhood, 34. the uses of the, 35. the muscular tissues of the, 36. malformation of the, dystocia from, 218. absolute narrowness of the, 230. exostoses of the, 232. Pemphigus, 855. Pendulous abdomen, 430. Percussion in the diagnosis of pregnancy, 120. Perineum, the, 38, 42. the muscles of the, 39. rigidity of the, 231. laceration of the, 241. Perineal hernia, 582. Peritoneal coat of the uterus, 59. Peritonitis, puerperal, 431, spurious, 453. Pertussis, 817. Phagedenic ulceration of the womb, 681. Phlegmasia dolens, 460. Physiology of labor, 173. and lesions of infantile nutrition, 750. Physometra, 706, 709. " Pica " during pregnancy, 291. Piles, 346. Piliferous bulbs, 49. Pityriasis, dandruff, 871. Placenta, formation of the, 146. delivery of the, 200. mode of extracting the, 202. breaking up adhesions of, 202. retention of, remedies for, 424. praevia, 398. praevia, diagnosis of, from accidental hsemor- rhage, 396. Plane of the superior strait, 26. of the inferior strait, 26. of the pelvic excavation or cavity, 32. Plethora during pregnancy, 341. Pneumo-hydrometra, 706. Pneumonia of children, 808. Podalic version, 251. Polypus as a cause of dystocia, 234. of the vagina, 607. of the uterus, 715. Pompholyx, 855. Porrigo larvalis, 869. Position affecting the axis of the pelvic cavity, 34. and presentation of the fetus at full term, 161. of the woman in applying the forceps, 263. Positions and presentations in labor, 179. Posterior commissure, 43. Post-partum haemorrhage,402. derangements, 424. PoBt-Bcarlatinal dropsy, 842. rheumatism, 846. Pot-belly after parturition, 430. Precipitate labor, 218. Pregnancy, 90. Pregnancy, the uterus during, 65. extra-uterine, 89. uterine, 89, false, 89. Bimple uterine, 89, 90. physiological and anatomical changes in, 90. changes in the uterine appendages in, 104. diagnosis of, 109. • signs of, 109. morning sickness of, 113. alterations of the mammae in, 114. the changes in the urine in, 116. statement of the principal signs of, 128. anomalous, 167. multiple, 167. extra uterine, 168. disorders incidental to, 285. hygiene of, 288. disorders of the digestive system during, 290. variations of appetite and taste during, 290. gastric derangements of, 294. morning sickness of, 294. heartburn during, 306. table of remedies for gastric disturbances during, 307. intestinal derangements during, 309. constipation during, 309. diarrhea during, 314. table of remedies for intestinal affections during, 323. disordered secretions and excretions during, 328. ptyalism during, 328. spitting of blood during, 328. urinary difficulties and derangements during,328. albuminuria during, 333. uraemia during, 355. table of remedies for urinary derangements during, 336. disorders of respiration during, 338. cough and dyspnea during, 338. derangements of circulation and of the circula- tory apparatus during, 341. plethora, hydraemia and ansemia during, 341. edema, anasarca and ascites during, 343. haemorrhoids during, 346. varicose veins during, 352. affections of the uterus and its appendages during, 354. pain and cramps during, 354. sensibility of the uterus during, 354. uterine displacement during, 355. prolapsus uteri during, 355. anteversion during, 355. retroversion during, 355. abnormal secretions during, 357. leucorrhea during, 357. hydrorrhea during, 357. false water during, 357. dropsy of the amnion dr/ring, 358. affections of the appendages of the uterus during, 360. pruritus of the vulva during, 360. pains experienced during, 361. disorders of the locomotive apparatus during,364. INDEX. 973 Pregnancy, inflammation of pelvic articulation during, 364. relaxation of pelvic articulation during, 365. disposition to fall during, 366. derangements and affections of nervous system during, 368.' loss of hearing during, 368. affections of the eyes during, 369. headache during, 371. neuralgia during, 371. toothache during, 374. chorea during, 375. hysteria during, 377. disturbance of intellectual faculties during, 378. disorders of the affections, emotions and feel- ings during, 379. melancholia during, 379. molar, 714. Premature labor, 171. induction of, 283. rupture of the membrane a cause of dystocia, 217. cessation of menstruation, 507. Presentation and position of fetus at full term, 161. and position in labor, 179. facial, mechanism of, 183. of the pelvic extremity, 186. of the breech, mechanism of, 186 of the trunk, 188. complicated, 249. of the trunk, general directions to be observed in, 260. Procidentia uteri, 612. Profuse urination, 900. Prolapsus as a cause of dystocia, 239. of the funis, 247. uteri during pregnancy, 355. uteri, 612. Prolapse of the vagina, 584. of the womb, 612. Promontory of the sacrum, 11. Prurigo of the external genital organs, 575. Pruritus vulva during pregnancy, 360. of the external genital organs, 575. Ptyalism during pregnancy, 328. Pubis, the, 17. Pudendum, 43. Puerperal convulsions, 411. convulsions, remedies for, 421. fever, 431. mania, 454. Pulsatilla in malposition of the fetus, 250. Purulent ophthalmia, 889. Pus, infiltration of, into the uterine tissues, 656. Putrefaction of the uterus, treatment of, 704. Pyrosis during pregnancy, 306. Quickening, 113,116. Rachitis, 887. a cause of deformed pelvis, 228. Ramollissement of the uterus, 704. Ranula, 874. Rational signs of pregnancy, 110. Recto-uterine ligament, 60. Rectocele, 587. Relations of menstruation to ovulation, 74. Relaxation of the pelvic articulations during preg- nancy, 365. Remittent fever of children, 937. Reproduction, 79. Respiratory organs, diseases of, in children, 801. Respiration of the fetus, 165. disorders of, during pregnancy, 338. Retained placenta, remedies for, 424. Retarded labor, 172. Retention of urine after parturition, 425. of urine in children, 900. Retroversion of the uterus, 624. of the uterus during pregnancy, 355. Retroflexion of the uterus, 627. Rhagades of the abdominal walls after child-birth, 431. Rheumatism after scarlet fever, 846. Rickets, 887. Rigidity of the perineum, 231. of the uterus as a cause of dystocia, 236. of the os uteri during labor, 388. of the vaginal walls during labor, 388. Roseola, 854. Round ligaments, the, 64. Rubeola, 848. Rugae, 53, 58. Rupture of the uterus, 239. of the vagina, 239. of the bladder, 241. in infants and children, 893. Sacrum, the, 11. function of the, 21. Sacro-vertebral angle, the, 11. Sacro-iliac symphysis, the, 22. Sanguineous tumors a cause of dystocia, 233. tumors of the head, 874. Scarlatina, 830. Scarlet fever, 830. fever, dropsy after, 842. fever, rheumatism after, 846. fever, neuralgia after, 847. fever, scrofulous affections after, 847. fever, otorrhea after, 848. rash, 854 Scirrhus of the mammae, 747. Scrofula, 885. Scrofulous affections after scarlet fever, 847. ophthalmia, 889. Sebaceous glands, 49. Secretion as a function of the fetus, 166. of milk, 214. Second stage of labor, 174. Sensible signs of pregnancy, 117. Sensibility of the uterus during pregnancy, 354. Serous cysts of the vagina, 609. Shortness of the cord, 248. Sigaultean operation, the, 282. Signs of pregnancy, 109. Sinuses of the uterus, 62. Size of the child a cause of dystocia, 244. Skin diseases, syphilitic, of children, 878. 974 ini Snuffles, the, 801. Softening of the uterus, 655. Solid ovarian tumors, 732. Sore mouth of infants, 778. nipples, 464. Sour stomach during pregnancy, 306. stomach of infants and children, 762. Sounds of the fetal heart, 125. Spasms, cramps and contractions of the vagina,588. of infants and children, 946. Spasm of the glottis, 823. Spinal deviation a cause of pelvic deformity,. 229. Spitting of blood during pregnancy, 328. Spontaneous evolution of the fetus, ISO. Spotted fever, 913. Spurious peritonitis, 453.. Statement of the principal signs of pregnancy, 128. Sterility, 644, 688.. Stomach, derangements of, during pregnancy, 294. Straits of the pelvis,, the, 25. Strangulation of the prolapsed vaginal wall, 58T. Stroma of the ovary, the, 68. Structure of the uterus, 59. St. Vitus' dance,, 933. dance during pregnancy, 375. Sudoriparous glands, the, 49: Superior strait of the pelvis, 25. Super-fetation, 170, Suppression of the menses, 505. of urine in children, 900. Swelling and elongation of the anterior uterine lip, a cause of dystooia,,238. Swooning during labor, 390. Sympathetic menorrhagia, 532. Symphysis pubis, the, 21. Symphyseotomy,. 282. Symptoms of menstruation, 76. Syncope complicating labor, 243. during labor, 390. Syphilitic ulcers of the genital organs, 578. ulcers of the uterus, 68. affections of children, 877. ophthalmia, 889. Table of remedies for variations- of appetite and taste during pregnancy, 292. of remedies for gastric derangements during pregnancy, 307. of intestinal affections during pregnancy, 323. of remedies for urinary derangements during pregnancy, 336. Taste and appetite during pregnancy, 290. Temper, change of, during pregnancy, 380. Term of gestation, the, 88. Teeth, mode of development of the, T67. Teething, 766. Therapeutics pf labor, 384. Third stage of labor, 177. Thrush, 778. Tocological flexible forceps of Casanova, 269. Touch, the, in the diagnosis of pregnancy, L18. Tongue-tie, 895. Toothache during pregnancy, 374. Traction to be made with the forceps, 267. Transverse presentations, 188. Trunk, presentation of the, 188. presentation of the, general directions to be ob- served in, 260. Tubercular meningitis, 903. Tubes, Fallopian, 66. Tumors as a cause of dystocia, 232, 236. of the vulva, 579. of the vulva, encysted, 579. bloody or oozing, of the external genitals, 582. of the vagina, 605. of the uterus, fibroid, 719. of the ovaries, 732. encysted, of infants, 873. Tumefaction of the vulva, 579. Tunica albuginea, 68. propria, 68. Turning, 250. by the bi-manual method, 255. cephalic, method of effecting, 257. Twin pregnancy, 168. Typhoid fever of children, 937. Ulcerated form of cancer of the womb, 696. Ulceration of the umbilicus after labor, 431. of the uterus, 677. of the uterus, granular, 679. of the uterus, follicular, 681. of the uterus, inflammatory, 681. of the uterus, syphilitic, 681. of the uterus, corroding, phagedenic or malig- nant, 681. of the uterus, treatment of, 683. Umbilical vesicle, the, 141. cord, formation and development of, 149. Umbilicus, ulceration of the, after labor, 431. Unavoidable haemorrhage, 398. Uraemia during pregnancy, 335, 342. Urethral orifice, 46. follicles, 50. Urination, delay of, after labor, 206. Urinary difficulties and derangements during preg- nancy, 328. derangements of pregnancy, table of remedies for, 336. difficulties of children, 899. calculi in children, 901. Urine, changes in the, in pregnancy, 116. retention of, after parturition, 425. Urticaria, nettle rash, hives, 867. Uses of the pelvis, 35. Uterine elevator for retroversion, 629. arteries, 62. veins, 62. sinuses, 62. lymphatic vessels, 62. nerves, 63. pregnancy, 89. displacements during pregnancy, 256. haemorrhage, remedies for, 406. catarrh, 639. tympanitis, 709. moles, 711. hydatids, 713. INDEX. 975 Uterine polypi, 715. fibroid tumore, 719. Utero-gestation, 88. Uterus, 54. virgin, the, 55. impregnated, the, 54. body of the, 56. cervix of the, 55. neck of the, 55. apex of the, 55. external dimensions of the, 58. structure of the, 59. muscular coat of the, 60. mucous coat of the, 60. blood-vessels of the, 61. during and after menstruation, the, 65. during and after pregnancy, the, 65. after parturition, the, 65. in' old age, the, 65. hour-glass contraction of the, 203. inversion of the, 203. tumors of the, as a cause of dystocia, 236. obliquity of the, as a cause of dystocia, 237. rupture of the, 239. and its appendages, affections of, during preg- nancy, 354. sensibility of the, during pregnancy, 354. prolapsus of, during pregnancy, 355. anteversion of, during pregnancy, 355. retroversion of, during pregnancy, 355. displacements of the, 611. prolapse of the, 612. inversion of the, 618. anteversion of the, 620. anteflexion of the, 623. retroversion of the, 624. retroflexion of the, 627. lateroversion and lateroflexion of the, 631. remedies for the displacements of the, 631. inflammation of the, 637. hypertrophy of the, 655. induration of the, 655. ramolissement of the, 655. gangrene of the, 655. infiltration of pus into the tissues of the, 656. effusion of coagulable lymph into the tissues of the, 656. chronic enlargement of the, 655, 657. irritable, 668. neuralgia of the, 671. ulceration of the, 677. cancer of the, 693. indurated form of cancer of tho, 693. ulcerated form of cancer of the, 696. cancer of the, encephaloid form of, 698. cancer of the, medullary form of, 698. cancer of the, colloid form of, 698. cancer of the, gelatinous form of, 698. epithelial cancer of the, 699. cauliflower excrescence of the, 699. cancer of the, treatment of, 700. gangrene of the, treatment of, 704. dropsy of the, 705. accumulation of gas in the, 706, 709. Vaccination, 864. Vagina, 41. orifice of the, 47. the, 51. malformation of the, 232. inversion of the, 232. rupture of the, 239. diseases and derangements of the, 584. prolapse of the, 584. inversion of the, 585. spasms, cramps and contractions of the, 588. neuralgia of the, 590. inflammation of the, 594. induration of the, 600. extreme narrowness of the, 601. gangrene of the, 604. morbid growths of the, 605. tumors of the, 605. morbid growths of the, remedies for, 608. serous cysts of the, 609. condylomata of the, 610. Vaginal follicles, 50. cicatrices, 232. hernia a cause of dystocia, 235. walls, rigidity of, during labor, 388. leucorrhea, 596. fistula, 602. polypi, 507. Vaginismus, 593. Vaginitis, 594. treatment of, 600. Variations of appetite and taste during pregnancy, 290. Varicella, 865. Varicose veins, 352. Variola, 856. Varioloid, 856. Vectis, the, 273. Veins uterine, 62. varicosed, 252. Vertex presentation, mechanism of, 180. Vertebral column, deviation of, a cause of pelvic de- formity, 229. Version, 250. by the feet, 251. by the bi-manual method, 255. cephalic, 257. Vermicular affections, 895. Vestibule, 46. Vestibular follicles, 50. Vesicles, the Graafian, 68. the germinal, 69. Vesical hernia, a cause of dystocia, 235. Vesicular moles, 713. Vesico-uterine ligaments, 60. vaginal fistula, 602. A'essels, uterine, sympathetic, 62. Alcarious menstruation, 507. Virgin uterus, the, 55. Vitelline membrane, the, 68. Vitellus, the, 69. Vomiting during pregnancy, 294. in infants and children, 762, 799. Vulva, the, and its appendages, 43. 976 INDEX. Vulva, adhesion of the, 231. contraction and rigidity of the, 231. pruritis of, during pregnancy, 360. erysipelatous inflammation of, 573. catarrhal inflammation of, 575. cutaneous affection of the, 575. edema of the, 579. tumefaction of the, 579. abscess of the, 579. tumors of the, 579. erectile tumors of the, 580. hernia of the, 582. neuralgia of the, 583. ascarides infesting the, 583. Vulvitis, inflammation of the vulva, 570. Vulvo vaginal glands, 50. Warts and wens of infants, 873. Warty excrescences of the external genitals, 578. excrescences of the vagina, 610. Wasting disease of children, 756. Water in the head, 903. Weakness during labor, 391. Weaning, directions for, 476. Weight of the fetus at different periods, 152. Wetting the bed, 901. Whooping cough, 817. Womb, mouth of the, 55. hour-glass contraction of the, 203. displacements of, during pregnancy, 355. falling of the, 612. inflammation of the, 637, 650. enlargement of the, 655. gangrene of the, 655. chronic enlargement of the, 657. Worms, 895. GLOSSARY. Abdomen. The cavity between the thorax and pelvis—the belly. Abnormal. Not natural; unhealthy. Abrasion. Loss of skin or membrane by scraping, etc.; excoriation. Accoucheur. He who practices the art of Mid- wifery. Acetabulum. Cup-like cavity, receiving the head of the femur at the hip-joint. Acne punctata. Red pimples upon the face and nose of young people. Acne rosacea. Same as above, but are more bright red. Acrid. Corrosive; pungent; irritating. Acromion. A process, or part, of the scapula. Acupuncture. Plunging of needles into the soft parts. Adenocele. Glandular tumor. Adenoid. Resembling a gland. Adipose. Pertaining to fat—as adipose tissue, fatty tissue. Adynamic. Attended with great debility, prostra- tion. Aeration. Transformation of the venous blood and chyle into arterial blood by respiration; forma- tion of blood in general. jEtioloqy. Doctrine of morbid causes. After-birth. See p. 146. After-pain. See p. 209. Agglutination. Adhesion; gluing together. Ague. Chill. Al.e nasi. Wings of the nose. Albugineous. Term applied to textures, humors, etc. which are perfectly white. Albumen. An organic element of the blood, etc., found almost pure in the white of an egg. Albuminuria. See p. 333. Alimentary. Connected with food. Alkaline. Substance which neutralizes acids. Allantois. See p. 137. Alveoli (alveolar). Bony sockets of the teeth. Alvine. Pertaining to the stomach or intestines. Amaurosis. Paralysis of the optic nerve. Amblyopia. Dimness of sight. Amenable. Governable. Amenorrhcea. See p. 501. Amnion. See p. 136. Amnion, Dropsy of. See p. 358. Anemia. See p. 342. 62 Anesthesia. The taking away of sensation, usually done by inducing sleep. Anasarca. Dropsy of the cellular tissue. A species of dropsy between the skin and flesh. Anastomosis. Inoscultation of vessels. Anchylosis. Stiffhess of a joint; adhesion of artic- ulating surfaces. Aneurism. Morbid enlargement of an artery. Angina. Inflammation of the air-passages of the throat. Anomalous. Irregular; unnatural. Anorexia. See p. 290. Anteflexion. See p. 623. Anterior. Before; in front. Anteversion. A bending forward. See p. 621. Antiphlogistic. Preventives of inflammation; cool- ing remedies. Antipsoric. Opposed to the itch. Anus. External opening of the rectum. Funda- ment, Aorta. The great artery of the body. Apathy. Insensibility; indifference. Aphtha. Roundish, whitish vesicles found in sore mouth. Apncea. Absence of respiration. Aponeurosis. Fascia; tendinous expansion of mus- cles. Apyrexia. Intermission of febrile paroxysms. Arachnoid. Membrane of the brain; tunic of the eye. Areola. Circle, as around the nipple. Areolar Tissue. Cellular tissue. Arteries. Vessels conveying the blood from the heart. Articulation. The union of bones with each other, and the manner of union. Ascarides. Small intestinal worms; pin-worms; thread-worms. Ascites. Abdominal dropsy. Asphyxia. Suspended animation, as by suffocation, etc. Assimilate. To convert into a similar substance, as food is assimilated by conversion into animal sub- stances, flesh, chyle, blood, etc. Asthenic. Debilitated; applied to disease, low. Asthma. Violent oppression of breathing. Astragalus. Upper bone of the tarsus, on which the tibia rests. I Astringents. Medicines used to contract muscular 977 978 GLOSSARY. fibre, and to constrict vessels to restrain dis- charges. Atelectasis pulmonum. See p. 827. Atlas. First vertebra of the neck. Atony. Relaxation, want of energy or tone. Atresia. Congenital imperforation of the intestinal canal. Atrophy. Wasting away of the system from func- tional disturbance. Auricle. A cavity of the heart. Auscultation. See p. 124. Autopsy. Ocular evidence. Axis. Second vertebra of the neck. Bag of Waters. See p. 177. Ballottement. See p. 123. Basilar. That which belongs to the base. This name has been given to several parts which seem to serve as bases to others. Belching. The throwing off, or ejecting, of wind from the stomach. Biliary. Pertaining to the secretions of the liver. Bistoury. A small surgical knife having a curved blade. Blastodermic Membrane. See p. 134. Blastodermic Vesicle. See p. 134. Borborygmus. Rumbling of wind in tho bowels. Breech. The lower part of the body, from the mid- dle down. Bronchia. Air-passages. Bronchitis. See p. 804. Bruit de Souffle. See p. 126. Buccal. Belonging to the cheeks; pertaining to the mouth. Bulimy. See p. 291. Bulle. Blisters. Burse. Bags. Cachectic. Adjective of Cachexia. Cachexia. Vitiated constitution; morbid condition of the body characterized by deficient digestion, nutrition and assimilation. Cadaverous. Resembling a corpse. Cecum. A portion of the intestines. Cesarean. See p. 279. Calcareous. Containing lime. Calculus. Stone; gravel. Callous. Hard. Cancer. A scirrhous, livid tumor, intersected by firm, whitish, divergent bands. Cancer. Colloid, gelatinous. See p. 687. Cancer. Fibrous, hard, scirrhous. See p. 687. Cancer. Soft, medullary, encephaloid. See p. 687. Cancroid. That which assumes a cancerous appear- ance. Canula. A small tube, metallic, wooden or rubber, used in surgery. Capillaries. Hair-like, minute vessels. Capsule. Membranous sac. Carcinoma. Cancer. Cardiac. Pertaining to the heart. Caries. Ulceration of the bone. Carious. Adjective of Caries. Carotids. Two large arteries of the neck Cartilage. An elastic and flexible substance found at the joints and at the extremities of the ribs. Caseine. Cheesy. Caseosa. A soft cheesy substance found on the skin of a newly-born babe. Catamenia. Menses. Catheter. A hollow tube, used to insert into the bladder to draw off urine. Caudal. Tail. Cell. A small cavity. Cellular Tissue. Net-like formation, composed of cells. Cellulitis. Cellular inflammation. Cephalematoma. A sanguineous tumor found on the heads of new-born infants. Cephalalgia. Headache. Cephalic. Pertaining to the head. Cephaloma. A tumor resembling brain. Cephalotribe. See p. 278. Cephalotripsy. See p. 278. Cerebral. Pertaining to the brain. Cerebriform. A morbid substance commonly form- ed by scirrhous or cancerous tumor. Cerebro-spinal Meningitis. See p. 935. Cerebrum. Upper and front part of the brain. Cerumen. Ear-wax. Cervicitis. Inflammation of the neck of the womb. Cervix. Neck. Change of Life. See Climacteric Period. Chemosis. Inflammatory swelling of the conjunc- tiva. Cholesterine. A substance forming the crystalline part of certain biliary calculi. Chlorosis. A disease affecting young females, more particularly those who have not menstruated. It is characterized by a pale, livid complexion, lan- guor, depraved appetite and digestion. Chlorotic. Pertaining to Chlorosis. Chorea. See p. 934. Chorion. See p. 131. Chronic. Of long standing. Chyle. A nutritive fluid. Chylopoetic. Relating to the formation of chyle. Cicatrix (pi. cicatrices). Scar left after the heal- ing of a wound. Cilie. The hairs on the eyelids. Clavicle. Collar-bone. Clavus. Kind of tumor. Climacteric Period. Cessation of menstrual func- tions, usually occurring about the forty-fifth year. Clitoris. See p. 45. Cloaca. The pouch at the extremity of the intesti- nal canal. Coagulum. Clot of blood. Coccyx. See p. 15. Coitis, or Coition. Sexual intercourse. Colitis. See p. 758. Collapse. Failure of vital power. Colliquative. A term applied to various discharges which produce rapid exhaustion. Colon. The large intestine. Colostrum. See p. 214. Coma. Lethargy; stupor; collapse. Comatose. Pertaining to Coma. GLOSSARY. 979 Comedones. Little black spots on the nose. Commissure. See p. 43. Conception. The impregnation of the ovum by the male sperm, whence results a new being. Condylomata. Wart-like excrescences on the puden- da or anus. Condyle. A knob at articulating joints. Congenital. Hereditary; existing at birth. Congeries. A collection of several particles or bodies in one mass. Congestion. Over-fullness of the blood-vessels. Constipation. See Costiveness. Contagion. Propagation of disease by contact. Contusion. Bruise. Cornea. Horny, transparent coat of front part of the eyelid. Corpus lutecm. Cicatrix of the ovarium after the escape of an ovum. Corpuscle. Globule. Coryza. Discharge from the nose. Costiveness. When evacuations from the bowels do not take place as frequently as usual; or are unnaturally hard and voided with difficulty. Cotyledon. A hollow cavity in a bone which re- ceives the head of another bone. Cranioclast. See p. 277. Craniotomy. See p. 274. Cranium. Skull. Crepitus. Crackling; grating Cretaceous. Containing or relating to chalk. Crochet. See p. 277. Crural. Belonging to the upper part of the inner side of the thigh. Crusta lactea. See p. 869. Crypt, or Follicle. A small hollow, roundish body, situate in the substance of the skin or mucous membranes. Curuncule myrtiformis. See p. 47. Cutaneous. Pertaining to the skin. Cuticle. Outer skin. Cycles. A period of a certain number of days or years. Cyst. A bladder. Cystocele. Hernia, or rupture, of the bladder. Decidua. See p. 139. Decidua reflexa. See pp. 87 and 139. Decidua vera. See pp. 87 and 139. Defecation. Stool; alvine evacuation. Deglutition. Act of swallowing. Deltoid. Muscle of the shoulder. Dementia. Insanity; idiocy. Dental. Pertaining to the teeth. Dentition. Process of cutting teeth. Dermis. True skin. Desquamation. Peeling off of the skin. Desiccation. Drying up. Diagnosis. The discrimination of diseases. Diaphragm. Muscular partition between the thorax and abdomen. Diathesis. Constitutional tendency. Dietetics. Pertaining to diet. Digital. Belonging to the fingers. Diphtheria. See p. 941. Diplopia. Double vision. Dislocation. Displacement, as of a joint. Diuresis. An abundant secretion of urine. Dorsal. Pertaining to the back or posterior part of anything. Dorsum. The back; the posterior side of anything. Dropsy. An unnatural collection of a watery fluid in any part of the body. Ductus venosus. A vein in the liver. Duplicatcre. Folding of a membrane upon itself. Dura mater. The outer membrane of the brain. Dyscrasia. Abnormal composition of the fluids. Dysentery. A disease of the intestines attended with frequent bloody and mucous stools. See page 788. Dysmenorrhcea. Painful menstruation. Dyspepsia. Weakness of digestion. Dysphagia. Difficulty of swallowing. Dyspncea. Difficult breathing. See p. 339. Dystocia. Difficult labor. See p. .215. Dysuria. Painful.micturition; difficulty in making water. Ecchymosis. Extravasation of blood under the skin, as in bruises. Eclampsia. Puerperal convulsions. Ecrasement. Pertaining to the Ecrasew. Ecraseur. A surgical instrument, very like a chain- saw. Eczema. Eruption of small vesicles on various parts of the skin, usually close or crowded together, with little or no inflammation round their bases. Eczema capitis. Seep. 869. Efflorescence. Redness of the skin. Effluvium. An impure exhalation. Embryo. The fetus in its earliest stages of develop- ment. Embryonic Spot. See p. 139. Embryulcia. See p. .278. Emetic. Medicine to produce vomiting. Emmenagogue. A medicine that promotes the men- strual discharge. Emphysematous. Pertaining to the effusion of air into the cellular tissue. Empirical. Practice based on experience alone. Emprosthotonos. Spasms in which the body is drawn forward. Emulgent. A name given to the renal artery and vein. Emulsify. To soften. Enceinte. Pregnant Encephalic. Pertaining to the brain. Enchondroma. A cartilaginous growth proceeding from bones. Encysted. Covered with a membranous sac. Endemic. Peculiar to a circumscribed locality. Endocarditis. Inflammation of the internal parts of the heart. Endocervicitis. Inflammation of the lining mem- brane of the neck of the womb. Endochorion. See p. 146. Endometritis. Inflammation of the lining mem- brane of the uterus. Endosmosis. The action by which fluids pass from without to within organic membranes. 980 GLOSSARY. Enema. Injection. Eneuresis. Incontinence of urine. Epichorion. One of the fetal membranes. Epidemic. A generally prevailing disease among human beings. Epidermis. The true skin; the outside coat on the whole body. Epidydimis. Parts of the testicles. Epigastric. Pertaining to the region of the stom- ach. Epilepsy. Disease of the brain, characterized by unconsciousness, convulsive fits, etc. Epistaxis. Bleeding from the nose. Epithelium. Cuticle of the mucous membrane. Erosion. Destruction by ulceration. Erotomania. Love-madness. Eructation. Belching; rising of wind from the stomach. Erysipelas. Inflammatory cutaneous disease cha- racterized by extreme redness. Erythema. See p. 576. Ethmoid Bone. One of the bones of the head. Etiology. History of the causes of disease. Eustachian Tubes. Leading from the throat to the inner ear. Euthesia. The ready return of a rupture or a dis- location. Evanescent. Vanishing; passing away. Exacerbation. Aggravation of a disease or symptom. Exanthema. Cutaneous eruption. Excito-motory. A term applied to a division of the nervous system, comprising the gray matter of the spinal marrow, with the afferent and efferent nerves connected with it; all of which are con- cerned in reflex actions. Excrement. Everything which is discharged from the body as superfluous, such as faecal matter, urine, perspiration, nasal mucus, etc. Exfoliation. Peeling off in thin layers, as of the bones or nails. Exostosis. A morbid enlargement or tumor of a bone. Extravasation. Effusion of blood into a structure. Exudation. Passage of fluid through a membrane. Facet. A small face; a small, circumscribed por- tion of the surface of a bone. Fecal. Pertaining to stool. Fallopian Tube. See p. 66. False Pains. Pains like, or resembling, labor-pains. Fascia. Fibrous membrane arranged in the form of an inextensible texture, and constituting a sheath for muscles. Fasciculus (p\. fasciculi). Bundle. Fauces. Throat. Febrile. Pertaining to fever; feverish condition. Fecundity. Fruitfulness. Felon. Very painful tumor found on the fingers or toes. Femoral. Pertaining to the femur. Femur (pi. femora). Thigh-bone. Fenestra. Aperture. Fibrils. Fibres. Fibrin. The filamentous portion of the blood. Fibula. Small bone of the leg. Filament. Same as fibril. Filiform. Thread-shaped. Fimbria. Fringe-like extremity of a structure. Fissure. A chap; crack; opening. Fistula. An ulcer, found usually in the anus. Flatulent. Pertaining to wind. Flatus. Wind. Flexion. Bending. Flocculi. Cloudy sediment. Flux. Flow. Fcetor. Stench; disagreeable odor. Fcetus. The young babe in the womb before it is born. Follicle. Fold; small sac. Fontanelle. Aperture in the infant skull at the junction of the sutures. Foramen. An aperture; a hole, as in bones. Fossa. Groove; shallow cavity. Fourchette. See p. 45. Frenum. Bridle, as of the tongue or prepuce. Fungus. Spongy, fleshy excrescence; proud flesh. Funis. See Umbilical Cord. Gallactorrhcea. Inordinate flow of milk. Gall-stone. A stone formed in the gall-bladder. Ganglion (pi. ganglia). A knot-like enlargement in a nerve. Gangrene. Mortification. Gastralgia. Pain in the stomach. Gastric. Pertaining to the stomach. Gastro-enteric. Relating to the stomach and in- testines. Gastro-intestinal. See above. Gastrotomy. The cutting into the abdomen. Gelatiniform. Having the form of gelatine. Genital. Pertaining to generation; sexual. Genus epidemicus. The prevailing type of a dis- ease. Germinal Spot. See p. 132. Germinal Vesicle. See p. 131. Gestation. See p. 88. Glands. Small secrotory bodies met with in various parts of the system. Globus hystericus. Choking sensation in hysteria. Glottis. Opening into the windpipe at the larynx. Gluteus. A muscle on the buttocks. Graafian Vesicle. See p. 68. Granula. A small grain or drop. Granular. Composed of, or containing, small grains. Gravid. Pregnant. Groin. The depression lying between the belly and thigh. Grumous. Clotted; dark-colored. Hematemesis. Vomiting of blood. Hematocele. Swelling of the scrotum from effusion of blood. Hematoma. A bloody tumor, especially of the scalp of the new-born. Hematuria. Hsemorrhage from the bladder. Hemoptysis. Spitting of blood. Hemorrhage. Morbid flow of blood. Hemorrhoids. See Piles. GLOSSARY. 981 Hemorrhoids, Blind. See Piles, Blind. Hemostatic. Pertaining to the stoppage of blood. Heartburn. Impaired appetite with gnawing or burning pain in the stomach. Hectic. Debilitating and emaciating fever. Hemicrania. Half-side of the head. Hepatic. Pertaining to the liver. Hepatitis. Inflammation of the liver. Hepatization. Change in the lung by which it assumes the appearanco of liver. Hermaphrodite. One who possesses the attributes of male and female; a term applied to one who is at the same time male and female. Hernia. Rupture. Herpes. See p. 576. Heterologous. Differing. Hilum. The fissure of the spleen, kidney, lung, ovary, etc. Also, a small blackish tumor in the eye. Homologous. Similar. Hooping Cough. See p. 817. Humerus. Bone of the upper arm. Hybrid. A thing produced from two different species; mongrel. Hydatid. Species of intestinal worm; serous vesicle. Hydremia. See p. 341. Hydrocele. Dropsy of the scrotum. Hydrocephalus. Water on the brain; dropsy of the head. See pp. 903 and 905. Hydrometra. A disease characterized by circum- scribed protuberance in the hypogastrium, pro- gressively enlarging, without ischuria or preg- nancy. Hydrorrhcea. See p. 357. Hydrothorax. Dropsy of the chest. Hydrosis. Perspiring. Hygiene. The science of preserving health. Hymen. See p. 47. Hyperesthesia. Excessive sensibility. Hypergenesis. The excess of formative power which gives occasion to monstrosities by excess of parts. Hyperplasia. Excessive formation of tissue. Hypertrophy. Morbid enlargement of an organ. Hypochondriac. One who is morbidly melancholy. Hypochondrium. The region under the false ribs. Hypogastrium. The lower anterior part of the abdomen. Hysteralgia. See pp. 555 and 671. Hysteria. See p. 555. Hysteroid. Resembling Hysteria. Ichor. Fetid, watery discharge from wounds, ul- cers, etc. Icterus. Jaundice. Idiopathic. Primary, original disease. Idiosyncrasy. Individual peculiarity of constitu- tion. Ileum. The longest of the small intestines. Iliac. Pertaining to the ilium. Ilium. See p. 15. Impregnation. Fecundation of the ova. Inanition. Exhaustioa from want of nourishment. Incarcerated. Imprisoned; strangulated; con- stricted. Incisor. See Tooth. Incontinence. Involuntary passage of urine; in- ability to retain semen, etc. Incubation. The period that elapses between the introduction of a morbific principle into the sys- tem, and the development of the disease. Incubus. Nightmare. Indices. Signs. Indigestion. Dyspepsia. Induration. Hardening. Infection. Propagation of disease by miasm or contact. Inferior. Lower. Infiltration. Flowing of fluids into the cellular tissue. a Influenza.' Epidemic catarrh. Ingesta. Food. Inguinal. Belonging to the groin. Innervation. The nervous influence necessary for the maintenance of life and the functions of the various organs. Innocuous. Harmless. Innominatum. See p. 15. Inosculation. Connecting of the extremities of the blood-vessels. Insomnia. Sleeplessness. Interstitial. Space between. Intertrigo. See p. 874. Intramural. Within or between walls. Intra-uterine. That which takes place within the womb. Intumescence. Increase of size in a part or in the whole of the body. Intussusception. A portion of the intestine falling into the adjoining part and choking up the open- ing, producing strangulation. Ischium. Hip-bone; lower part of the pelvis. Ischuria. Retention or impossibility of discharg- ing the urine. Isomeric. A term applied to different bodies which agree in composition, but differ in properties. Jactitation. Tossing about; restlessness; twitch- ing. Jaundice. A bilious disease, inducing yellowness of the skin, etc. Jugular. Large vein in the neck. Jurisprudence. Embodied laws and regulations that relate to the teaching and practice of med- icine. Legal medicine. Kiesteine. A peculiar albuminoid pellicle which forms on the urine of a pregnant female when allowed to stand for a few days. Labia majora or externa. See p. 43. Labia minora or intbrna, or nymphe. See p. 45. Labor. Parturition. Child-birth. Labor-pains. See p. 177. Laceration. Tearing. Lachrymation. Discharge of water from the eyes. Lactation. Secretion of milk. Lactiferous. Milk-carrying vessels. Lamine. Thin, flat part of a bone. 982 GLOSSARY. Laryngismus stridulus. See p. 823. Labynx. Upper part of the windpipe. Lees. Liquor potassae. Lesion. Hurt or injury caused by violence or dis- ease. Leucophlegmatic. Torpid or sluggish temperament. Leucorrhcea. Whites. A discharge of a white, yel- lowish or greenish mucus from the vagina. Lichen. A papular cutaneous eruption. See p. 576. Lienteria. Diarrhea consisting of undigested food. Ligament. Inelastic, tendinous cord. Ligature. Cord tied around a bleeding vessel. Linea albicantes. See p. 108. Linea nasalis. A lino extending from the wings of the nose to the corners of the-mouth* Liquor amnii. Fluid by which the fetus is surround- ed in the womb. Lithotomy. The removal of stone from the bladder by surgical means.. Lobclate. Tho dividing of an organ into lobes. Lochia. See p. 210. Lumbar. Pertaining to the loins. Lumbrici. Round worms in the intestines. Luxation. Dislocation. Lymph. A transparent fluid found in the lymphatic vessels and thoracic duct. Malacia. See p. 291. Malacosteon. Softening of the bones. Malaise. Indisposition. Malak. Pertaining to the cheek. Malformation. Unnatural formation. Malignant. Term used to denote great severity of u disease. M uposition. Wrong, position. M vmme. Tl»e female breasts. Mammary. Relating to the breasts. Mania. Madness. Marasmus. Wasting away of the body; emaciation. Mastitis. Inflammation, of the breasta. Mastoid. A process connected with the temple bone. Masturbation. Excitement of the genital organs by hand; self-abuse. Maturation. Ripening; fall development of mat- ter. Meatus urinarius. See p. 46. Meconium. Excrement discharged from the bowels of a newly-born infant. Median Line. An imaginary vertical line through the middle of the body. Medication. Treatment by medicine. Medulla oblongata. Part of the brain within the cranium. Nervous system of the senses. Membrana granulosa. See p. 68. Membrane. A thin, supple, more or le8s elastic, web. Menopause. Cessation of the menstrual flow; change of life. Menorrhagia. Excessive menstruation; excessive haemorrhage. Menses or Catamenia. Monthly courses of women. Menstruation. See Menses. Mesentery. The investing and supporting mem- brane of the small intestines. Mesial Line. An imaginary " middle line " in the body. Metacarpal Bones. Five parallel bones forming the back of the hand externally, and the palm of the hand internally. Metastasis. Transfer of a disease from one part to another. Metatarsal. Five bones on the back of the foot. Metritis. Inflammation of the womb. Metrorrhagia. Discharge of blood from the womb; uterine haemorrhage. Miasm. Poisonous influence in the atmosphere. Micturition. Urination. Miliaria. See p. 855. Molar. See Tooth. Mole. False conception. Molimen. An attempt; a struggle; the courses. Mons veneris. A projection on the lower part of the abdomen, over the vulva, covered with hair. Morbid. Diseased; unhealthy; unnatural. Morbili. See p. 848. Morning Sickness. See p. 111. Mother's Marks. See p. 872. Muciparous. Mucus-producing. Mucous Membrane. The lining of the cavities com- municating with the external air, as lining of the mouth, intestines, etc. Mucus. Fluid discharged from the mucous mem- branes. Multiform. Having many forms. Multilocular. Having many cells or small cavities. Multipare. One who has borne several children, used in contradistinction to Primiparae. Mumps. See p. 891. Nevi materni. See p. 872. Nares. The nostrils. Nates. Tho two projections of the body on which we sit. Nausea. Sickness of stomach. Neonatorum. Newly-born. Nephritis. Inflammation of the kidneys. Nettle Rash. See Urticaria. Neuralgia. Pain of the nerves. Neurilemma. See p. 100. Nisus. The monthly courses of women. Normal. Natural; healthy. Nosology. Classification of diseases by name. Nucleus. Any body about which matter is col- lected; tho germ of a new cell. Nulliparous. Having borne no children. Nutriment. A substance capable of nourishing and repairing the losses of the system. Nutrition. Nutrition is that function by which the nutritive matter already elaborated by the various organic actions assumes the nature of the differ- ent living tissues, to repair their losses and main- tain their strength. Nymphe. See Labia interna. Obesity. Abnormal accumulation of fat. Obturator foramen. See p. 18. GLOSSARY. 983 Occiput. Back part of the head. GSdema. Dropsical swelling. (Esophagus. Gullet; passage from the pharynx to the stomach. (Estruation. See p. 74. Oleaginous. Oily. Olecranon. Elbow-bone. Omentum. Caul; peritoneal covering of the bowels. Onanism. Masturbation. Opalescent. Reflecting a colored lustre. Ophthalmia. Inflammation of the eye. Opisthotonos. Spasmodic bending backward. Orbits. The circular cavities which contain the eyes. Orgasm. A strong impulse or desire for something. Orthopncea. Difficult respiration. Os. Mouth. Also, bone. Os calcis. Bone of the heel. Os tince. Mouth of the womb. Osseous. Bony. Ossification. Conversion into bone. Otorrhcea. Running from the ear. Ovale foramen. See p. 18. Ovarialgia. Pain in the ovary. Ovariotomy. Surgical operation for removing the ovary. Ovaritis. Inflammation of the ovary. Ovary. See p. 66. Ovisac. See p. 68. Ovology. Description of the ovum. Ovulation. See p. 17. Ovule. A small egg. Ovum (pi. Ova). An egg. Oxyuri. Species of intestinal worm. Ozcena. Ulcerative destruction of the Schneiderian membrane. Palpation. See p. 120. Palpebre. Eyelids. Pampiniform. See p. 69. Pancreas. A gland deeply seated in the abdomen, secreting a juice, the use of which is to emulsify fatty matters. Papescent. Thin; pap-like. Papille. Eminences on the tongue, skin, the inner coat of the bowels, etc. Papular. Abounding in pimples. Papulous. See Papular. Paracentesis. Tapping for the relief of dropsy. Parenchyma. See p. 68. Parenchymatous. Pertaining to parenchyma. Parietes. Walls or sides, as of the vagina, etc. Parotid Glands. Salivary glands beneath the ears. Parotitis. See p. 891. Parturient. In labor. Parturition. The act of child-birth. Pathology. Doctrine of the nature of diseases. Patulous. Spreading, open. Pectoral. Pertaining to the chest. Pediluvia. Baths for the feet. Pellicle. A thin skin. Pelvis. See p. 11. Penis. The male organ of generation. Percussion. See p. 120. Pericardium. Sac containing the heart. Pericarditis. Inflammation of the pericardium. Pericranium. The periosteum which covers the cranium externally. Perineum. See p. 38. Periosteum. Membrane enveloping the bones. Periphery. Circumference. Peristaltic Motion. Alternate contraction and dila- tation. Peritoneum. Serous membrane lining the abdomen and enveloping its contents. Peritonitis. Inflammation of the peritoneum. Pertussis. See p. 817. Pessary. An instrument to insert into the vagina to support a prolapsed uterus. Petechie. Purple spots on the skin. Phagedenic. Corroding, ragged sores. Pharynx. Throat; upper part of the gullet. Phlebitis. Inflammation of the veins. Photophobia. Intolerance of light. Phlegmasia dolens. Milk leg. Phlegmonous. Pertaining to inflammation in the cellular tissue. Inflammation with swelling. Phrenitis. Inflammation of the brain. Phthisical. Consumptive; pertaining to consump- tion. Phthisis. Consumption. Phthisis pulmonalis. Consumption of the lungs. Physiology. Science of life in health. Physometra. A circumscribed protuberance in the hypogastrium, with occasionally noisy discharge of wind through the os uteri. Pica. See p. 291. Pigment Cell. Dark cell. Piles. Painful tumors around or within the anus. Piles, Blind. Those which do not bleed. Piliferous Bulbs. See p. 49. Pityriasis. See p. 871. Placenta. See p. 146. Placenta previa. In child-birth, when the placenta precedes the child. Planes, Inclined. See p. 24. Pleno rivo. Full stream. Plethora. Over-fullness of the blood vessels; re- pletion. Pleura. Lining membrane of the thorax, covering also the lungs. Plexus. Network of nerves or vessels. Plexus, Cceliac. Formed of numerous nervous fila- ments, and is situated in the abdomen. Plexus, Solar. Network of nerves lying upon the vertebral column, the aorta and the pillars of the diaphragm. Plica polonica. A disease characterized by inter- lacing, twisting and agglutination or matting of the hair. Pnecmogastric. Belonging to the lungs and stom- ach. Pneumonia. Inflammatii n of the lungs. Pneumo-thorax. Air in the pleural cavity. Polychrest. Having many virtues. Medicines useful in many diseases. Polypoid. Pertaining to, or similar to,polypus. Polypus. Soft tumor in the nose, uterus, etc., at- tached by a pedicle. 984 GLOSSARY. Popliteal. Pertaining to the ham. Porrigo larvalis. See p. 869. Posterior. The back part of anything. Post-mortem. After death. Post-partum. After child-birth. Precursory. Forewarning. Pregnancy. The state of a female who is with child. Pregnancy, Uterine. See p. 89. Pregnancy, Extra uterine. See p. 89. Primipara. A woman about to bear her first child. Procidentia. Complete falling of the womb, so it protrudes from the vulva. See p. 612. Prodromic. Immediately preceding the attack of a sickness. Prognosis. Art of foretelling results in disease—how long it will last, what will be the end, etc. Progressive locomotor ataxia. Inability to walk steadily. See p. 612. Prolapsus. Falling, as of the womb or rectum. Proliferous. To be prolific; to abound. Prophylactics. Means used as preventives against disease. Prostate Gland. Situated around the neck of tho bladder in the male. Prurient. Itching; uneasy with desire. Prurigo. Itching disease of the skin. Pruritus. Itching of the skin. See p. 575. Psoas Muscles. In the loins. Psora. Itch. Psoriasis. Cutaneous disease, with a rough and scaly state of the skin. Ptyalism. See p. 328. Puberty. The period when childhood ends and adolescence begins. Pubic Arch. The arch at the front part of the lower circumference of the pelvis. Pubis. See p. 17. Puerperal. Pertaining to child-bed. Pulmonary. Pertaining or belonging to the lungs. Puriform. Pus-like; resembling pus or corrup- tion. Purulent. Composed of pus or corruption. Pus. Cream-like matter produced in abscesses, etc. Putrescence. Rottenness; decay. Pyloris. Lower orifice of the stomach. Pyriform Muscles. See p. 17. Pyrosis. See p. 306. Quickening. See pp. 113 and 116. Rachitis. Inflammation of the spine. Radius. Upper bone of the fore arm. Rale. Peculiar rattling sound in the lungs. R unification. Division of arteries, nerves or veins into branches. Ramollescence. Softening. Ranula. See p. 874. Rectocele. See p. 587. Rectum. Straight gut, terminating at the anus. Regurgitation. Return of food or drink from the stomach. Rbhal. Belonging to the kidneys. Respiration. The act of breathing. Rete mucosum. Mucous tissue beneath the cuticle. Retina. A very thin membrane found in the eye. Retention. Stopping of natural discharges, as of urine, etc. Retrocession. Retirement of symptoms. Retroflexion. Bending backward. Retroversion. A bending backward. See p. 624, Rhagades. Chaps or cracks of the skin. Rhonchus. Wheezing or rattling sound. Rickets. See Rachitis. Rigor, Coldness. Roseola. See p. 854. Rouleaux. Rolls. Rubeola. See p. 848. Ruge. Wrinkles; folds. Sac. Bag. Saccharine. Partaking of the nature of sugar. Sacrum. Posterior bone of the pelvis on which the spine rests. Saculate. Bag-shaped; bag formation. Saliva. Spittle. Salivary Glands. Gland secreting saliva or spittle. Salivation. See p. 112. Sanguineous. Consisting of blood. Sanguinolent. Tinged with blood. Sanies. Ichor. Saphena. Vein in the leg. Sarcoma. Fleshy tumor. Scalpel. One of the smaller sized surgical knives. Scapula. Shoulder-blade. Scarify. To make a slight scratch. Scarlatina. Scarlet-fever. See p. 830. Schneiderian. The mucous membranous lining of the nose. Sciatic. Pertaining to the hip. Scirrhus. Indolent, hard tumor, a form of cancer. Sclerotica. The hard coat of the eyelid; white of the eye. Scorbutic. Pertaining to scurvy. Scrofula. A morbid state of the system charac- terized by indolent, glandular tumors ; they sup- purate slowly, heal with difficulty, leave scars, etc. Scrotum. Bag holding the testicles. Sebaceous. See p. 49. Secretion. A flowing or discharge. Secundines. All that remains in the womb after the birth of the child—viz., the placenta, a por- tion of the umbilical cord, the membranes, etc. Segment. A portion. Semen. The generating fluid furnished by the male. Septicemia. An unhealthy condition of the blood. Septum. A partition. Sequele. Consequences resulting from disease. Sero-mucous. Partaking of serum and mucus. Serous. Thin; watery. Serum. Fluid portion of the blood. Serratus magnus. A muscle situate at the sides of the thorax. Sibilant. Hissing. Sigaultean Operation. See p. 282. GLOSS, Similimum. The remedy that corresponds most nearly to the existing symptoms. Sinciput. Fore part of the head. Sinus. A cavity or hollow. Slough. The part which separates from a foul ulcer, decaying bone, etc. Soporous. Sleepy state. Sordes. Dark-colored deposit on the teeth. Spasms. Severe, morbid contractions of the muscles. Spermatic. Pertaining to the male sexual organs. Spermatorrhcea. An involuntary emission of semen. Spermatozoa. Animalcules in the semen. Sphacelated. Struck with gangrene or mortification. Sphincter. Circular muscles to close the rectum or bladder. Sporadic. Scattered; not epidemic Sputa. Spittle. Stercoraceous. Vomiting of faecal matter. Sternum. The breast-bone. Stertor. Noisy respiration. Stethoscope. A hollow cylindrical instrument used in examining tho chest, the beating of the heart, etc. Stillicidium. The flow of any fluid, particularly the urine, drop by drop. Stomach. Situate beneath the diaphragm, and is the first receptacle of food. Stool. Faecal matter. Strabismus. Squinting. Strait, Inferior. See p. 28. Strait, Superior. See p. 25. Strangury. Painful or suppressed urination. Stroma. See p. 68. Strumous. Scrofulous. Stupor. Drowsiness; sleep. Styptic. A substance employed to arrest haemor- rhage. Sub. A term signifying "under" or "in a lower degree." Subacute. Not severe. Subcutaneous. Beneath the skin. Sublingual. Beneath the tongue. Submaxillary. Belonging or pertaining to the lower jaw. Subsultus tendinum. Spasmodic twitching of the tendons. Sudoriparous Glands. See p. 49. Sulcus. A furrow; a groove. Superior. Upper. Suppuration. Production of pus. Supra. Above. Suture (Anatomy) of Bones. A kind of immovable articulation in which the bones unite, are dove- tailed into each other. Suture, Coronal. See p. 159. Suture, Lamboidal. See p. 159. Suture, Sagittal. See p. 159. Suture {Surgery). The sewing up of a wound. Suture, Interrupted. This consists in passing a ligature through the lips of a wound previously brought into contact, and then tying the ends of the ligature all the stitches being made in this way. Suture, Quilled. Same as previous, except the liga- ARY. 985 tures are tied ovor two quills, rolls of plaster or bougies, which are laid along the sides of the wound. Suture, Twisted. A pin is passed through the edges of a wound to keep them together, and a piece of thread is then wound around the pin in the form of the figure 8. Sycosis. Fig-wart, a venereal disease. Symphysis. Union of bones. Symphyseotomy. See p. 282. Symptom. Any unnatural change perceptible to the senses in any organ or function. Synchronous. Occurring at the same time. Syncope. Fainting. Synochal. Inflammatory fever. Synovia. The unctuous fluid which lubricates the joints. Syphilis. A venereal disease communicated by sexual intercourse Tabulate. To shape with a flat surface. Tenia. Tapoworm. Tarsus. Bones which connect the leg with the foot. Tenaculum. A fine hook used in surgery to seize a blood-vessel. Tendon. Tho white, tough extremity of the muscles. Tenesmus. Painful, ineffectual urging to stool. Testes. See Testicles. Testicles. Two glandular organs of the male con- tained in the 6crotum, whose office is to secrete semen. Tetanus. Lock-jaw. Tetter. Herpetic eruption. Therapeutics. Relating to the cure of disease by remedial agents. Therapia. Therapeutics. Thorax. The chest. Thrush. Aphthae. Thymus Gland. Gland behind the sternum. Thyroid foramen. See p. 18. Tibia. Large bone of the leg. Tonsils. Glands on each side of the thorax. Teeth, Canine. Eye teeth. Teeth, Incisor. The sharp, cutting teeth. Teeth, Molar. Grinding teeth ; jaw teeth. Tormina. See p. 790. Torticollis. Twisted or wry neck. Toxemia. Poison in the blood. Trachea. Windpipe. Traumatic. Resulting from wounds or injuries. Trephine. A circular instrument for perforating the bones of the skull. Trismus. See p. 947. Trocar. An instrument used to evacuate fluids from cavities, as in dropsy, etc. Trochanter. Tuberosity on the thigh-bone. Trochlearis. Muscle of the eye. Trunk. The principal part of the body, to which the limbs are joined. Tubercle. A tumor in the substance of organs, from the production of new matter; no sensation; slow growth. Tuberculosis. The morbid condition which gives rise to tubercles. SARY. 986 GLOSi Tuberosity. A rough eminence or tubercle on a bone. Tuberous. Knobbed. Tumefaction. Swelling. Tumor. A swelling, larger or smaller, developed by a morbific cause in some part of the body. Tunica. A membranous coat or covering. Tunica albuginea. See p. 68. Tunica propria. See p. 68. Turgescence. Swelling up; growing large; disten- sion of the blood-vessels. Turning. See p. 250. Tympanitis. Flatulent distension of the abdo- men. Ulceration. The formation of an ulcer. Umbilical Cord or Funis. See p. 149. Umbilicus. The navel. Unilocular. Having one cell or cavity. Urachus. See p. 141. Uremia. See p. 335. Urea. A compound of the urine, existing in large quantities. Urethra. See p. 47. Urticaria. See p. 867. UiERrNE Prolapsus. See p. 355. Uterus. See p. 54. Uvula. The fleshy, cone-shaped body hanging in the mouth. Vagina. See p. 51. Vaginismus. See p. 593. Vaginitis. See p. 594. Varicella. Chicken-pox. Varices. Dilated veins. Varicose. Dilated. Vascular. Pertaining to vessels, particularly the blood-vessels. Vaso-motor. The force which controls the circula- tion of the blood. Vectis. See p. 273. Veins. Vessels for the conveyance of black blood from every part of the body to the heart. Velum. A veil or cover. Vena cava. Veins returning the blood to the heart. Venous. Pertaining to veins. Ventricles. Cavities in the brain or heart. Vermicular. That which resembles a worm. Version. See p. 250. Vertebre. Bones of the spine. Vertex. Crown of the head. Vertigo. Dizziness; giddiness. Vesical. Pertaining to the bladder. Vesication. The formation of blisters. Vesicle, Germinal. See p. 69. Vesicule seminales. Two small membranous sacs which serve as reservoirs for the semen. Vesicular. Containing small vesicles or cells. Vestibule. See p. 46. Viable. Capable of living. Villi. Minute processes on the surface of some membranes constituted of blood-vessels, nerves and absorbents. Virulent. Highly noxious. Viscera. Entrails. Viscid. Sticky. Vitelline. See p. 68. Vitellus. See p. 69. Vomit. To throw up the contents of the stomach. Vulva. See p. 43. Vulvitis. See p. 570. Waterbrash. Regurgitation of a watery fluid from the stomach. Whitlow. Felon. Wolffian Bodies. See p. 152. Womb. See Uterus. Zygoma. Cheek-bone. Zymotic. A term used to characterize the entire class of epidemic, endemic and contagious dis- eases. BOERIOKE & TAPEL'S (Successors to WM. KADDE.) JoMopatjjtc JpnMicaiions. ---•-•-•--- Aconite, Monograph upon. By Dr. Reil.............. ................. $0 75 Apis Melllfica. Provings. By C. W. Wolff.......................... 25 Baehe, B. Therapeutics, 2 vols., just issued............................ 10 00 Beckee, A. C. On Constipation........................................ 50 Dentition.......................................... 50 Diseases of the Eye................................. 50 Bell on Diarrhcea. Bound in muslin................................ 1 25 sheepskin or half morocco.................... 1 75 interleaved with writing paper, half morocco.. 2 25 Beejeatt, on Stphilis, Gonoebhcea, Speematoeehcea, and Urinary Diseases. Revised, and with numerous additions, by Frost, in linen.......... 1 50 half morocco or sheep ..,. 2 00 interleaved, half morocco.. 3 00 Bbeyfogle's Epitome of Homceopathic Medicines...................... 1 50 Interleaved with writing paper, half morocco................ 3 00 Bryant, J. Pocket Manual and Repertory.............................. 2 00 Burt, Chaeacteeistic Mateeia Medica................................. 3 00 Interleaved with writing paper, half morocco................ 5 00 Boennxnghausen, C. On Intermittent Fever............................ 50 Therapeutic Pocket Book........................ 3 00 Sides of the Body.............................. 25 Characteristic Materia Medica. Wm. H. Burt....................... 3 00 Caspaei, Homceopathic Domestic Physician............................. 1 00 Cockburn, Medical Reform........................................... 50 Ceoseeio, Obstetrics.................................................. 90 Curtis and Lillie's Epitome.......................................... 75 Douglass, on Inteemittent Fevee..................................... 38 Family Homceopathy. Ellis........................................... 1 50 Feanklin, E. C, Science and Aet of Surgery. Vol. I.............--- 8 00 Gray and Hempel, Homceopathic Examiner, new series, two volumes, bound......................................................... 5 00 Gross, Comparative Materia Medica, translated and edited, with addi- tions, by C. Heeing............................................ 10 00 Guernsey, Egbert, Domestic Practice................................... 2 50 Gentleman's Handbook............................. 1 00 2 Hahnemann, Lesser Writings.......................................... $4 00 Materia Medica, Puba.................................... 9 00 Cheonic Diseases, 5 vols.................................. 10 00 Obganon. ... ............................................ 1 50 Haetmann, Diseases of Chlldeen..................................... 3 00 Chief Remedies, second series............................. 1 00 Helmuth, on Surgery................................................ 3 50 Hempel, C. J., Domestic, in German.................................... 75 French................................... 75 Organon................................................ 1 00 homceopathy........................................... 1 00 Large Repertory....................................... 9 00 Materia Medica, 2 vols................................. 12 00 Hempel and Beakley, Theory and Practice............................. 3 50 Henderson, Homceopathic Practice................................... 50 Heeing, C, Domestic Physician....................................... 2 50 Hitchmann, Consumption............................................. 75 Holcombe, W. H., Yellow Fever........................................ 38 Homceopathic Cookery................................................ 50 Hughes, Pharmacodynamics............................................ 2 00 Therapeutics................................................ 2 00 Hull, Homceopathic Examiner, few copies only remain of this very valu- able periodical, three vols., handsomely bound................. 15 00 Hulls, Jahr Symptomatology......................................... 7 00 Repeetoey............................................. 4 00 Humpheey, on Dysenteey............................................. 50 Choleea............................................. 38 Hydeiatics, Manual of the Water Cube.............................. 50 Jahe, G. H. G., Foety Yeaes' Peactice................................. 3 50 Clinical Guide or Pocket Repertory, second American from the third German edition, with the addition of the new remedies by Lilienthal.......................... 3 00 Diseases of Females................................. 2 50 the Skin ................................ 1 50 New Manual, with additions, by Possaet, and Clinical Repertory.......................................... 4 50 Venereal Diseases.................................... 4 00 Jahr and Gruner, Pharmacopceia...................................... 3 00 Josltn, Principles of Homceopathy.................................... 75 Homceopathic Treatment of Cholera.......................... 1 00 Keeusslee, Acute and Cheonic Diseases............................. 75 Laurie, Homceopathic, Domestic....................................... 60 Appendix to Domestic Practice............................... 1 25 Parent's Guide............................................... 1 00 Lippe, Text-Book of Mateeia Medica................................. 6 00 Interleaved with writing paper, and bound in two volumes, half morocco.............. ,............................... 10 00 Lutze, Theoey and Peactice.......................................... 2 50 Madden, Uterine Diseases............................................ 50 3 Malan, Family Guide................................................ $0 30 in Spanish..................................... 75 Marcy, Homoeopathy and Allopathy................................... 50 Maecy and Hunt, Theoey and Peactice, 2 vols........................ 12 00 Mateeia Medica of American Peovings................................ 1 00 Metcalfe, Homoeopathic Peovings.................................... 1 50 Millard, Consumption.............................................. 75 Guide foe Emeegencies..................................... 50 Morgan, Indigestion, Constipation, &c................................ 75 Munde, Scarlet Feveb.............................................. 50 Muee, Mateeia Medica.............................................. 1 00 Neidhaed, Ceotalus Horridus in Yellow Fever....................... 1 00 Diphtheria................ .......................... 1 75 New Peovings, Cistus Can, Cobaltum Zingibebis, &c.................... 75 North Ameeican Joubnal of Homceopathy, per vol..................... 4 00 whole set, 18 volumes, bound. 50 00 Peters, Headache and Diseases of the Head.......................... 3 00 Apoplexy....... ............................................ 1 00 Diseases of Females and Married Women.................--- 1 50 Diseases of Maebied Females................................ 1 00 Peincipal Diseases of the Eye ............................. 1 50 Inteenal Diseases of the Eye................................ 1 00 Diseases of the Brain..................^..................... 1 00 Neevous Derangement .... ................................... 1 00 Pbinciples and Practice of Medicine......................... 3 50 Philadelphia Journal of Homceopathy, 4 vols., bound.................. 8 00 Rapou, on Typhoid Fever........................................... 50 Raue, C. G., Pathology and Therapeutics............................. 5 00 Interleaved with writing paper.............................. 8 00 Rau, Organon......................................................... 1 25 Reel, on Aconite..................................................... 75 rokitansky, pathological anatomy.................................... 75 Rueckert's Therapeutics ........................................... 4 00 Ruoff's Repertory.................................................... 1 50 Rush, Veteeinaey..................................................... 50 Schaefeb, Veterinary Homceopathy................................... 2 00 Shaep's Teacts, 12 numbers.......................................... 75 Small, Homceopathic Practice......................................... 3 00 Pocket Manual............................................... ^0 Diseases of the Nervous System............................... 1 00 Stapf, Additions to Materia Medica.................................. 1 50 Tessler, Asiatic Cholera.............................................. 75 Pneumonia.................................................. '5 Therapeutic Guide, Foety Yeaes' Peactice, G. R G. Jahr............. 3 50 Therapeutics, The Science and Art of, B. Baehr, 2 vols................. 10 00 Williamson, Diseases of Females and Children....................... 1 00 Wolff, Apis. Mellotca............- • •............---.................. Diasw do Aavaan tvnouvn snidiosw do Aavaan tvnouvn snidiosw do Aavaan ivnouvn snidiosw do a /\sf I ^ riONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE DIQ3W do Aavaan tvnouvn snidiosw do Aavaan tvnouvn TIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE Diasw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn Q- TIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE iDiasw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn TIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE Diasw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw so ai / riONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE Q 3 Q_ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRA Diasw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw so J ■■,J\ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARYftOF MEdI*. a J -a ^ snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL 3NIDI03W so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidkwv NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL I snidiosw so Aavaan tvnouvn snidiosw so Aavasn tvnouvn snidiosw so Aavaan tvnouvn snidiothi ? r&Zk' \ t / y&ZL\ ? rWR^\ t- X js>kQ $ rW$k\ t- / jm § 5 j&l / % c ask 5 at*. / i ^ ~^R * a NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidkwi NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL m snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidiosw so Aavaan tvnouvn snidhHW i r 1 FK/ I NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATION*1 ■MBMH Wi &BW MM NLM OOSflDflTD 1 32 53 MBUS UAMH HP H| NLM005808901